Feasibility of Short-Term Use of Ivabradine in Critical Ill Patients Who Have Atrial Fibrillation and Tachycardia.

Background: Ivabradine is approved for heart rate reduction in patients with stable symptomatic heart failure (HF). The United States Food and Drug Administration and Taiwan Central Health Insurance Agency approved the use of ivabradine for patients with chronic stable HF with sinus rhythm, but it has not yet been approved for patients with acute decompensated HF or with atrial fibrillation (AF). Objectives: To investigate whether short-term ivabradine use is feasible in critically ill patients with AF and rapid ventricular response (RVR). Methods: This study retrospectively analyzed 23 patients admitted to an intensive care unit with acute HF and AF-RVR who received ivabradine. All patients initially received a slow IV of amiodarone. Other medications for HF were prescribed according to current HF guidelines. The time taken for ivabradine to reduce HR to 80 beats per minute, referred to as "Time to 80," was measured in each patient. Results: Overall, 69.6 % (16/23) of the patients had New York Heart Association functional class IV HF. In addition, 60.9% (14/23) of the patients required endotracheal intubation and ventilatory support, with more than half receiving vasopressor treatment to manage hypotension. Five patients died during the study period. The surviving patients had a significantly shorter "Time to 80" compared to those who did not survive (p = 0.037). Conclusions: Adding ivabradine to standard treatment might be feasible for critically ill patients with AF and tachycardia. The finding that surviving patients had a shorter "Time to 80" duration than those who did not survive may have clinical implications. However, further investigations are needed to assess its clinical utility.

2018 TSOC guideline focused update on diagnosis and treatment of pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension.

Myocardial Tissue Doppler Imaging Detects Right Ventricular Dysfunction after Percutaneous Angioplasty of Dysfunctional Hemodialysis Access in Uremic Patients.

BACKGROUND: Right ventricular dysfunction has been observed in uremic patients receiving percutaneous transluminal angioplasty (PTA). This prospective study focuses on the impact of tissue Doppler imaging echocardiographic parameters on assessing right ventricle function in uremic patients post PTA of dysfunctional hemodialysis access. METHODS: Sixty uremic patients were divided into two groups by angiographic findings: an occlusive group (26 patients) and a stenotic group (34 patients). All uremic patients underwent routine echocardiography with tissue Doppler imaging both before and immediately following PTA to assess the right ventricular (RV) function and pulmonary artery systolic pressure (PASP). The right ventricular (RV) myocardial performance index (MPI) was obtained during tissue Doppler imaging over the lateral tricuspid annulus. The M index was measured and defined as the peak early diastolic mitral inflow velocity divided by the RV MPI. The RV MPI, RV isovolumic relaxation time (IVRT) and M-index were used to evaluate RV function post-PTA. RESULTS: Immediately following PTA, PASP (31.6 ± 11.3 mmHg versus 42.6 ± 12.0 mmHg, p = 0.001), RV MPI (0.46 ± 0.08 versus 0.62 ± 0.13, p < 0.001) and IVRT (75.1 ± 12.9 versus 98.4 ± 27.7 ms, p < 0.001) increased significantly in the occlusive group. However, PASP and RV function did not change significantly in the stenotic group. In 42.3% patients from the occlusive group, the M-index fell below 112 and RV MPI rose above 0.55 post-PTA; this occurred in only 8.8% of the stenotic group. CONCLUSIONS: This prospective study demonstrated that there was a higher incidence of RV dysfunction in uremic patients with elevated PASP with totally occluded hemodialysis access than those with stenotic access post-PTA. KEY WORDS: Myocardial performance index; Percutaneous transluminal angioplasty; Pulmonary hypertension; Tissue Doppler image; Uremic.

