Outcome of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Patients With Intermediate SYNTAX II Score.

Patients with intermediate SYNTAX II score have been representing a confusion in our daily practice for interventional cardiologists whether to treat them by percutaneous coronary intervention (PCI) using second generation drug eluting stents or by coronary artery bypass grafting (CABG). We enrolled 214 consecutive patients with intermediate SYNTAX II score to undergo revascularization (109 patients underwent PCI and 105 patients underwent CABG) after Heart Team discussion. We compared both procedures with respect to the primary composite end point of major adverse cardiac or cerebrovascular events (all-cause mortality, myocardial infarction, target vessel revascularization or stroke) at 40 months post procedure. At 40 months post revascularization procedure, the primary end-point occurred in 22 patients and 15 patients in the PCI and CABG groups, respectively (hazard ratio, 1.65; 95% confidence interval, 0.87-3.14; P = 0.13). No significant differences were detected between both groups regarding the composite incidence of all-cause mortality, myocardial infarction, target vessel revascularization, and stroke. CABG significantly provided better quality of life than PCI for patients with intermediate SYNTAX II score. In patients with intermediate SYNTAX II score, there was no statistically significant difference between the PCI using second generation drug eluting stents and CABG with respect to the incidence of MACCE at 40 months post revascularization procedure.

Laser trabeculoplasty for open-angle glaucoma and ocular hypertension.

BACKGROUND: Open-angle glaucoma (OAG) is an important cause of blindness worldwide. Laser trabeculoplasty, a treatment modality, still does not have a clear position in the treatment sequence. OBJECTIVES: To assess the effects of laser trabeculoplasty for treating OAG and ocular hypertension (OHT) when compared to medication, glaucoma surgery or no intervention. We also wished to compare the effectiveness of different laser trabeculoplasty technologies for treating OAG and OHT. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; LILACS, ClinicalTrials.gov and the WHO ICTRP. The date of the search was 28 October 2021. We also contacted researchers in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing laser trabeculoplasty with no intervention, with medical treatment, or with surgery in people with OAG or OHT. We also included trials comparing different types of laser trabeculoplasty technologies. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. Two authors screened search results and extracted data independently. We considered the following outcomes at 24 months: failure to control intraocular pressure (IOP), failure to stabilise visual field progression, failure to stabilise optic neuropathy progression, adverse effects, quality of life, and costs. We graded the 'certainty' of the evidence using GRADE. MAIN RESULTS: We included 40 studies (5613 eyes of 4028 people) in this review. The majority of the studies were conducted in Europe and in the USA. Most of the studies were at risk of performance and/or detection bias as they were unmasked. None of the studies were judged as having low risk of bias for all domains. We did not identify any studies of laser trabeculoplasty alone versus no intervention. Laser trabeculoplasty versus medication Fourteen studies compared laser trabeculoplasty with medication in either people with primary OAG (7 studies) or primary or secondary OAG (7 studies); five of the 14 studies also included participants with OHT. Six studies used argon laser trabeculoplasty and eight studies used selective laser trabeculoplasty. There was considerable clinical and methodological diversity in these studies leading to statistical heterogeneity in results for the primary outcome "failure to control IOP" at 24 months.  Risk ratios (RRs) ranged from 0.43 in favour of laser trabeculoplasty to 1.87 in favour of medication (5 studies, I2 = 89%). Studies of argon laser compared with medication were more likely to show a beneficial effect compared with studies of selective laser (test for interaction P = 0.0001) but the argon laser studies were older and the medication comparator group in those studies may have been less effective. We considered this to be low-certainty evidence because the trials were at risk of bias (they were not masked) and there was unexplained heterogeneity. There was evidence from two studies (624 eyes) that argon laser treatment was associated with less failure to stabilise visual field progression compared with medication (7% versus 11%, RR 0.70, 95% CI 0.42 to 1.16) at 24 months and one further large recent study of selective laser also reported a reduced risk of failure at 48 months (17% versus 26%) RR 0.65, 95% CI 0.52 to 0.81, 1178 eyes). We judged this outcome as moderate-certainty evidence, downgrading for risk of bias. There was only very low-certainty evidence on optic neuropathy progression. Adverse effects were more commonly seen in the laser trabeculoplasty group including peripheral anterior synechiae (PAS) associated with argon laser (32% versus 26%, RR 11.74, 95% CI 5.94 to 23.22; 624 eyes; 2 RCTs; low-certainty evidence); 5% of participants treated with laser in three studies of selective laser group had early IOP spikes (moderate-certainty evidence). One UK-based study provided moderate-certainty evidence that laser trabeculoplasty was more cost-effective.  Laser trabeculoplasty versus trabeculectomy Three studies compared laser trabeculoplasty with trabeculectomy. All three studies enrolled participants with OAG (primary or secondary) and used argon laser. People receiving laser trabeculoplasty may have a higher risk of uncontrolled IOP at 24 months compared with people receiving trabeculectomy (16% versus 8%, RR 2.12, 95% CI 1.44 to 3.11; 901 eyes; 2 RCTs). We judged this to be low-certainty evidence because of risk of bias (trials were not masked) and there was inconsistency between the two trials (I2 = 68%). There was limited evidence on visual field progression suggesting a higher risk of failure with laser trabeculoplasty. There was no information on optic neuropathy progression, quality of life or costs. PAS formation and IOP spikes were not reported but in one study trabeculectomy was associated with an increased risk of cataract (RR 1.78, 95% CI 1.46 to 2.16) (very low-certainty evidence). AUTHORS' CONCLUSIONS: Laser trabeculoplasty may work better than topical medication in slowing down the progression of open-angle glaucoma (rate of visual field loss) and may be similar to modern eye drops in controlling eye pressure at a lower cost. It is not associated with serious unwanted effects, particularly for the newer types of trabeculoplasty, such as selective laser trabeculoplasty.

