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Background Obesity is an important risk factor for atrial fibrillation and heart failure. However, little is known about the underlying pathophysiology. Left atrial (LA) dysfunction due to diastolic dysfunction and chronic volume overload may play a significant role in morbid obesity. Purpose To compare LA function in morbid obese and non-obese individuals, and secondly, to determine whether LA function in morbid obese patients improves one year after bariatric surgery. Methods Data of morbid obese patients without known cardiac disease included in the CARdiac Dysfunction In Obesity (CARDIOBESE) study were used. Patients and age- and gender matched non-obese controls underwent transthoracic echocardiography. In the morbid obese patients echocardiography was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were analyzed with speckle tracking using dedicated software (TomTecArena, integrated in Sectra IDS7). Results 64 morbid obese patients were compared with 46 non-obese controls. Obese patients had significantly decreased LA function compared with non-obese individuals (LASr 39.6±10.8% vs 31.3±8.3%, p Conclusions Morbid obese patients without known cardiac disease have impairment in all phases of LA function. This subclinical cardiac dysfunction would have remained largely unmasked with assessment of diastolic function according to current guidelines, as shown by the comparable proportion of obese and non-obese individuals with diastolic dysfunction. LA dysfunction in obesity may therefore be an early sign of cardiac disease and a predictor for developing atrial fibrillation and heart failure. LA function did not improve one year after bariatric surgery. Longer follow-up after bariatric surgery may be needed to investigate whether improvement of LA function will occur after a longer period following weight loss surgery. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): BeterKeten Outcomes of the study populationLeft atrial strain outcomes

Background Obesity doubles the lifetime risk of developing heart failure. Current knowledge on the role of obesity in causing cardiac dysfunction is insufficient for optimal risk stratification. Purpose The aim of the study was first to identify the prevalence of subclinical cardiac dysfunction in obesity patients and second to investigate the underlying pathophysiology by comparing obesity patients with and without cardiac dysfunction. Methods The CARDIOBESE-study is a cross-sectional multicentre study of 100 obesity patients (BMI ≥35 kg/m2) without known cardiovascular disease, and 50 age- and gender-matched non-obese controls (BMI ≤30 kg/m2). Echocardiography was performed, blood samples were collected and a Holter monitor was affixed. Cardiac dysfunction was defined as either reduced LV ejection fraction, decreased global longitudinal strain (GLS), diastolic dysfunction, sustained supraventricular or (non)sustained ventricular arrhythmia or an increased BNP. Results Figure 1a shows the characteristics of the obesity patients and the non-obese controls. 59 obesity patients (48 [42–50] years, 70% female) showed subclinical cardiac dysfunction: 57 patients had decreased GLS, 2 patients with normal GLS had either diastolic dysfunction or increased brain natriuretic peptide. Only 1 non-obese control had diastolic dysfunction, none had another sign of cardiac dysfunction. Figure 1b shows the characteristics of obesity patients with and without cardiac dysfunction. Multivariable logistic analysis identified male gender and SDNN-index, which is a heart rate variability parameter and thereby a measure of autonomic dysfunction, as independent significant risk factors for subclinical cardiac dysfunction in obesity patients. Conclusions There was a high prevalence (61%) of subclinical cardiac dysfunction in obesity patients without known cardiovascular disease, which appeared to be best identified by GLS. Subclinical cardiac dysfunction in obesity was linked to autonomic dysfunction and male gender, and not to the presence of traditional cardiac risk factors, inflammation, increased cardiac filling pressure, cardiomyocyte damage or increased left ventricular mass. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Stichting BeterKeter