2014 Guidelines of Taiwan Society of Cardiology (TSOC) for the Management of Pulmonary Arterial Hypertension.

UNLABELLED: Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition, defined as a mean pulmonary arterial pressure exceeding 25 mmHg at rest. According to the recent classifications, it is grouped into pulmonary arterial hypertension (PAH), heart-related, lung-related, thromboembolic, and miscellaneous PH. In the past two decades, tremendous advances have occurred in the field of PH. These include (1) development of clinical diagnostic algorithm and a monitoring strategy dedicated to PAH, (2) defining strong rationales for screening at-risk populations, (3) advent of pulmonary specific drugs which makes PAH manageable, (4) recognition of needs of having proper strategy of combining existing pulmonary specific drugs, and/or potential novel drugs, (5) pursuit of clinical trials with optimal surrogate endpoints and study durations, (6) recognition of critical roles of PH/right ventricular function, as well as interdependence of ventricles in different conditions, especially those with various phenotypes of heart failure, and (7) for rare diseases, putting equal importance on carefully designed observation studies, various registries, etc., besides double blind randomized studies. In addition, ongoing basic and clinical research has led to further understanding of relevant physiology, pathophysiology, epidemiology and genetics of PH/PAH. This guidelines from the working group of Pulmonary Hypertension of the Taiwan Society of Cardiology is to provide updated guidelines based on the most recent international guidelines as well as Taiwan's domestic research on PH. The guidelines are mainly for the management of PAH (Group 1) ; however the majority of content can be helpful for managing other types of PH. KEY WORDS: Pulmonary arterial hypertension; Taiwan guidelines.

Delivery of Superoxide Dismutase 3 Gene with Baculoviruses Inhibits TNF-α Triggers Vascular Smooth Muscle Cell Proliferation and Inflammation.

BACKGROUND: Superoxide dismutase 3 (SOD3), recognized as a potent free radical scavenger, exhibits antioxidant, anti-inflammatory, and anti-angiogenic properties. However, the molecular mechanisms underlying the protective effects of SOD3 on the vascular smooth muscle cell during atherosclerosis remain unclear. OBJECTIVES: This study aimed to investigate the efficacy of the baculovirus expressing SOD3 gene delivery to vascular smooth muscle cells (VSMCs) and investigate whether the overexpression of SOD3 mitigates cell proliferation and migration induced by tumor necrosis factor-α (TNF-α). METHODS: A baculoviral vector containing SOD3 cDNA (vAcMBac-CMV-IE-SOD3) was constructed and utilized to deliver the SOD3 gene into primary rat VSMCs. Cells were stimulated with recombinant TNF-α, and then cell proliferation and migration were evaluated using the bromodeoxyuridine and wound healing assay. Western blot was used to verify the expression of cell cycle regulators, cellular mediators, and proliferative biomarkers. Zymography, immunofluorescence staining, and ELISA assay were conducted to assess the expression levels of matrix metalloproteinases. RESULTS: The results demonstrated efficient and non-cytotoxic transduction of vAcMBac- CMV-IE-SOD3 in VSMCs. SOD3 overexpression significantly suppressed cell proliferation and motility by inhibiting cell cycle regulators in TNF-α-induced cells. TNF-α elevated protein levels of phospho-ERK and phospho-Akt were reduced markedly by SOD3-overexpressing. Additionally, SOD3 overexpression attenuated the elevation of MMP-2 and MMP-9, the pro-inflammatory and proliferative biomarkers. Overall, the SOD3 gene delivery exhibited potent anti-proliferation and anti-inflammation effects on TNF-α-induced VSMCs. CONCLUSION: An effective SOD3 gene delivery using a recombinant baculoviral vector has been successfully established and is useful for overexpression of the SOD gene family. This approach provides new therapeutic strategies in gene therapy against atherosclerosis.

The Effect of Intensified Low Density Lipoprotein Cholesterol Reduction on Recurrent Myocardial Infarction and Cardiovascular Mortality.