Feasibility and Clinical Outcomes of 48 mm Drug-Eluting Stents in the Management of Patients With Coronary Artery Disease.

BACKGROUND: Long coronary lesions represent a formidable challenge during percutaneous coronary intervention (PCI). Implantation of multiple contiguous stents may result in sections of overlapping stents or gaps of unstented segments and is an independent predictor of restenosis and major adverse cardiovascular events (MACEs). OBJECTIVES: The study goal was to assess the feasibility and short-term clinical outcomes of implanting 48 mm drug-eluting stents (DESs) for the treatment of long lesions in patients with coronary artery disease (CAD). METHODS: This prospective study enrolled 300 patients, with a single CAD planned to undergo PCI with 48 mm DES. Clinical data, procedural outcomes, and follow-up to 6 months were obtained. MACEs were considered the combined study endpoint, defined as cardiac death, non-fatal myocardial infarction, unstable angina, and the need for target-lesion revascularization (TLR). RESULTS: Among the 300 subjects enrolled, 80% were men and mean age was 60.8 ± 8.6 years. Procedural success rate was 97.3%. Failure of crossing was encountered in 4 patients due to severe tortuosity. Six-month clinical outcome was compared between diabetic (DM) (n = 90) and non-DM patients; 6-month cumulative MACEs were significantly lower in the non-DM group than in DM group (2.9% vs 13.3%, respectively; P=.01). Clinically driven TLR was 4% and 2 cardiac deaths were reported. The independent predictors of repeat revascularization were insulin-treated type 2 DM and reference vessel diameter (RVD) ≤2.75 mm. CONCLUSION: The use of 48 mm DES is feasible, safe, and cost effective in the treatment of long coronary lesions. Independent predictors of repeat revascularization are type 2 DM and RVD ≤2.75 mm.

Routine versus selective computed tomography in non-traumatic acute abdominal pain: meta-analysis of randomised trials.

PURPOSE: To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute abdominal pain (AAP) to a surgical service. METHODS: We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP. RESULTS: Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI - 0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD - 0.26, 95% CI - 2.07, 1.55, P = 0.78). CONCLUSIONS: The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.

