Self-Extubation in Patients with Traumatic Head Injury: Determinants, Complications, and Outcomes.

BACKGROUND: Self-extubation is a common clinical problem associated with mechanical ventilation in trauma patients worldwide. OBJECTIVES: This study aimed to evaluate the predisposing factors, complications, and outcomes of self-extubation in patients with head injury. METHODS: This was a retrospective cohort study. SETTINGS: The study was conducted in a trauma intensive care unit (TICU). PATIENTS: All intubated patients with head injury admitted to TICU between 2013 and 2015 were included in the study. INTERVENTIONS: Planned compared to selfextubation during weaning from sedation. MEASUREMENTS: Risk, predictors, and outcomes of self-extubation were measured. MAIN RESULTS: A total of 321 patients with head injury required mechanical ventilation, of which 39 (12%) had self-extubation and 12 (30.7%) had reintubation. The median Glasgow Coma Scale, head abbreviated injury score, and injury severity score were 9, 3, and 27, respectively. The incidence of self-extubation was 0.92/100 ventilated days. Self-extubated patients were more likely to be older, develop agitation (P = 0.001), and require restraints (P = 0.001) than those who had planned extubation. Furthermore, self-extubation was associated with more use of propofol (P = 0.002) and tramadol (P = 0.001). Patients with self-extubation had higher Ramsay sedation score (P = 0.01), had prolonged hospital length of stay (P = 0.03), and were more likely to develop sepsis (P = 0.003) when compared to the planned extubation group. The overall in-hospital mortality was significantly higher in the planned extubation group (P = 0.001). Age-adjusted predictors of self-extubation were sedation use (adjusted odds ratio [aOR]: 0.06; P = 0.001), restraint use (aOR: 10.4; P = 0.001), and tramadol use (aOR: 7.21; P = 0.01). CONCLUSIONS: More than one-tenth of patients with traumatic head injury develop self-extubation; this group of patients is more likely to have prescribed tramadol, develop agitation, and have longer hospital length of stay and less sedation use. Further prospective studies are needed to assess the predictors of self-extubation in TICU.

The cardiovascular implication of single nucleotide polymorphisms of chromosome 9p21 locus among Arab population.

BACKGROUND: Based on several reports including genome-wide association studies, genetic variability has been linked with higher (nearly half) susceptibility toward coronary artery disease (CAD). We aimed to evaluate the association of chromosome 9p21 single nucleotide polymorphisms (SNPs): rs2383207, rs10757278, and rs10757274 with the risk and severity of CAD among Arab population. MATERIALS AND METHODS: A prospective observational case-control study was conducted between 2011 and 2012, in which 236 patients with CAD were recruited from the Heart Hospital in Qatar. Patients were categorized according to their coronary angiographic findings. Also, 152 healthy volunteers were studied to determine if SNPs are associated with risk of CAD. All subjects were genotyped for SNPs (rs2383207, rs2383206, rs10757274 and rs10757278) using allele-specific real-time polymerase chain reaction. RESULTS: Patients with CAD had a mean age of 57 ± 10; of them 77% were males, 54% diabetics, and 25% had family history of CAD. All SNPs were in Hardy-Weinberg equilibrium except rs2383206, with call rate >97%. After adjusting for age, sex and body mass index, the carriers of GG genotype for rs2383207 have increased the risk of having CAD with odds ratio (OR) of 1.52 (95% confidence interval [CI] = 1.01-2.961, P = 0.046). Also, rs2383207 contributed to CAD severity with adjusted OR 1.80 (95% CI = 1.04-3.12, P = 0.035) based on the dominant genetic model. The other SNPs (rs10757274 and rs10757278) showed no significant association with the risk of CAD or its severity. CONCLUSION: Among Arab population in Qatar, only G allele of rs2483207 SNP is significantly associated with risk of CAD and its severity.

Prevalence and outcome of cigarette and waterpipe smoking among patients with acute coronary syndrome in six Middle-Eastern countries.

