The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study.

Background The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates. Aim This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery. Methods The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured. Results The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L. Conclusions In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.

Purple, stiff lesions resembling varicose veins on lower limb: certainly consider Kaposi sarcoma.

Kaposi's sarcoma (KS) typically presents multiple cutaneous lesions of the lower extremities. Lesions can rarely mimic varicose veins without venous insufficiency, vascular or stasis ulcers. As the initial diagnosis of KS is generally determined clinically, a high index of suspicion and palpation of lesions are necessary for all patients with atypical presentations of varicose-like lesions of lower extremities. Tissue biopsy with histological analysis is essential for all uncertain lesions. This is a case of KS occurring in a 79-year-old man who presented with indurated vascular plaques resembling varicose veins on the right foot.

Is chronic obstructive pulmonary disease a risk factor for epistaxis after coronary artery bypass graft surgery?

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has customarily been associated with increased surgical morbidity and mortality rates after coronary artery bypass graft surgery (CABG). The aim of this study was to determine whether there is a relationship between epistaxis and COPD after CABG surgery. METHODS: There were 3 443 patients who consecutively underwent isolated CABG from January 2002 to March 2012. We retrospectively analysed the data of 27 patients (0.8%) with newly developed and serious spontaneous epistaxis, which required consultation with the Ear Nose and Throat (ENT) Department. The patients were divided into three groups according to severity of nasal bleeding. Twenty-one (77.7%) patients in the three groups had COPD. RESULTS: There were 19 males (70%) and eight females (30%). Their ages ranged between 52 and 72 years (mean 61 ± 5). Fifty-five per cent of the patients had hypertension and 78% had COPD. The overall duration of hospital stay was six to 11 days (mean 7.9 ± 1.1). Epistaxis was seen particularly on the fourth and seventh days postoperatively and 17 patients (63%) were treated with anterior, posterior, or anterior and posterior nasal packing (group 1). Nasal bleeding was controlled with electrocautery in six patients (22%) (group 2), and four (15%) were treated with surgical excision and blood transfusions (group 3). All patients (100%) had a good recovery with no mortality. CONCLUSION: The high coincidence between epistaxis and COPD made us wonder whether COPD may be a risk factor for epistaxis after CABG surgery. However, we could not find any direct causative link between COPD and epistaxis in patients who had undergone CABG. Epistaxis was more common in patients with COPD and it was more serious clinically in patients who had both COPD and hypertension.

Effects of topical hypothermia on postoperative inflammatory markers in patients undergoing coronary artery bypass surgery.

BACKGROUND: We aimed to examine the effects of topical hypothermia on inflammatory markers in patients undergoing coronary artery bypass surgery. METHODS: Fifty patients undergoing isolated coronary artery bypass surgery were included the study. They were randomised to two groups. Mild hypothermic cardiopulmonary bypass (28-32°C) was performed on both groups using standardised anaesthesiology and surgical techniques. Furthermore, topical cooling with 4°C saline was performed on patients in group I. We recorded peri-operative and intra-operative results of blood samples, pre-operative and postoperative outcomes of electrocardiography and echocardiography, diaphragm levels on X-ray, and the necessity of positive inotropic medication and intra-aortic balloon pump (IABP). RESULTS: Time-dependent changes in blood samples were compared between the two groups. The changes on complement 3 (C3) and TNF-α levels were more significant in group I than group II (p < 0.05 and p < 0.001, respectively). Spontaneous restoration rate of sinus rhythm was higher in group II than group I (80 vs 32%, p < 0.01). Atrial fibrillation was seen in six patients in group I and one patient in group II (p < 0.05). IABP was performed on four patients (16%) in group I (p < 0.05). Diaphragmatic paralysis was seen in seven patients in group I but not in group II (p < 0.01). Partial pericardiotomy rates were compared within the groups but there was no statistically significant difference (p > 0.05). One patient in group I died on the 18th postoperative day, but operative mortality rate was not statistically significant between the two groups (p > 0.05). CONCLUSIONS: Topical hypothermia had a negative impact on inflammatory markers and postoperative morbidities.

