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The method of shock wave therapy (ESWT) was used for the treatment of several symptoms of chronic pain. There were especially: cervical syndromes, lumbago, plantar fasciitis, achillodynia, metatarsalgia and humeral epicondylitis. We confirmed the positive effect of shock wave therapy for pain relief on these syndromes. This method is also effective in other pain syndromes. The effect of this application is very individual and therefore it is necessary to indicate differing numbers of therapeutic applications. We recommend this method as a very useful tool for completion possibilities in the treatment of chronic pain.

Free radicals play an important role in nasal and paranasal diseases. The formation of free radicals in these diseases is similar to other tissues. In many cases antioxidants can ameliorate the course of the disease. Inflammations such as rhinitis, allergic rhinitis, sinusitis, acute and chronic tonsillitis or inflammations evoked by cigarette smoke are common nasal and paranasal diseases associated with free radicals. Nitric oxide, as a free radical, has been shown to effect vasodilatation, patency of the nose, secretion of saliva, immunological properties, cytokine stimulation, and wound healing. Nasal and paranasal diseases often influence the composition of saliva; this characteristic can be used to make a diagnosis or better manage patient therapy. Polyps and tumors are affected by free radicals as well, but antioxidant therapy of tumors, especially in advanced cases, may be not suitable.

This study was designed to assess the principal markers of thrombogenicity and biocompatibility during continuous veno-venous hemodiafiltration (CVVHDF) using regional citrate anticoagulation (RCA). In a prospective study, 11 procedures with a polysulfone membrane were performed in nine critically ill patients with acute renal failure and impaired hemostasis. Blood samples were taken before and during CVVHDF at diafilter outlet--before calcium-induced reversal of the effect of citrate--at 15, 60, 360, and 1440 minutes. In four patients, 10 CVVHDF sessions were performed with systemic heparin anticoagulation (HA) using a polyacrylonitrile membrane. During RCA, blood thrombocyte count, plasma thrombin-antithrombin III complexes, beta-thromboglobulin, and von Willebrand factor levels did not differ significantly from baseline. Plasma D dimer levels rose significantly at 360 minutes; however, the difference between diafilter inlet and outlet levels was nonsignificant. There was a significant increase in plasma C5a concentrations and a decline in blood leukocyte count in the early phase of CVVHDF. Just as in RCA, no increase in plasma thrombogenicity indices was observed during HA. However, clotting times in blood entering patients' circulation were significantly prolonged. Plasma C5a concentrations increased significantly at the beginning of CVVHDF. RCA can effectively inhibit the thrombogenic effect of the extracorporeal circuit in CVVHDF. The effect of HA may be similar, however, at the expense of systemic anticoagulation and risk of bleeding. RCA, performed in a way that overcomes thrombogenicity, does not completely eliminate complement activation and/or transient leukopenia during CVVHDF.

Pretreatment with tempol, a membrane-permeable radical scavenger, has been shown to be protective in rodent models of endotoxic and Gram-positive shock. However, neither the pretreatment design nor hypodynamic endotoxic shock in rodents mimics the clinical scenario. Therefore, we investigated the effects of tempol in a posttreatment model of long-term, volume-resuscitated, hyperdynamic porcine bacteremia.Prospective, randomized, controlled experimental study.University animal laboratory.Sixteen anesthetized, mechanically ventilated, and instrumented pigs.Sepsis was induced and maintained for 24 hrs with continuous infusion of live Pseudomonas aeruginosa. After 12 hrs of hyperdynamic sepsis, animals were randomized to receive either vehicle (control, n = 8) or continuous infusion of tempol (n = 8, 30 mg/kg/hr).Systemic and hepatosplanchnic hemodynamics, oxygen exchange, metabolism, ileal mucosal microcirculation, and tonometry as well as oxidative stress and coagulation variables were assessed before and after 12, 18, and 24 hrs of P. aeruginosa infusion. Tempol significantly attenuated reduction in mean arterial pressure. Despite comparable mesenteric macrocirculation, tempol attenuated the otherwise progressive deterioration in ileal mucosal microcirculation and prevented mucosal acidosis. By contrast, treatment with tempol failed to influence the P. aeruginosa-induced derangements of hepatosplanchnic redox state, liver lactate clearance, and regional acidosis but prevented the development of renal dysfunction. In addition, tempol reduced nitrosative stress without significant effect on the gradual increase in plasma 8-isoprostanes. Finally, tempol attenuated sepsis-induced endothelial (von Willebrand factor) and hemostatic dysfunction (thrombin-antithrombin complexes, plasminogen activator inhibitor-type 1).The radical scavenger tempol partially prevented live bacteria from causing key features of hemodynamic and metabolic derangements in porcine hyperdynamic sepsis and beneficially affected surrogate markers of sepsis-induced endothelial and coagulation dysfunction. Incomplete reduction of oxidative stress because of dilutional effects and/or missed optimal therapeutic window for antioxidant treatment when used in posttreatment approach may account for the only partial protection by tempol in this model.

The Czech Society of Cardiology is proposing here the new classification of acute coronary syndromes at the time of the first medical contact. The proposal suggests to remove the terms “ST elevation myocardial infarction” and “non-ST elevation acute coronary syndrome” and to replace these terms by “acute coronary syndrome with ongoing myocardial ischemia” and “acute coronary syndrome without ongoing myocardial ischemia”. The proposed new classification better reflects current treatment approaches and will facilitate the decision making at the first medical contact.

To evaluate the effects of post-pyloric enteral nutrition (EN) on hepato-splanchnic and systemic hemodynamics, metabolism and gastric mucosal energy balance in septic patients.Prospective clinical study.Medical intensive care unit (ICU) in a university hospital.Ten hemodynamically stable, mechanically ventilated patients with severe sepsis. Eight patients required norepinephrine.Low dose post-pyloric EN (Survimed, 40 ml bolus, 40 ml h(-1) continuously).Three data sets: F1 = baseline fasting, EN(120) = after 120 min of EN, F2=120 min after EN cessation. In addition to global hemodynamics and gastric mucosal PCO(2), we measured hepato-splanchnic blood flow (HSBF) using continuous primed indocyanine green dye infusion with hepatic venous sampling. The mean arterial pressure remained unchanged. During EN systemic vascular resistance decreased ( p0.05), while cardiac index increased (p0.001). Simultaneously, HSBF increased during EN and decreased again at F2 (1.54 [0.88; 1.66] l min(-1) m(-2 )at F1; 1.72 [1.18; 1.83] l min(-1) m(-2 )at EN and 1.38 [0.91; 1.63] l min(-1) m-(2 )at F2, p0.001). Hepatic venous acid base status, lactate/pyruvate ratio and splanchnic lactate balance remained unchanged. There was also no change in splanchnic oxygen extraction ratio or in gastric mucosal to arterial PCO(2) difference.The initiation of low dose post-pyloric EN in medical ICU patients with severe sepsis led to the parallel increase of systemic and hepato-splanchnic blood flow. Hepato-splanchnic energy metabolism, oxygen kinetics and gastric mucosal energy balance did not deteriorate during EN, suggesting that EN during sepsis may not be harmful even in patients requiring norepinephrine.