BACKGROUND: Lipid-lowering therapy plays an important role in preventing the recurrence of cardiovascular events in patients after acute myocardial infarction (AMI). This study aimed to assess the effect of intensified low density lipoprotein cholesterol (LDL-C) reduction on recurrent myocardial infarction and cardiovascular mortality in patients after AMI. METHOD: The 562 enrolled AMI patients (84.2% male) were divided into two groups according to 3-month LDL-C decrease percentage equal to or more than 40% (n = 165) and less than 40% (n = 397). To evaluate the long-term efficacy of LDL-C reduction, the 5-year outcomes were collected, including time to the first occurrence of myocardial infarction and time to cardiovascular death. RESULTS: The baseline characteristics and complication rates were not different between the two study groups. The patients with 3-month LDL-C decrease ≥ 40% had higher baseline LDL-C and lower 3-month, 1-year, 2-year, 3-year, 4-year and 5-year LDL-C than the patients with 3-month LDL-C decrease < 40%. In Kaplan-Meier analyses, those patients with 3-month LDL-C decrease ≥ 40% had a higher rate of freedom from myocardial infarction (p = 0.006) and survival rate (p = 0.02) at 5-year follow-up. The 3-month LDL-C < 40% parameter was significantly related to cardiovascular death (HR: 9.62, 95% CI 1.18-78.62, p < 0.04). CONCLUSIONS: After acute myocardial infarction, 3-month LDL-C decrease < 40% was identified to be a significant risk factor for predicting 5-year cardiovascular death. The patients with 3-month LDL-C decrease ≥ 40% had a higher rate of freedom from myocardial infarction and lower cardiovascular mortality, even though these patients had higher baseline LDL-C value. KEY WORDS: Acute myocardial infarction; Cardiovascular death; Low-density lipoprotein cholesterol; Mortality; Statin.

Body Mass Index and Outcome of Acute Myocardial Infarction - Is There an Obesity Paradox?

BACKGROUND: Although there have been some studies focusing on the relationship between body mass index (BMI), coronary artery disease (CAD) and acute coronary syndrome, the clinical effects of BMI on outcomes after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) are not well known in a Taiwanese population. METHODS: From January 2005 to December 2011, 1298 AMI patients who received PCI were enrolled from a single center in Taiwan. The patients were divided into 4 groups according to their BMI: underweight (BMI < 18.5 kg/m(2)); normal weight (18.5 ≤ BMI < 24 kg/m(2)); overweight (24 ≤ BMI < 27 kg/m(2)) and obese (BMI ≥ 27). All patients had been followed up for at least 12 months, and 30-day and 5-year all-cause and cardiovascular-cause mortality were compared among the study groups. RESULTS: The patients in the underweight group had a lower 30-day survival rate than the other 3 groups, and the underweight and normal weight patients had a lower 5-year survival rate than the overweight and obese patients. The multivariate regression analysis showed that Killip class ≥ 2, non-use of statin, older age, hemoglobin < 12 g/dl and chronic kidney disease, but not BMI, are independent predictors of all-cause mortality. CONCLUSIONS: In this present study, the major factors affecting long-term survival are lack of using statin and older age, but not obese paradox. KEY WORDS: Acute myocardial infarction; Mortality; Obesity; Percutaneous coronary intervention; Survival.

Moderate glucose control results in less negative nitrogen balances in medical intensive care unit patients: a randomized, controlled study.

INTRODUCTION: Hyperglycemia and protein loss are common in critically ill patients. Insulin can be used to lower blood glucose and inhibit proteolysis. The impact of moderate insulin therapy on protein metabolism in critically ill patients has not been evaluated. We compared urinary nitrogen excretion, nitrogen balance, serum albumin concentrations, prealbumin concentrations, and clinical outcomes between patients receiving moderate insulin therapy (MIT) and conventional insulin therapy (CIT) in a medical ICU. METHODS: Patients were randomly divided into groups and treated with MIT (glucose target 120 to 140 mg/dl) or CIT (glucose target 180 to 200 mg/dl). Calories and protein intake were recorded each day. On days 3, 7 and 14, the 24-hour urinary nitrogen excretion, nitrogen balance, and serum albumin and prealbumin concentrations were measured. Clinical outcomes data were collected. RESULTS: A total of 112 medical ICU patients were included, with 55 patients randomized to the MIT group and 57 patients randomized to the CIT group. Patients treated with MIT showed a trend towards increased nitrogen balance (P = 0.070), significantly lower urinary nitrogen excretion (P = 0.027), and higher serum albumin (P = 0.047) and prealbumin (P = 0.001) concentrations than patients treated with CIT. The differences between the two groups were most significant on day 3, when all factors showed significant differences (P < 0.05). CONCLUSIONS: Moderate glucose control results in less negative nitrogen balances in medical ICU patients. Differences are more significant in the early stages compared with the late stages of critical illness. TRIAL REGISTRATION: ClinicalTrial.Gov NCT 01227148.