Objective To investigate 1‑year outcomes with routine prasugrel treatment after acute coronary syndrome (ACS) in a large-scale registry. Methods The Rijnmond Collective Cardiology Research registry is a prospective, observational study that enrolled 4,258 consecutive ACS patients treated with percutaneous coronary intervention (PCI) with 1‑year follow-up. Patients received prasugrel as first-choice antiplatelet agent, except for increased bleeding risk patients in which clopidogrel was recommended. Events were validated by an independent clinical endpoint committee. Results A total number of 2,677 patients received prasugrel at discharge after the index event. Eighty-one percent of the target population was on prasugrel treatment at hospital discharge. At 1 year, the primary endpoint, a composite of all-cause mortality and myocardial infarction, occurred in 2.4% of patients receiving prasugrel. All-cause mortality occurred in 1.0%, myocardial infarction in 1.5%, target-vessel revascularisation in 3.1%, stent thrombosis in 0.6%, and stroke in 0.5% of the patients treated with prasugrel. Thrombolysis in Myocardial Infarction defined major bleeding episodes not related to coronary artery bypass grafting were observed in 1.4% of patients receiving prasugrel. Conclusions In routine practice, a tailored approach of prasugrel prescription in ACS patients undergoing PCI, resulted in low ischaemic and low bleeding rates up to 1 year post PCI. Electronic supplementary material The online version of this article (10.1007/s12471-018-1126-0) contains supplementary material, which is available to authorized users.

Introduction Obesity is becoming a global epidemic. Current knowledge on early signs of cardiac dysfunction in obesity patients is insufficient. The onset of heart failure in obesity patients cannot be fully explained by the presence of traditional cardiovascular risk factors. Purpose To detect early signs of cardiac dysfunction in obesity patients without known cardiovascular disease. Methods The CARDIOBESE-study is a cross-sectional multicentre study of 100 obesity patients scheduled for bariatric surgery (body mass index (BMI) ≥35 kg/m2) without known cardiovascular disease, and 50 age-matched and gender-matched non-obese controls (BMI ≤30 kg/m2). Speckle tracking echocardiography, biomarkers and Holter monitoring were used to identify parameters that are able to show cardiac dysfunction at a very early stage in obesity patients. Results Obesity patients had impaired left ventricular ejection fraction, global longitudinal strain (GLS) and diastolic function parameters (e.g. septal e" velocity, lateral e" velocity, E/e’ and E/A-ratio) as compared to the non-obese controls (Table). C-reactive protein (CRP) and heart rate were increased, whereas heart rate variability (Standard deviation of NN intervals, SDNN) was decreased. Obesity patients were subdivided in patients with impaired (< -17%, n = 56) or normal GLS (n = 36). Comparison between these patients revealed no differences regarding BMI, prevalence of traditional cardiovascular risk factors or CRP value. Nevertheless, patients with abnormal GLS had a higher waist circumference and lower SDNN. Conclusion There is a high prevalence of subclinical cardiac dysfunction as measured by GLS in obesity patients (56%), which appears to be related to abdominal fat and decreased heart rate variability and not to BMI, traditional cardiovascular risk factors or CRP. Non-obese controls (n = 50) Obesity patients (n = 100) p-value Obesity patients with normal GLS (n = 36) Obesity patients with impaired GLS (n = 56) p-value Age (years) 49.2 ± 9.5 47.9 ± 7.6 0.36 47.6 ± 7.1 48.3 ± 7.6 0.68 BMI (kg/m2) 24.9 ± 3.2 42.9 ± 4.1

Background The Endothelial Progenitor Cell (EPC) stent was designed to capture circulating EPCs and promote early stent re-endothelization. Erythropoietin (EPO) stimulates mobilization of EPC from the bone marrow. Combination of EPO and the EPC stent in the setting of ST-segment elevation myocardial infarction (STEMI) has never been investigated. Methods STEMI patients enrolled in the HEBE-III trial were randomized to a single bolus of EPO or No-EPO after implantation of the EPC capture stent. Late lumen loss (LLL) was determined at 9-month angiographic follow-up. Clinical data was collected at 30 days and 12 months. Results 196 patients were randomized to EPO (n=100) or No-EPO (n=96). No significant difference in baseline characteristics was observed between the two groups. A significant reduction in angiographic LLL was observed with EPO (0.43±0.57mm) as compared to No-EPO (0.74±0.63mm) (p=0.011). At 12 months follow up, no difference with regard to death or re- infarction was observed in both groups, whereas significant reduction in the need for target vessel revacularization for the EPO versus No-EPO was observed with rates of 7.1% and 19.1% respectively (p=0.013). Angiographic and clinical results EPO (n=39) No-EPO (n=45) P-value Angiography Lume late loss 0.43±0.57 0.74±0.63 0.011 12 months clinical Death 0 0 ns Re infarction 0 1 (2.2%) ns Additional PCI 4 (10.3%) 17 (37.8%) 0.004 CABG 2 (5.1%) 2 (4.4%) ns CVA 0 0 ns Bleeding 3 (7.7%) 4 (8.9%) ns ns = not significant; CVA = cerebrovascular accident; CABG = coronary bypass graft; PCI = percutaneous coronary intervention. Conclusion In STEMI patients treated with EPC capture stent, additional EPO can further improve angiographic LLL