Autonomic functions in acrocyanosis assessed by heart rate variability.

OBJECTIVE: To evaluate the autonomic activity of patients with acrocyanosis by using heart rate variability indices. MATERIAL AND METHODS: The study group consisted of 24 patients with acrocyanosis and the control group contained 22 sex- and age-matched healthy subjects. All subjects underwent 24-hour Holter monitoring. Among the heart rate variability (HRV) parameters, time-domain and frequency-domain indices were analysed. RESULTS: The time-domain indices of HRV indicating global autonomic functions were found to be increased, and indices indicating parasympathetic activity showed a significant decrease in the patient group. Power-spectral analysis of HRV revealed that the low frequency and high frequency power were higher in the patient group than in controls. However, the ratio of Low Frequency/High Frequency was found to be lower in the patient group than in controls. CONCLUSION: In acrocyanosis, both sympathetic and parasympathetic systems seem to be disrupted. Therefore, we may conclude that acrocyanosis may be resulted of systemic autonomic imbalance rather than pure sympathetic over-activation. Also, these results suggest that acrocyanosis is not a localised disorder; on the contrary, it is associated with various abnormalities of the systemic autonomic nervous system.

Surgical repair of aneurysm of arteriovenous fistula in patients with chronic renal failure.

THE AIM OF THE STUDY: The aim of the study was to show the efficacy and results of aneurysm reconstruction that was developed for relieving the patients from pain and mass effects and to give an early hemodialysis option. MATERIAL AND METHODS: Medical records were retrospectively screened over a period of 17 years to identify patients diagnosed with and surgically treated for aneurysm of an AV fistula. Twenty-eight patients were included in this study. The mean average age was 44 ± 3 years (31-60). Seventeen (60.7%) patients were female. Twenty-two (78.5%) patients had hypertension and 9 (32.1%) patients had diabetes mellitus. Aneurysm was examined by using ultrasonography to reveal the flow dynamics. The aneurysm was resected and an appropriate sized graft was interposed under local anesthesia. The same vein was dissected and anastomosed over the graft in an end-to-side fashion. RESULTS: Mean aneurysm diameter was 40 ± 12 mm. All aneurysm tissues and thrombotic materials were removed from the surgical field. Mean graft length was 37 ± 11 mm. Three (10.7%) patients need surgical revision because of postoperative bleeding. Dermal necrosis occurred in 1 (3.5%) patient. Infection was noted in 1 (3.5%) patient. Vascular access was started from the reconstructed venous area 2 or 4 days later in all patients. The patency rate was 100% in three years. CONCLUSIONS: Surgical reconstruction of the arteriovenous fistula aneurysm can be safely performed in hemodialysis patients with low complication rates. It gives early vascular access with high patency rates. All patients are relieved from pain and distended mass effect.

Is cytoimmunological monitoring a safe follow-up method for heart transplantation patients?

THE AIM OF THE STUDY: The aim of the study is to show the effects of cytoimmunological monitoring and its role in the patient's follow-up period after heart transplantation. MATERIAL AND METHODS: Between 2002 and 2009, 8 patients underwent heart transplantation at Gulhane Military Medical Academy Hospital. Seven patients were male. The average age was 43 ± 12 years. Donor hearts were implanted orthotopically in all patients. The patients were then subjected to cytoimmunological monitoring and endomyocardial biopsy. 431 laboratory blood tests were carried out for all patients to analyze their cytoimmunological profiles and diagnose a possible infection or rejection. RESULTS: The total and average follow-up periods were 17.5 patient years and 30 ± 36 months (1-120 months), respectively. The first patient had two rejection episodes in 3 months. A viral infection was diagnosed in the third patient, who had painful muscle spasms in both lower limbs and the CD4/CD8 ratio was below 0.4. In the fourth patient, the CD4/CD8 ratio suddenly increased and a urinary infection was diagnosed. Only one patient passed away in the early period (less than 30 days). Four patients died because of an infection or hemodynamic deterioration within three months. CONCLUSIONS: Cytoimmunological monitoring is a simple and effective technique of evaluating the patient's immunological profile. It may provide an adjunctive laboratory test and may decrease the number of endomyocardial biopsies.

