Prognosis and risk factors of nerve injuries in displaced pediatric supracondylar humerus fractures.

BACKGROUND: Supracondylar humerus (SCH) fractures are serious injuries due to the neighborhood of critical neural and vascular structures. One of the most devastating complications of SCH fractures is neurological damage, since it may cause permanent disability. The aim of this study is to categorize neurological complications, to report long-term functional outcomes, and to determine risk factors associated with childhood SCH fractures. METHODS: The records of 375 children were reviewed retrospectively. Data about amount and direction of displacement, the shape of the fracture, age at the time of fracture, gender, time from impaction to surgery, time of surgery, type of neurological injury, and recovery time were recorded. RESULTS: Neurological complications were seen in 37 (9.85%) children. Thirteen (35.1%) of the children had an iatrogenic nerve injury. All iatrogenic injuries were fully recovered in this study. However, 2 children who had combined neurological injury of radial, ulnar, and median nerves did not recover. Nearly 95% of all children who had neurological injury recovered fully. An anterior long and sharp bone fragment (spike) was observed in most of the children with neurological injury, and this spike was seen in 14 (58.3%) patients who had a trauma-related injury (n = 24). CONCLUSION: The prognosis of these nerve injuries is excellent, especially the iatrogenic ones. A long and sharp bone fragment (spike) may be responsible for nerve injuries in some children. Surgical exploration is not necessary after an iatrogenic nerve injury when there is no neurotmesis. Patience and care are utmost needed to handle neurological complications.

Turkish version of the Johns Hopkins Restless Legs Syndrome Quality of Life Questionnaire (RLS-QoL): validity and reliability study.

BACKGROUND AND PURPOSE: Restless legs syndrome (RLS), as well as problems secondary to RLS, may worsen the quality of life. Our aim was to modify the Restless Legs Syndrome Quality of Life (RLS-QoL) questionnaire advanced by Abetz (Health Qual Life Outcomes 3:79, 2005) and to analyse the validity and reliability of the questionnaire. METHODS: Two hundred and one consecutive patients with RLS and forty-three control subjects were included in the study. Permission regarding the translation and validation of the RLS-QoL questionnaire was obtained. The translation was conducted according to the guidelines provided by the publisher. RESULTS: For the RLS subjects, the mean Insomnia Severity Index (ISI) score, the International Restless Legs Syndrome Severity Rating Scale (IRLSSG) score and the computed score of the RLS-QoL questionnaire were 22.60 ± 3.39, 24.83 ± 5.28 and 45.93 ± 17.62, respectively. Among the RLS subjects without insomnia, the mean (±standard deviation) ISI score, IRLSSG score and computed score of the RLS-QoL questionnaire were 6.67 ± 2.34, 15.11 ± 4.03 and 41.93 ± 16.12, respectively. A significant difference was identified between both groups on all scores (ISI: p = 0.001, RLS: p = 0.001). The groups with and without insomnia were similar regarding the computed score of the RLS-QoL questionnaire (p = 0.140). According to a correlation analysis, a significant correlation was identified between the ISI and IRLSSG or RLS-QoL scores (r = 0.513, p = 0.001 and r = -0.383, p = 0.001, respectively). Although the coefficient of correlation is significant between IRLSSG score and RLS-QoL scale score, it should not be considered as a powerful enough correlation (r = 0.190, p = 0.007). Most items also exhibited a strong correlation with each other. The internal consistency determined by Cronbach's alpha indicated an extremely good correlation (0.975). DISCUSSION: These findings suggest the Turkish version of the RLS-QoL questionnaire is a valid and reliable tool for the assessment of the quality of life in patients with RLS.

The prevalence of restless legs syndrome in Edirne and its districts concomitant comorbid conditions and secondary complications.