Evaluation of the impact of percutaneous coronary intervention of chronic total occlusion on regional myocardial function using strain echocardiography.

BACKGROUND: Successful revascularization of chronic total occlusions has been associated with potential effects on left ventricular (LV) function. Strain and strain rate are more sensitive measures of LV mechanics than LV ejection fraction (LVEF). This study was conducted to investigate the impact of revascularization of chronic total occlusion (CTO) on LV function using tissue Doppler (TDI) strain echocardiography. RESULTS: This study included 60 patients divided into two main groups: the percutaneous coronary intervention (PCI) group including patients who had a successful PCI of CTO on left anterior descending (LAD) artery and was presented for elective PCI with symptomatic angina and/or positive functional ischemic study. They included 18 males with a mean age of 57 ± 5 years. The optimum medical treatment (OMT) group, including 30 patients, had non-revascularized CTO-LAD and was kept on OMT alone; 20 of them were males with a mean age of 58 ± 4 years. In the PCI group, there was a significant improvement in all the TDI strain parameters of the LAD territory segments. Six months after PCI, the peak systolic strain rate improved from - 0.65 ± 0.21 to 1.05 ± 0.31 1/s (p value < 0.01), the peak systolic strain improved from 6.54 ± 2.48 to 11.51 ± 3.33% ( p value < 0.001 ), and the end systolic strain improved from 7.88 ± 2.77 to 10.51 ± 3.14% (p value < 0.01 ). There was no significant improvement in the mean LVEF (60.70 ± 8.33 vs 61.91 ± 8.16% (p value = 0.6)). In the OMT group, there was no improvement in all the strain parameters and there was no change in the mean LVEF. In the PCI group, there was a significant improvement in the angina class (p value = 0.03) while, in the OMT group, there was no significant improvement (p value = 0.835). CONCLUSIONS: Successful PCI for CTO improved regional LV myocardial function assessed by TDI strain echocardiography. This improvement was associated with improvement in the angina class.

Interobserver reliability when using the Van Herick method to measure anterior chamber depth.

INTRODUCTION: The Van Herick method is a quick and easy way to estimate anterior chamber depth, which allows grading of patients according to the likelihood of having primary acute closed-angle glaucoma. However, as the test is highly subjective, measurements and thus grading may vary between observers. AIM: The aim of this study was to investigate the degree of variation of Van Herick scores among observers and to investigate agreement between temporal and nasal scores. MATERIALS AND METHODS: A total of 15 observers measured the temporal and nasal Van Herick scores from 18 patients, grouped into cohorts at outpatient glaucoma and corneal clinic. Analysis of data involved assigning a patient to a Van Herick grade based on the median score and then determining the mean standard deviation and percentage consistency for each grade. RESULTS: We found that Grades 1 and 4 had a high mean percentage consistency (80% and 84.6%, respectively) and a low mean standard deviation (0.45 and 0.26, respectively). Grades 2 and 3 had low mean percentage consistencies (57.5 and 5, respectively) and high mean standard deviations (0.71 and 0.89, respectively). The temporal and nasal scores showed good agreement (κ = 0.61P < 0.001). CONCLUSION: The Van Herick score has a good interobserver reliability for Grades 1 and 4; however, Grades 2 and 3 require further tests such as gonioscopy or ocular coherence tomography. Temporal and nasal scores demonstrated good agreement; therefore, if the nasal score cannot be measured due to nasal bridge size, the temporal can be used as an approximation.

Outcomes of DES in Diabetic and Nondiabetic Patients with Complex Coronary Artery Disease after Risk Stratification by the SYNTAX Score.

