Use of the hCONSORT criteria as a reporting standard for herbal interventions for common dermatoses: a systematic review.

BACKGROUND: The use of complementary and alternative medicine (CAM) is increasing in Western countries, including in the area of dermatology. However, Western healthcare providers have not integrated CAM into regular practice owing to a lack of reliable data supporting its use. To encourage high-quality research related to the use of CAM and specifically herbal interventions, the CONsolidated Standards Of Reporting Trials (CONSORT) extension criteria on reporting herbal interventions (hCONSORT) were published in 2006. OBJECTIVES: To evaluate the adherence of randomized controlled trials (RCTs) investigating herbal interventions for acne, atopic dermatitis (AD) and psoriasis to the hCONSORT criteria. METHODS: A comprehensive search of the PubMed, Embase and Cochrane Library databases was conducted. RCTs published between 2009 and 2014 assessing therapeutic outcomes of plant-based interventions for acne, AD or psoriasis were included. Investigators determined the number of unique hCONSORT criteria satisfied per report. anova was used to examine differences in scores by disease entity. RESULTS: The vast majority of reviewed studies reported < 50% of information recommended in the hCONSORT criteria. Limitations include the small number of dermatological conditions examined, exclusion of reports based on language and lack of assessment of overall adherence to CONSORT criteria. CONCLUSIONS: Our data indicate lack of adherence to hCONSORT extension criteria. Adherence to hCONSORT guidelines should be encouraged in order to provide high-quality reporting of research on herbal interventions in dermatology. Doing so may ease the integration of CAM into conventional medical practice and provide actionable data to providers.

Risk factors of obesity in a cohort of 1001 Cypriot adults: An epidemiological study.

BACKGROUND AND AIMS: To measure the prevalence of overweight and obesity in adults in the Republic of Cyprus, and to evaluate and relate possible obesity risk factors of the adult Cypriot population. METHODS: This is an epidemiological cross-sectional study on a stratified random sample of 1001 (48.5% males-51.5% females) subjects, aged 18-80 years old. Anthropometric, biochemical, and dietary/lifestyle characteristics included in the study. RESULTS: The prevalence of overweight (Ow) and obesity (Ob) was 46.9% and 28.8% for males and 26% and 27% for females, respectively. Overweight and obese subjects were found to have statistically significant higher levels of Body Mass Index (p<0.001), Waist circumference (p<0.001), Total serum cholesterol (p<0.001), Low density lipoprotein (p<0.005), Glucose (p<0.007) and Triglycerides (p<0.001) compared to normal peers. In addition, Ow and Ob participants consumed significantly lower levels of fruits and vegetables (p<0.001), exercised less time/d (p<0.001) and smoke more cigarettes/d (p<0.001), compared to normal subjects, respectively. In multiple regression analysis of factors associated with overweight and obesity, Waist Circumference (beta: 1.132, p<0.001), Glucose (beta: 0.892, p<0.045), alcohol consumption (beta: 0.563, p<0.001), and exercise levels (beta: -0.444, p<0.001), were the most significant ones. CONCLUSION: The prevalence of overweight and obesity is very high in Cypriot adults. The current study also revealed a significant positive relation of Ow and Ob with waist circumference, high blood glucose levels and increased consumption of alcohol and a negative one with decreased levels of exercise.

Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter.

Chlorhexidine allergy has been described in the literature, mainly in Japanese individuals. Most reactions have been limited to the skin, mild in severity and a result of chlorhexidine containing solutions such as 'Savlon' (Novartis Consumer Health, Horesham, UK). We describe what we believe is the first reported case of anaphylaxis in a European patient to a chlorhexidine- sulphadiazine-coated central venous catheter.

Transmural repolarisation in the left ventricle in humans during normoxia and ischaemia.