OBJECTIVE: We evaluated the prevalence and effect of cigarette smoking (CS) and waterpipe (WP) smoking on patients with acute coronary syndrome (ACS) in six Middle-Eastern countries. METHODS: Analysis of the Gulf Registry of Acute Coronary Events (Gulf RACE) survey, which included 6704 consecutive patients hospitalized with ACS, was made and patients were divided into four groups depending on whether they were smokers - cigarette-CS, waterpipe-WS, combined cigarette and waterpipe (CW) - or non-smokers (NS). RESULTS: Overall 38% of patients were smokers; 4.4% of patients were waterpipe smokers (1.4% WS and 3% CW). When compared to the three smokers' groups, non-smokers were older. Overall, smokers had fewer cardiovascular risk factors when compared to NS. ST-segment elevation myocardial infarction was more common among nicotine smokers (CS 54.4%, WS 57.3%, 47.3% CW vs 30% NS, p = 0.001) while NS were more likely to have non-ST elevation ACS. Cigarette (and not waterpipe) smokers were more likely to present early and with typical symptoms when compared to NS and WS. Admission heart rate and blood pressures were higher in the non-smoker group and WS. Non-smokers and WS were also more likely to present with Killip class >1. After adjustment for baseline variables, smoking was not an independent predictor of adverse cardiac events. CONCLUSION: Cigarette smoking is prevalent among Middle-Eastern patients presenting with acute coronary syndrome. Waterpipe smoking use is low; however it is relatively more frequent in women when compared to cigarette smoking. The current study underscores the need for further studies into the effects of different forms of nicotine smoking.

Prevalence of the metabolic syndrome in patients with acute coronary syndrome in six middle eastern countries.

The objective of this study was to evaluate the prevalence and effect of the metabolic syndrome (MetS) on patients with acute coronary syndrome (ACS) in six Middle Eastern countries using the new definition of MetS. Analysis of the Gulf Registry of Acute Coronary Events (Gulf RACE), which included 8716 consecutive patients hospitalized with ACS, was conducted and patients were divided into two groups: patients with and patients without the MetS. Overall, 46% of patients had MetS. Patients with MetS were more likely to be female and less likely to be smokers. In-hospital mortality and cardiogenic shock were comparable between the two groups, although MetS patients were more likely to have congestive heart failure and recurrent ischemia. In ST-elevation myocardial infarction, MetS was also associated with increased risk of recurrent myocardial infarction and stroke. Using the recent MetS definition, MetS is highly prevalent among Middle Eastern patients presenting with ACS. MetS is associated with higher-risk profile characteristics and increased risk for development of heart failure and recurrent myocardial ischemia without an increase in hospital mortality.

Prevalence and prognosis of chronic obstructive pulmonary disease among 8167 Middle Eastern patients with acute coronary syndrome.

BACKGROUND: The purpose of this study was to report the prevalence and the significance of clinically recognized chronic obstructive pulmonary disease (COPD) during acute coronary syndrome (ACS). HYPOTHESIS: COPD in patients with ACS is associated with worse outcome. METHODS: Data were derived from a prospective, multicenter, multinational study of 8167 consecutive patients hospitalized with ACS from February to June 2007 in 6 Middle Eastern countries. Data were analyzed according to the presence or absence of COPD. Demographic, management, and in-hospital outcomes were compared. RESULTS: The prevalence of COPD was 5.3%. When compared with non-COPD patients, COPD patients were older and more likely to have diabetes, hypertension, and dyslipidemia. Atypical presentations were more common in COPD patients (P = 0.001). COPD patients were less likely to be treated with thrombolytic therapy (P = 0.001), beta-blockers (P = 0.001), and glycoprotein IIb/IIIa inhibitors, and more likely to receive angiotensin-converting enzyme (ACE) inhibitors. Although there was no difference in in-hospital mortality between the 2 groups, patients with COPD were more likely to have heart failure (P = 0.001). Despite the fact that COPD patients with ST-segment elevation myocardial infarction were less likely to receive thrombolytic therapy, they suffered more bleeding complications (2.8% vs 1%, P = 0.04), resulting in prolonged hospitalization. COPD was not an independent predictor of increased in-hospital mortality. CONCLUSIONS: In this large cohort of patients with ACS, the prevalence of COPD was 5.3%. Atypical presentation is common among COPD patients, and this may result in delayed therapy. ACS in COPD patients was associated with higher risk of heart failure and major bleeding complications without increased risk of in-hospital mortality.