We aimed to determine the prevalence and risk factors of restless legs syndrome in Edirne and its districts, located in Western Thrace, which is the most western part of Turkey. In this study, 4003 individuals who could communicate and agreed to participate in the study were evaluated. To obtain the data from the applicants in 30 Family Health Centres in Edirne and its districts, a face-to-face questionnaire that consisted of 54 questions was prepared by the researchers. The questionnaire included general information, questions to evaluate potential concomitant comorbid conditions and questions regarding the symptomatology used in restless legs syndrome (RLS) diagnosis, as well as questions to evaluate insomnia and tension-type headache secondary to insomnia according to the ICD-II Criteria (International Classification of Sleep Disorders-II Criteria). Of 4003 individuals, 282 were diagnosed with RLS according to the questionnaire results from Edirne and its districts, and the prevalence of RLS was 7%. Approximately, 47.9% of the patients with RLS were male, and 52.1% were female, which was not significantly different (p > 0.05). Anaemia was identified in 41.1 % of the cases and control group was detected in 19.4 %, which was significantly different (p < 0.001). Secondary insomnia was identified in 64.2% of the cases with RLS and was not detected in 35.8%, which was significantly different (p < 0.001). RLS prevalence studies will increase the awareness of the community and provide early diagnosis and treatment, as well as serve as a basis to reduce morbidity and improve the quality of life.

TURKISH VERSION QUALITY OF LIFE IN ESSENTIAL TREMOR QUESTIONNAIRE (QUEST): VALIDITY AND RELIABILITY STUDY.

BACKGROUND: Our aim was to translate the Quality of Life in Essential Tremor Questionnaire (QUEST) advanced by Troster (2005) and to analyse the validity and reliability of this questionnaire. METHODS: Two hundred twelve consecutive patients with essential tremor (ET) and forty-three control subjects were included in the study. Permission for the translation and validation of the QUEST scale was obtained. The translation was performed according to the guidelines provided by the publisher. After the translation, the final version of the scale was administered to both groups to determine its reliability and validity. RESULTS: The QUEST Physical, Psychosocial, communication, Hobbies/leisure and Work/finance scores were 0.967, 0.968, 0.933, 0.964 and 0.925, respectively. There were good correlations between each of the QUEST scores that were indicative of good internal consistency. Additionally, we observed that all of the QUEST scores were most strongly related to the right and left arms (p=0.0001). However, we observed that all of the QUEST scores were weakly related to the voice, head and right leg (p=0.0001). DISCUSSION: These findings support the notion that the Turkish version of the Quality of Life in Essential Tremor (QUEST) questionnaire is a valid and reliable tool for the assessment of the quality of life of patients with ET.

Comparison of the effectiveness of delirium evaluation tools in intensive care patients: pre-deliric versions 1 and 2, E-pre-deliric and ICDSC.

OBJECTIVE: This study's objective was to compare the effectiveness of the delirium prediction model (pre-deliric) and the early prediction model (E-pre-deliric) in delirium prediction in an intensive care unit (ICU) according to the Intensive Care Delirium Screening Checklist (ICDSC). Our aim was to determine these models' usability and cut-off values for ICU patients. PATIENTS AND METHODS: We classified the studied patients based on their highest ICDSC scores (tested twice daily) during ICU hospitalization. ICDSC scores of 4 or higher indicated positive results for delirium, whereas a score of 0 represented a negative result. We recorded the patients' demographic and clinical details and characteristics and calculated their E-pre-deliric and pre-deliric version 1 and version 2 scores. To evaluate the effectiveness of the models, we used receiver operating characteristic (ROC) curve analysis. RESULTS: Two hundred fifty patients (55.6% males, mean age 60.6±18.7 years) participated in this study. Their mean Acute Physiology and Chronic Health Evaluation II (APACHE-II) score was 17.0±9.1. Delirium was more common in men, patients of older ages, those with high APACHE-II scores, those who had undergone urgent admissions, those with histories of trauma, those with high urea or creatinine values and those who had undergone sedation or mechanical ventilation. Compared to patients who did not develop delirium, those who did had longer ICU stays and hospital stays, as well as greater mortality risk. The cutoff values for the patients' pre-deliric version 1, pre-deliric version 2 and E-pre-deliric scores were 38% [area under ROC (AUROC)=1], 22% (AUROC=1) and 28% (AUROC=1), respectively. CONCLUSIONS: This study is the first to compare the pre-deliric and E-pre-deliric prediction models. These models' validity and reliability were acceptable. They were clinically useful, and we identified their cut-off values. These models provide options for early detection of delirium and are easily applicable in the ICU.