UNLABELLED: Diabetes mellitus (DM) increases the risk of adverse outcomes after coronary revascularization. Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). AIM: The aim of this study was to assess the outcomes of drug-eluting stent (DES) insertion in DM and non-DM patients with complex coronary artery disease (CAD) after risk stratification by the percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score. METHODS AND RESULTS: We performed multivessel percutaneous coronary intervention (PCI) for 601 lesions in 243 DM patients and 1,029 lesions in 401 non-DM patients. All included patients had MVD and one or more lesions of type B2/C. The two-year outcomes and event rates were estimated in the DM and non-DM patients using Kaplan-Meier analyses. The baseline SYNTAX score was ≤22 in 84.8% vs. 84%, P = 0.804, and 23-32 in 15.2% vs. 16%, P = 0.804, of the DM and non-DM patients, respectively. The number of diseased segments treated (2.57 ± 0.75 vs. 2.47 ± 0.72; P = 0.066) and stents implanted per patient (2.41 ± 0.63 vs. 2.32 ± 0.54; P = 0.134) were similar in both groups. After a mean follow-up of 642 ± 175 days, there were no differences in the major adverse cardiac and cerebrovascular events (MACCE; 26.7% vs. 20.9%; P = 0.091), composite end point of all-cause death/myocardial infarction (MI)/stroke (12.3% vs. 9%; P = 0.172), individual MACCE components of death (3.7% vs. 3.2%; P = 0.754), MI (6.6% vs. 4%; P = 0.142), and absence of stroke in the DM and non-DM patients. An increased need for repeat revascularization was observed in DM patients (18.5% vs. 10.2%; P = 0.003). In the multivariate analysis, DM was an independent predictor of repeat revascularization (hazard ratio: 1.818; 95% confidence interval: 1.162-2.843; P = 0.009). CONCLUSIONS: DES implantation provides favorable early and mid-term results in both DM and non-DM patients undergoing PCI for complex lesions. After a mean follow-up of two years, DM and non-DM patients with complex CAD treated by PCI using new-generation DES showed no differences with regard to MACCE and other secondary end points. However, higher rates of ischemia-driven repeat revascularization were observed in DM patients.

Identification of High-Risk Patients with Non-ST Segment Elevation Myocardial Infarction using Strain Doppler Echocardiography: Correlation with Cardiac Magnetic Resonance Imaging.

UNLABELLED: Assessment of left ventricular (LV) function is important for decision-making and risk stratification in patients with acute coronary syndrome. Many patients with non-ST segment elevation myocardial infarction (NSTEMI) have substantial infarction, but these patients often do not reveal clinical signs of instability, and they rarely fulfill criteria for acute revascularization therapy. AIM: This study evaluated the potential of strain Doppler echocardiography analysis for the assessment of LV infarct size when compared with standard two-dimensional echo and cardiac magnetic resonance (CMR) data. METHODS: Thirty patients with NSTEMI were examined using echocardiography after hospitalization for 1.8 ± 1.1 days for the assessment of left ventricular ejection fraction, wall motion score index (WMSI), and LV global longitudinal strain (GLS). Infarct size was assessed using delayed enhancement CMR 6.97 ± 3.2 days after admission as a percentage of total myocardial volume. RESULTS: GLS was performed in 30 patients, and 82.9% of the LV segments were accepted for GLS analysis. Comparisons between patients with a complete set of GLS and standard echo, GLS and CMR were performed. The linear relationship demonstrated moderately strong and significant associations between GLS and ejection fraction (EF) as determined using standard echo (r = 0.452, P = 0.012), WMSI (r = 0.462, P = 0.010), and the gold standard CMR-determined EF (r = 0.57, P < 0.001). Receiver operating characteristic curves were used to analyze the ability of GLS to evaluate infarct size. GLS was the best predictor of infarct size in a multivariate linear regression analysis (ß = 1.51, P = 0.027). WMSI >1.125 and a GLS cutoff value of -11.29% identified patients with substantial infarction (≥12% of total myocardial volume measured using CMR) with accuracies of 76.7% and 80%, respectively. However, GLS remained the only independent predictor in a multivariate logistic regression analysis to identify an infarct size ≥12%. CONCLUSION: GLS is a good predictor of infarct size in NSTEMI, and it may serve as a tool in conjunction with risk stratification scores for the selection of high-risk NSTEMI patients.