Arsenic, vinyl chloride, viral hepatitis, and hepatic angiosarcoma: a hospital-based study and review of literature in Taiwan.

BACKGROUND: Hepatic angiosarcoma (HAS) is a rare type of liver cancer that is often fatal, and arsenic and vinyl chloride monomer (VCM) are two major causal agents. Whereas Taiwan is an endemic area of liver cancer, epidemiologic data on HAS are limited. We reviewed the cases observed at a teaching hospital to evaluate the roles of VCM, arsenic, and viral hepatitis in the occurrence of HAS. METHODS: We reviewed the medical records of patients with pathological proof of HAS from January 2000 to August 2010 at a teaching hospital which is adjacent to the major VCM processing area in Taiwan and nearby an endemic area of arsenic exposure from drinking water. We also conducted a literature review and included all patients of HAS reported in Taiwan. RESULTS: Six male and three female cases aged from 56 to 83 years (64.6 ± 8.2 years) were identified at the hospital. The differences in clinical features between men and women were not statistically significant. None of them had exposure to VCM or arsenic in drinking water. Two had evidence of hepatitis C infection, but none had evidence of hepatitis B infection. Five male and four female cases aged 30 to 82 years (58.6 ± 15.5 years) were identified in the literature, including two with arsenic exposure and one with chronic hepatitis B infection. CONCLUSIONS: HAS is rare in Taiwan, and we found no evidence supporting a major role of VCM, arsenic in drinking water, or viral hepatitis in its occurrence.

l -Arginine Can Enhance the Beneficial Effect of Losartan in Patients with Chronic Aortic Regurgitation and Isolated Systolic Hypertension.

Information about the effects of angiotensin II receptor blocker (ARB) therapy on the hemodynamic and cardiac structure in patients with chronic aortic regurgitation (CAR) and isolated systolic hypertension (ISH) is limited. This study planned to test the hypothesis that l -arginine could further enhance the beneficial effect of an ARB, losartan, and provide a favorable effect on the natural history of CAR and ISH. Sixty patients with CAR and ISH were enrolled in a randomized, double-blind trial comparing hemodynamic and ultrasonic change in two treatment arms: losartan + l -arginine and losartan-only treated groups. Serial echocardiographic and hemodynamic studies were evaluated before and after treatment. Both groups had a significant reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP), left ventricular end-diastolic volume index (LVEDVI), LV end-systolic volume index (LVESVI), LV mass index (LVMI), and LV mean wall stress after 6- and 12-month treatment ( p <0.01 in all comparisons). Both groups had a significant increase in LV ejection fraction and exercise duration after 6- and 12-month treatment ( p < 0.01 in all comparisons). Using multivariate linear regression analysis, only losartan + l -arginine therapy achieved a significantly lower LVESVI (38.89 ± 0.23 mL/m 2 ), LVEDVI (102.3 ± 0.3 mL/m 2 ), LVMI (107.6 ± 0.3 g/m 2 ), SBP (123.5 ± 1.0 mm Hg), and greater exercise duration (7.38 ± 0.02 minutes) than those of the losartan-only treated groups ( p <0.01 in all comparisons). These findings suggest that early co-administrative strategy provides a beneficial approach to favorably influence the natural history of CAR.

Right ventricular infarction and tissue Doppler imaging ­ insights from acute inferior myocardial infarction after primary coronary intervention ­.