Prevalence and Clinical Features of Idiopathic Parkinson's Disease in Western Turkey.

Introduction: We aimed to determine the prevalence and risk factors of idiopathic Parkinson's disease (IPD) in Western Turkey, which encompasses Edirne and its surrounding districts. Methods: In this study, 9887 individuals, able to communicate and agreed to participate in the study, were evaluated. The data was obtained by answering a face-to-face questionnaire consisting of 53 questions from volunteers living at 30 randomly selected family health centers in Edirne and its counties. The questionnaire included demographic information, questions to evaluate potential concomitant conditions, and questions regarding the symptomatology used in IPD diagnosis. Following the questionnaire, it was planned to determine the degree of IPD with the Unified Parkinson's Disease Rating Scale (UPDRS) and the Hoehn and Yahr scale (HY) clinical rating scale in patients diagnosed with IPD to assess disease severity in patients diagnosed with IPD. Results: Of the 9887 individuals, 118 were diagnosed with IPD according to the questionnaire results from Edirne and its districts, and the prevalence of IPD was 1.2%. Approximately, 58.4% of the patients with IPD were male and 41.6% were female, which was not significantly different (p=0.214). Non-motor symptoms such as difficulty urinating, anxiety, depression, fatigue, REM sleep behavior disorder, and difficulty falling asleep or staying asleep were also examined in patients diagnosed with IPD. Depression was identified in 45.7% of the cases, while the control group was 4.3% (p=0.001). Fatigue was identified in 46.8% of the cases and control group was 3.5% (p=0.002). Conclusions: IPD prevalence studies will increase the awareness in the community and provide early diagnosis and treatment as well as serve as a basis to increased life expectancy, reduce morbidity, and improve life quality.

Effects of bupivacaine versus levobupivacaine on pulmonary function in patients with chronic obstructive pulmonary disease undergoing urologic surgery: a randomized, double-blind, controlled trial.

BACKGROUND: There are limited data to determine the impact of subarachnoid blockade with local anesthetics on perioperative pulmonary function. The effects of local anesthetics used in spinal anesthesia are very important in terms of respiratory function in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: The aim of this study was to evaluate the effects of bupivacaine versus levobupivacaine on pulmonary function in patients with COPD undergoing urologic surgery. METHODS: Patients were randomized into 2 groups: group B (n = 25) received 3 mL of hyperbaric 0.5% bupivacaine; group L (n = 25) received 3 mL of isobaric 0.5% levobupivacaine. Both agents were administered intrathecally. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEFR), vital capacity (VC), and FEV1/FVC ratio were measured using spirometry 10 and 30 minutes after spinal anesthesia and 30 minutes after completion of the operation. An arterial blood gas test was performed before and after spinal anesthesia. RESULTS: Fifty male patients aged 40 to 80 years completed the study. There were no differences in the results of preoperative and postoperative FVC, FEV1, PEFR, VC, FEV1/FVC ratio, and arterial blood gas between the bupivacaine (n = 25) and levobupivacaine (n = 25) groups. However, patients who took bupivacaine showed a significant decrease in intraoperative PEFR at 30 minutes compared with baseline, a result not seen in patients who took levobupivacaine (P = 0.036 and P = 0.282, respectively). CONCLUSIONS: In 50 patients with moderate COPD undergoing urologic surgery, hyperbaric bupivacaine caused a decrease in intraoperative PEFR compared with baseline because of higher level block; however, the effects of hyperbaric bupivacaine and isobaric levobupivacaine on pulmonary function in these patients showed equally effective potencies for spinal anesthesia.

Prognostic factors other than the performance status and age for glioblastoma multiforme: a single-institution experience.