Comparison of results of autologous versus homologous blood transfusion in open-heart surgery.

BACKGROUND: The aim of this study was to determine a method to decrease the use of homologous blood during openheart surgery using a simple blood-conservation protocol. We removed autologous blood from the patient before bypass and used isovolumetric substitution. We present the results of this protocol on morbidity and mortality of surgery patients from two distinct time periods. METHODS: Patients from the two surgical phases were enrolled in this retrospective study in order to compare the outcomes using autologous or homologous blood in open-heart surgery. A total of 323 patients were included in the study. The autologous transfusion group (group 1) comprised 163 patients and the homologous transfusion group (group 2) 160 patients. In group 1, autologous bloods were prepared via a central venous catheter that was inserted into the right internal jugular vein in all patients, using the isovolumetric replacement technique. The primary outcome was postoperative In-hospital mortality and mortality at 30 days. Secondary outcomes included the length of stay in hospital and in intensive care unit (ICU), time for extubation, re-intubations, pulmonary infections, pneumothorax, pleural effusions, atrial fibrillation, other arrhythmias, renal disease, allergic reactions, mediastinitis and sternal dehiscence, need for inotropic support, and low cardiac-output syndrome (LCOS). RESULTS: The mean ages of patients in groups 1 and 2 were 64.2 ± 10.3 and 61.5 ± 11.6 years, respectively. Thirty-eight of the patients in group 1 and 30 in group 2 were female. There was no in-hospital or 30-day mortality in either group. The mean extubation time, and ICU and hospital stays were significantly shorter in group 1. Furthermore, postoperative drainage amounts were less in group 1. There were significantly fewer patients with postoperative pulmonary complications, pneumonia, atrial fibrillation and renal disease. The number of patients who needed postoperative inotropic support and those with low cardiac output was also significantly less in group 1. CONCLUSION: Autologous blood transfusion is a safe and effective method in carefully selected patients undergoing cardiac surgery. It not only prevents transfusion-related co-morbidities and complications but also enables early extubation time and shorter ICU and hospital stay. Furthermore, it reduces the cost of surgery.

Delayed chylopericardium as a rare complication after combined mitral valve and coronary artery bypass surgery.

Chylopericardium is a rare complication of cardiac surgery that is performed from a midline sternotomy. Here we present a case of a 61-year-old male patient with late-onset postoperative chylopericardium following combined coronary artery bypass grafting and mitral valve surgery, and the applied treatment modality.

The effects of perindopril on aortic elasticity and inflammatory markers in hypertensive patients.

BACKGROUND: Inflammation plays an important role in hypertension and in atherosclerosis. Inflammatory changes induced even in prehypertensive subjects can lead to increased arterial stiffness. The effects of perindopril on both inflammatory and aortic elasticity markers were tested in hypertensive patients. MATERIAL/METHODS: One hundred nine hypertensive patients not taking any antihypertensive therapy were included in the study. Aortic strain, aortic distensibility, aortic stiffness index, and inflammatory markers, including CRP, IL-1alpha IL-1beta, and TNF-alpha, were measured in all patients before and after twenty weeks of perindopril therapy. RESULTS: While aortic strain and distensibility showed statistically significant increases with perindopril therapy, the aortic stiffness index and inflammatory markers were found to decrease. CONCLUSIONS: Perindopril therapy resulted in an improvement in aortic elastic properties. There was also an attenuation of inflammatory status of the patients as reflected by lower inflammatory marker levels compared with pretreatment values.

Anticoagulation after coronary artery surgery in patients with polycythemia vera: report of two cases.