Purpose. To investigate the pattern of changes of gut mucosal, glomerular, and pulmonary permeability in response to major resectional intestinal surgery, and to evaluate whether these changes are related to oxidative stress. Methods. Eight patients undergoing elective intestinal surgery. Lactulose/mannitol ratio (LMR), urinary albumin/creatinine ratio (MACR), and extravascular lung water and its ratio to intrathoracic blood volume (EVLW/ITBV) were measured preoperatively and at different time points postsurgery. The oxidant/antioxidant balance was assessed by measuring thiobarbituric acid-reactive species, reduced glutathione, plasma total antioxidant capacity, superoxide dismutase, and glutathione peroxidase. Results. Uncomplicated intestinal surgery was associated with early increase in LMR and MACR. The EVLW/ITBV ratio increased, but still remained within the normal range. The amount of EVLW was not affected. While renal permeability changes resolved rapidly, increased intestinal permeability persisted longer postoperatively. There was no evidence for any marked disturbances in the oxidant/antioxidant balance. Conclusions. This pilot study indicated that a moderate increase in gut and renal permeability, even in the absence of clinical sequelae, is an early feature of uncomplicated intestinal surgical trauma. These alterations are not accompanied by any clinically detectable changes in pulmonary permeability.

Background: This study evaluated the effects of protocol-guided fluid loading on extravascular lung water (EVLW) and hemodynamics in a group of patients at high risk for volume expansion-induced pulmonary and systemic edema. Methods: Nine acutely admitted septic patients with acute lung injury (ALI) were prospectively studied. In addition to sepsis and ALI, the following criteria indicating increased risk for edema formation had to be fulfilled: increased vascular permeability defined as microalbuminuria greater than fivefold normal and hypoalbuminemia

Objective: The impact of the start of continuous veno-venous haemodiafiltration (CVVHDF) on gastric mucosal carbon dioxide concentration (PiCO2) - a marker of gastric mucosal perfusion and CO2 production - was studied. Design: Prospective observational study. Setting: University hospital medical intensive care unit (ICU). Subjects: Sixteen critically ill haemodynamically stable patients (APACHE II on admission 30±7) with multiple organ dysfunction syndrome, in whom CVVHDF was started because of acute renal failure were studied. Two patients were excluded from the analysis because of major haemodynamic instability during the study period. Interventions: Initiation of CVVHDF, placement of gastric tonometer. Measurements and main results: PiCO2 was measured using saline tonometry in 13 patients, and air tonometry in one patient at baseline and then at 1,2,3 and 6 h after starting CVVHDF. A gastric-arterial CO2 gap of > 15 torr (2 kPa) was chosen asa cut-off value of the presence of gastric musocal acidosi...

The effect of exercise on gastric mucosal energy status has not been fully elucidated. The aim of this study was to evaluate the impact of submaximal cycling on gastric mucosal energy balance and its relationship to changes in systemic energy status. Ten healthy volunteers (age 20-40 years) were investigated at rest (BL), during 30 min of submaximal exercise (E) on bicycle ergometry and during the 30 min after the completion of cycling. Gastric mucosal PCO(2) ( P(gm)CO(2)) was measured by air tonometry at 10-min intervals and the gastric mucosal-arterial PCO(2) difference ( PCO(2)gap) was calculated. Hemodynamics, arterial blood gases, lactate and pyruvate were also measured. PCO(2)gap significantly increased throughout exercise [BL: 0.2 kPa (median), -0.1-0.6 kPa (25th-75th percentiles); E(10 min): 1.0 kPa, 0.8-1.7 kPa; E(20 min): 1.35 kPa, 0.8-1.8 kPa; E(30 min): 1.5 kPa, 0.9-2.0 kPa]. The early changes in PCO(2)gap ( PCO(2)gap at E(10 min) minus PCO(2)gap at BL) correlated significantly and positively with corresponding changes in arterial lactate ( r(2)=0.58, P

IntroductionRepetitive transcranial magnetic stimulation (rTMS) has important role in treatment of neuropsychiatric disorders. Theta burst stimulation (TBS), a modification of rTMS, seems to produce greater changes in cortical excitability (CE) than those observed in conventional rTMS protocols. TBS is used in different protocols: intermittent TBS (iTBS) and continuous TBS (cTBS). While iTBS facilitates CE, cTBS leads to CE inhibition. However, a prolonged cTBS produces facilitatory effect similar to that of iTBS. Prolonged TBS (pTBS), a novel rTMS paradigm, is of great clinical interest for its short duration, but also because it may induce stronger effect.AimTo prove the effect of pTBS of motor cortex on changes of motor threshold (MT), CE and pain threshold (PT) in healthy volunteers (HV). To compare the effects of two different forms of active pTBS (pcTBS, piTBS) with placebo.MethodsA double-blind, placebo-controlled, cross-over study compared the effects of different pTBS of contralateral M1 area on MT, CE and PT. We enrolled 24 HV to the study, who underwent all types of pTBS in randomized order and were assessed before and after each pTBS application. We used MagPro R30 (with coil focused to contralateral M1 area, 1200 pulses/session, 90% MT).ResultsA significant changes in CE and MT were found after application of continuous pTBS. Intermittent and placebo pTBS did not confirm the effect. There were no significant changes on PT after pTBS. Continuous pTBS was better tolerated than intermittent pTBS.ConclusionpTBS should be considered as an effective and safe treatment option for neuropsychiatric disorders.Disclosure of interestSupported by AZV 16-31380A.