PURPOSE: To evaluate the survival of patients with glioblastoma multiforme (GBM) and analyse the prognostic factors influencing survival. PATIENTS AND METHODS: Seventy-eight consecutive patients with GBM treated with radiotherapy (RT) and temozolomide (TMZ) (in 21 patients) between 1999 and 2006 were retrospectively analysed. RESULTS: Sixty-seven (85.5%) patients had undergone gross total or subtotal resection before RT. The median overall survival was 9.8 months, and significantly influenced by age (p=0.02), Karnofsky performance status (p=0.001), RT (p<0.0001), gender (p=0.02), concomitant TMZ (p=0.003), RT waiting time (p=0.014), and treatment time (p=0.01) in univariate analysis. In multivariate analysis, older age (p=0.03), male gender (p=0.01), absence of concomitant TMZ (p=0.008), RT dose below 60 Gy (p=0.03), RT waiting time more than 20 days (p=0.01), and treatment time more than 76 days (p=0.0072) were poor prognosticators. CONCLUSION: This study emphasizes the importance of female gender, dose and duration of RT, and RT waiting time in patients with glioblastoma multiforme.

The prevalence of essential tremor in Edirne and its counties accompanied comorbid conditions.

Objective: We aimed to determine the prevalence and risk factors of Essential Tremor (ET) in Edirne and its districts, located in Western Thrace, which is the most western part of Turkey. Methods: In this study, 3008 individuals who could communicate and agreed to participate in the study were evaluated. To obtain the data from the applicants in 30 Family Health Centres in Edirne and its districts, a face-to-face questionnaire that consisted of 37 questions was prepared by the researchers. The questionnaire included general information, questions to evaluate potential concomitant comorbid conditions and questions regarding the symptomatology used in ET diagnosis, as well as questions to evaluate ET severity, was examined with the spiral test. Patients were classified by using the Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) diagnostic and clinical evaluation scale. According to the diagnostic criteria for ET (used in participants who were examined and in those whose medical records were reviewed) were similar to those used in astudy conducted in Turkey. Results: Of 3008 individuals, 173 were diagnosed with ET according to the questionnaire results from Edirne and its districts, and the prevalence of ET was 5.8%. Approximately, 43.4% of the patients with ET were male, and 56.6% were female, which was not significantly different (p > 0.05). Participants with tremor related to alcohol withdrawal, hyperthyroidism, anxiety, depression other known causes of tremor were not considered to have ET. Thyroid disease was identified in 0.0% of the cases, and the control group was detected in 1.4%, which was not significantly different (p = 0.170). Psychiatric disease was identified in 0.0% of the cases, and the control group was detected in 1.3%, which was not significantly different (p = 0.271). Conclusions: ET prevalence studies will increase the awareness of the community and provide early diagnosis and treatment, as well as serve as a basis to reduce morbidity and improve the quality of life.

Endoscopic removal of a chondromatous hamartoma by bronchoscopic electrosurgical snare and argon plasma coagulation.

A 31-year-old woman presented with a cough, pain on the left side on deep inspiration, dyspnea, and fever. A chest x-ray showed pneumonic infiltration of the left middle and lower lung and decreased left hemithorax volume. A computed tomography (CT) revealed an occlusion of the left main bronchus by an intraluminal tumour. Bronchoscopic biopsy specimens suggested an endobronchial hamartoma. Therefore, we resected the tumour endobronchially using a bronchoscopic electrosurgical snare and argon plasma coagulation.

Determining the Efficiency of Different Preoperative Difficult Intubation Tests on Patients Undergoing Caesarean Section.

