Cardiology

Lyme is a tick-borne disease. The genetic diversity of Borreliae its distribution worldwide and its epidemiology have been related to different clinical manifestations. Carditis is a rare manifestation of Lyme disease. The commonest abnormality is atrioventricular block of various degrees, though other rhythm abnormalities have been reported. Pericarditis, myocarditis, cardiomyopathy and degenerative valvular disease have been associated with B. burgdorferi. Temporary pacing might be required in unstable patients. The majority of the conduction disturbances have a benign prognosis, if the infectious agent is identified and treated appropriately.

There are two families of dopamine (DA) receptors, called D1 and D2, respectively. The D1 family consists of D1- and D5-receptor subtypes and the D2 family consists of D2-, D3-, and D4-receptor subtypes. The amino acid sequences of these receptors show that they all belong to a large superfamily of receptors with seven transmembrane domains, which are coupled to their

Cardiology is vital to interpreting the results of various diagnostic tests and planning an effective therapeutic plan for a case. This article will provide a review of the anatomy and physiology of the reptilian cardiovascular system, the common diagnostic tests used to assess cardiac function, and the common disease presentations associated with the cardiovascular system.

Cardiovascular risk is poorly managed in women, especially during the menopausal transition when susceptibility to cardiovascular events increases. Clear gender differences exist in the epidemiology, symptoms, diagnosis, progression, prognosis, and management of cardiovascular risk. Key risk factors that need to be controlled in the peri-menopausal woman are hypertension, dyslipidaemia, obesity, and other components of the metabolic syndrome, with the avoidance and careful control of diabetes. Hypertension is a particularly powerful risk factor and lowering of blood pressure is pivotal. Hormone replacement therapy is acknowledged as the gold standard for the alleviation of the distressing vasomotor symptoms of the menopause, but the findings of the Women's Health Initiative (WHI) study generated concern for the detrimental effect on cardiovascular events. Thus, hormone replacement therapy cannot be recommended for the prevention of cardiovascular disease. Whether the findings of WHI in older post-menopausal women can be applied to younger peri-menopausal women is unknown. It is increasingly recognized that hormone therapy is inappropriate for older post-menopausal women no longer displaying menopausal symptoms. Both gynaecologists and cardiovascular physicians have an important role to play in identifying peri-menopausal women at risk of cardiovascular morbidity and mortality and should work as a team to identify and manage risk factors such as hypertension.

In the panorama of scientific literature, there is a paucity of literature on how to palpate the heart area in
the osteopathic setting and relevant indications on which palpatory sensations the clinician should perceive
during the evaluation. The article reviews the fascial anatomy of the heart area and the heart movements
derived from magnetic resonance imaging (MRI) studies and describes the landmarks used by the cardiac
surgeon to visualize the mediastinal area. The text sets out possible suggestions for a more adequate
osteopathic palpatory evaluation and describes any tactile sensations arising from the patient's chest. To the
knowledge of the authors, this is the first article that seeks to lay solid foundations for the improvement of
osteopathic manual medicine in the cardiology field.

Textbook in Internal medicine consists of 30 chapters. This textbook is made up of text material and enough illustrations, including clinical findings and schematic figures. The textbook is intended for English-speaking students of medical and pharmaceutical faculties of higher educational establishments of Ukraine.

Підручник з внутрішньої медицини складається з 30 розділів. Містить текстові матеріали та достатньо ілюстрацій, у тому числі клінічні матеріали та схематичні рисунки. Підручник призначений для англомовних студентів медичних та фармацевтичних факультетів вищих навчальних закладів України.