Background Polarization-sensitive (PS-) optical frequency domain imaging (OFDI) measures polarization properties of tissue together with conventional cross-sectional OFDI images of subsurface microstructure. PS-OFDI offers refined insight into plaque morphology and composition, which are implicated in the pathogenesis of acute coronary syndromes (ACS). Purpose This first-in-human pilot study of intravascular polarimetry aimed to investigate birefringence and depolarization features of coronary plaques in patients and to examine the relationship of these features with established structural characteristics available to conventional OFDI and with clinical presentation. Methods 30 patients undergoing PS-OFDI (acute coronary syndrome; ACS, n=12 and stable angina pectoris; SAP, n=18) participated in this study. 342 cross-sectional images evenly distributed along all imaged coronary arteries were classified into one of seven plaque categories according to conventional OFDI. Polarization features averaged over the entire intimal area of each cross-section were compared between plaque types and with structural parameters. Further, we assessed the polarization properties in the fibrous caps of ACS and SAP culprit lesions and compared them with structural features using a generalized linear model. Results The median birefringence and depolarization showed statistically significant differences among plaque types (both p Intravascular polarimetry Conclusions Intravascular polarimetry provides quantitative metrics that help to characterize coronary arterial tissues and may offer refined insight into coronary arterial atherosclerotic lesions in patients (Figure). Quantitative assessment of plaque polarization properties by intravascular polarimetry may open new avenues for studying plaque progression and detecting high-risk patients. Acknowledgement/Funding The JSPS Overseas Research Fellowship, the Uehara Memorial Foundation, and the Japan Heart Foundation and Bayer Yakuhin

Background: Sex differences in acute coronary syndrome (ACS) have been reported, but little is known about the situation in the Netherlands. Methods: This registry is a merge of available data on ACS patients in the electronic data capture systems of 11 centres with 24/7 interventional cardiology services. We included patients >18 years undergoing a cardiac catheterisation between 2010–2012. We evaluated sex differences in clinical and procedural characteristics and 1‑year mortality. Results: A total of 29,265 ACS patients (8,720 women and 20,545 men) were registered. Women were on average 4.5 years older (68.5 vs 63.0 years, p < 0.001) and had a higher prevalence of hypertension (62.7 vs 49.8%, p < 0.001) and insulin-dependent diabetes mellitus (9.6 vs 6.8%, p < 0.001) than men. Women less often presented with ST-elevation myocardial infarction (43.7% vs 47.6%, p < 0.001) and appeared to have less extensive coronary artery disease than men. Women less often underwent coronary angiography by radial access (52.5 vs 55.9%, p < 0.001). One-year mortality was higher in women than in men (7.3% and 5.6%, p < 0.001). More specific, the relationship between sex and mortality was age-dependent and showed higher mortality in women ≤71 years, but lower mortality in older women compared with men (p-interaction

Aims In pre-hospital settings handled by paramedics, identification of patients with myocardial infarction (MI) remains challenging when automated electrocardiogram (ECG) interpretation is inconclusive. We aimed to identify those patients and to get them on the right track to primary percutaneous coronary intervention (PCI). Methods and results In the Rotterdam-Rijnmond region, automated ECG devices on all ambulances were supplemented with a modem, enabling transmission of ECGs for online expert interpretation. The diagnostic protocol for acute chest pain was modified and monitored for 1 year. Patients with an ECG that met the criteria for ST-elevation myocardial infarction (STEMI) were immediately transported to a PCI hospital. ECGs that did not meet the STEMI criteria, but showed total ST deviation ≥800 µv were transmitted for online interpretation by the ECG expert. Online supervision was offered as a service if ECGs showed conduction disorders, or had an otherwise ‘suspicious’ pattern according to the ambulance paramedics. We enrolled 1,076 patients with acute ischaemic chest pain who did not meet the automated STEMI criteria. Their mean age was 63 years; 64% were men. After online consultation, 735 (68%) patients were directly transported to a PCI hospital for further treatment. PCI within 90 min was performed in 115 patients. Conclusion During a 1-year evaluation of the modified pre-hospital triage protocol for patients with acute ischaemic chest pain, over 100 acute MI patients with an initially inconclusive ECG received primary PCI within 90 min. Because of these results, we decided to continue the operation of the modified protocol.