BACKGROUND: Pregnancy-induced anatomical and physiological changes in the airway make airway management difficult in obstetric patients; thus, preoperative evaluation of the airway is important for obstetric patients. AIMS: To determine the effectiveness of the modified Mallampati test; the interincisor, sternomental and thyromental distances and the upper limb bite test. The second aim was to assess the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. STUDY DESIGN: Cross-sectional study. METHODS: Pregnant women (n=250) scheduled for caesarean section were analysed. The patients' ages, heights and weights were collected. Preoperative airway evaluation was done by using a modified version of the Mallampati test. The interincisor, sternomental and thyromental distances were measured, and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by using Cormack-Lehane classification. RESULTS: No statistically significant differences were found between groups in age, height or weight (p>0.05). The modified Mallampati test and interincisor, sternomental and thyromental distances revealed a lower number of easy intubations than that determined by the Cormack-Lehane classification and a higher number of difficult intubations than the actual number of cases (p<0.05). The sensitivity and specificity of the modified Mallampati test, the upper limb bite test, the interincisor distance test and the sternomental and thyromental distance tests were found to be 73.08, 57.69, 84.62, 80.77 and 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05, respectively. When the combinations were examined, the sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test were found to be 57.69 and 100, respectively. When the upper limb bite test was combined with the interincisor distance, the sensitivity and specificity were 46.15 and 100, respectively. We found a sensitivity and specificity of 93.75 and 95.30, respectively, for the combination of the upper limb bite test with the thyromental distance test. The sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test and interincisor distance test were found to be 46.15 and 100, respectively. For combination of all the tests, the sensitivity and specificity was 42.31 and 100, respectively. CONCLUSION: When all combinations are evaluated in the decision of difficult intubation, the combination of the upper limb bite test and thyromental distance test is superior to the use of other methods alone to predict difficult intubation in pregnant women.

[The prognostic value of cerebral oxygen saturation measurement for assessing prognosis after cardiopulmonary resuscitation]. / O valor da medida da saturação cerebral de oxigênio para avaliar o prognóstico após ressuscitação cardiopulmonar.

BACKGROUND: Despite new improvements on cardiopulmonary resuscitation (CPR), brain damage is very often after resuscitation. OBJECTIVE: To assess the prognostic value of cerebral oxygen saturation measurement (rSO2) for assessing prognosis on patients after cardiopulmonary resuscitation. DESIGN: Retrospective analysis. MEASUREMENTS AND RESULTS: We analyzed 25 post-CPR patients (12 female and 13 male). All the patients were cooled to a target temperature of 33-34°C. The Glascow Coma Scale (GCS), Corneal Reflexes (CR), Pupillary Reflexes (PR), arterial Base Excess (BE) and rSO2 measurements were taken on admission. The rewarming GCS, CR, PR, BE and rSO2 measurements were made after the patient's temperature reached 36°C. RESULTS: In survivors, the baseline rSO2 value was 67.5 (46-70) and the percent difference between baseline and rewarming rSO2 value was 0.03 (0.014-0.435). In non-survivors, the baseline rSO2 value was 30 (25-65) and the percent difference between baseline and rewarming rSO2 value was 0.031 (-0.08 to -20). No statistical difference was detected on percent changes between baseline and rewarming values of rSO2. Statistically significant difference was detected between baseline and rewarming GCS groups (p=0.004). No statistical difference was detected between GCS, CR, PR, BE and rSO2 to determine the prognosis. CONCLUSION: Despite higher values of rSO2 on survivors than non-survivors, we found no statistically considerable difference between groups on baseline and the rewarming rSO2 values. Since the measurement is simple, and not affected by hypotension and hypothermia, the rSO2 may be a useful predictor for determining the prognosis after CPR.

Gastroprotective effect of L-carnitine on indomethacin-induced gastric mucosal injury in rats: a preliminary study.

BACKGROUND: Numerous studies have shown that use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with various gastric mucosal lesions, collectively referred to as NSAID gastropathy, but the detailed mechanism is still not properly understood. L-carnitine, a vitamin-like substance, is a naturally occurring enzymatic antioxidant with a potent free oxygen radical quencher and scavenger capacity; it protects the biological membranes against lipid peroxidation. It has recently been shown that L-carnitine has a gastroprotective effect on gastric mucosa. To our knowledge, the role of L-carnitine on NSAIDs-induced gastric mucosal injury is undefined. AIM: The aim of the present study was to determine the gastroprotective effect of L-carnitine on indomethacin-induced gastric mucosal lesions in the rat stomachs. MATERIAL AND METHODS: In our study, gastric mucosal injury was induced by the intragastric administration of indomethacin (30 mg/kg). L-carnitine (10, 50, 100 mg/kg) was given to rats by gavage 30 min before the indomethacin administration. The animals were killed 3 h after administration of indomethacin. The stomach of each animal was removed. Mucosal damage was evaluated with macroscopic study and histopathologically. RESULTS: The intragastric administration of indomethacin induced hyperemia and hemorrhagic erosions in the rat stomachs. L-carnitine significantly prevented gastric ulcerogenesis induced by indomethacin and decreased the ulcer index macroscopically and histopathologically. CONCLUSION: L-carnitine decreases indomethacin-induced gastric mucosal injury and this gastroprotective effect may be attributed to its well-known antioxidant effect.