The aim of the present study was to investigate the prevalence of left ventricular (LV) thrombus formation and important determinants in patients with acute ST elevation myocardial infarction localized to the anterior wall treated with percutaneous coronary intervention (PCI) and dual-antiplatelet therapy. One hundred selected patients with ST elevation myocardial infarctions revascularized with PCI in the left anterior descending coronary artery were included. The patients participated in the Autologous Stem Cell Transplantation in Acute Myocardial Infarction (ASTAMI) trial. All were treated with aspirin 75 mg/day and clopidogrel 75 mg/day and underwent serial echocardiography and magnetic resonance imaging during the first 3 months after PCI. After 4 to 5 days, the ejection fraction and infarct size in percentage of the left anterior descending coronary artery area were assessed using single photon-emission computed tomography in addition to the ejection fraction by echocardiography. LV thrombi were detected in 15 patients during the first 3 months, 2/3 of them within the first week. No differences in baseline characteristics between the groups with and without LV thrombi were shown. However, in the thrombus group, significantly higher peak creatine kinase levels (6,128 vs 2,197 U/L, p <0.01), larger infarct sizes (82.5% vs 63.8%, p <0.01), and lower ejection fractions on single photon-emission computed tomography (35.5% vs 40.0%, p ‫؍‬ 0.03) and on echocardiography (43.0% vs 46.0%, p ‫؍‬ 0.03) were found compared to patients without LV thrombi. In conclusion, LV thrombus formation is a frequent finding in patients with anterior wall ST elevation myocardial infarction treated acutely with PCI and dualantiplatelet therapy and should be assessed by echocardiography within the first week.

Background. Conventional pulmonary artery banding (CPAB) is associated with high morbidity and mortality. We studied the changes in outcome with the use of an adjustable pulmonary artery band (APAB). Methods. Between June 2001 and June 2006, 147 patients underwent PAB: 91 underwent CPAB and 56 underwent APAB. Results. The clinical profile of patients was similar in both groups. Inotropic drugs were used in 91 (100%) patients in the CPAB group and in 12 (21%) in the APAB group (p < 0.001). Early band related reoperation was required in 17 patients in the CPAB group compared with 2 patients in the APAB group (p ‫؍‬ 0.014). There were 21 (23%) early deaths in CPAB group compared with 1 (1.8%) in the APAB group (p < 0.001). There was no difference in the intensive care unit stay, hospital stay, and final band gradients in the two groups. On a mean follow-up of 22.8 ؎ 18.6 months (range, 4 to 72 months), there was PA distortion in 6 patients and band-migration in 4 patients in the CPAB group. These were not observed in the APAB group. Conclusions. Similar band gradients were achieved with the use of conventional or adjustable PAB. However, the use of this simple and inexpensive technique of APAB was associated with a significant reduction in the early band-related deaths, need for early multiple reoperations, and early adverse acute events, thus making it a safer alternative to CPAB, more so in unstable patients.

The increasing use of coronary computed tomography angiography (CCTA) requires the establishment of standards meant to ensure reliable practice methods and quality outcomes. The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting these studies in a standardized fashion. Indications and contraindications for specific services or procedures are not included in the scope of these documents. These recommendations

Infective endocarditis (IE) can be diagnosed using the Duke criteria, which cannot be conclusive especially when the results of blood cultures are negative. This study aimed at using real-time polymerase chain reaction (PCR) technique to isolate bacteria present in whole blood samples of patients with definitive IE on the basis of the method designed in this study. This laboratory and test study was conducted on 20 whole blood samples taken from patients with definitive IE. Real-time PCR of the 16s rRNA was utilized to directly analyze whole blood samples to diagnose bacterial IE. Of 20 whole blood samples with definitive IE, only one blood culture (5%) was positive and the isolated bacterium belonged to group. Also, 13 whole blood samples were positive using real-time PCR technique. The isolated bacteria were with seven (35%) cases, with two (10%) cases, with one (5%) case, with one (5%) case, with one (5%) case, and with one (5%) case. Sensitivity, specificity, positive predictive...