Purpose In patients with structural heart disease (SHD) or inherited primary arrhythmia syndrome (IPAS), the occurrence of unexplained syncope or palpitations can be worrisome as they are at increased risk of sudden cardiac death. An implantable loop recorder (ILR) can be a useful diagnostic tool. Our purpose was to compare the diagnostic yield, arrhythmia mechanism, and management in patients with SHD, patients with IPAS, and those without heart disease. Methods Retrospective single-center study in consecutive patients who underwent an ILR implantation. Results Between March 2013 and December 2016, a total of 94 patients received an ILR (SHD, n = 20; IPAS, n = 14; no SHD/IPAS, n = 60). The type of symptoms at the time of implantation was similar between groups. During a median follow-up of 10 months, 45% had an ILR-guided diagnosis. Patients with IPAS had a lower diagnostic yield (14%) in comparison to the other groups (no SHD/IPAS 47%, P = 0.03; SHD 60%, P = 0.01, respectively). Furthermore, patients with SHD had a higher incidence of nonsustained VT in comparison to patients without SHD/IPAS (30 versus 3%, P

SummaryPatients with chronic kidney disease (CKD) have an increased risk of cardiovascular disease. Previous studies have suggested that patients with CKD have less therapeutic benefit of antiplatelet therapy. However, the relation between renal function and platelet reactivity is still under debate. On-treatment platelet reactivity was determined in parallel by ADP- and AA-induced light transmittance aggregometry (LTA) and the VerifyNow® System (P2Y12 and Aspirin) in 988 patients on dual antiplatelet therapy, undergoing elective coronary stenting. Patients were divided into two groups according to the presence or absence of moderate/severe CKD (GFRClinical Trial Registration: www.clinicaltrials.gov: NCT00352014.

Background Medical discharge management of acute coronary syndromes (ACS) remains suboptimal outside randomised trials and constitutes an essential quality benchmark for ACS. We sought to evaluate the rates of key guideline-recommended pharmacological agents after ACS and characteristics associated with optimal treatment at discharge. Methods The Rijnmond Collective Cardiology Research (CCR) registry is an ongoing prospective, observational study in the Netherlands that aims to enrol 4000 patients with ACS. We examined discharge and 1-month follow-up medication use among the first 1000 patients enrolled in the CCR registry. Logistic regression was performed to identify patient and hospital characteristics associated with collective guideline-recommended pharmacotherapy at hospital discharge. Results At discharge, 94 % of patients received aspirin, 100 % thienopyridines, 80 % angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, 87 % β-blockers, 96 % statins, and 65 % the combination of all 5 agents. ST-segment elevation myocardial infarction, hypertension, hypercholesterolaemia, and enrolment in an interventional centre were positive independent predictors of 5-drug combination therapy at discharge. Negative independent predictors were unstable angina and advanced age. Conclusion Current data from the CCR registry reflect a high quality of care for ACS discharge management in the Rotterdam-Rijnmond region. However, potential still remains for further optimisation.

Background Platelet inhibition is crucial in reducing both short- and long-term atherothrombotic risks in patients with acute coronary syndromes (ACS) managed with percutaneous coronary intervention (PCI). Based on randomised trials, recent recommendations in the current guidelines include the endorsement of prasugrel as a first-choice adenosine diphosphate receptor inhibitor. Yet, there is limited experience with the use of prasugrel in routine practice. Methods The Rijnmond Collective Cardiology Research (CCR) registry is a prospective, observational study that will follow-up 4000 PCI-treated ACS patients in the larger region of Rotterdam, the Netherlands. Based on recently implemented hospital protocols, all patients will receive prasugrel as first-choice antiplatelet agent, unless contraindicated, in accordance with European guidelines, and will be followed for up to 1 year post-discharge for longitudinal assessment of outcomes and bleeding events. This registry exemplifies a collaborative study design that employs a regional PCI registry platform and provides feedback to participating sites regarding their practice patterns, thereby supporting and promoting improvement of quality of care. Conclusion The CCR registry will evaluate the adoption of prasugrel into routine clinical practice and thus, will provide important evidence with regard to the benefits and risks of real-world utilisation of prasugrel as antiplatelet therapy in PCI-treated ACS patients.