Impact of the Residual SYNTAX Score on Outcomes of Revascularization in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease.

UNLABELLED: Primary percutaneous coronary intervention (P-PCI) has become the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI) when performed by an experienced team in a timely manner. However, no consensus exists regarding the management of multivessel coronary disease detected at the time of P-PCI. AIM: The aim of this study was to evaluate the use of the residual SYNTAX score (rSS) following a complete vs. culprit-only revascularization strategy in patients with STEMI and multivessel disease (MVD) to quantify the extent and complexity of residual coronary stenoses and their impact on adverse ischemic outcomes. METHODS: Between October 1, 2012, and November 30, 2013, we enrolled 120 consecutive STEMI patients with angiographic patterns of multivessel coronary artery disease (CAD) who had a clinical indication to undergo PCI. The patients were subdivided into those who underwent culprit-only PCI (60 patients) and those who underwent staged-multivessel PCI during the index admission or who were staged within 30 days of the index admission (60 patients). Both the groups were well matched with regard to clinical statuses and lesion characteristics. Clinical outcomes at one year were collected, and the baseline SYNTAX score and rSS were calculated. RESULTS: The mean total stent length (31.07 ± 12.7 mm vs. 76.3 ± 14.1 mm) and the number of stents implanted per patient (1.34 ± 0.6 vs. 2.47 ± 0.72) were higher in the staged-PCI group. The rSS was higher in the culprit-only PCI group (9.7 ± 5.7 vs. 1.3 ± 1.99). The angiographic and clinical results after a mean follow-up of 343 ± 75 days demonstrated no significant difference in the occurrence of in-hospital Major Adverse Cardiac and Cerebrovascular Events (MACCE) between both the groups (6.7% vs. 5%, P = 1.000). However, patients treated with staged PCI with an rSS ≤8 had significant reductions in one-year MACCE (10.7% vs. 30.5%, P = 0.020*), death/Myocardial infarction (MI)/Cerebrovascular accident (CVA) (5% vs. 13.8%, P = 0.016*), and repeat revascularization (4.8% vs. 25%, P = 0.001*). We found that culprit-only, higher GRACE risk scores at discharge and an rSS >8 were independent predictors of MACCE at one year. CONCLUSIONS: Staged PCI that achieves reasonable complete revascularization (rSS ≤8) improves mid-term survival and reduces the incidence of repeat PCI in patients with STEMI and MVD. Nonetheless, large-scale randomized trials are required to establish the optimal revascularization strategy for these high-risk patients.

Neutrophil/Lymphocyte Ratio as a Predictor of In-Hospital Major Adverse Cardiac Events, New-Onset Atrial Fibrillation, and No-Reflow Phenomenon in Patients with ST Elevation Myocardial Infarction.