This study was designed to determine the predictive value of lipid hydroperoxide (LOOH) levels for adverse cardiovascular outcomes in patients with stable coronary artery disease (CAD). Oxidative modification of circulating lipids contributes to inflammation and endothelial dysfunction, which are hallmark features of atherosclerosis. A serum biomarker of oxidation is LOOH, which is a primary product of fatty acid peroxidation. Serum LOOH levels were measured and correlated with clinical events over a 3-year period in 634 patients with angiographic evidence of CAD. Baseline LOOH levels in the highest quartile were associated with hazard ratios of 3.24 (95% confidence interval [CI] 1.86 to 5.65; p = 0.0001) for nonfatal vascular events (n = 149), 1.80 (95% CI 1.13 to 2.88; p = 0.014) for major vascular procedures (n = 139), and 2.23 (95% CI 1.44 to 3.44; p = 0.0003) for all vascular events and procedures. Baseline LOOH levels correlated with serum levels of soluble intercellular adhesion molecule-1 (p = 0.001) and thiobarbituric acid reactive substances (p = 0.001) as well as the mean percent change in stenosis for large segments &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;50% stenosed (p = 0.048). A multivariate proportional hazards model, adjusted for traditional risk factors and inflammatory markers, showed an independent effect of LOOH on nonfatal vascular events, vascular procedures, and all events or procedures. Amlodipine treatment was associated with reduced cardiovascular events and changes in LOOH levels compared with placebo. Elevated LOOH levels were predictive of nonfatal vascular events and procedures in patients with stable CAD, independent of traditional risk factors and inflammatory markers.

Placental blood flow was measured with the aid of radioactive microspheres, in normal (N) and manifest diabetic (MD) rats, and related to fetal body growth and incidence of congenital malformations. The total blood flow in the placentae of the MD rats was decreased to about one-half of the normal flow on gestational days 20 and 22. The placentae of the MD offspring were enlarged, whereas the fetuses in this group were smaller than normal. Thus, the placental blood flow per placental weight was drastically decreased in the MD fetuses on both days 20 and 22. In contrast, the placental blood flow per fetal weight was not different in the N and MD groups on gestational day 20 whereas it was decreased in the MD offspring on gestational day 22. Placental blood flow in the malformed fetuses of the MD group did not differ significantly from that in the nonmalformed MD fetuses.

Fractional tubular reabsorption (FTR) of free and acyl carnitine was measured in 15 patients with various selective tubular transport defects and in 19 patients with more generalized tubular dysfunction (Fanconi syndrome). FTR of free carnitine was normal in all patients with a selective tubulopathy, FTR of acyl carnitine was normal in most, and plasma carnitine levels were normal without exception. In these patients, there was no evidence for the existence of a defective renal transport mechanism shared by carnitine. In the patients with Fanconi syndrome, mean FTR of free and acyl carnitine was low; their plasma carnitine levels were lowered and correlated with the FTR. In individual patients, FTR of free and acyl carnitine also correlated with the severity of the disease. In the group of Fanconi syndrome patients, FTR of free and acyl carnitine correlated linearly with that of valine. We concluded that the lowering of plasma carnitine in the patients with Fanconi syndrome was caused by excessive loss of carnitine in urine. Its pathophysiological significance remained to be established.

Hypertension is a well established risk factor for atherosclerosis and elevated blood D~ssure is common among population and a significant D~disposing factor for cardiovascular complications such as coronary heart disease, stroke, and heart failure. Its high prevalence, great impact on cardiovascular disease events and controllability justify a highest priority for detection and treatment by clinicians and public health professionals. The D~valence of self awareness, medication, and well control rates was also important issues in general population. In Talwan, hypertension elicits great risk in general population and clinicians and public health workers should tackle the problems effectively. Clinical trial can test one specific hypothesis, but the prospective cohort study, although its observational characteristics, can define multiple outcomes among the cohort population. There were important cohort studies on cardiovascular diseases among Talwan, and the Chin Shan Community Cardiovascular Cohort (CCCC) study, a prospective population study for more than a decade, can provide unique knowledge for hypertension prevalence, incidence and risk for cardiovascular disease events among Talwanese. The CCCC study staff, supervised by Prof. Yuan Teh Lee, collected detailed iifformation of hypertension associated data and followed up the morbidity of mortality regularly. Several subclinical disease endpoints, such as echocardiographic left ventricular mass, vascular resistance and distensibility and carotid atherosclerosis were also collected. These subclinical diseases provided more information for gauge the hypertension impact on cardiovascular diseases among Talwanese.