Survival and predictors of disability in Turkish MS patients. Turkish Multiple Sclerosis Study Group (TUMSSG).

OBJECTIVE: To examine the natural history, survival, and prognostic factors in a sample of Turkish MS patients. METHOD: This multicenter study included 1,259 definite MS patients diagnosed according to the criteria of Poser et al. Actuarial analysis of selected disability levels of 3, 6, 8, and 10 achieved with the Expanded Disability Status Scale (EDSS); a multivariate Cox regression analysis for prognostic factors related to time to reach EDSS > or = 6; and Pearson's correlation coefficient for individual factors were performed. RESULTS: The survival (+/- SE) at 15 years from onset was 94.6 +/- 2.9%, and at 25 years was 89.0 +/- 5.8%. The disability reached by 15 years was EDSS > or = 3 in 66.4%, EDSS > or = 6 in 41.2%, EDSS > or = 8 in 10.5%, and EDSS = 10 in 5.4%. The most significant unfavorable prognostic factors were progressive course (relative risk [RR], 3.73; CI, 2.71 to 5.13) and sphincter symptoms at onset (RR, 1.86; CI, 1.23 to 2.82), followed by male sex, motor symptoms at onset, and a high attack frequency within the first 5 years. Primary progressive disease was correlated positively with male sex (r = 0.0895, p = 0.001), older age (r = 0.1807, p = 0.000), and motor (r = 0.1433, p = 0.000) or sphincter symptoms (r = 0.1001, p = 0.000) at onset, unlike relapsing-remitting and secondary progressive disease. CONCLUSIONS: Although a slightly better prognosis is observed in the Turkish MS population, early prognostic factors are similar to most of the previous Western series. Primary progressive disease, mostly seen in older men with motor and sphincter involvement at onset, has a worse prognosis and may represent a distinct behavioral variant of MS.

Risk of recurrence after first unprovoked tonic-clonic seizure in adults.

The likelihood of seizure recurrence after a first unprovoked seizure has profound social, vocational and emotional implications for the patients. Recurrence rates have varied between 27% and 71% in various studies, and the management of patients with a single unprovoked seizure is a controversial topic. In this prospective study we investigated the influence of age, sex, family history, EEG patterns, and anticonvulsant drug (ACD) therapy on seizure recurrence after a first unprovoked tonic-clonic seizure in adults. For this purpose, between October 1988 and January 1991, we studied adult patients who had experienced their after unprovoked tonic-clonic seizure within last 2 months before neurological consultation, and followed them until June 1993. There were 147 patients who met the criteria for inclusion. Overall cumulative recurrence rates were 31.8% by 6 months, 41.3% by 1 year, 44.1% by 2 years, 42.2% by 3 years, and 45.2% by 4 years. Among the risk factors that were evaluated, the time of the day at which the initial seizure occurred was associated significantly (P < 0.05) with seizure recurrence. In our series, 62 patients received ACD and 85 did not. We did not find a significant difference in recurrence rate with regard to ACD therapy. Our results are comparable with those of studies reported previously and suggest that the majority of recurrences after a first unprovoked seizure were seen in the first year (in our series 89% of all recurrences). In our study there was no significant predictor of seizure recurrence, except the time of day at which the initial seizure occurred.

Congenital sinus of valsalva aneurysm dissecting into the interventricular septum with left ventricular communication.

In this report we describe a case of a right coronary sinus of Valsalva aneurysm dissecting into the interventricular septum with spontaneous rupture into the left ventricle. Sufficient information was provided by echocardiography, cardiac catheterization, and aortography to confirm the diagnosis. Surgical findings were in complete accordance with cross-sectional and color flow Doppler imaging by transthoracic and transesophageal approaches.