Předkladame kasuistiku třicetilete ženy s infekcni endokarditidou, u niž byla spravna diagnoza stanovena teměř půl roku po zacatku obtiži. K vysetřeni na kardiologii nasi kliniky se nemocna dostala až ve stadiu zavažných srdecnich komplikaci a v celkově vycerpanem stavu. Přitom již před pěti měsici byla podrobně vysetřovana pro ischemickou cevni mozkovou přihodu, jejiž přicina nebyla uspokojivě objasněna.

Acute heart failure (AHF) is a clinical syndrome of different etiology and several clinical presentations. Cardiogenic shock patients have highest long-term mortality. In contrast to chronic heart failure, we have no evidence of therapeutic benefit for any treatment strategy from randomized clinical trials. Search for new pharmacologic and non-pharmacologic therapies is ongoing. Both causal and symptomatic treatment of AHF episode should be initiated as soon as possible. This review is focused on trends in acute heart failure therapy at the beginning of 21st century.

Despite the extensive armamentarium of antihypertensive medication available, the control of hypertension remains poor. Therefore any possibilities of non-pharmacological treatment of resistant hypertension are welcome. Recently, close attention was paid to renal denervation. Present work summarizes the scientific reports and clinical trials related to this topic published so far and addresses the unanswered questions. Moreover, it also contains brief summary of authors own experience with the method.

Neither pain, nor depression exist as independent phenomena per se, they are highly subjective inner states, formed by our brain and built on the bases of our experiences, cognition and emotions. Chronic pain is associated with changes in brain physiology and anatomy. It has been suggested that the neuronal activity underlying subjective perception of chronic pain may be divergent from the activity associated with acute pain. We will discuss the possible common pathophysiological mechanism of chronic pain and depression with respect to the default mode network of the brain, neuroplasticity and the effect of antidepressants on these two pathological conditions. The default mode network of the brain has an important role in the representation of introspective mental activities and therefore can be considered as a nodal point, common for both chronic pain and depression. Neuroplasticity which involves molecular, cellular and synaptic processes modifying connectivity between neurons and neuronal circuits can also be affected by pathological states such as chronic pain or depression. We suppose that pathogenesis of depression and chronic pain shares common negative neuroplastic changes in the central nervous system (CNS). The positive impact of antidepressants would result in a reduction of these pathological cellular/molecular processes and in the amelioration of symptoms, but it may also increase survival times and quality of life of patients with chronic cancer pain.

Seven healthy volunteers and nine stable intensive care unit (ICU) patients with poor tolerance of gastric feeding were investigated. In volunteers, postpyloric feeding does not interfere with gastric tonometry measurement and gastric bolus leads to a PiCO2 decrease. The impact of postpyloric and gastric feeding on gastric tonometry in ICU patients with compromised gut is variable.

An epileptic seizure and postictal period in addition to well-known features are also characterized by massive consumption of energy. This is thought to lead to oxidative stress and increased generation of free radicals, which is reflected by increased levels of oxidative products. Our previous work described the neuroprotective effects of melatonin in preventing cognitive worsening after a single epileptic seizure. This work was aimed on direct measurement of free radicals in brain tissue using the EPR method 1, 15 and 60 minutes after seizure. The measurement was performed in adult male Wistar rats at the mentioned intervals after a single tonic-clonic seizure induced by flurothyl. In comparison to control animals there was a significant increase in hydroxyl and nitroxyl radicals 60 minutes after the seizure. The levels of hydroxyl radicals were significantly lower in animals that received melatonin 60 minutes before seizure induction compared to animals without preventive treatment. Therefore, melatonin affected the generation of the measured free radicals differently. An important finding was the delayed increase in free radicals after a single seizure in the later phases of recovery.

The effect of stress anticipation was studied in two inbred Wistar rat strains with high and low sensitivity to isoprenaline. The animals were exposed to tail-flick and 4-hr water immersion restraint stress on two consecutive days. On the first day stress was applied to one group and the next day to the anticipation group. The changes in adrenal, heart and spleen weights, tail-flick latency, incidence of gastric ulcers, and the antioxidant defense system in the sensorimotor cortex were compared with two non-stressed control groups. Anticipatory stress decreased adrenal weights. The content of thiobarbituric acid reactive substances (TBARS) was increased both in acute and anticipatory stress; superoxide dismutase, glutathione peroxidase, and antioxidative capacity were increased in anticipatory stress only. Stress anticipation decreased the pain threshold in the isoprenaline-sensitive and increased in the isoprenaline-resistant rats and led to more frequent gastric ulcers in the isoprenaline-resistant group. Significant sex differences were observed both in adrenal weights and TBARS content. The relative adrenal weights were negatively correlated with the TBARS content. We suggest that the outcome of anticipatory stress may depend upon the relation between the hormonal and antioxidant functions of the adrenals and that anticipation-induced activation of antioxidant enzymes may ameliorate the acute stress response. Anticipation itself was found to be a stronger stressor than physical acute stress.

Aim of the study was to verify the efficacy of "mesodiencephalic" modulation (MDM), as named by the commercial promoters, in reducing symptoms accompanying painful diabetic neuropathy and in improving mental health.32 patients with type 1 and 2 diabetes mellitus, with painful neuropathy, were enrolled in the prospective, double-blind, placebo-controlled, cross-over study. The modulation was performed using MDM electrotherapeutic device (ZAT a.s), sham modulation was used as a placebo. Pain relief (visual analogue scale-VAS; total symptom score-TSS) and changes in mental state (Beck Depression Inventory-BDI-II; OSWESTRY and SF-36 questionnaires) were evaluated.The study was completed by 30 patients. Pain evaluation: VAS: pain relief was statistically insignificantly higher after real (R) compared to sham (S) modulation (-0.7 vs. -0.3; p=0.06), effect of both modulations was equal after 1 month (-0.4 vs. 0.0; p=0.46). TSS: the effect of R and S modulation did not differ immediately after the procedure (-1.3 vs. -1.0; p=0.27), nor after 1 month (-1.5 vs. -0.34; p=0.9). Psychological tests: according to SF-36, the physical health improved considerably after R compared to S (2.5 vs. -2.0; p0.01), however, changes in the mental health were equal (-1.5 vs. 0.0; p=0.78). Oswestry (0 vs. 0; p=0.95) and BDI-II (-0.5 vs. -1.0; p=0.42) were comparable after R and S modulation. Order of the procedures (R vs. S) did not affect results.The study did not demonstrate any positive effect of MDM on painful diabetic neuropathy compared to placebo, relative to pain or mental state evaluations. The study emphasizes the need of using placebo-controlled studies, especially when testing a new analgesic drug or a method for pain modulation.