A procedure to fuse the information of short-axis cine and late enhanced magnetic resonance images is presented. First a coherent 3D reconstruction of the images is obtained by objectbased interpolation of the information of contiguous slices in stacked short-axis cine acquisitions and by the correction of slice misalignments with the aid of a set of reference longaxis slices. Then, late enhanced stacked images are also interpolated and aligned with the anatomical information. Thus, the complementary information provided by both modalities is combined in a common frame of reference and in a nearly isotropic grid, which is not possible with existing fusion procedures. Numerical improvement is established by comparing the distances between unaligned and aligned manual segmentations of the myocardium in both modalities. Finally, a set of snapshots illustrate the improvement in the information overlap and the ability to reconstruct the gradient in the long-axis.

Certifico que el presente trabajo fue desarrollado bajo mi dirección por ________________________________ ha sido revisada prolijamente, autorizando la presentación de esta monografía de grado la cual cumple con todas las normas internas requeridas por la Unidad Educativa FAE Nº4 -Manta Manta, 12 de diciembre del 2014 ___________________________ Tutor de Monografía de Grado ii AUTORIA ( NOMBRE ) estudiante, declaro bajo juramento que el trabajo aquí descrito es de mi autoría; y que, previamente no ha sido presentada por otro estudiante; y, que se han consultado las referencias bibliográficas que se incluyen en este documento, las ideas, pensamientos, opiniones y la información de esta investigación monografica son de única responsabilidad del autor. __________________________ 3ro de Bachillerato "B"

Background: Although good prognosis and clinical long-term outcome have been commonly reported in minimally symptomatic adult patients with ASD, this information has been based on studies with a relatively small number of adult patients. We studied unoperated patients aged over 40 years to define the patterns of presentation, anatomical characteristics, outcome and predictive factors for free-event survival of major cardiovascular and pulmonary events. Methods and results: Two-hundred survivors of atrial septal defect aged over 40-yr attended from 1985 to 1998 were reviewed and followed-up from 1.6 to 22 years. Patients were classified in three groups according to age at entry: Group 1, between 40 and 49; Group 2; 50 and 59; and Group 3, z 60 years old. The mean age at presentation was 48.8 F 9.2 years, and the most common clinical presentations were arrhythmia and dyspnea (51.4%). There were 37 (18.5%) events: 7 heart failure-related, 5 sudden death, 13 severe pulmonary infections, 5 embolisms, and 4 strokes. According to Cox's regression analysis, predictors of primary end point included age group at presentation (hazard ratio 1.71, 95% confidence limits 1.16 to 2.54), and either pulmonary hypertension (mean pulmonary pressure > 35 mmHg; hazard ratio = 0.65 (4.6, confidence limits 2.2 to 9.5) or, arterial oxygen saturation < 80% (hazard ratio 1.71, 95% confidence limits 1.16 to 2.54). Conclusions: This study supports that long term outcome of patients aged >40 years with unoperated ASD is importantly determined by the mPAP (>35 mmHg), SaO2% (_80) and the age at diagnosis. Nevertheless we identified an inverse association between the mPAP level and SaO2% (interaction). The event-free survival expectancy may be estimated using the age at diagnosis and either SaO2% or mPAP. This prognostic stratification based on pathophysiological principles, may help in making decisions for therapeutic interventions. SaO2% should always be measured as a part of the initial clinical approach of those patients with atrial septal defect aged over 40 years. D

ABSTRAK Penyakit jantung koroner merupakan penyakit arteri koroner yang ditandai adanya endapan lipid yang terkumpul di dalam sel yang melapisi dinding suatu arteri koroner dan menyumbat aliran darah. Tujuan penelitian mengkaji pengaruh Lipid Profile Terhadap Penyakit Jantung Koroner. Disain penelitian adalah survey analitik. Sampel penelitian adalah sebagian pasien di Instalasi Rawat Jalan Penyakit Dalam RSUD Nganjuk dengan jumlah 32 orang. Variabel penelitian adalah lipid profile yang terdiri dari HDL, LDL, Trigliserida. Instrumen penelitian adalah observasi dan hasil pemeriksaan laboratorium lipid profile. Analisis data menggunakan uji Fisher Exact . Hasil penelitian menunjukkan sebagian memiliki kadar HDL yang normal, lebih dari sebagian memiliki kadar LDL dan trigliserida yang tinggi. Pasien Penyakit Jantung Koroner Di  Instalasi Rawat Jalan Penyakit Dalam RSUD Nganjuk didapatkan terbanyak adalah NSTEMI dan terkecil adalah Asymtomatik. Hasil uji fisher exact menunjukkan terdapa...