BACKGROUND: Tissue Doppler imaging (TDI) data for acute inferior myocardial infarction (MI) patients who have received primary percutaneous coronary intervention (PCI) are sparse. METHODS AND RESULTS: One hundred and sixty-five patients received primary PCI for acute inferior MI were enrolled. Right ventricular infarction (RVI) was defined as a culprit lesion proximal to the right ventricular branch of right coronary artery (RCA). Echocardiograms and TDI were obtained within 6 h after primary PCI. The prevalence of multi-vessel disease in the RCA-P culprit group (50%) was higher than that in other groups (39% of RCA-D culprit, 43% of left circumflex artery (LCX) culprit). The myocardial performance index (MPI) of the lateral tricuspid annulus provides discriminatory power for identifying RVI, whereas systolic velocity (Sm) of the lateral tricuspid annulus does not. Lateral mitral annular MPI divided by the lateral tricuspid annular MPI is a reliable index for identifying a culprit lesion (>1.06 predicts culprit over LCX; <0.96 predicts culprit over RCA-P and RVI). Kaplan-Meier survival curves revealed that late cardiovascular events were more likely in RVI patients. However, multivariate Cox proportional hazards analysis revealed that the most important factor in hard events and all cardiovascular events was multivessel disease. CONCLUSIONS: TDI is useful for identifying RVI and culprit lesions in inferior MI patients received primary PCI. RVI itself isn't associated with 1-year hard events and all cardiovascular events.

Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.

OBJECTIVE: To determine whether medical intensive care unit (ICU) patients receiving nasoduodenal (ND) feedings achieve optimal nutritional support and better clinical outcomes compared with patients receiving nasogastric (NG) feedings. DESIGN: A prospective, randomized, clinical study. SETTING: Medical ICU of a university-affiliated tertiary medical center. PATIENTS: One hundred twenty-one medical ICU patients required enteral feeding. INTERVENTIONS: Patients were randomized to receive enteral feeding. One group received ND feedings and the other group received NG feedings. All patients followed the same protocol. MEASUREMENTS AND MAIN RESULTS: The primary outcome of optimal nutritional support was assessed by measurement of time to goal tube feed rate and daily calorie and protein intake. Secondary clinical outcomes included number of ICU, hospital and ventilator days, number of the days in the study, blood-glucose levels, incidence of vomiting, diarrhea, gastrointestinal bleeding, tube replaced, tube clogged, fever, bacteremia, and ventilator-associated pneumonia (VAP), and mortality rate. Results showed that the ND group had a higher average daily calorie and protein intake compared with NG group and achieved nutritional goals earlier. In terms of clinical outcomes, patients in the ND group had a lower rate of vomiting and VAP. The other clinical outcomes such as number of ICU days, hospital days, ventilator days, blood-glucose level, tube replaced or clogged, diarrhea, gastrointestinal bleeding, fever, bacteremia, and mortality rate were not significantly different between two groups. CONCLUSIONS: Patients who received ND feedings achieved nutritional goals earlier than those who received NG feeding. ND feeding group also has a lower rate of vomiting and VAP in the medical ICU setting.

Inhibition of Neointima Hyperplasia, Inflammation, and Reactive Oxygen Species in Balloon-Injured Arteries by HVJ Envelope Vector-Mediated Delivery of Superoxide Dismutase Gene.

Extracellular superoxide dismutase (EC-SOD) has been implicated in regulation of vascular function but its underlying molecular mechanism is largely unknown. These two-step experiments investigate whether hemagglutinating virus of Japan envelope (HVJ-E) vector-mediated EC-SOD gene delivery might protect against neointima formation, vascular inflammation, and reactive oxygen species (ROS) generation, and also explore cell growth signaling pathways. The first in-vitro experiment was performed to assess the transfection efficacy and safety of HVJ-E compared to lipofectamine®. Results revealed that HVJ-E has higher transfection efficiency and lower cytotoxicity than those of lipofectamine®. Another in-vivo study initially used balloon denudation to rat carotid artery, then delivered EC-SOD cDNA through the vector of HVJ-E. Arterial section with H&E staining from the animals 14 days after balloon injury showed a significant reduction of intima-to-media area ratio in EC-SOD transfected arteries when compared with control (empty vector-transfected arteries) (p < 0.05). Arterial tissue with EC-SOD gene delivery also exhibited lower levels of ROS, as assessed by fluorescent microphotography with dihydroethidium staining. Quantitative RT-PCR revealed that EC-SOD gene delivery significantly diminished mRNA expression of tumor necrosis factor (TNF)-α and interleukin (IL)-1ß (p < 0.05 in all comparisons). An immunoblotting assay from vascular smooth muscle cell (VSMC) cultures showed that the EC-SOD transfected group attenuated the activation of MEK1/2, ERK1/2, and Akt signaling significantly. In conclusion, EC-SOD overexpression by HVJ-E vector inhibits neointima hyperplasia, inflammation, and ROS level triggered by balloon injury. The modulation of cell growth-signaling pathways by EC-SOD in VSMCs might play an important role in these inhibitory effects.