Background Although radial approach is increasingly used in percutaneous coronary interventions (PCIs) including in acute myocardial infarction (MI), patients with cardiogenic shock have been excluded from comparisons with femoral approach. The aim of our study was to compare clinical outcomes in patients undergoing primary PCI with cardiogenic shock by radial and femoral approach. Methods and Results From 2,663 patients presenting with ST-elevation MI in 2 large volume radial centers, we identified 197 patients (7.4%) with signs of cardiogenic shock immediately before undergoing primary PCI. Radial approach was used in 55% of cases when at least 1 radial artery was weakly palpable, either spontaneously or after intravenous noradrenaline bolus. Patients in the radial group were older (69 ± 12 vs 64 ± 12 years, P = .010), had less diabetes (13% vs 26%, P = .028), and required less often intubation prior PCI (42% vs 66%, P = .0006) or intraaortic balloon pump (36% vs 55%, P = .0096). Mortality at 1 year was 44% in the radial group and 64% in the femoral group ( P = .0044). Independent predictors of late mortality included radial approach (hazard ratio [HR] 0.65, 95% CI 0.42-0.98, P = .041), the use of glycoprotein IIb-IIIa receptor inhibitors (HR 0.63, 95% CI 0.40-0.96, P = .032), baseline creatinine ≥110 μmol/L (HR 3.34, 95% CI 2.20-5.12, P 200 mg/dL (HR 2.02, 95% CI 1.34-3.11, P = .0008), and age >65 years (HR 1.80, 95% CI 1.18-2.79, P = .006). Conclusion Radial approach was safe and feasible in more than half of the patients with ST-elevation MI and cardiogenic shock treated by primary PCI. After adjustment for baseline and procedural characteristics, radial approach remained associated with better survival. However, prognosis of patients undergoing primary PCI in cardiogenic shock remains poor.

Background Older age, as a factor we cannot affect, is consistently one of the main negative prognostic values in patients with acute myocardial infarction. One of the most powerful factors that improves outcomes in patients with acute coronary syndromes is the revascularization preferably performed by percutaneous coronary intervention. No data is currently available for the role of age in large groups of consecutive patients with PCI as the nearly sole method of revascularization in AMI patients. The aim of this study was to analyze age-related differences in treatment strategies, results of PCI procedures and both in-hospital and long-term outcomes of consecutive patients with acute myocardial infarction. Methods Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patients divided into two groups according to age (1800 patients ≤ 65 years and 2014 patients > 65 years). Significantly more older patients had a history of diabetes mellitus and previous myocardial infarctions. Results The older population had a significantly lower rate of coronary angiographies (1726; 95.9% vs. 1860; 92.4%, p Conclusions In a consecutive AMI population, the older group (>65 years) was associated with a less pronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomy by coronary angiography and proceed to PCI if suitable regardless of age is crucial in all patients, though the primary success rate of PCI in the older age is lower. Age, when viewed as a risk factor, was a dominant discriminating factor in all patients.

Background Traditionally, acute myocardial infarction (AMI) has been described as either STEMI (ST-elevation myocardial infarction) or non-STEMI myocardial infarction. This classification is historically related to the use of thrombolytic therapy, which is effective in STEMI. The current era of widespread use of coronary angiography (CAG), usually followed by primary percutaneous coronary intervention (PCI) puts this classification system into question. Objectives To compare the outcomes of patients with STEMI and ST-depression myocardial infarction (STDMI) who were treated with emergency PCI. Methods This multicentre registry enrolled a total of 6 602 consecutive patients with AMI. Patients were divided into the following subgroups: STEMI (n = 3446), STDMI (n = 907), left bundle branch block (LBBB) AMI (n = 241), right bundle branch block (RBBB) AMI (n = 338) and other electrocardiographic (ECG) AMI (n = 1670). Baseline and angiographic characteristics were studied, and revascularisation therapies and in-hospital mortality were analysed. Results Acute heart failure was present in 29.5% of the STDMI vs 27.4% of the STEMI patients (p < 0.001). STDMI patients had more extensive coronary atherosclerosis than patients with STEMI (three-vessel disease: 53.1 vs 30%, p < 0.001). The left main coronary artery was an infract-related artery (IRA) in 6.0% of STDMI vs 1.1% of STEMI patients (p < 0.001). TIMI flow 0–1 was found in 35.0% of STDMI vs 66.0% of STEMI patients (p < 0.001). Primary PCI was performed in 88.1% of STEMI (with a success rate of 90.8%) vs 61.8% of STDMI patients (with a success rate of 94.5%) (p = 0.012 for PCI success rates). In-hospital mortality was not significantly different (STDMI 6.3 vs STEMI 5.4%, p = 0.330). Conclusion These data suggest that similar strategies (emergency CAG with PCI whenever feasible) should be applied to both these types of AMI.

The aim of the present study was to compare the response to sub-chronic application of methamphetamine (MA) in adulthood in male and female rats prenatally exposed to the same drug. The spontaneous locomotor activity and exploratory behavior of adult male and female rats prenatally exposed to 5 mg/kg MA or saline (SAL) were tested in a Laboras apparatus (Metris B.V., Netherlands) for five consecutive days, 1 hr daily. MA 1 mg/kg or SAL were used as a challenge prior to testing. Our results showed that rats prenatally exposed to MA were more sensitive to sub-chronic administration of MA in adulthood than prenatally SAL-exposed rats. However, this sensitizing effect of prenatal MA exposure was manifested differently in males and females. In contrast, prenatal MA exposure decreased baseline locomotion in females. This study indicates that gender plays an important role in the sensitivity to MA during prenatal development and in adulthood. © 2012 Wiley Periodicals, Inc. Dev Psychobiol 55: 232–242, 2013

The outcome of acute myocardial infarction (AMI) complicated with cardiogenic shock is poor. The aim of this study was to analyse, whether upfront abciximab administration could improve the outcomes of cardiogenic shock.This multicentre open trial randomized 80 patients with AMI complicated by cardiogenic shock expected to undergo primary PCI into group A (routine upfront-pre-procedural-abciximab bolus followed by 12-h abciximab infusion) and group B (standard therapy). The study primary objective was 30-day combined outcome (death/reinfarction/stroke/new severe renal failure).PCI was technically successful in 90% (A) versus 87.5% (B) patients. Abciximab was used in 100% (A) versus 35% (B). The primary endpoint occurred in 17 group A patients (42.5%) and 11 group B patients (27.5%, P = 0.24). Ejection fraction among survivors after 30 days was 44 ± 11% (A) versus 41 ± 12% (B, P = 0.205). Major bleeding occurred in 17.5% (A) versus 7.5% (B, P = 0.310). No differences (A versus B) were found in TIMI-flow and MBG after PCI.This study did not show any benefit from routine pre-procedural abciximab when compared with a selective abciximab use during the intervention in patients with cardiogenic shock undergoing primary PCI. However, small sample size of the trial preclude any definitive conclusion, a larger prospective, randomized, multicentered trial is needed.