Traditional cardiovascular risk factors have been shown to cause microvascular dysfunction. Most studies that have evaluated microcirculation rely on invasive measurement tools. We used dobutamine stress echocardiography, a validated method to measure coronary flow velocity (CFV) and coronary flow reserve (CFR), in a previously unstudied population without known significant coronary artery disease to determine the impact of traditional risk factors on CFR. Consecutive patients who had no evidence of regional wall motion abnormalities at rest or during dobutamine stress echocardiography were studied. Left anterior descending artery CFV was measured at baseline and at peak dobutamine stress and CFR was calculated as the ratio of peak stress CFV to baseline CFV. Fifty-nine consecutive patients (28 men) with mean age of 66.8 ؎ 14.5 years were studied. CFR was lower in patients with diabetes mellitus (DM) compared with those without (1.7 ؎ 0.74 vs 2.48 ؎ 0.98, p <0.007), in patients with hypertension compared with those without (2 ؎ 0.8 vs 2.6 ؎ 0.9, p <0.02), and in obese patients compared with nonobese patients (1.6 ؎ 0.5 vs 2 ؎ 0.6, p <0.02). CFR was further impaired in the presence of DM with hypertension, DM with obesity, DM with a wide pulse pressure (>50 mm Hg), and obesity with a wide pulse pressure. In a multivariate model, DM, obesity, and wide pulse pressure were significantly associated with variation in CFR (p <0.0008). In conclusion, CFR was abnormal in patients with DM, hypertension, and obesity. CFR impairment is exaggerated as the number of risk factors increases. Despite a negative dobutamine stress echocardiographic result, aggressive risk factor assessment and control should be implemented in patients with coronary risk factors due to an underlying abnormal CFR.

Background Intensive sport may induce cardiac modifications. No recent study has been performed in elite tennis players. The aim of this cross-sectional study was to analyze the cardiac characteristics in a population of professional tennis players.

Anticoagulation therapy for cardiopulmonary bypass in patients with recently diagnosed heparin-induced thrombocytopenia can be particularly challenging. Although heparin is the standard of care, in these situations anticoagulation is achieved with alternative agents such as direct thrombin inhibitors. Therapeutic concentrations are difficult to assess with direct thrombin inhibitors, and their use is riddled with bleeding and thrombotic complications. We report the successful use of a specific chromogenic antifactor IIa assay in a patient with heparin-induced thrombocytopenia who received anticoagulation therapy with bivalirudin during cardiopulmonary bypass for coronary artery bypass graft surgery.

Background and aim: The problem of a possible gender bias in coronary heart disease management is still controversial. We studied gender differences in secondary preventive drug prescriptions and in referral to cardiac rehabilitation after acute coronary events in France. Methods: An observational survey was carried out in 1998 -1999 in 150 French intensive cardiac care units. A sample of 2626 consecutive patients admitted for myocardial infarction or unstable angina and alive at discharge was included. Data were retrospectively collected from medical records after discharge. Results: The sample was composed of 1921 men and 705 women. At discharge, antiplatelet agents were prescribed in 93.4% of men and 91.5% of women ( p = 0.09), beta-blockers in 73.4% and 63.7% ( p < 0.0001), angiotensin-converting enzyme (ACE) inhibitors in 39.9% and 44.3% ( p < 0.05), and statins in 47.0% and 40.7% ( p < 0.01). The percentage of subjects referred to a cardiac rehabilitation program at discharge was 26.2% in men and 15.5% in women ( p < 0.0001). In multivariate analysis, taking into account confounding factors, gender did not appear as an independent determinant of drug prescriptions. Conversely, being a woman was independently associated with a lower probability to be referred to a cardiac rehabilitation program at discharge (adjusted female-to-male odds ratio: 0.44 (95% confidence interval: [0.31 -0.64], p < 0.0001). Conclusions: In this study, gender was not an independent determinant of secondary preventive drug prescriptions after acute coronary events. Conversely, we found a gender bias in referral to cardiac rehabilitation programs at discharge. D