The initial response to inhaled nitric oxide treatment for intensive care unit patients with acute respiratory distress syndrome.

BACKGROUND: Inhaled nitric oxide (INO) can improve hypoxemia and reduce pulmonary hypertension, but there is a wide range of response to INO. OBJECTIVES: The aim of this study was to evaluate the effect of different INO concentrations in acute respiratory distress syndrome (ARDS) patients. METHODS: Thirty-two adult ARDS patients who were supported by mechanical ventilator were included. INO was given at a concentration of 1, 5, 10, 20 and 40 ppm, sequentially. Arterial blood gas and mean pulmonary artery pressure (MPAP) were measured 30 min after INO concentrations changed. RESULTS: There was a significant increase in PaO(2)/FiO(2) (p < 0.0001) and a decrease in pulmonary vascular resistance index and MPAP (p < 0.0001) after INO use. INO concentrations required for improving oxygenation were in the range of 1-20 ppm, whereas concentrations required for decreasing MPAP were in the range of 1-40 ppm. PaO(2)/FiO(2) worsened when the INO dose was adjusted above 20 ppm. Sixty-nine percent of ARDS patients were responders; 31% of them were nonresponders. Among responders, 64% of patients responded at 1 ppm, 36% at 5 ppm. CONCLUSIONS: The optimal doses for improving oxygenation and reducing PAP differ. The maximum PaO(2)/FiO(2) was observed at a lower INO concentration than that required for the minimal MPAP. There was no further improvement in PaO(2)/FiO(2) when the INO dose was adjusted above 20 ppm. Higher doses of INO treatment worsened oxygenation.

Idiopathic Pulmonary Arterial Hypertension Was Diagnosed Initially by the Computed Tomographic Angiogram.

Idiopathic pulmonary arterial hypertension (IPAH) is a rare and progressive disease with non-specific signs and symptoms. A 50-year-old woman with IPAH presented to the emergency department (ED) with a complaint of episodic dyspnea that had persisted for the previous two months. Based on the fi ndings of the initial chest computed tomographic angiography conducted in the ED, we suspected pulmonary hypertension. IPAH was eventually confi rmed following a series of investigations, including right heart catheterization. The history of this interesting case is reported with a review of the relevant literature.

Multidetector row computed tomography can identify and characterize the occlusive culprit lesions in patients early (within 24 hours) after acute myocardial infarction.

BACKGROUND: The reliable noninvasive assessment of occluded disrupted plaques and thromboses in culprit vessels could constitute an important step forward in risk stratification of patients early after acute myocardial infarction (AMI). However, noninvasive identification of patency of culprit vessels remains a challenging issue. This prospective study was designed to identify the occluded culprit vessels by multidetector row computed tomography (MDCT) and to compare the stenotic and occlusive culprit lesions by MDCT in patients early (within 24 hours) after AMI. METHODS: We enrolled 62 patients with first Q-wave AMI (54 males). Multidetector row computed tomography was performed 16.5 +/- 7.1 hours after the onset of chest pain without any complication. Coronary angiography was done within 6 hours after MDCT. Patients were divided into 2 groups according to angiographic findings: stenotic group (35 patients) and occluded group (27 patients). The following MDCT data were collected: luminal artery stenosis, remodeling index, plaque burden, and lesion attenuation. RESULTS: Compared to coronary angiography, MDCT detected occluded culprit vessels with sensitivity, specificity, negative predict value, and positive predict value of 92.6%, 88.6%, 93.9%, and 86.2%, respectively. Compared with the stenotic group, culprit lesions in the occlusive group had significantly longer length (18.9 +/- 9.7 vs 11.9 +/- 6.2 mm; P = .024) and higher MDCT lesion attenuation (38.8 +/- 15.6 vs 29.2 +/- 12.9 Hounsfield unit; P = .008). Multidetector row computed tomography attenuation was negatively correlated with thrombolysis in myocardial infarction flow (Spearman rho = -0.46; P < .001). CONCLUSIONS: Multidetector row computed tomography could accurately and safely identify occluded culprit lesions in patients early after AMI, providing important information to aid in risk stratification.