BACKGROUND: Studies in isolated tissues and myocytes show different repolarisation properties in subepicardium, midmyocardium and subendocardium. Whether these differences are present in vivo and are relevant to humans has been the subject of controversy. Our objectives were (1) to ascertain whether transmural repolarisation gradients are present in humans, (2) to determine whether the greater sensitivity of subepicardial cells to ischaemia in vitro is manifest during early ischaemia in humans in vivo. METHODS AND RESULTS: We studied 21 patients during routine coronary artery surgery. Unipolar activation recovery intervals (ARI) were recorded from five transmural locations between subepicardium and subendocardium in the left ventricular wall. A pacing protocol spanned a range of cycle lengths from a cycle length of 300 ms to the maximum permitted by the intrinsic atrial activity. Following the onset of cardiopulmonary bypass recordings were obtained before (control) and during a 3-min period of global ischaemia. During control transmural ARIs were homogeneous between 300 and 1500 ms (ventricular pacing) and 750 and 1500 ms (atrial spontaneous beats). During ischaemia, ARIs shortened similarly at all transmural electrode sites and transmural homogeneity was maintained. CONCLUSIONS: Transmural repolarisation differences within the ventricular wall of the human heart were absent at cycle lengths within the physiological range but also during prolonged cycles. During early (global) ischaemia repolarisation changed equally in subepicardial and subendocardial regions and transmural homogeneity of repolarisation was preserved.

Repolarisation and refractoriness during early ischaemia in humans.

OBJECTIVES: To determine whether effective refractory period (ERP) shortens or lengthens in the first minutes of ischaemia in humans, and the relation between ERP changes and action potential duration (APD). METHODS: ERP and monophasic action potential duration (MAPD) were measured from a single left ventricular epicardial site in 26 patients undergoing coronary artery surgery. Cardiopulmonary bypass was instituted and normothermia maintained. Refractory period was determined by the extrastimulus technique at a basic cycle length of 500 ms, at four times (group 1, 15 patients) or two times (group 2, 11 patients) the preischaemic diastolic threshold. A three minute period of ischaemia was instituted by aortic cross clamping between the input from the pump oxygenator and the heart. RESULTS: After three minutes of ischaemia, mean (SEM) ERP lengthened from 232 (5) ms (control) to 246 (7) ms (p < 0.005) in group 1, and from 256 (10) ms (control) to 348 (25) ms (p < 0.005) in group 2. In the same time MAPD shortened from 256 (5) ms (control) to 189 (9) ms (p < 0.001) with no difference between groups. Thus postrepolarisation refractoriness developed during ischaemia. Before ischaemia, ERP showed a good correlation with APD (R(2) = 0.64) but by one minute of ischaemia the correlation was poor (R(2) = 0.29). CONCLUSIONS: These results show that during the first three minutes of global ischaemia in patients with coronary artery disease: (1) ERP lengthened in response to both a low and a high stimulus strength; and (2) there was a good correlation between ERP and APD before ischaemia, which was lost by one minute as APD decreased and ERP increased. These findings may have important implications in arrhythmogenesis.

Inhomogeneous transmural conduction during early ischaemia in patients with coronary artery disease.