Polycythemia vera is a myeloproliferative disorder associated with the thromboembolic events. Normalization of the hematocrit and elevated platelet counts is obligatory to reduce the thrombotic risk of patients with PV. Therapeutic strategies include phlebotomy, myelosuppressive agents, and, more recently, interferon-alpha. In addition, appropriate antiplatelet therapy should be administered to prevent life-threatening complications and reducing the viscosity of the blood. Although aspirin is widely preferred in such patients, this monodrug therapy or combined with clopidogrel as an alternative approach might not be enough, especially after coronary artery surgery. Therefore, warfarin should be added to anticoagulant therapy. This short report describes the use of warfarin, associated with aspirin and clopidogrel as an anticoagulant regimen after coronary artery bypass surgery in two cases with polycythemia vera. We believe that a combination of warfarin with other oral antiplatelet agents may be more effective in preventing the coronary artery bypass graft thrombosis.

Combination sedoanalgesia with remifentanil and propofol versus remifentanil and midazolam for elective cardioversion after coronary artery bypass grafting.

Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. Elective cardioversion, a short but painful procedure, remains an option for patients who do not convert to sinus rhythm with medical therapy. Combinations of remifentanil (a potent analgesic with a short elimination time) with propofol (a hypnotic agent) or midazolam (a sedative agent) produce a synergistic interaction. This study was undertaken to compare these combinations in terms of effectiveness and pain relief when given as sedoanalgesia for elective cardioversion. In this prospective, randomized trial, 60 adult patients with postoperative AF after coronary artery bypass grafting were given a single dose of propofol 1 mg/kg combined with remifentanil 0.1 microg/kg (group 1), or midazolam 0.05 mg/kg combined with remifentanil 0.1 microg/kg (group 2). Cardiorespiratory parameters were monitored and recorded. Demographic data were similar (P>.05) and sufficient sedoanalgesia and successful cardioversion were achieved in both groups. Hemodynamic parameters revealed no significant differences between groups (P>.05); however, induction time, time to eye opening, recuperation time, and time to full recovery of psychomotor function were faster in group 1 than in group 2 (P<.05). The remifentanil/propofol combination provided sufficient analgesia, satisfactory hemodynamic stability, and mild respiratory depression, along with faster recovery and discharge times from the intensive care unit.

Do N-acetylcystein, beta-glucan, and coenzyme Q10 mollify myocardial ischemia-reperfusion injury?

BACKGROUND: N-acetylcysteine, beta-glucan, and coenzyme Q10 have been shown to have antioxidant and anti-inflammatory effects on reperfusion injury. The aim of our study was to determine and evaluate the effects of these agents on myocardial ischemia-reperfusion injury. METHODS: Forty-four New Zealand white rabbits, all female, weighing 2.4 to 4.1 kg (mean, 3.6 kg) were used in the study. Four study groups of 11 animals were arranged by randomization. The groups were the control group (group C), a group premedicated with coenzyme Q10 (group Q), a group premedicated with beta-glucan (group betaT), and a group premedicated with N-acetylcysteine (group N). After exploration of the heart, a basal myocardial biopsy was taken from the anteroapical left ventricle, and the first blood sampling was done before ischemia. For the ischemia-reperfusion experiments, the major left anterior descending artery was occluded after baseline measurements. After a 45-minute transient ischemic period, the heart was perfused for 120 minutes. After perfusion, the second myocardial biopsy was taken from the anteroapical left ventricle, and the second blood sampling was done. Blood and tissue analysis were performed and evaluated statistically. RESULTS: Baseline and reperfusion levels of glutathione peroxidase, superoxide dismutase, malonyldialdehyde, and nitric oxide changed significantly. While malonyldialdehyde levels increased in group C, they decreased in the other study groups (P =.001). The increases in glutathione peroxidase and superoxide dismutase levels were significant in all groups except group C (P =.0001 and P <.05, respectively). Levels of nitric oxide were found to be decreased in group C, whereas they increased in the other groups (P =.001). CONCLUSION: Antioxidant medication may help in lowering the risk of myocardial ischemia-reperfusion injury. All the medications in our study are shown to have effective roles in preventing ischemia-reperfusion injury to some extent through their antioxidant properties.