It is well known that hypertension, aortic dilatation, and collagen disorders predispose to acute aortic dissection (AAD). The inciting events that precede the instant of AAD are incompletely understood. One hundred seventy-five consecutive patients having AAD, treated at our institution during a 10-year period, were reviewed; 65 were women and 110 were men (mean age 61 years). The ascending aorta was affected in 110 patients, and the descending in 65. Information was collected using patients' charts supplemented with direct telephone interviews. Ninety patients were contacted; 65 (24 women, 41 men, mean age 61 years, average aortic size 5.56 cm) could recall specific inciting events for their dissection. In 34 patients, the ascending aorta was involved and in 31 the descending. Eighteen patients (28%) had a positive family history of aortic disease, defined as having >1 first-degree relative with aortic disease (aneurysm or dissection). In 24 of the 90 patients contacted (27%), strenuous activity was identified as a clear precipitating factor before the acute onset of thoracic pain; in 36 of 90 (40%) severe emotional stress preceded the onset of dissection pain. Three dissections were iatrogenic. Two additional patients reported a severe exacerbation of chronic obstructive pulmonary disease before their acute onset of chest pain. In conclusion, severe physical and emotional stress may precipitate AAD, presumably on the basis of a transient, severe hypertensive reaction.

Background Real world cardiology is faced with a low diagnostic yield of coronary angiography (CXA) in patients presenting with ACC/AHA class II CXA indication. Our aim was to analyze the clinical implication of a Cardiac MR (CMR) protocol including adenosine stress perfusion in this patient population. We examined whether CMR could enhance appropriate CXA indication and thus reduce the rate of pure diagnostic CXA. In addition, we compared the relative impact of CMR exam components (perfusion, function and viability assessment) in achieving this target. Methods 176 patients were referred for CXA with class II indication. 171 underwent complete additional CMR exam in a 1.5-T whole body CMR-scanner for myocardial function, ischemia and viability prior to CXA. The routine protocol for assessment of CAD consisted of functional imaging (long and short axes), adenosine stress- and rest-perfusion in short axis orientation and “late enhancement” imaging in long and short axes. Images were analyzed by two independent and blinded investigators. Interobserver differences were resolved by a third reader. Results There was a high association between CMR results and subsequent invasive findings (chi square for CMR perfusion deficit and stenosis >70% in CXA: 113.7, p70%. Four (2.3%) patients had false negative CMR findings. In 58 patients (33.9%) no relevant coronary artery stenosis could be observed, correctly predicted by CMR in 48 cases; in 10 (5.8%) patients CMR provided false positive results. Sensitivity of CMR to detect relevant CAD (>70% luminal narrowing) was 0.96, specificity 0.83, positive predictive value 0.92 and negative predictive value 0.92. Of the CMR components, perfusion deficit was the strongest independent predictor (odds ratio 132.3, p Conclusion In a great number of patients being referred to cath lab with ACC/AHA class II indication for CXA, CMR provides a high accuracy for decision making regarding appropriateness of the invasive exam. CMR prior to CXA could substantially reduce pure diagnostic coronary angiographies in patients with intermediate probability for CAD, in our patient-cohort from approximately 34% to 6%. Further studies are warranted to identify rare false negative CMR results.

