Impact of PAI-1 4G/5G and C > G polymorphisms in acute ST elevation myocardial infarction and stable angina patients: A single center Egyptian study

Background: Many genetic factors, including polymorphisms in the genes regulating blood coagulation and fibrinolysis have been proposed as risk factors for coronary artery disease (CAD). PAI-1 is the chief inhibitor of tissue plasminogen activator and urokinase plasminogen activator. PAI-1 has a crucial role in regulation of fibrinolysis.Aim of the study: Is to investigate the association between Plasminogen activator inhibitor-1 (PAI-1) 4G/5G, PAI-1C/G polymorphisms and CAD. In addition, studying the relation of these polymorphisms to the level of active PAI-1 in Egyptian patients presenting to a single tertiary center in Cairo.Subjects and methods: One hundred and forty-four patients were included in this study: 42 STEMI (ST elevation myocardial infarction) patients, 63 stable angina patients, and 39 as a control group. Detection of PAI-1 4G/5G and C > G polymorphisms was done using allele specific polymerase chain reaction and restriction fragment length polymorphism (RFLP) respectively. Plasma plasminogen activator inhibitor-1 activity was detected using enzyme linked immunosorbent assay (ELISA).Results: In the studied CAD patients, PAI-14G/5G polymorphism showed 31.7%, and 68.3% for 5G/5G, and (4G/5G + 4G/4G) respectively; however for the control group, 5G/5G, and (4G/5G + 4G/4G) were detected in 21.6%, and 78.4% respectively (p value 0.59). The genotypic frequencies for PAI-1C/G in CAD patients accounted for 27% (CC), 73% (CG + GG); while in the control group these frequencies were 35.3%, and 64.7% respectively (p value 1.43).Conclusion: No significant association between PAI-1 4G/5G and C > G polymorphisms and the risk of coronary artery disease or the activity level of PAI-1 among the studied Egyptian population sample. However, STEMI patients showed significant presence of combined mutant allele of both genes more frequently.Keywords: Coronary artery disease, Plasminogen activator inhibitor, Genetic polymorphism, 4G/5G, C>

The usefulness of Veno-Arterial Extracorporeal Membranous Oxygenation in Patients with Cardiogenic Shock

BACKGROUND: Venoarterial extracorporeal membranous oxygenation is a form of temporary mechanical circulatory support that gets as a salvage technique in patients with cardiogenic shock, we intended to evaluate the effect of (VA ECMO) support on hemodynamics and lactate levels in patients with cardiogenic shock.AIM: The aim of our study is to detect the ability to introduce veno-arterial extracorporeal membranous oxygenation (VA ECMO) as a temporary extracorporeal life support system (ECLS) in our unit, demonstrate the role of ECMO in cardiogenic shock patients regarding improving hemodynamics and microcirculation, and demonstrate the complications and drawbacks in our first center experience regarding VA ECMO.MATERIAL AND METHODS: This was a single-centre observational study that included 10 patients admitted with cardiogenic shock for which VA ECMO was used as mechanical circulatory support. RESULTS: The MAP increased after initiation of the support. It was 41.8 ± 9.3 mmHg and 59.5 ± 6.8 mmHg (P = 0.005). The use of VA ECMO support was associated with a statistically significant decrease in the base deficit (-10.6 ± 4.2 and -6.3 ± 7.4, P = 0.038). The serum lactate declined from 5.9 ± 3.5 mmoL/L to 0.6 ± 4.4 mmoL/L by the use of VA ECMO; a statistically significant change (P = 0.005).CONCLUSIONS: We concluded that VA ECMO as mechanical support for patients with cardiogenic shock might improve mean arterial blood pressure, base deficit and lactate clearance

Use of automatic tube compensation (ATC) for weaning from mechanical ventilation in acute respiratory failure

Aim of study: To evaluate the automatic tube compensation (ATC) as a method of weaning from mechanical ventilation in acute respiratory failure in comparison to pressure support volume (PSV). Patients and methods: 60 patients with, acute respiratory failure were enrolled in this study. Patients who met the criteria of weaning had one hour of a spontaneous breathing trial (SBT) either with ATC (n = 35) or with PSV (n = 25). Patients who passed the weaning trial were extubated and put on oxygen, while others who didn’t pass were put back on mechanical ventilation. Results: The SBT in the 60 enrolled patients weaning was successful in 35 patients (58.3%). 20 of the 35 patients (57.1%) who underwent ATC had successful weaning, and 15 out of the 25 patients (60%) who underwent PSV had also successful weaning. The difference had no statistical significance (p = 0.7). Sensitivity of 80.36% with a positive predictive value (PPV) of 90.14% and a specificity of 79.63% with a negative predictive value (NPV) of 81.25% were shown in ATC, while PSV showed a sensitivity of 76.35% with a PPV of 88.63% and a specificity of 80.36% with a NPV of 71.4%. ATC was superior to PSV regarding PaO2/FIO2 ratio, oxygen saturation, oxygen tension, dynamic compliance and airway resistance. Conclusion: ATC is a useful mode of weaning in patients mechanically ventilated due to acute respiratory failure