Do people from Taiwan have higher heavy metal levels than those from Western countries?

INTRODUCTION: This study investigated whether heavy metal levels were higher in people from Taiwan as compared to those from Western countries. METHODS: We measured the level of heavy metals (lead, mercury, arsenic and cadmium) in the blood of 40 apparently healthy adults. Since mercury does not respond to ethylenediaminetetraacetic acid (EDTA) infusion, only urine lead, arsenic and cadmium levels were determined by applying the body burden concept after calcium disodium EDTA infusion. These three heavy metals were extracted from daily urine samples for three consecutive days. RESULTS: The mean blood lead, mercury and cadmium levels of the Taiwanese individuals (24.46 ± 9.69 µg/L, 9.64 ± 6.98 µg/L and 0.73 ± 0.27 µg/L, respectively) were greater than those of the Americans. The Taiwanese also had greater blood mercury and cadmium levels than the Germans. The first-day urine lead, arsenic and cadmium levels were 77.9%, 33.1% and 62.4%, respectively, of the total lead, arsenic and cadmium excretion during the three days. This indicates that the first-day urine lead and cadmium excretion represented most (> 60%) of the lead and cadmium excretion in those three days. CONCLUSION: This study demonstrated that the Taiwanese population has higher blood mercury and cadmium levels than Western populations. To study the urine lead and cadmium body burden of patients, detection of first-day, rather than three-day, urine lead and cadmium levels can be done, as the former yields results that are fairly representative, and is more time- and cost-effective.

Comparison of the diuretic effect of furosemide mixed with human albumin or fresh frozen plasma for patients with hypoalbuminemia in the intensive care unit.

BACKGROUND: Diuretics are commonly used in the intensive care unit (ICU) for patients with fluid over-loading. Hypoalbuminemia is a major cause of diuretic resistance. Albumin mixed with furosemide can promote diuresis and sodium excretion in patients with hypoalbuminemia. The purpose of this study is to compare the diuretic effect of furosemide (FU) mixed with human albumin (HA) or fresh frozen plasma (FFP) in ICU patients with hy-poalbuminemia. METHODS: Patients with fluid overloading and hypoalbuminemia who needed diuretic treatment were enrolled and were divided into 2 groups: the first group having clearance of creatinine (CCr) >20 ml/min, and the second group having CCr < or = 20 ml/min. FU (60 mg) mixed with HA (HA group), 60 mg FU mixed with FFP (FFP group) and water (placebo group) were given intravenously to these patients for 60 minutes in random order on the first, third and fifth day. After drug administration, 8-hour urine was collected, and urine amount and urinary sodium excretion were checked. RESULTS: Both the HA group and the FFP group had significantly higher urinary volume and sodium excretion than the placebo group in the patients with CCr >20 ml/min or CCr < or = 20 ml/min (p < 0.01). In the patients with CCr >20 ml/min, there was no difference in the amount of urine excretion and cumulative urinary sodium excretion between the HA group and FFP group. In the patients with CCr < or =ml;20 ml/min, the HA group had a significantly higher urine output and urinary sodium excretion than the FFP group (p < 0.05). CONCLUSIONS: In ICU patients, 60 mg FU mixed with HA or FFP has a similar diuretic effect in patients with CCr >20 ml/min. FFP is an effective alternative choice for improving diuresis for ICU patients with hypoalbuminemia. In patients with CCr < or = 20 ml/min, albumin mixed with 60 mg FU has a superior diuretic effect compared with FFP mixed with FU.