BACKGROUND: Neutrophil/lymphocyte (N/L) ratio represents the balance between neutrophil and lymphocyte counts in the body and can be utilized as an index for systemic inflammatory status. The no-reflow phenomenon is defined as inadequate myocardial perfusion through a given segment of the coronary circulation without angiographic evidence of mechanical vessel obstruction. Systemic inflammatory status has been associated with new-onset atrial fibrillation (NOAF) as well as no-reflow. AIM: To evaluate the predictive value of N/L ratio for in-hospital major adverse events, NOAF, and no-reflow in patients with ST elevation myocardial infarction (STEMI). PATIENTS: Two hundred consecutive patients with STEMI presenting to Alexandria Main University Hospital and International Cardiac Center Hospital, Alexandria, Egypt, from April 2013 to October 2013 were included in this study. METHODS: Laboratory investigation upon admission included complete blood count with mean platelet volume (MPV) and N/L ratio, and random plasma glucose (RPG) level. The results of coronary angiography indicating the infarct-related artery (IRA), initial thrombolysis in myocardial infarction (TIMI) flow in the IRA, and the TIMI flow after stenting were recorded. The patients were studied according to the presence of various clinical and laboratory variables, such as age, gender, pain-to-balloon time, location of the infarction, RPG level and complete blood count including N/L ratio and MPV on admission, and initial TIMI flow in the IRA. They were also evaluated for the final TIMI flow after the primary percutaneous coronary intervention, incidence of NOAF, and the incidence of in-hospital major adverse cardiac events (MACE). RESULTS: The incidence rate of no-reflow, NOAF, and in-hospital MACE was 13.2%, 8%, and 5%, respectively, with cardiac death as the predominant form of in-hospital MACE. The group of no-reflow, NOAF, and/or MACE showed significantly older age (62.29 ± 7.90 vs 56.30 ± 10.34, P = 0.014), longer pain-to-balloon time (15.90 ± 7.87 vs 6.08 ± 3.82 hours, P < 0.001), higher levels of RPG, N/L ratio (8.19 ± 3.05 vs 5.44 ± 3.53, P, 0.001), and MPV (11.90 ± 2.09 vs 8.58 ± 1.84 fL, P < 0.001) on admission. After adjustment of confounding factors, the independent predictors of NOAF, no-reflow, and in-hospital MACE were higher N/L ratio (odds ratio [OR] = 3.5, P = 0.02) and older age (OR = 3.1, P = 0.04). CONCLUSIONS: Older patient age, longer pain-to-balloon time, hyperglycemia, higher N/L ratio, and MPV on admission are useful predictive factors for the occurrence of no-reflow postprimary percutaneous coronary intervention, NOAF, and/or in-hospital MACE. N/L ratio is a new strong independent predictor of no-reflow, NOAF, and/or in-hospital MACE in patients with STEMI. The use of this simple routine biomarker may have a potential therapeutic implication in preventing NOAF and improving prognosis in STEMI revascularized patients.

Present and possible therapies for age-related macular degeneration.

Age-related macular degeneration (AMD) is the most common cause of blindness in the elderly population worldwide and is defined as a chronic, progressive disorder characterized by changes occurring within the macula reflective of the ageing process. At present, the prevalence of AMD is currently rising and is estimated to increase by a third by 2020. Although our understanding of the several components underpinning the pathogenesis of this condition has increased significantly, the treatment options for this condition remain substantially limited. In this review, we outline the existing arsenal of therapies available for AMD and discuss the additional role of further novel therapies currently under investigation for this debilitating disease.

Macular oedema related to idiopathic macular telangiectasia type 1 treated with dexamethasone intravitreal implant (ozurdex).

A 65-year-old female presented with visual disturbance in her right eye lasting for over 2 months. Following investigations, she was diagnosed with MacTel type 1 in the right eye. Visual symptoms were refractory to initial treatment with intravitreal bevacizumab and thereafter intravtireal triamicinolone. The patient was then treated with Ozurdex, following which central macular thickness (CMT) decreased (from 397 µm to 286 µm) and visual acuity deteriorated (from logMAR 0.48 to 0.59). At 14 weeks posttreatment with Ozurdex, a recurrence of cystoid macular oedema (CMO) was observed. Following a second Ozurdex, visual acuity improved (from logMAR 0.7 to 0.64) and CMT decreased (from 349 µm to 279 µm). An additional recurrence of CMO was observed at eighteen weeks following the second Ozurdex. Following a third Ozurdex injection visual acuity deteriorated (from logMAR 0.74 to 0.78) and CMT decreased (from 332 µm to 279 µm). Conclusion. Treatment of macular oedema secondary to MacTel with Ozurdex demonstrated promising anatomical outcomes. However, visual outcomes continued to gradually deteriorate.

The management of familial hypercholesterolaemia in Morocco.

Familial hypercholesterolaemia (FH) is an autosomal dominant disorder characterized by high levels of low-density lipoprotein cholesterol (LDL-C) as a result of mutations that impair their removal from plasma.The clinical consequence is a high risk of premature cardiovascular disease. Because of the extreme risk of mortality and morbidity, diagnosis, recruitment and management of FH patients must be one of the priorities of public health. In Morocco, specialized consultation for dyslipidaemia and strategy for management of this cardiovascular major risk factor does not exist, making FH identification and management difficult. In this review, we present the first FH state of the art in our country through a sample of 66 subjects. By this analysis, we have tried to elucidate some points that impede the identification and recruitment of heterozygous FH and the management of both heterozygous and homozygous FH in Morocco. Also, we have attempted to propose some strategies for an adequate management of FH in our country, taking into account the local specifications.