Background Previous studies have suggested that women do not accrue equal therapeutic benefit from antiplatelet medication as compared with men. The physiological mechanism and clinical implications behind this gender disparity have yet to be established. Methods On-treatment platelet reactivity was determined in 717 men and 234 women on dual antiplatelet therapy, undergoing elective coronary stent implantation. Platelet function testing was performed using arachidonic acid and adenosine diphosphate-induced light transmittance aggregometry (LTA) and the VerifyNow P2Y12 and Aspirin assays. Also the incidence of all-cause death, non-fatal acute myocardial infarction, stent thrombosis and ischaemic stroke was evaluated. Results Women had higher baseline platelet counts than men. Women exhibited a higher magnitude of on-aspirin platelet reactivity using LTA, but not using the VerifyNow Aspirin assay. The magnitude of on-clopidogrel platelet reactivity was significantly higher in women as compared with men with both tests used. The cut-off value to identify patients at risk as well as the incidence of clinical endpoints was similar between women and men (16/234[6.8%] vs. 62/717[8.6%], p = 0.38). Conclusion Although the magnitude of platelet reactivity was higher in women, the absolute difference between genders was small and both the cut-off value to identify patients at risk and the incidence of the composite endpoint were similar between genders. Thus, it is unlikely that the difference in platelet reactivity accounts for a worse prognosis in women.

SummaryThis is a prospective, observational study performed in all consecutive ST-elevation myocardial infarction (STEMI) patients who had activated clotting time (ACT) measurement on arrival in the cathlab before coronary angiography. We studied the therapeutic effects of a pre-hospital fixed heparin bolus dose in consecutive patients with STEMI. A total of 1,533 patients received pre-hospital administration of aspirin, high dose clopidogrel (600 mg) and a fixed bolus dose of 5,000 IU unfractionated heparin (UFH), according to the national ambulance protocols. Some patients were also treated with glycoprotein IIb/IIIa inhibitors (GPI) in the ambulance. A therapeutic ACT range was defined according to the ESC guidelines as 200–250 seconds when patients had GPI pretreatment and 250–350 seconds when no GPI pretreatment. Of the 1,533 patients, 216 patients (14.1%) had an ACT within the therapeutic range, 82.3% of the patients had a too low ACT, whereas 3.5% of the patients had a too high ACT. After multivariable analysis, the only independent predictor of a too low ACT was increasing weight (odds ratio 1.02/kg, 95% confidence interval 1.01–1.03, p=0.001). Patients with a too low ACT had less often an open infarct related vessel (initial TIMI flow 2,3) as compared to patients with an ACT in range (36.5% vs. 45.9%, p=0.013). In only a minority of patients with STEMI, pre-hospital treatment with a fixed bolus dose UFH is within the therapeutic ACT range. Increased weight is an independent determinant of a too low ACT. We strongly recommend weight adjusted administration of UFH in the ambulance.

Background The TRITON-TIMI 38 study has identified three subgroups of patients with a higher risk of bleeding during treatment with the thienopyridine prasugrel: patients with a history of stroke or transient ischaemic attack (TIA), patients >= 75 years and patients with a body weight = 75 years and a history of stroke were independent predictors of a higher on-treatment platelet reactivity. In contrast, a body weight = 75 years and patients with previous stroke, onclopidogrel platelet reactivity is increased. In contrast, in patients with a low body weight, on-clopidogrel platelet reactivity is decreased, suggesting that a stronger response to a thienopyridine might only lead to more bleeds in patients with low body weight