Early left ventricular dyssynchrony in acute ST elevation myocardial infarction: A gated single photon emission computed tomography study

Introduction: The resulting left ventricular (LV) dysfunction in acute STEMI is definitely secondary to loss of myocardial muscle mass (Krumholz et al., 2009; Guerchicoff et al., 2014) but may have an additional component of LV dyssynchrony. Aim: Detection of LV dyssynchrony in acute STEMI patients and its relation to LV dysfunction in these patients. Patients and methods: 60 patients presenting with acute STEMI were injected with 25 mCi of Tc99m SestaMIBI prior to primary PCI. Acquisition was deferred after the procedure within 6 h of injection. Images were analyzed using QGS Cedars Sinai software to measure the histogram bandwidth, standard deviation and entropy using GSPECT phase analysis. The results were compared to 60 patients with negative perfusion scans upon maximal exercise imaged using the same protocol during rest. Results: Our study included a total number of 60 acute STEMI patients, 54 males, mean age 54.8 ± 10.38 years, Compared to 60 controls mean age 50.7 + 20.3 years. Risk factors for CAD were smoking in 41 patients, hypertension in 17, dyslipidemia in 7, diabetes in 15, and positive family history of CAD in 21. 30 patients had acute anterior STEMI and 30 had inferior. LVEDV and LVESV were larger compared to controls; 133.0 ± 88.7 vs. 62.0 ± 19.2 ml and 89.7 ± 82.1 vs. 19.9 ± 12.3 ml respectively, p < 0.001, and lower LVEF 39.0 ± 16.8 vs. 71.1 ± 10.4%, p < 0.001. Histogram bandwidth (BW), standard deviation (SD) and entropy (E) values were significantly higher in patients when compared to controls; 76.2 ± 54.7 vs. 17.8 ± 5.3, 20.7 ± 15.2 vs. 4.1 ± 2.0 and 51.1 ± 18.6 vs. 21.8 ± 7.1 degrees respectively, p < 0.001. BW, SD and E significantly negatively correlated with LVEF in acute STEMI cases; r = −.733, p < 0.001, r = −.75, p < 0.001, and r = −.858, p < 0.001 respectively. Conclusion: LV dyssynchrony may be acquired acutely very early in STEMI and may have a negative impact on LV ejection fraction

Extracorporeal Membrane Oxygenation in a case of opioid-induced acute respiratory distress syndrome

Introduction: Currently Extracorporeal Membrane Oxygenation (ECMO) is used for long-term support of respiratory and/or cardiac function, ECMO is primarily indicated for patients with temporary severe ventilation and/or oxygenation problems that they are unlikely to survive conventional lung protective mechanical ventilation. Aim of the work: We describe our experience in the management of a case of opioid-induced acute respiratory distress syndrome with ECMO. Methods: A 22 year old female, known Heroin addict, admitted with severe ARDS, failed to improve with conventional ventilation, Murray Lung Injury Score was 3.5, RESP score (8) was 4, underwent Veno-venous (V-V) ECMO via femoro-atrial approach using Maquet Cardiohelp console. The ECMO run duration was 12 days. Successful decannulation was done after weaning off ECMO by decreasing FiO2 on ECMO, and continuing mechanical ventilation on pressure support ventilation. Results: Successful weaning of ECMO on day 12 and successful extubation on day 14. Conclusion: ECMO can be used safely and successfully in the treatment of Heroin induced ARDS

Veno-venous Extracorporeal Membrane Oxygenation in a case of organophosphorus poisoning

Extracorporeal Membrane Oxygenation (ECMO) is emergently used for long-term support of respiratory and/or cardiac functions. ECMO is most useful in cases when the primary lung insult is reversible. CESAR trial in 2009 showed survival benefits in severe ARDS patients when transferred to an ECMO center compared to those receiving standard care in their ICU. Organophosphate (OP) compounds are large groups of chemicals used in domestic and industrial settings. These compounds are still used in different forms in developing countries. It can affect the respiratory system through causing: rhinorrhea, bronchorrhea, bronchospasm, cough and severe respiratory distress. Respiratory failure is the most life threatening condition and requires immediate intervention. We present a case report of OP induced severe ARDS in which conventional lung protective ventilation failed to maintain adequate oxygenation that was accomplished by ECMO

Histogram bandwidth is a better predictor than Echocardiographic Tissue Doppler peak systolic velocity for Cardiac Resynchronization Therapy response