Further evidence of the usefulness of Acute Physiology and Chronic Health Evaluation II scoring system in acute paraquat poisoning.

OBJECTIVE AND METHOD: We have previously successfully applied the Acute Physiology and Chronic Health Evaluation (APACHE) II system to assess the severity of patients with acute paraquat poisoning, and this article investigates further evidence of the usefulness of APACHE II system in predicting the in-hospital mortality of 64 patients with acute paraquat poisoning over a period of 12 years. The predictive factors including APACHE II score, plasma paraquat concentration, severity index of paraquat poisoning (SIPP), and estimated ingestion dosage of paraquat for evaluating the outcome in paraquat-poisoned patients were assessed. RESULTS: Overall mortality was 71.9%: 46 out of 64 patients died. Non-survivors (n = 46) had a higher APACHE II score (23.3 +/- 12.7) than survivors (n = 18) (6.1 +/- 4.2) (p < 0.001). The plasma paraquat concentration, SIPP, and estimated ingestion dosage of paraquat were significantly higher in non-survivors than in survivors (p < 0.05, in all comparisons). By multiple logistic regression analysis, only the APACHE II score and peak data of blood sugar in 24 h after admission were capable of predicting in-hospital mortality. By using the area under receiver operating characteristic curves (AURC), the APACHE II system yielded better discriminative power (AURC = 0.893) than SIPP (AURC = 0.674), plasma paraquat concentration (AURC = 0.676), and estimated ingestion dosage of paraquat (AURC = 0.673). An APACHE II score greater than 13 predicted in-hospital mortality with 67% sensitivity and 94% specificity. CONCLUSIONS: The APACHE II score is a simple, reproducible, and practical tool for evaluating the severity of acute paraquat poisoning.

Role of shortened QTc dispersion in in-hospital cardiac events in patients undergoing percutaneous coronary intervention for acute coronary syndrome.

BACKGROUND: QT dispersion (QTD) refers to the difference between maximal and minimal QT values on the electrocardiogram (ECG). QTD values are calculated and corrected with Bazett's formula (corrected QTD = QTcD = QTD/square root of RR). QTcD increases in patients with acute coronary syndrome (ACS). Recovery of increased QTcD (shortened QTcD) develops after successful revascularization, but prolonged QTcD occurs in certain patients. The aim of this study is to ascertain the clinical significance between shortened and prolonged QTcD groups after percutaneous coronary intervention (PCI). METHODS: We retrospectively enrolled 128 patients with ACS who had received PCI. The values of QTcD were measured manually on 12-lead standard ECGs obtained within 3 days before and after PCI (pre-PCI QTcD and post-PCI QTcD). All the patients were divided into 2 groups. The shortened QTcD group was defined as those patients with a decrease in QTcD after PCI and the prolonged QTcD group as those with an increase in QTcD after PCI. The underlying diseases, various clinical classifications and some prognostic factors were taken into comparison and statistical analysis between these 2 groups. RESULTS: The shortened QTcD group showed a significantly higher rate of in-hospital cardiac death (13% vs. 0%, p = 0.006) and a greater pre-PCI QTcD (100.8 +/- 39.5 vs. 61.3 +/- 24.1 ms, p < 0.001) than the prolonged QTcD group. There was a significantly greater pre-PCI QTcD in patients with cardiac death than those without cardiac death (111.6 +/- 38.3 vs. 83.3 +/- 38.3ms, p = 0.027). Furthermore, the patients with in-hospital cardiac death presented with a significantly more frequent occurrence of in-hospital ventricular arrhythmia, compared with those without cardiac death (30.0% vs. 4.0%, p = 0.014). CONCLUSION: Among the patients with ACS undergoing PCI, directly divided into shortened and prolonged QTcD groups regardless of initial pre-PCI QTcD, the shortened QTcD group showed a higher occurrence of in-hospital cardiac death and a greater pre-PCI QTcD. Shortened QTcD might be 1 risk factor for in-hospital cardiac death.