Objective: The aim of this study was to assess the feasibility and safety of a new proximal anastomotic device during off-pump coronary surgery. Methods: The Novare Enclose II is a manual proximal anastomotic device that enables the surgeon to perform proximal anastomoses without side-biting clamps in a fully pressurized aorta. The device was used in 30 off-pump coronary artery bypass graft (CABG) patients (Group A) for performing 25 vein, 10 free right internal thoracic artery and 14 radial artery anastomoses to the aorta.The number of proximal anastomoses varied between 1 and 3 per patient. Intraoperative transcranial Doppler measurements were performed to detect cerebral microemboli during the use of the device and were compared with transcranial Doppler measurements of 30 off-pump patients where a partial side clamp was used for proximal anastomoses (Group B).The aorta was evaluated using transesophageal echocardiography (TEE) and epiaortic echocardiography (EAE) in both groups before the procedure and patients with a calcified aorta were excluded. Results: In Group A, 49 proximal anostomoses were performed as planned with the device using conventional hand-sewn methods. Twenty-four of these were arterial conduits. In Group B, 32 proximal anastomoses were performed using 25 veins and 7 arterial grafts. There were no procedure related to adverse events or complications in both groups. The median number of microemboli was 15 (range 5-48) in Group A and 68 (range 35-290) in Group B (P!0.05). Conclusion: The Enclose II device can be a valuable tool to perform venous or arterial proximal anastomoses during off-pump CABG. Transcranial Doppler results suggest that the device seems to be less traumatizing than side clamping and may reduce clamp-associated complications during off-pump coronary artery surgery. Q

Background: Acute anterior myocardial infarction (MI) caused by proximal occlusion of the left anterior descending coronary artery (LAD), is associated with unfavourable outcome and should be recognized by simple noninvasive methods like the 12-lead electrocardiogram (ECG). Methods: In a prospective post-hoc DANAMI-2 substudy we compared two pre-specified ECG patterns to determine the level of LAD occlusion. The ECG findings were correlated to coronary angiography from the acute phase. The impact on clinical outcome of ECG and angiographic signs of proximal versus distal LAD occlusion was studied. Results: In 146 patients without confounding factors on the ECG, either ST-elevation ≥ 0.5 mm in lead aVL or any ST-elevation in lead aVR in association with precordial ST-segment elevation in at least two contiguous leads (including V 2 , V 3 or V 4 ) had a sensitivity of 94%, specificity of 49%, positive predictive value of 85% and negative predictive value of 71% to predict a proximal LAD lesion. Surprisingly, ECG or angiographic signs of lesion proximality were not associated with worse outcome at 30 day or 2.7 year follow-up. Conclusions: The site of occlusion in the LAD could be reliably predicted by 12-lead ECG in patients with acute anterior MI. The prognostic significance of the level of occlusion in the LAD in the modern era of acute ST-elevation MI treatment should be reassessed.

Methods. All patients aged 80 years or older (n ‫؍‬ 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES log ) risk stratification. Surgical risk was defined as low risk (ES log < 10% [n ‫؍‬ 107]), moderate risk (10% < ES log < 20% [n ‫؍‬ 103]), and high risk (ES log > 20% [n ‫؍‬ 72]). Patient age was 82 ؎ 2 years (low risk), 82.7 ؎ 2.7 years (moderate risk), and 83.6 ؎ 3.1 years (high risk), respectively (p < 0.05). Mean ES log predicted risk of mortality was 7.3% ؎ 1.4% (low risk), 13.7% ؎ 2.5% (moderate risk), and 33.0% ؎ 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

Problem: Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision. Design: Locally developed action research projects with an explicit objective of reducing inequalities in access. Setting: Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services. Key measures for improvement: Changes in service provision, increasing attendance rates in targeted groups. Strategies for change: Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change. Effects of change: A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations. Lessons learnt: Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A ''toolkit'' has been developed to support the identification and implementation of appropriate changes.

A 55-year-old male patient presented after a single shock caused by oversensing of isolated nonphysiologic signals on both the distal HV and pace-sense channels. No other abnormalities were found. He subsequently returned complaining of device "vibration" and his St. Jude implantable defibrillator (ICD; St. Jude Medical, St. Paul, MN, USA) was found to be in VVI backup mode and could not be interrogated. Direct testing in the electrophysiology lab showed normal lead impedances and thresholds with an inability to reproduce the abnormal signals. Detailed cine fluoroscopy of the leads found no abnormalities. A new ICD was connected and successfully delivered a 20-joule shock but failed to deliver a maximum output (39-joule) shock. The new ICD was again found to be in backup mode. A new Endotak Reliance G lead (Boston Scientific, Natick, MA, USA) was implanted and a maximum-output shock was successful using a new Fortify DR ICD. This case likely represents a Durata lead insulation defect in the form of an inside-out abrasion under the distal HV coil. Increased awareness of this defect is warranted, particularly since routine interrogation and submaximum-output shocks may fail to detect the problem. (PACE 2013; 00:1-4) Durata lead, insulation, electrical failure, Riata lead