Electrical inhomogeneity and conduction slowing are critical factors in the initiation and maintenance of ventricular arrhythmias during early ischaemia. Studies in animal models have shown delay in epicardial activation compared to endocardial activation. Epicardial activation delay has been attributed to either enhanced sensitivity of epicardium to ischaemia or to mid-myocardial conduction delay. No information is available in humans and in particular in patients with chronic ischaemia due to coronary artery disease who may have altered electrophysiological properties. Twenty-three patients undergoing routine coronary surgery were studied. All had severe two or three vessel coronary artery disease and a documented history of angina for a mean of 2.4 years. On cardiopulmonary bypass a 3 min period of ischaemia was created by cross clamping the aorta between the input from the pump oxygenator and the coronary arteries. During atrial pacing (normal endocardial to epicardial activation) intramyocardial activation time within the left ventricular free wall between subendocardial and subepicardial plunge electrode terminals, increased from 12.7+/-1.5 ms (control) to 28.2+/-3.2 ms after 3 min ischaemia at the base. At the apex, the activation time increase (over the same distance) was less (19.5+/-2 ms at 3 min ischaemia). This difference in increase in activation time at the base and apex was significant (P<0.05). At the apex the ischaemia induced activation delay occurred primarily over the endocardial half of the wall, whereas the opposite was observed at the base of the heart. Using an epicardial electrode array stimulation along the long axis of the epicardial fibres showed minimal conduction delay during ischaemia whereas stimulation transverse to the epicardial fibres resulted in substantial conduction time prolongation, as was the case with intramural conduction. Intramural conduction during ischaemia was similar in non-infarcted regions of infarcted hearts compared to hearts with no previous MI. To conclude, in patients with coronary artery disease epicardial activation delay early during ischaemia is caused primarily by intramural delay and not by delay along the epicardium. Moreover, the ischaemia-induced transmural activation delay is inhomogeneous.

Complement activation during major surgery: the effect of extracorporeal circuits and high-dose aprotinin.

OBJECTIVE: To assess the in vivo contribution to complement activation of an extracorporeal circuit and the use of high-dose aprotinin during major surgery. DESIGN: Sequential samples were obtained from 8 patients undergoing thoracic surgery, 20 patients undergoing orthotopic liver transplantation (OLT) using venovenous bypass, and 19 patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTION: The latter two groups were part of a randomized controlled trial of high-dose aprotinin. MEASUREMENTS: Total complement activation was measured with the hemolytic complement activity and the C3 activation-specific marker, C3d antigen. MAIN RESULTS: Complement activation did not occur during thoracic surgery. During OLT, C3d antigen levels, expressed as mean +/- standard deviation (SD), were elevated from baseline at skin closure (8.6 +/- 2.5 v 13.0 +/- 5.2 mg/L; p = 0.0082). During cardiac surgery, C3d antigen levels increased 10 minutes after the start of CPB (pre-CPB, 8.0 +/- 1.9 v 14.2 +/- 3.1 mg/L; p = 0.0001) and remained at greater than baseline values postoperatively (8.0 +/- 1.9 v 11.8 +/- 2.3 mg/L; p = 0.002). There was no difference in complement activation in those receiving high-dose aprotinin during OLT or cardiac surgery. Complement activation during cardiac surgery using extracorporeal circulation occurred to a greater extent than during OLT and thoracic surgery. Complement activation during cardiac surgery or OLT was not attenuated by the use of high-dose aprotinin.

Activation of coagulation and fibrinolysis during cardiothoracic operations.

BACKGROUND: During open cardiac operations using cardiopulmonary bypass, there is activation of coagulation and fibrinolysis. We assessed the separate contributions of the surgical procedure itself and cardiopulmonary bypass to this, by studying sequential samples from patients undergoing routine open cardiac operations or thoracic operations without cardiopulmonary bypass. METHODS: Activation of coagulation and the extent of fibrinolysis were measured from sequential samples obtained before the operation to 48 hours after the operation for 7 thoracic patients and 8 cardiac patients. RESULTS: In the thoracic group operation length was shorter (p = 0.002), and there was no significant increase in thrombin-antithrombin III complexes or D-dimers until 24 hours postoperatively. In contrast, there was a highly significant increase in thrombin-antithrombin III complexes (p = 0.0043) and D-dimer levels (p = 0.009) during cardiopulmonary bypass. The increase in fibrinolytic activity was caused by an increase in tissue plasminogen activator (p = 0.013). At 48 hours postoperatively, the cardiac patients had a more hypercoagulable state than thoracic patients with significantly higher levels of thrombin-antithrombin III complexes (p = 0.041) and plasminogen activator inhibitor-1 activity (p = 0.0033). CONCLUSIONS: This study suggests the major activation of coagulation and fibrinolysis seen during cardiac operations is caused by the use of cardiopulmonary bypass.