Use of drug-eluting stents in patients with coronary artery disease and renal insufficiency.

Renal insufficiency (RI) has been shown to be associated with increased major adverse cardiovascular events after percutaneous coronary intervention. We reviewed the impact of RI on the pathogenesis of coronary artery disease and outcomes after percutaneous coronary intervention in the form of drug-eluting stent (DES) implantation in these high-risk patients. We searched the English-language literature indexed in MEDLINE, Scopus, and EBSCO Host research databases from 1990 through January 2009, using as search terms coronary revascularization, drug-eluting stent, and renal insufficiency. Studies that assessed DES implantation in patients with various degrees of RI were selected for review. Most of the available data were extracted from observational studies, and data from randomized trials formed the basis of a post hoc analysis. The outcomes after coronary revascularization were less favorable in patients with RI than in those with normal renal function. In patients with RI, DES implantation yielded better outcomes than did use of bare-metal stents. Randomized trials are needed to define optimal treatment of these high-risk patients with coronary artery disease.

The prevalence and outcome of excess body weight among Middle Eastern patients presenting with acute coronary syndrome.

We evaluated the effect of body weight on the outcome of Middle Eastern patients presenting with acute coronary syndrome (ACS). Analysis of the Gulf Registry of Acute Coronary Events (Gulf RACE) survey that included 7843 consecutive patients hospitalized with ACS was made. Patients were categorized as normal weight, overweight, or obese based on their body mass index (BMI). Overall, 67% of patients were overweight or obese; obese and overweight patients were more likely to be female and have diabetes mellitus, hypertension, dyslipidemia, and less likely to be smokers. In-hospital mortality, congestive heart failure, cardiogenic shock, and strokes were comparable between the groups, although patients with obesity were more likely to have recurrent ischemia and major bleeding complication in the ST-elevation myocardial infarction group. Excess body weight with ACS is associated with higher risk profile characteristics without an increase in hospital mortality or cardiovascular events.

Clinical implications of cytokines in the critical-care unit.

To understand the role of different cytokines in the pathophysiology and management of different acute cardiovascular disorders in critically ill patients, we reviewed most of the pertinent articles published on Medline, Scopus and EBSCO host research databases from 1985 to January 2009. We used the indexing terms 'cytokines', 'cardiovascular', 'sepsis', 'critical care', 'myocardial dysfunction', 'shock', 'thromboembolism', 'inflammatory' and 'arrhythmias'. Myocardial dysfunction, dysrhythmic and thromboembolic disorders all appear associated with important fluctuations in cytokines. When and how to sample cytokine levels and the ways in which cytokines contribute to patient deterioration or improvement require further clinical studies. The measurement and interplay of several different cytokines may ultimately be of substantial clinical importance in the diagnosis, treatment and prognosis of patients with different acute cardiovascular disorders managed by critical-care physicians in intensive-care units. Although the role of cytokines in cardiovascular disorders is debatable, the clinical implication of cytokines in the critical-care unit is a new horizon that warrants more attention.

Impact of gender in patients with acute coronary syndrome.