Comparative study on differential accumulation of PSP toxins between cockle (Acanthocardia tuberculatum) and sweet clam (Callista chione).

At the western Mediterranean coast of Morocco, the cockle (Acanthocardia tuberculatum) contained persistent high levels of paralytic shellfish toxins for several years, while other bivalve molluscs such as sweet clam (Callista chione) from the same vicinity were contaminated seasonally to a much lesser extent. In order to understand the causes of this prolonged contamination, a comparative study on PSP decontamination between sweet clam and cockle was conducted from November 2001 until June 2002. PSP toxicity was analysed by automated pre-column oxidation (Prechromatographic oxidation and LC-FD) in several organs of both species, namely digestive gland, foot, gill, mantle, muscle and siphon for sweet clams. The results showed that cockle sequester PSP toxins preferably in non-visceral organs (Foot, gill and mantle) contrary to sweet clam that sequester them in visceral tissues (digestive gland). The toxin profile of cockle organs indicated dominance of dcSTX, whereas sweet clam tissues contained especially C-toxins. Substantial differences in toxin profile between cockle and sweet clam, from the same area as well as from the composition of PSP toxin producer, Gymnodinium catenatum, confirm the bioconversion of PSP toxins in cockle.

Percutaneous treatment of coronary subclavian steal syndrome.

Coronary subclavian steal syndrome arises when a stenosis of the subclavian artery results in reduced antegrade or retrograde flow in an internal mammary artery with resultant coronary ischemia. This occurs in patients who have previously undergone surgical coronary revascularization utilizing an internal mammary artery graft. This syndrome can be successfully treated percutaneously with excellent immediate and long-term results.

Impact of restenosis and disease progression on clinical outcome after multivessel stenting in diabetic patients.

Clinical outcome after percutaneous coronary intervention (PCI) is significantly worse in diabetic patients in comparison to nondiabetic patients. The subset of diabetic patients in the ARTS trial treated with multivessel stenting had the lowest 1-year event-free survival. We examined our experience of multivessel PCI in diabetics to assess clinical outcome outside clinical trials and to determine if repeat revascularizations are the result of restenosis or the progression of nontreated disease. Between January 2000 and December 2001, we performed multivessel PCI in 99 diabetic patients. Our group was well matched with those in the ARTS trial, with mean age of 69 +/- 8 years, male sex 70%, hypertension 68%, hypercholesterolemia 51%, and mean LV ejection fraction 60%. The mean number of diseased segments treated was 2.8 +/- 0.9 and 56% of the patients had three-vessel disease. There were 2.3 +/- 0.6 stents implanted per patient. Target vessels included the LAD in 90%, LCx in 77%, and the RCA in 87% of cases. The in-hospital MACE rate was 8%, which included eight nonfatal MI but no deaths or repeat revascularizations. After a mean follow-up of 14 +/- 8 months, there were 4 deaths (4%), no further MIs, and 21 (21%) repeat revascularizations (2 CABG; 19 PCI), giving a 1-year event-free survival of 67%. There were 18 repeat revascularizations (2 CABG; 16 PCI) for restenosis, but in 9 of the 18 (50%) patients treatment was also required for progression of disease. Three further patients had PCI for symptomatic disease progression without restenosis. Thus, disease progression contributed to 57% of repeat revascularization procedures. The medium- and longer-term success of multivessel PCI in diabetic patients is limited principally by the need for repeat revascularization. However, it is important to realize that these revascularizations are performed not only for restenosis but also for disease progression in more than 50% of patients. Consequently, even if drug-eluting stent technology can eliminate restenosis, disease progression will continue to impact the clinical outcome of diabetic patients after PCI.