A prospective randomised controlled trial of postoperative autotransfusion with and without a heparin-bonded circuit.

Autotransfusion has been included in the routine protocol in some units as an effort towards blood conservation. In this study we aimed to measure the efficacy and limitations of autotransfusion and whether a heparin-bonded circuit had any advantage. One hundred five patients were randomised to one of three post-operative treatments. Group 1 (n = 34) was not autotransfused whereas groups 2 (n = 36) and 3 (n = 35) received autotransfusion with the circuit of group 3 coated with heparin. Homologous blood and blood products were given according to strict protocols identical for all groups. Transfused and circulating blood was analysed for haemostatic variables and the requirement for homologous blood was recorded. Autotransfused blood contained no intact platelets and very high levels of D-Dimers (a peptide fragment released when fibrin is lysed) which resulted in high levels of systemic D-Dimers in patients receiving autotransfusion. Flow cytometric analysis revealed that whilst platelet glycoprotein 1 b receptors were severely reduced immediately following surgery, there was no additional damage caused by autotransfusion. Furthermore, there was no difference in platelet aggregation, von Willebrand factor (vWF) multimetric analysis or clotting profiles between the groups. Median (interquartile range) blood loss was 898 ml (638-1195) in group 1, 853 ml (595-1348) in group 2 and 770 ml (615-1000) in group 3 (Kruskal-Wallis P = 0.46). Median transfusion requirements were 2 units in each group. Whilst auto-transfusion does not appear to compromise haemostasis, it does not reduce the requirement for homologous blood and heparin-bonding of the circuit has no impact.

Aortic root replacement and extraanatomic bypass for interrupted aortic arch in an adult.

We describe an unusual case of interrupted aortic arch, aneurysmal ascending aorta, and aortic regurgitation in a 24-year-old man. He presented with general malaise, weakness of his legs, and hypertension. A single-stage operation was performed in which the aortic root was replaced with concomitant extraanatomic bypass of the interrupted segment of the aortic arch. He made a full recovery and has returned to work.

Thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax.

Initial experience of thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax is reported. Thirty-three out of 49 patients admitted with spontaneous pneumothorax were suitable for treatment with this minimally invasive method. This series demonstrates that this surgical management offers early discharge and return to normal activities with excellent medium-term results, despite the three early failures. It is felt that with increased experience in thoracoscopy and improved selection of patients, thoracoscopic bullectomy and pleurodesis will become the treatment of choice for primary spontaneous pneumothorax.

Comparison of two strategies for myocardial management during coronary artery operations.

Despite the current trend for using blood cardioplegia, ventricular fibrillation with intermittent ischemia is still used as a strategy to manage the myocardium with impressive results. These two methods of myocardial management were compared in 40 patients undergoing elective coronary artery operations using creatine kinase MB isoforms and troponin T assays. Each patient was randomized to have either cold blood cardioplegia (n = 20) or ventricular fibrillation with intermittent ischemia (n = 20) for myocardial management during the construction of distal anastomoses. Until recently, the comparison of different methods of myocardial management has been hindered by the lack of a specific and sensitive marker of myocardial damage. Analysis of creatine kinase MB isoforms (MB2, cardiac tissue form; MB1, plasma-modified form) and cardiac-specific troponin T (a structural protein) has been shown to improve the sensitivity for the detection of myocardial damage. There were no significant differences between the two groups in age, sex ratio, extent of disease, or left ventricular function. Blood samples for analysis were collected before cross-clamp application and at time intervals up to 48 hours after. Median peak creatine kinase MB2 activity was found to be significantly higher in the blood cardioplegia group compared with ventricular fibrillation (26.5 U/L versus 19.5 U/L, respectively, p = 0.04). Although median peak troponin T concentration was higher in the blood cardioplegia group, the difference failed to reach significance (2.2 ng/mL versus 1.6 ng/mL, p = 0.15).(ABSTRACT TRUNCATED AT 250 WORDS)

Creatine kinase MB isoforms: sensitive markers of ischemic myocardial damage.