In this article, we review the impact of gender on the pathophysiology, management and outcomes after acute coronary syndrome (ACS). We searched the English-language literature indexed in MEDLINE, Scopus and EBSCOhost Research databases from 1988 through January 2009 using the indexing terms 'gender', 'short- and long-term outcomes' and 'acute coronary syndrome' and 'myocardial infarction'. Data comparing gender differences in outcomes after ACS showed that females have a higher mortality rate than males. Observational studies showed that guideline-recommended management strategies are used significantly less frequently in females than males. The undertreatment and worse outcome of female patients with ACS are probably multifactorial and have been reported in different ethnicities and cultures. However, there are conflicting data regarding to the impact of gender on early versus long-term outcomes, the benefit of early intervention in low- and high-risk females and the influence of unmeasured selection biases in the use of therapies in the observational data. These gender discrepancy trends warrant close follow-up, as this might reflect changes in primary and secondary prevention in the community. Furthermore, gender discrepancy gives an indication of healthcare quality and whether care is given in an unbiased manner. All high-risk females, and males with ACS, should receive optimal medical management, coronary angiography and revascularization whenever indicated.

Multidisciplinary approach for circulatory support in patients with advanced heart failure.

Despite the efficacy of heart-failure (HF) therapy, patients may still decompensate and require hospitalization. In addition to the gap between guidelines and clinical practice, this highlights the need for a multidisciplinary approach to the management of HF. The third European Mechanical Circulatory Support Summit presented the latest trials and trends in conservative therapy of end-stage HF (ESHF) and the alternative options over a ten-session program. The meeting covered topics such as epidemiological trends, different HF registries and guidelines for ESHF therapy. In addition to databases and HF trials, the presenters discussed the integration of multiple biomarkers in HF stratification, biological solution and embryonic stem cells for HF therapy, up-to-date myocardial recovery and the surgical aspects of ESHF treatment. Therapeutic options following short-term left ventricular support were discussed, such as: which patients should receive a ventricular assist device (VAD) and when; what the perfect window for implantation of a VAD is; bridge-to-bridge and device selection; VAD-weaning criteria; left ventricular unloading, patient-device matching (short-term device), cardiac transplantation following short-term support. There was a device update, presenting Circulite, Abiomed Impella, Levacor, Levitronix, VentrAssist, Heartmate II, DuraHeart and Heartware. Finally, the International VAD registry, European VAD registry and The International Society for Heart & Lung Transplantation Mechanical Circulatory Device database were also discussed. Herein, a commentary is givenon some of the interesting topics that indicate the importance of the community, the physician and the patient's awareness of HF, the utilization of the updated guidelines and landmark studies and registries, as well as recent evidence-based modalities in the management of ESHF.

Prevalence and impact of diabetes mellitus in patients with acute myocardial infarction: a 10-year experience.

BACKGROUND: Diabetes mellitus is associated with a higher incidence of acute myocardial infarction. OBJECTIVE: To study the prevalence and outcome of patients with diabetes among patients with acute myocardial infarction. METHODS: Retrospectively, patients who presented with acute myocardial infarction in a 10-year period were identified from the coronary care unit database. RESULTS: A total of 1598 Qatari patients were admitted with acute myocardial infarction, 863 (54%) of them had diabetes mellitus (females 68.5% vs males 48.3%; P < .001). In-hospital mortality rate was non-significantly higher in diabetic patients (18% vs 15% P = .15). Aspirin (odds ratio 2.39, 95% confidence interval 1.96-2.90, P = .003] and beta-blocker use (odds ratio 1.75, 95% CI 1.21-2.52, P = .0001) were independently associated with reduced mortality risk. CONCLUSIONS: The prevalence of diabetes mellitus among patients with acute myocardial infarction in a geographically defined population in the developing world is high with a trend for poor outcomes. However, mortality was not significantly higher in diabetes mellitus than non-diabetes mellitus patients.

Cytokines and coronary artery disease: the state of the art.

Initiation and progression of coronary atherosclerosis has been associated with inflammation and cytokines balance. The objective of this study is to understand the role of cytokines in the pathophysiology and management of coronary artery disease. Coronary artery disease has been revisited with revision of the pertinent published articles in the Medline, Scopus, and EBSCO Host research from 1987 to 2007. The 2 groups of cytokines (proinflammatory and anti-inflammatory) have been detected in human atherosclerotic plaques. The balance between the 2 groups may reflect the intensity of occult plaque inflammation and the vulnerability to rupture. Multiple studies have determined that a diverse set of proinflammatory biomarkers can furnish prognostic information beyond the traditional risk factors. Inflammatory responses after coronary revascularization are known to play key role in vascular lesion formation early in atherosclerosis and restenosis. Clinical utilization of cytokines remains promising yet incompletely explored and need more studies.