We are pleased to address Dr. Lee’s comments on the results of the STEMI-RADIAL (ST Elevation Myocardial Infarction treated by RADIAL or femoral approach) trial published in the Journal [(1)][1]. First, this letter has already been published twice with almost identical content [(2,3)][2]. Second

Radial artery occlusion (RAO) can result from transradial catheterization. We compared the incidence of RAO with 2 heparin dosage regimens after transradial coronary angiography, and we evaluated the efficacy and safety of transient homolateral ulnar artery compression to achieve acute radial artery recanalization. Patients referred for coronary angiography were randomized to very-low-dose heparin (2,000 IU) or low-dose heparin (5,000 IU). On sheath removal, hemostasis was obtained using the TR band with a plethysmography-guided patent hemostasis technique. In the case of RAO as assessed by duplex ultrasonography 3 to 4 hours after hemostasis, immediate 1-hour ulnar artery compression was applied. Hematomas >15 cm 2 were also assessed. We randomized 465 patients, 222 in the 2,000-IU group and 243 in the 5,000-IU group. The baseline and procedural characteristics were comparable in both groups. The incidence of initial RAO was 5.9% in the 2,000-IU group and 2.9% in the 5,000-IU group (p = 0.17), with a compression time of 2.10 ± 0.78 hours and 2.25 ± 0.82 hours, respectively (p = 0.051). After ulnar artery compression, the final incidence of RAO was 4.1% in the 2,000-IU group and 0.8% in the 5,000-IU group (p = 0.03). The incidence of local hematoma was 2.3% and 3.7% in the 2,000- and 5,000-IU groups, respectively (p = 0.42). In conclusion, acute RAO after transradial catheterization can be recanalized by early 1-hour homolateral ulnar artery compression. This simple nonpharmacologic method was effective and safe in patients with very-low- and low-dose heparin. Nevertheless, the incidence of final RAO remained significantly lower after a higher anticoagulation level.

article i nfo Our previous studies repeatedly demonstrated that prenatal methamphetamine (MA) exposure alters seizure susceptibility in adult rats. Both the inhibitory GABA system and the excitatory NMDA system play a role in the effect of MA on epileptic seizures. On the basis of our previous behavioral results, the effect of cross- fostering on seizure susceptibility in adult female rats was examined in the present study. Bicuculline (GABAA receptor antagonist) and NMDA (NMDA receptor agonist) were used to induce seizures in adult female offspring exposed to MA in the prenatal and/or preweaning periods. Female dams were injected with MA (5 mg/kg daily) or physiological saline (S) for approximately 9 weeks (about 3 weeks prior to impregnation, for the entire gestation period (22 days), and in the preweaning period (21 days)). Absolute controls (C) did not receive any injections. On postnatal day 1, pups were cross-fostered so that each mother received pups from all three treatments. Thus, nine groups (based on the prenatal and postnatal drug exposures) of adult female rats were tested in each seizure test: C/C, C/S, C/MA, S/C, S/S, S/MA, MA/C, MA/S, MA/MA. The present study demonstrated that both the excitatory NMDA system and the inhibitory GABA system are involved in the proconvulsive effect of MA during prenatal and partially also postnatal development in female rats. However, because our results did not show any improvement in seizure susceptibility in prenatally MA- exposed animals that were fostered by control mothers (MA/C) relative to their siblings fostered by MA- treated mothers (MA/MA), our hypothesis of the cross-fostering effect seems to be incorrect in contrast to our behavioral studies.

Background. Unoperated severe tricuspid regurgitation (TR) leads to the right ventricle (RV) failure. We wanted to determine if there was near-term postoperative progression of noncorrected mild to moderate functional TR in patients who underwent mitral valve surgery for chronic significant mitral regurgitation (MR) and if RV size and function were affected.Methods and Results. We compared two groups of patients retrospectively. In the first group (TVA+, ), tricuspid valve annuloplasty (TVA) had been performed in conjunction with either mitral valve replacement (MVR) or mitral valve repair (MVP). The second group (TVA−, ) underwent MVP or MVR without TVA. TVA+ group revealed a significant decrease in TR and right ventricle diameter. In the TVA− group, 7 patients (32%) showed a significant progression, by one or more grades, of noncorrected TR together with dilatation and decreased ejection fraction of the right ventricle.Conclusions. Tricuspid annuloplasty performed concurrently with MVP or MVR can prevent subsequent progression of tricuspid regurgitation along with right ventricular dilatation and systolic dysfunction in the near-term postoperative period.

While the effect of cortex stimulation on pain control is widely accepted, its physiological basis remains poorly understood. We chose an animal model of pain to study the influence of sensorimotor cortex stimulation on tooth pulp stimulation evoked potentials (TPEPs). Fifteen awake rats implanted with tooth pulp, cerebral cortex, and digastric muscle electrodes were divided into three groups, receiving 60 Hz, 40 Hz and no cortical stimulation, respectively. TPEPs were recorded before, one, three and five hours after continuous stimulation. We observed an inverse relationship between TPEP amplitude and latency with increasing tooth pulp stimulation. The amplitudes of the early components of TPEPs increased and their latency decreased with increasing tooth pulp stimulation intensity. Cortical stimulation decreased the amplitude of TPEPs; however, neither the latencies of TPEPs nor the jaw-opening reflex were changed after cortical stimulation. The decrease in amplitude of TPEPs after cortical stimulation may reflect its anti-nociceptive effect.