Objectives: The aim of this study is to compare degree of left ventricular dyssynchrony as assessed with phase analysis from Gated myocardial perfusion SPECT (GMPS) to that assessed with Echocardiographic Tissue Doppler Imaging (TDI) in patients with left ventricular EF <35%, QRS complex >120 ms. Patients & methodology: 30 patients were included, all scheduled for CRT. TDI was measured as standard deviation of time to peak systolic velocity in 6 basal segments. Gated SPECT TC-99m sestamibi acquisition was performed, software phase analysis parameters is histogram bandwidth which include 95% of the element of the phase distribution. Study population was divided into two groups: responders and non-responders according to increase of at least 15% of LVEF after 3 months. Results: ROC analysis was done to reveal that Phase analysis parameter acted in better way to predict CRT response with histogram bandwidth 55.5° Area Under Curve (AUC) 68.9% sensitivity 87% specificity 42.9% positive predictive value (PPV) 83.3% negative predictive value (NPV) 50% compared to TDI sensitivity 52.25%, specificity 71.4% PPV 85.7% NPV 31.3% When applying histogram bandwidth cutoff 55.5° dyssynchrony was illustrated in 20 (87%) patients in comparison to 14 (60%) patients with Echo TDI, there was significant difference in sensitivity of histogram bandwidth compared to TDI with p value 0.043. Conclusion: Histogram bandwidth of GMPS Tc99m sestamibi may be more predictive of significant response to CRT as compared to TDI

Ultrasound-guided percutaneous nephrolithotomy versus conventional c-arm-guided percutaneous nephrolithotomy: a prospective randomized comparative study

Abstract Background Ultrasound guidance for renal access in percutaneous nephrolithotomy (PCNL) is a safe, effective, and low-cost procedure. The current study compared the safety and effectiveness of ultrasound-guided PCNL (US-PCNL) for renal stone therapy versus fluoroscopy-guided PCNL (FL-PCNL) in prone position. Results Successful puncture was attained in all cases in both groups. Unlike fluoroscopy, US guidance reduced the time needed for achieving renal puncture that was (22.45 ± 6.95 s) compared to fluoroscopy that was (68.28 ± 56.76 s) (P value < 0.001). The mean duration of access that was reported in our study was (3.92 ± 0.72 min) in the US-PCNL group and (4.03 ± 0.77 min) in the FL-PCNL group (P value 0.460). There was no significant difference in the total operative time between both groups in our study as the mean operative time in the US-PCNL group was (61.47 ± 6.07 min) and (65.86 ± 20.86 min) in the FL-PCNL group with a (P value of 0.349). Stone-free rate was nearly similar in both groups (P value 0.336). Three cases in our study in the FL-PCNL group had bleeding that required blood transfusion post-operative; mean Hb change was 0.23 g/dL and 0.55 g/dL in US-PCNL and FL-PCNL groups, respectively, which is clinically irrelevant despite statistical significance (P value 0.007). Mean fluoroscopy time was (6.38 ± 3.84) minutes in FL-PCNL group. Conclusion Ultrasound guidance is a reliable tool in the hands of experienced urologists in performing PCNL with less or even zero radiation

Acute myocardial perfusion imaging – A useful tool for evaluation of therapeutic modalities & a predictor of urgent need for revascularization in acute coronary syndromes

We have been evaluating different therapeutic modalities using acute MPI, & we aimed at the use of acute MPI as a predictor of patients in need for urgent revascularization. Methods: A total of 85 patients with ACS were included in our study, 57 males, mean age 52.9 ± 10.6 years, 35% were diabetics, 50% hypertensive, 54% smokers, 30% dyslipidemic & 33% had +ve family history of CAD. Acute MPI was done by SPECT technique using triple head Gamma Camera. Every patient had two sets of images, first set done on admission by injecting 25 mCi Tc99m SestaMIBI intravenously before initiating therapeutic intervention and acquired within 6 h of injection. Second set of images was acquired 2 days later. Myocardium at risk (MAR) was calculated using 20 segment scoring system from the 1st set of images (scale 0–4/segment). Residual ischemia (RI) was calculated from the second set of images. Salvage index (SI = MAR − RI/MAR × 100) was taken as an end point for successful reperfusion (SI > 30%). All risk factors and MPI parameters were analyzed as independent predictors for the need for urgent revascularization vs. conservative strategy. Results: Patients were subdivided according to therapeutic modalities used into three groups, group I: (50 pts) received unfractionated heparin, group II: (20 pts) received low molecular weight heparin & group III: (15 pts) received GPIIb/IIIa. There was no statistical difference as regards risk factors, age, sex, & MAR. Salvage index was highest in group II & lowest in group I (39 ± 21% vs. 64 ± 33.6% vs. 58 ± 25%) P = 0.07. Successful reperfusion was achieved in 67.3% in group I & 90% of group II, 86.7% in group III (P = 0.06). Out of 85 pts, 31 patients (group A) were in need for inhospital target vessel revascularization & 54 patients (group B) showed a good response on medical treatment (conservative strategy). Compared to group B, group A had higher values of RI (11 ± 7 vs. 5 ± 4%, P  0.05. High SI > 60%, and absence of diabetes (DM) were good predictors for conservative management strategy (specificity 96%); however, SI < 30% as well as presence of DM may recognize patients in need for urgent revascularization (sensitivity 50%) with overall predictive accuracy of 78.8%. Conclusion: Acute MPI is a useful tool for evaluating therapeutic interventions. SI > 60% as well as absence of DM could recognize the subset of patients who can be managed conservatively whereas SI < 30% as well as presence of DM may recognize patients in need for urgent revascularization