Application of proximal isovelocity surface area method to determine prosthetic mitral valve area.

BACKGROUND: In this study, we investigated the accuracy of orifice area determination of the prosthetic valve (Biocor) by using proximal isovelocity surface area method (PISA). Thirty-two patients (26 women, 6 men; mean age 44 +/- 8.1 years) were studied. Eleven patients were in normal sinus rhythm and the rest were in atrial fibrillation. Associated valvular lesions were mild aortic regurgitation in 12 patients and moderate tricuspid regurgitation in 19 patients. Sizes of prosthetic valves were 27 to 31, and implantation duration was 4 to 8 years. METHODS AND RESULTS: We analyzed the flow convergence zone proximal to the valve orifice with the concept of a hemispheric model. Mitral valve area (MVA) calculation was formulated by MVA = 2pi r2 x Va/Vm x (Vm/Vm-Va), where Vm is the maximal mitral velocity and Vm/Vm - Va is a correction factor to account for flattening of isotachs near the prosthetic orifice. MVA calculations by PISA were compared with pressure half-time (PHT), continuity equation (CONT), and color flow area (CFA) methods. Mitral valve areas were 2.17 +/- 0.17 cm2, 2.22 +/- 0.21 cm2, 2.19 +/- 0.22 cm2, and 2.16 +/- 0.17 cm2 in PISA, CFA, PHT, and CONT methods, respectively. Values in the comparison of MVA measurements by different methods were PISA vs PHT, r =.86; PISA vs CFA, r =.77; and PISA vs CONT, r =.89. CONCLUSIONS: The PISA method gives reliable estimates of large orifices such as prosthetic valves. Although the best correlation was seen with the CONT method, results of this study also confirmed that the PISA method can be applied with reasonable accuracy.

Exercise electrocardiography test in patients with aortic stenosis. Differential features from that of coronary artery disease.

BACKGROUND AND AIM OF THE STUDY: Studies that have been conducted with an exercise test in patients with aortic stenosis (AS) have demonstrated that results of an exercise test can mimic that of coronary artery disease (CAD). The objective of our study was to investigate if there was any differential feature(s) of an exercise test in patients with AS compared to those with CAD. METHODS: We prospectively studied 42 patients with AS (AS group, age 37 +/- 23, range 8-75) with an averaged maximal gradient of 42 +/- 19 mmHg (range 26-95). All patients had undergone a coronary angiography within 1 week of the exercise test and none had CAD. Another 100 patients with CAD, diagnosis proven with coronary angiography, comprised our second group for the comparison (CAD group). Cornell protocol was used in all patients. RESULTS: ST-segment depression was observed in all patients (160 +/- 25 microV in AS group and 170 +/- 20 microV in CAD group, P>0.05). Thirty-four (81%) patients in AS group and 88 (88%) patients in CAD group exceeded the classical threshold for the test positivity (P>0.05). ST/HR slopes derived from heart rate adjustment to ST-segment level did not differ between the study groups (3.2 +/- 2.3 and 3.7 +/- 2.2 microV/beat/min, in AS and CAD groups, respectively, P>0.05). Recovery-phase patterns of ST-segment in heart rate domain were quite different between AS and CAD (clockwise loop: 86% vs. 0%; counterclockwise loop: 9% vs. 88% in AS group and CAD group, respectively, both P<0.0001). Percentage of intermediate loop was 5% in AS group and 12% in CAD group (P>0.05). CONCLUSIONS: Our study demonstrated that patients with AS could be distinguished from those with CAD with the method of rate-recovery loop analysis.

Prevalence of microbubbles associated with mechanical prosthetic cardiac valves: a prospective transesophageal echocardiography study.