Stimulant drugs are often associated with increased seizure susceptibility. Inhibitory γ-aminobutyric acid (GABA) and excitatory N-methyl- d -aspartate (NMDA) systems play a role in the effect of stimulants in the genesis of epileptic seizures. Our previous studies showed that prenatal methamphetamine (MA) exposure induced long-term changes in seizure susceptibility. The aim of the present study was to investigate the effect of cross-fostering on the prenatal and postnatal MA-exposed rats, respectively, on their seizures in adulthood. Bicuculline (GABAA receptor antagonist), NMDA (NMDA receptor agonist) and flurothyl (a convulsant gas) were used to induce seizures in adult male offsprings. Female dams were injected with MA (5 mg/kg daily) or physiological saline (S) for approx. 9 week [about 3 week prior to impregnation, for the entire gestation period (22 days) and in preweaning period (21 days)]. Absolute controls (C) did not receive any injections. On postnatal day 1, pups were cross-fostered so that each mother received pups from all three treatments. Thus, nine groups (based on the prenatal and postnatal drug exposure) of adult male rats were tested in each seizure test: C/C; C/S; C/MA; S/C; S/S; S/MA; MA/C; MA/S; MA/MA. The present study demonstrates that the effect of prenatal and/or postnatal MA exposure is seizure model specific. In addition, our data show that there is an effect of cross-fostering on seizures; particularly, the effect of prenatal MA exposure shown in animals fostered by control mothers is no longer apparent in animals fostered postnatally by MA-treated mothers. Such effect of postnatal treatment is not manifested in prenatal controls. In summary, it seems that: (1) prenatal MA exposure alters seizure susceptibility more than postnatal MA exposure; (2) especially in seizures induced by chemicals that affect GABAergic system (bicuculline, flurothyl) notable effect of adoption (cross-fostering) is apparent; (3) in seizure models that are associated with NMDA system (NMDA, flurothyl), effect of prenatal stress seems to play a role.

The objective was a systematic study of the biochemical markers which are descriptive for the dynamics of pain processes.The patients who had not been systematically treated for pain prior to their participation in this study consisted of 20 non-oncological (mean age 56.5 years) and 20 oncological patients (mean age 64.8 years). Pain intensity, assessed using the visual analogue scale (VAS) on a scale from 0-10, and the following biochemical parameters were measured during the initial patient workups: blood serum total protein, glucose, total cholesterol, HDL cholesterol, LDL cholesterol, atherosclerotic indexes, triacylglyceroles, apolipoprotein A, apolipoprotein B, albumin, alpha1 globulin, alpha2 globulin, beta globulin and gamma globulin. Biochemical measurements were repeated as soon as VAS assessments fell below 5. Therapy in non-oncological patients involved administration of NSA and weak opioids; while oncological patients received NSA, medium strength and strong opioids, and antidepressants.Prior to therapy, concentration of albumin in serum, HDL cholesterol, and apolipoprotein A were lower, whereas CRP and alpha1 globulin were higher in oncological patients compared to non-oncological patients. After therapy, levels of glucose and alpha1 globulin were significantly higher and levels of apolipoprotein A were lower in oncological patients compared to non-oncological patients. Irrespective of diagnosis, patients treated with antidepressants showed higher levels of gamma globulin compared to non treated patients.We can conclude that observed biochemical markers in patients with malignancies are more similar to the values of patients with chronic benign pain than to the values of patients with acute pain.

A higher mean arterial pressure (MAP) achieved by norepinephrine up-titration may improve organ blood flow in critically ill, whereas norepinephrine-induced afterload rise might worsen myocardial function. Our aim was to assess the effects of norepinephrine dose titration on global hemodynamics in cardiogenic shock. We prospectively evaluated 12 mechanically ventilated euvolemic patients (aged 67±12 years) in cardiogenic shock (10 patients acute myocardial infarction, 1 patient dilated cardiomyopathy, 1 patient decompensated aortic stenosis). Hemodynamic monitoring included arterial and Swan-Ganz catheters. The first data were obtained at MAP of 65 mm Hg, then the norepinephrine dose was increased over 40 min to achieve MAP of 85 mm Hg. Finally, the norepinephrine-dose was tapered over 40 min to achieve MAP of 65 mm Hg. Norepinephrine up-titration increased MAP to the predefined values in all patients with concomitant mild increase in filling pressures and heart rate. Systemic vascular resistance increased, whereas cardiac output remained unchanged. During norepinephrine down-titration, all hemodynamic parameters returned to baseline values. We observed no changes in lactate levels and mixed venous oxygen saturation. Our data suggest that short-term norepinephrine dose up-titration in cardiogenic shock patients treated or pretreated with inotropes was tolerated well by the diseased heart.

The aim of our study was to examine the effect of prenatal methamphetamine (MA) exposure and cross-fostering on cognitive functions of adult male rats tested in Morris water maze (MWM). Rat mothers were exposed daily to injection of MA (5 mg/kg) or saline for 9 weeks: prior to impregnation, throughout gestation and lactation periods. Females without any injections were used as an absolute control. On postnatal day 1, pups were cross-fostered so that each mother raised 4 pups of her own and 8 pups from the mothers with the other two treatments. Four types of tests were used: (1) Place navigation test (Learning), (2) Probe test (Probe), (3) Retention memory test (Memory) and (4) Visible platform task. Our results demonstrate that the prenatal exposure to MA does not impact learning and memory, while postnatal exposure to MA shows impairments in cognition. In the test of learning, all animals fostered to MA-treated dams had longer latencies, bigger search error and used lower spatial strategies than the animals fostered to control or saline-treated mother, regardless of prenatal exposure. Regardless of postnatal exposure, the animals prenatally exposed to saline swam faster in all the tests than the animals prenatally exposed to MA and controls, respectively. This study indicates that postnatal but not prenatal exposure to MA affects learning in adult male rats. However, it is still not clear whether these impairments are due to a direct effect of MA on neuronal structure or due to an indirect effect of MA mediated by impaired maternal care.