Impact of left bundle branch block and activation pattern on the heart.

Left bundle branch block (LBBB) is known to impair the mechanical function of the left ventricle. For a better understanding of the impact of LBBB on the structure and function of the heart and how this influences the management and outcome in patients with heart failure, we reviewed the most pertinent articles published from 1950 to 2007. Epidemiological studies identified LBBB as an independent risk factor for cardiac mortality. It is not only the morphology or duration of QRS but also the underlying myocardial pathology, ejection fraction or New York Heart Association class that may determine the clinical implications of LBBB. Data indicate that LBBB inversely affects the perfusion, systolic, diastolic performance and hemodynamics of the heart. However, there is no solid evidence answering the question of whether LBBB is a predictor, cause or consequence of myocardial dysfunction. Further studies are warranted for better understanding of these relationships, as this will allow better selection of patients and optimal time for resynchronization therapy in patients with LBBB.

Cytokines and myocardial dysfunction: state of the art.

BACKGROUND: Myocardial dysfunction has been associated with inflammation and cytokine modulation. OBJECTIVES: The study objective was to understand the role of cytokines in the pathophysiology and management of myocardial dysfunction. METHODS: Heart failure has been revisited with revision of the pertinent published articles in the Medline, Scopus, Cochrane Database of Systematic Reviews, and EBSCO Host research. RESULTS: For the proinflammatory cytokines, illumination of this important point requires further diagnostic and therapeutic investigations. Data on chronic heart failure are not so reassuring; therefore, patients with advanced heart failure should not be treated with anticytokines at this time. CONCLUSION: Further studies are warranted to pave the way for introducing cytokine and immunomodulation therapy at the optimal and appropriate time.

Detection of myocardial dysfunction in the presence of normal ejection fraction.

Detection of subclinical myocardial involvement is of utmost importance in risk stratification and prognosis; the role of ejection fraction in the detection of subclinical disease may be unhelpful. Our aim was to evaluate the methodology and importance of early detection of myocardial involvement in the presence of normal ejection fraction. Most of the pertinent English and non-English articles published from 1980 to 2006 in Medline, Scopus, and EBSCO Host research databases have been reviewed. Serial assessment of systolic function with different techniques should be avoided, since imaging modalities and ejection fraction measurements are not interchangeable. Additional non-invasive tools still are needed for the identification of subclinical left ventricular dysfunction in certain diseases. The recognition of subclinical involvement will prompt initiation of specific therapy to prevent the development of overt left ventricular dysfunction. This also is needed for determining the best timing for intervention in asymptomatic patients with metabolic and valvular disorders.

Contrast-enhanced 64-section coronary multidetector CT angiography versus conventional coronary angiography for stent assessment.