BACKGROUND AND AIM OF THE STUDY: The study aim was to identify the prevalence of microbubbles in different types of mechanical cardiac valve and, if feasible, to associate microbubbles with various clinical conditions, including thrombotic occlusion of the valves. METHODS: A total of 153 mechanical prosthetic valves were studied (58 aortic, 95 mitral) in 140 patients, prospectively. All valves were functioning normally. In addition, eight mitral prosthetic valves were selected without microbubbles and with an obstructive valvular thrombosis that had undergone successful thrombolysis (group 1); a further eight patients with unsuccessful thrombolysis (group 2) were studied by transesophageal echocardiography before and after thrombolytic therapy. RESULTS: Microbubbles were detected in 75% (114/153) of prosthetic valves, 99% (88/89) of bileaflet valves, and 45% (29/64) of monoleaflet valves (p < 0.0001). Only 14% (4/28) of Sorin monoleaflet valves were associated with microbubbles, which is distinctively less than other valves (p < 0.001 for each); 71% and 77% of aortic and mitral prosthetic valves, respectively, were associated with microbubbles (p = NS). Prosthetic valves with an obstructive thrombosis and no microbubbles in group 1 showed new appearance of microbubbles in 88% (7/8) of cases after successful thrombolysis. Absence of microbubbles in group 2 persisted in all eight patients at the second examination. CONCLUSIONS: Microbubbles were detected in a greater proportion of patients than reported previously and were found to be associated more with bileaflet prosthetic heart valves than with monoleaflet valves. Sorin monoleaflet valves were associated with microbubbles dramatically less than all other valves. The new appearance of microbubbles after thrombolytic therapy of mechanical prosthetic heart valves with an obstructive thrombosis may indicate successful thrombolysis.

High prevalence of hypercoagulable states in patients with recurrent thrombosis of mechanical heart valves.

BACKGROUND AND AIMS OF THE STUDY: Thrombosis is one of the most feared and life-threatening complications of mechanical heart valves (MHV), with an incidence of 1-3 per 100 patient-years. Hypercoagulable states are highly prevalent in the general population and can predispose MHV to thrombus formation. Thus, we conducted a study to investigate the frequency of hypercoagulable states in patients with MHV who had recurrent thrombosis at least twice after valve implantation. METHODS: Fifteen patients (mean age 42 +/- 11 years; range: 18 to 55 years) with recurrent thrombosis of MHV (2.4 +/- 0.8 recurrences/patient) (group 1) and 15 matched patients (mean age 40 +/- 12 years; range: 18 to 55 years) with MHV without thrombosis (group 2) were followed up with transthoracic and transesophageal echocardiography. Patients' sera were monitored for antibodies to cardiolipin (ACLA-IgG and ACLA-IgM), phosphatidylserine (APSA), lupus-type anticoagulant (LA) and lipoprotein(a) (LP(a)). RESULTS: Average values for group 1 versus group 2 were: ACLA-IgG (normal range < 15 GPLU/ml) 24.7 +/- 14.6 versus 6.2 +/- 2.7 (p < 0.001); ACLA-IgM (< 12.5 MPLU/ml) 7.9 +/- 5.0 versus 3.3 +/- 1.7 (u = 185; p < 0.001); APSA (< 12 RLU/ml) 4.8 +/- 5.7 and 2.9 +/- 1.2 (p = 0.56); and LP(a) (< 30 mg/dl) 36.5 +/- 26.5 and 13.4 +/- 7.1 (p < 0.001). The frequency of LA-positive cases was 4/15 in group 1 and 0/15 in group 2 (p > 0.05). The frequency of abnormally high levels of ACLA-IgG was 9/15 in group 1 and 0/15 in group 2 (p < 0.001); of ACLA-IgM, 2/15 in group 1 and 0/15 in group 2 (p > 0.05); of APSA, 1/15 in group 1 and 0/15 in group 2 (p > 0.05); and of LP(a), 5/15 in group 1 and 0/15 in group 2 (p < 0.05). At least one of the factors included in this study was abnormal in 14 of 15 (93%) patients (p < 0.0001). CONCLUSIONS: Hypercoagulable states are highly prevalent in patients with recurrent thrombosis of MHV. All patients evaluated for therapy of obstructive thrombosis of MHV should be investigated for hypercoagulable state. Moreover, in high-risk patients, surgical replacement of the MHV with a bioprosthesis should be considered.