The aim of the study was to demonstrate that direct measurement of hydroxyl radicals and singlet oxygen in the tail of living rats is possible. The basic level of hydroxyl radicals and singlet oxygen were measured and the effects of antioxidants on their levels were studied in the tail of living anaesthetized rats after acute postoperative pain. Laparotomy was performed as the source of acute abdominal pain. After closure of the abdominal cavity, the animals began to awaken within 30-60 minutes. They were left to recover for 2-3 hours; then they were reanesthetized and the effect of antioxidants was measured on the numbers of hydroxyl radicals and singlet oxygen via blood in the tail.The laparotomy was preformed under general anesthesia (Xylazin and Ketamin) using Wistar rats. After recovery and several hours of consciousness they were reanaesthetized and free radicals and singlet oxygen were measured. An antioxidant mixture (vitamins A, C, D and Selenium) was administered intramuscularly prior to the laparotomy. All measurements were done on the tail of anaesthetized animals. In this particular article, the effect of antioxidants is only reported for hydroxyl radicals.After laparotomy, which represented both somatic and visceral pain, hydroxyl radicals and singlet oxygen were increased. Antioxidant application prior to laparotomy decreased the numbers of hydroxyl radicals.Results are in agreement with our previous finding regarding the increase in hydroxyl free radicals and singlet oxygen following nociceptive stimulation, in this case a combination of both somatic and visceral pain. The administered antioxidants mitigated the increase. This is further confirmation that direct measurement of free radicals and singlet oxygen represents a very useful method for the biochemical evaluation of pain and nociception.

Sudden circulatory arrest is most often of cardiac origin. Our aim was to evaluate circulatory arrest etiology and treatment strategies in patients after cardiopulmonary resuscitation (CPR) with persistent impairment of consciousness in relation to survival and the subsequent quality of life.Retrospective analysis of patients after CPR treated according to the local protocol including mild hypothermia in the intensive cardiac care unit.Over 2 years, we admitted 57 mechanically ventilated patients after CPR. 47 patients (82%) were resuscitated outside the hospital. In 33 patients (58%) the initial rhythm was ventricular fibrillation; in the remaining patients (42%) asystole/pulseless electrical activity. Urgent coronary angiography was performed in 36 patients and percutaneous coronary intervention in 25 of them. The admission APACHE II score was 32,4 +/- 3,4 with predicted mortality of 77,1%. The hospital survival rate was 54% and 47% of the patients were discharged home in a good state of health (Glasgow outcome score 4-5).Our results suggest that comprehensive post-resuscitation care including therapeutic hypothermia and percutaneous coronary intervention in selected cases may have a positive impact on the prognosis of patients after CPR.

The fetus reacts to nociceptive stimulations through different motor, autonomic, vegetative, hormonal, and metabolic changes relatively early in the gestation period. With respect to the fact that the modulatory system does not yet exist, the first reactions are purely reflexive and without connection to the type of stimulus. While the fetal nervous system is able to react through protective reflexes to potentially harmful stimuli, there is no accurate evidence concerning pain sensations in this early period. Cortical processes occur only after thalamocortical connections and pathways have been completed at the 26th gestational week. Harmful (painful) stimuli, especially in fetuses have an adverse effect on the development of humans regardless of the processes in brain. Moreover, pain activates a number of subcortical mechanisms and a wide spectrum of stress responses influence the maturation of thalamocortical pathways and other cortical activation which are very important in pain processing.

The present study tested the hypothesis that cross-fostering influences the development of rat pups. Mothers were exposed daily to injection of methamphetamine (M) (5 mg/kg) or saline for 9 weeks: 3 weeks prior to impregnation, throughout gestation and lactation periods. Control females animals without any injections were used. On postnatal day (PD) 1, pups were cross-fostered so that each mother received four pups of her own and eight pups from the mothers with the other two treatments. Offspring were tested for sensorimotor development in preweaning period by using tests of: negative geotaxis, tail pull, righting reflexes, rotarod and bar-holding. Further, the pups were weighed daily. Our results showed that birth weight in prenatally M-exposed pups was lower than in control or saline-exposed pups. Prenatally M-exposed pups gained less weight than control or saline-exposed pups regardless of postnatal treatment and sex. Further, our data demonstrated that prenatal and postnatal M exposure impairs sensorimotor functions in most of the tests. On the other hand, the negative effect of prenatal M exposure was partially suppressed in prenatally M-exposed pups by cross-fostering to control dams. Our hypothesis that cross-fostering may affect postnatal development of pups was confirmed.

The aim of the study was to demonstrate the ability to measure free radicals and singlet oxygen, using EPR methods, in the tail of anaesthetized rats. The advantage of this method lies in the potential for continuous evaluation of free radicals and singlet oxygen during nociceptive processes.Electron paramagnetic (spin) resonance (EPR/ESR) was used. DMPO and PBN as spin traps and thermal mechanical pulp (TMP) as a spin detector of singlet oxygen were used. Thirty-one adult male (Wistar) rats were used for the experiments. They were housed according to principles of good laboratory practice. The animals were stimulated for 10 minutes on 5 consecutive days by using clamps on the hind limbs. During the EPR measurement they were anaesthetized with a mixture of ketamine and xylazine. Hydroxyl and nitroxide free radicals, as well as singlet oxygen were measured.After nociceptive stimulation, free hydroxyl radicals were increased as well as free nitroxide radicals. Singlet oxygen was also increased after nociceptive stimulation. Antioxidants significantly decreased the increase in hydroxyl radicals after nociceptive stimulation.Our results confirmed an increase in free radicals and singlet oxygen after nociceptive stimulation and a reduced increase after application of antioxidants. Direct EPR methods were first used in the tail of anaesthetized rats and represent an extremely useful tool for the evaluation of pain intensity in living animals.

Background Precise determination of the aortic annulus size constitutes an integral part of the preoperative evaluation prior to aortic valve replacement. It enables the estimation of the size of prosthesis to be implanted. Knowledge of the size of the ascending aorta is required in the preoperative analysis and monitoring of its dilation enables the precise timing of the operation. Our goal was to compare the precision of measurement of the aortic annulus and ascending aorta using magnetic resonance (MR), multidetector-row computed tomography (MDCT), transthoracic echocardiography (TTE), and transoesophageal echocardiography (TEE) in patients with degenerative aortic stenosis. Methods and results A total of 15 patients scheduled to have aortic valve replacement were enrolled into this prospective study. TTE was performed in all patients and was supplemented with TEE, CT and MR in the majority of patients. The values obtained were compared with perioperative measurements. For the measurement of aortic annulus, MR was found to be the most precise technique, followed by MDCT, TTE, and TEE. For the measurement of ascending aorta, MR again was found to be the most precise technique, followed by MDCT, TEE, and TTE. Conclusion In our study, magnetic resonance was found to be the most precise technique for the measurement of aortic annulus and ascending aorta in patients with severe degenerative aortic stenosis.