Background. Evidence from multiple trials demonstrates the efficacy of prophylactic ␤-blocker, amiodarone, and corticosteroid administration in reducing the incidence of postoperative atrial fibrillation. Despite this information, these interventions remain infrequently or inappropriately utilized. This study was designed to assess the frequency with which these prophylactic strategies are currently being used and to identify concerns and barriers to more widespread application. Methods. A link to an online survey was e-mailed to all practicing cardiac surgeons in Canada. Each surgeon was given a unique log-in identification number to complete the survey online through a secure web page. Results. Surveys were sent to 166 surgeons; 119 completed surveys (72%) were returned. Only 58% of respondents routinely use ␤-blockade for prophylaxis. For nonusers, 44% are unconvinced of the evidence for this practice. The routine use of amiodarone among surgeons was 19%. Of the remainder, 43% cited a perceived increased risk of complications as the reason for not using this therapy. An additional 29% considered the therapy was excessively complicated or time consuming. Corticosteroids were routinely used by only one surgeon. Major barriers to use of steroids were unconvincing evidence (76%), a perceived increased risk of wound infection (38%), and hyperglycemia (30%). Conclusions. Despite level 1 evidence, the use of ␤-blockers, amiodarone, and corticosteroids for prophylaxis of atrial fibrillation among Canadian surgeons remains less than expected. The results of this survey support the need for further clinical trials with robust and clinically relevant outcomes that may further influence surgeons to adopt this practice.

Introducción: Gracias a los adelantos científico-tecnológicos, cada vez son más las personas con algún tipo de cardiopatía congénita que alcanzan la edad adulta, sin embargo, esta condición supone un impacto significativo en la esfera emocional; por ello, en el presente estudio se hace referencia a la ansiedad. Objetivo: Analizar el nivel de ansiedad que presentan los pacientes adultos con cardiopatía congénita en una institución de alta especialidad. Material y métodos: Estudio no experimental, analítico, prospectivo y transversal. Se aplicó previo consentimiento informado, un instrumento validado sobre ansiedad State and Trait Anxiety Inventory. Se determinó una muestra estadística aleatorizada simple (n = 248) con personas mayores de 17 años que tuvieran cardiopatía congénita cianógena o acianógena. Se analizaron los datos sociodemográficos con frecuencias, porcentajes y medidas de tendencia central; se compararon y asociaron variables ordinales con U de Mann Whitney, Pearson y S...

Early detection of developmental delay and childhood disorders are important for early intervention. This study aimed to describe the distribution of responses in a large population-based survey, identify cutoff points for the parent concern checklist (PCC) suitable for the Chinese language and culture, and explore how many children were identified as having evidence of problems at age 18 mo different from those at age 6 mo. Using a national randomly selected sample, the overall development of 21,248 children was investigated using the Taiwan Birth Cohort study instrument, and the PCC, a problem-oriented screening instrument. The Newton-Raphson iteration showed that the PCC should be separated into three groups, those scoring 1-2 in the first group, 3-6 in the second group, and 7-8 in the third group. Structural equation models showed that 6-mo development was predictive of 18-mo development; additionally, 18-mo development and the PCC showed good concurrent validity. This study identified three groups with distinct developmental trajectories and two cutoff points of 2/3 and 6/7. Thus, the PCC can be used as a first-stage screening instrument in a two-stage window screening procedure. Further studies are needed to investigate the factors, which contribute to the differences among these groups; follow-up on the typical and atypical development of these children is necessary.

on behalf of the GISSI-3 Investigators* Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 ؎ 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction <40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class >I and early intravenous ␤-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral ␤-blocker therapy given or not given after early intravenous ␤-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction <40%. Killip class >I and the early intravenous ␤-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI. ᮊ1998 by Excerpta Medica, Inc.