We investigated the use of creatine kinase (CK) MB isoforms as a marker of myocardial cell injury in a preliminary study of 16 patients with chronic stable angina after successful percutaneous transluminal coronary angioplasty (PTCA) and 25 patients after coronary artery bypass grafting (CABG). Three control groups were studied: apparently healthy volunteers (n = 31), patients undergoing thoracotomy (n = 10), and patients undergoing routine coronary angiography (n = 9). Patients in the PTCA group showed an association between ischemic ST segment changes lasting > 3 min and a transient increase in the MB2/MB1 ratio; however, all had total CK-MB activity within normal limits. Routine coronary angiography subjects had no significant change in MB2/MB1. In the CABG patients, MB2/MB1 peaked within 1 h after the cross-clamp release and returned to baseline by 24 h postoperatively. The median time to peak MM3/MM1 and total CK-MB activity was 2 and 8 h after reperfusion, respectively, returning to baseline values by 2 and 5 days, respectively. After thoracotomy, MB2/MB1 was increased only in elderly patients (n = 5) with risk factors for ischemic heart disease; total CK-MB activity was increased in only three of these. Apparently, CK-MB isoforms can detect myocardial damage in clinical settings with less overt damage than myocardial infarction.

Pacing thresholds of temporary epicardial electrodes: variation with electrode type, time, and epicardial position.

We compared the variation in pacing thresholds of two widely used temporary pacing electrodes at different epicardial sites in 67 patients after coronary artery operations performed with either cardioplegia or ventricular fibrillation. In 33 patients, a bare, braided pacing wire (DW) was placed on the right ventricle and a Medtronic localized epicardial electrode (MED), on each ventricle. In the other 34 patients, the DW wire was placed on the right atrium and a MED electrode, on each atrium. Pacing thresholds were measured at the time of placement; at 1 hour, 6 hours, and 12 hours postoperatively; and daily for 4 days. The pacing thresholds (mean +/- standard error of the mean) at implantation were as follows: DW wire = 0.93 +/- 0.08 V and MED electrode = 0.63 +/- 0.1 V in the ventricles and DW = 1.28 +/- 0.18 V and MED = 0.65 +/- 0.09 V in the atria. On the fourth postoperative day, the pacing thresholds were DW = 2.08 +/- 0.21 V and MED = 1.19 +/- 0.22 V in the ventricles and DW = 2.33 +/- 0.29 V and MED = 1.04 +/- 0.09 V in the atria. The pacing thresholds of both types of wire increased significantly over time, but this deterioration was more pronounced with the braided wire both on the ventricle and on the atrium. The pacing threshold patterns were not affected by chamber side or mode of myocardial preservation. The braided ventricular wire failed to capture after 24 hours in 9 of 30 patients, whereas the localized epicardial electrode captured in all instances (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pre-operative aspirin decreases platelet aggregation and increases post-operative blood loss--a prospective, randomised, placebo controlled, double-blind clinical trial in 100 patients with chronic stable angina.

Aspirin has an established benefit in reducing the incidence of coronary events and vein graft occlusion. We have now assessed the risk of pre-operative aspirin in a prospective, randomised, double-blind clinical trial in 100 patients scheduled for elective coronary artery surgery. Any prescribed aspirin and non-steroidal anti-inflammatory drugs were discontinued 2 weeks pre-operatively and these were replaced by a randomly assigned tablet of either aspirin 300 mg daily or placebo taken until the day of surgery. Patient compliance was confirmed by serum and urinary salicylate analysis. The two groups were similar in demographic characteristics, bypass time, number of grafts placed and number of internal mammary arteries used. All patients survived to be discharged home (see Table). Aspirin decreases platelet aggregation to arachidonic acid and to collagen both pre- and post-operatively. The benefit of pre-operative aspirin has to be balanced against the risk of increasing post-operative blood loss, re-exploration for excessive bleeding and transfusion requirements.