PURPOSE: To prospectively evaluate the accuracy of 64-section computed tomography (CT) for diagnosis of stent restenosis, by using conventional coronary angiography as the reference standard. MATERIALS AND METHODS: The ethics committee granted permission for the study; patients gave written consent. Contrast material-enhanced coronary CT angiography was performed in 53 patients (45 men, eight women; mean age, 54 years +/- 9 [standard deviation]) suspected of having stent restenosis. Coronary CT angiographic findings were compared with conventional coronary angiographic findings. Two physicians analyzed coronary CT angiographic data sets with multiplanar reformatted images and three-dimensional reformations by using a volume-rendering technique and looked for stent detectability, low-attenuation in-stent filling defects, and grades of restenosis. Conventional coronary angiographic results were interpreted by one of several observers in consensus for stent restenosis; they were blinded to coronary CT angiographic data. Statistical software and general estimating equations were used for data analysis. RESULTS: One hundred ten stents were identified in 53 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of coronary CT angiography in detection of in-stent restenosis were 96.9%, 88.0%, 77.5%, 98.5%, and 91%, respectively. Coronary CT angiography depicted in-stent low-attenuation filling defects with an accuracy of 91% and negative predictive value of 98.5% (95% confidence interval: 90.9, 99.9). Coronary CT angiography depicted the status of 97 of 107 stents. There was no significant difference between in-stent lumen visibility and stent diameter (P = .104). Coronary CT angiography helped diagnose 15 of 18 stent restenoses with less than 50% narrowing, five of five stent restenoses with 50%-74% narrowing, and nine of nine (100%) stent restenoses with 75% or greater narrowing or total occlusion of the stent lumen. CONCLUSION: Coronary CT angiography can depict in-stent low-attenuation filling defects, which appear to be a reliable sign of stent restenosis, and 64-section CT depicts such defects with a high degree of accuracy.

Left main coronary artery stenosis: state-of-the-art.

Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.

Noncompaction cardiomyopathy in the State of Qatar.

OBJECTIVE: To study the development of noncompaction of the ventricular myocardium (NCCM) in the state of Qatar and to highlight the prognostic parameters in those patients. METHODS: We conducted this study from 2000 to 2004 on patients who were referred to Hamad General Hospital with questionable echocardiographic features of cardiomyopathy with or without clinical manifestations of heart failure and were found to have NCCM. The diagnosis of NCCM was made according to echocardiographic criteria in 12 cases and those patients are followed up for 2-5 years. RESULTS: The mean age at diagnosis of NCCM was 6.5 years. Among them, 4 were males and 8 were females. Family history of NCCM was reported in 5 cases. Normal ejection fraction was detected in 5 patients; in this group pulsed-Tissue Doppler Imaging revealed evidence of subclinical systolic dysfunction in 4 cases. All patients showed variable degrees of diastolic dysfunction. Severely impaired ejection fraction was found in 3 cases. Progression to dilated cardiomyopathy occurred in 4 cases. Site of noncompaction included left ventricle apex in all cases, inferoposterior in 11 cases, and lateral wall in 11 cases while biventricular noncompaction was noted in 4 cases. Electrocardiogram findings included right bundle branch blocker (3) patients, left bundle branch blocker (2), left ventricular hypertrophy (6) and right ventricular hypertrophy in 3 cases. Atrial tachyarrhythmias developed in 4 cases. Wolff-Parkinson-White syndrome was detected in one patient. Associated congenital anomalies included ventricular septal defect, pulmonary stenosis, aortic coarctation, and Ebstein anomaly. The overall mortality rate was 25%. CONCLUSION: Noncompaction cardiomyopathy is so rare to be easily missed. The prognosis is poor in symptomatic cases; however, detection of subclinical systolic dysfunction is needed.

Obesity: a risk factor for acute myocardial infarction with angiographically patent epicardial coronary vessels in an adolescent.

OBJECTIVE: Toreport a causal relationship between myocardial infarction (MI) and obesity in an adolescent in the absence of the well-known risk factors for MI. CASE PRESENTATION AND INTERVENTION: A morbidly obese 17-year-old male, a nonsmoker, nondiabetic and normotensive patient, who sustained acute inferior MI with no family history of coronary artery disease, presented with central chest pain. ECG showed low voltage, normal sinus rhythm and ST segment elevation in the inferior leads; cardiac enzymes were elevated. Screening for ethanol and cocaine were negative. He was admitted to the coronary-care unit as a case of inferior MI with late presentation. Cardiac catheterization revealed patent epicardial coronary arteries; short- and long-term plans for weight reduction and family counseling were started. The hospital stay was uneventful, and the patient was discharged home on the fourth day. CONCLUSION: Based on clinical and laboratory findings, we assume that the MI might partly be secondary to coronary artery spasm or invisible premature atherosclerotic plaques. Public education and awareness for this complication in a young obese patient are warranted.