The aim of our study was to reveal whether acute methamphetamine (MA) administration changes the sensitivity to seizures induced by N-methyl-D-aspartate (NMDA) in prenatally MA-exposed adult rats. Adult rats with respect to sex and female estrous cycle (prenatally MA-exposed, prenatally saline-exposed, and controls) were divided into groups with acute MA (1 mg/kg) or without acute drug administration (saline injection). Intraperitoneal administration of 250 mg/kg of NMDA was used as a seizure model. The present study demonstrated that both prenatal MA and prenatal saline exposure decreased the latency to onset of stereotypy and clonic-tonic seizures. Acute MA administration decreased latency to onset of stereotypic behavior in all groups, while increased latency to onset of clonic-tonic seizures in prenatally saline-exposed rats. The duration of NMDA seizures was longer after acute MA administration relative to animals without acute MA pretreatment in both control groups. In addition, males displayed decreased susceptibility to NMDA-induced seizures relative to females regardless of their estrous cycle. Our study suggests that acute MA exposure changes susceptibility to NMDA-induced seizures in respect of prenatal exposure and sex. However, it seems that the effect of prenatal exposure is not induced by the drug per se but rather by the repeated injection exposure that causes prenatal stress.

Hippocampal lesions in newborn rats alter the development of mechanisms involved in the processing of nociception. The hippocampal lesion was induced by the bilateral infusion, into the lateral cerebral ventricles, of 0.25 microL of saline containing either 0.25 micromol quinolinic acid (QUIN) and/or 0.25 micromol N-acetyl-L-aspartyl-L-glutamate (NAAG) on postnatal day 12. The same amount of sterile saline was injected into the sham-operated animals (group SHAM). It was expected that the QUIN- and NAAG-lesioned rats would exhibit some differences in thermal pain perception; however, we wanted to know if the control rats would exhibit, at least in part, similar changes in pain perception as their chemically lesioned siblings with which they were housed. Young adult NAAG-injured rats exhibited increased withdrawal latencies in the tail-flick and plantar tests, whereas young adult QUIN-injured animals exhibited only marginally decreased latencies. Nociceptive responses in the SHAM rats paralleled the littermates that had been neonatally treated with QUIN or NAAG, i.e. the responses in the SHAM(QUIN) group decreased, whereas the responses in the SHAM(NAAG) group increased. No significant changes in nociception were observed in intact animals, regardless of which group they were housed with. Our results show that social factors, which were originally demonstrated only for the pain behavior, may also influence basal nociceptive sensitivity in rats. We concluded that the "sham operation" may have had a long-term, nonspecific impact on nociceptive behavior by inducing behavioral mimicry of other animals.

Our previous studies demonstrated that methamphetamine (MA) administration during gestation and/or lactation affects maternal behavior in rats and that birth weight and sensory-motor coordination of their pups are also influenced. The present study tested the hypothesis that the effect of MA induces long-term changes affecting second generation of rats that were not exposed to the drug. Adult females exposed during prenatal and preweaning periods to 5 mg/kg MA daily, were examined for regularity of estrous cycle and mated with stimulus, unexposed males. Dams (nontreated absolute control, saline- and MA-exposed) were observed with their pups in two tests of maternal behavior (observational and retrieval tests). Their pups were further tested throughout the preweaning period to examine their development. Our data demonstrate that MA-exposed mothers displayed more nursing, were more often in the nest and in contact with their pups, and were faster in retrieving their pups than saline-exposed and/or control mothers. There were no differences in litter characteristics, birth weight and weight gain of pups between groups. Interestingly, pups from mothers exposed to MA during prenatal and preweaning period had impaired sensory-motor coordination. They achieved righting reflex in mid-air later than both control groups. Additionally, they had more falls in rotarod and bar-holding tests than pups from both control and saline-exposed mothers. In homing performance, pups from MA- and saline-exposed dams learned slower to return to the home box than pups from control dams. Thus, the present study demonstrates that MA abused by mothers may affect two generations of their offspring.

Coagulation abnormalities have been implicated in the pathogenesis of sepsis and organ dysfunction. Nitric oxide (NO) is regarded as a critical mediator of many vascular pathologies, including sepsis. However, limited evidence is available to document a relationship between NO generated by inducible NO synthase (iNOS) and hemostatic abnormalities in sepsis. Therefore, we evaluated the effects of selective iNOS inhibition on markers of endothelial and coagulation homeostasis in a clinically relevant model of porcine bacteremia induced and maintained for 24 hours (h) with a continuous infusion of live P. aeruginosa. After 12 h of sepsis, animals received either vehicle (Control, n=7) or continuous infusion of selective iNOS inhibitor L-NIL (n=7). Before as well as 12, 18 and 24 h after starting P. aeruginosa following variables related to i) endothelial dysfunction (von Willebrand factor [vWf]; tissue plasminogen activator activity [t-PA]; ii) coagulation (thrombin-antithrombin complexes [TAT]; platelet count); iii) fibrinolysis (t-PA activity, activity of plasminogen activator inhibitor type 1 (PAI-1 act); and iv) oxidative/nitrosative stress (isoprostanes, nitrate/nitrite levels) were measured. L-NIL inhibited sepsis-induced increase in plasma nitrate/nitrite and isoprostanes concentrations, prevented hypotension and acidosis. L-NIL significantly attenuated sepsis-induced rise in plasma vWF and TAT. P. aeruginosa-induced drop in t-PA activity was blunted by iNOS inhibition, while increased PAI-1 and reduced platelet count were not reversed by the treatment. In conclusion, selective iNOS inhibition was associated with attenuation of sepsis-induced coagulation and endothelial dysfunction suggesting the interplay between mediators of vascular system and hemostatic balance. Reduction of oxidative stress probably contributes to the beneficial effects afforded by iNOS blockade.

A 72-year-old patient with multiple myeloma was admitted to the intensive care unit because of hypercalcemic crisis and acute renal failure. After 7 days of comprehensive therapy including diuretics steroids, calcitonin, and intermittent hemodialysis (IHD) with low-calcium dialysate, calcium still reached high levels between IHD treatments and thrombocytopenia developed after chemotherapy. CVVHDF with calcium-free bicarbonate dialysate was started. Anticoagulation with 2.2% citrate was performed in order to chelate calcium, and thus treat the hypercalcemia, and to provide regional anticoagulation, and thus reduce the risk of bleeding due to thrombocytopenia. CVVHDF with citrate anticoagulation was continued for 6 days, and standard heparin anticoagulation was started when the hypercalcemia and thrombocytopenia abated.