Aprotinin inhibits fibrinolysis, improves platelet adhesion and reduces blood loss. Results of a double-blind randomized clinical trial.

The present recommendation is that aprotinin should be started before cardiac surgery, but as bleeding is only a problem in a minority, most patients are treated unnecessarily. In a prospective, randomised, double-blind trial we have studied the use of aprotinin, given only to the minority of patients who bled significantly post-operatively and who had not received prophylactic aprotinin. Sixty patients, who bled in excess of 400 ml in the first 3 h post-operatively were randomised to receive either aprotinin (2 x 10(6) KIU loading dose followed by an infusion of 0.5 x 10(6) KIU/h for 4 h) or placebo, in addition to conventional treatment. The demographic characteristics and the surgical procedures performed were similar in the two groups. Haematological variables were measured (A) before and (B) at the end of the infusion. Three patients were re-explored for excessive bleeding in each group and one patient died in each group. The patients in the aprotinin group bled significantly less and had higher haemoglobin levels on discharge than the patients in the placebo group. The tissue plasminogen activator antigen decreased and the fibrinogen level increased in the aprotinin group. In addition, aprotinin increased the number of surface GPIb platelet receptors as estimated by flow cytometry (36% versus 5%, P < 0.01) and maintained the platelet von Willebrand Factor activity (vWF). There was no significant difference in D-dimers, fibrin(ogen) degradation products, plasma vWF activity and antigen, platelet vWF antigen, platelet aggregation (to collagen, arachidonic acid, platelet activating factor and ristocetin), platelet count or transfusion of blood products between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudoaneurysm of aortocoronary vein graft secondary to late venous rupture: case report and literature review.

Formation of pseudoaneurysms of saphenous vein grafts after coronary artery bypass grafting has been reported previously in relation to anastomoses or secondary to infection. Pseudoaneurysm of the saphenous vein graft after late rupture of the saphenous vein and containment by the obliterated pericardial cavity has not been documented. Such a case is reported and published reports of similar cases are reviewed.

Rupture of a sinus of Valsalva aneurysm through the tricuspid septal leaflet.

We report a case of rupture of an aneurysm of the noncoronary sinus of Valsalva with the tract of the fistula emerging through the tricuspid septal leaflet. This rare pathology created a diagnostic dilemma, as the direction of the jet of blood was alternating between the right atrium and the right ventricle.

Disability and distress following cardiac surgery in patients over 70 years of age.

We have reviewed the outcome in a consecutive series of 254 patients over the age of 70 undergoing cardiac surgery between 1987-89. Of the patients, 62% were male and the median age was 73 years. Operations included: coronary bypass 57%, valve replacement 26%, combinations 14% and other procedures 3%. The hospital mortality was 7.5% and late mortality was 13.8%. Complications included: intraaortic balloon 6%, resternotomy for bleeding 4%, permanent pacing 3%, chest infection 14%, tracheostomy 5%, major cerebrovascular events 3% and minor 4%. Eighty-two percent left the intensive care unit within 24 h and 89% left hospital within 8 days. Two questionnaires (York University) were sent to 207 patients believed to be alive in order to evaluate the change in their quality of life following surgery. Of the 207 questionnaires 197 (95%) were returned, 7 of which were from relatives of patients who had died and 7 were incomplete. The responses of 183 assessable patients (at a mean follow-up of 36 months) were converted into Rosser disability (I-VIII) and distress (A-D) groups. There was a decrease in disability and distress in 60% and 67%, respectively, no change in 34% and 30% and deterioration in 6% and 3%. Cardiac surgery can be carried out in elderly patients with an acceptable early morbidity and mortality, and although many patients show sustained improvement in their quality of life, this was not demonstrated in about a third of patients. As the emphasis in the elderly should be on quality of life we ought to continue to concentrate on careful selection in this age group.