Background/Objectives. We aimed to investigate the incidence and clinical outcome of coronary artery bypass grafting (CABG) performed in contemporary patients with ST-elevation myocardial infarction (STEMI) within 30 days after presentation. Methods. All 1071 patients enrolled in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) were included in this analysis. CABG was indicated for both ischaemic and anatomical reasons according to the current treatment guidelines for STEMI. For all surgical as well as non-surgical patients, clinical outcome was assessed at both 30 days and one year. Results. CABG was performed within 30 days of presentation in 59/1071 (5.5%) patients, in 13 (22%) within 24 hours, in eight (14%) between one and three days, and in 38 (64%) between four and 30 days. Compared with non-surgical patients, surgical patients required more initial intra-aortic balloon pump support (33 vs. 5%, p

Background: Specific criteria have been described and accepted worldwide for diagnosing patients with complex regional pain syndrome (CRPS). Nevertheless, a clear-cut diagnosis cannot be confirmed in a number of cases. Aim: The objective of this study was to investigate the effectiveness of the described diagnostic criteria used by several clinical disciplines. Methods: We included 195 patients who were referred to our pain clinic within a period of 1 year. Data were collected on patient characteristics, signs, symptoms, disease-related medication, and the background of the referring clinicians. Results: The Harden and Bruehl criteria were confirmed in 95 patients (49%). These patients used a higher than average number of analgesics, opiates, and anti-oxidants, and frequently received prescriptions for benzodiazepines instead of anti-depressants. The mean disease duration was 29 ± 4.6 months and the mean visual analogue score for pain was 8.1 ± 0.19. A subgroup of patients had a colder temperature in the affected extremity compared with the unaffected extremity. This subgroup showed a longer disease duration and higher visual analogue scale pain. Conclusion: The diagnostic criteria used to determine CRPS should be further improved. A large number of referred patients experienced substantial pain, without receiving adequate medication. Disease-related medication is unrelated to CRPS-specific disease activity. Knowledge of underlying mechanisms is warranted before an adequate pharmaceutical intervention can be considered.

Background. We investigated the association between clinical characteristics, angiographic data and ventricular arrhythmia in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI)Methods. In patients with STEMI (n=225), a Holter analysis was performed the first 12 hours after primary PCI.Results. A total of 151 (66%) patients had >/=1 episode of ventricular tachycardia (VT). Age

The microcirculation appears to be impaired in cold chronic complex regional pain syndrome (CRPS). This double-blind, placebo-controlled, randomized trial investigated the effect of the nitric oxide (NO) donor isosorbide dinitrate (ISDN) on the peripheral blood flow in patients with chronic CRPS. Twenty-four patients received 1% ISDN in Vaseline (R) or a placebo ointment applied. to the dorsum of the affected hand four times daily for 10 weeks. The patients participated in a physical therapy program to improve activity. The Primary outcome ,measure was blood distribution in the affected extremity, which was determined by measuring the skin temperature using videothermography. Me also measured NO and endothelin-1 concentrations in blister fluid, pain using the visual analog scale, and activity limitations using an upper limb activity monitor and the Disabilities of Arm Shoulder and Hand Questionnaire. ISDN failed to produce a significant improvement in temperature asymmetry in chronic cold CRPS patients, and it did not result in the expected reduction. in pain and increase in activity compared with Placebo either Them may be other central or peripheral factors contributing to the disturbed vasodynamics in cold chronic CRPS that are not influenced by NO substitution. This study does not show an improvement of the regional blood distribution by ISDN in the involved extremity of patients with cold-type CRPS. J Pain Symptom Manage 2009;38:401-408. (C) 2009 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

In this prospective, observational, 2-armed study, we compared the plasma amino acid profiles of patients undergoing awake craniotomy to those undergoing craniotomy under general anesthesia. Both experimental groups were also compared with a healthy, age-matched and sex-matched reference group not undergoing surgery. It is our intention to investigate whether plasma amino acid levels provide information about physical and emotional stress, as well as pain during awake craniotomy versus craniotomy under general anesthesia. Both experimental groups received preoperative, perioperative, and postoperative dexamethasone. The plasma levels of 20 amino acids were determined preoperative, perioperative, and postoperatively in all groups and were correlated with subjective markers for pain, stress, and anxiety. In both craniotomy groups, preoperative levels of tryptophan and valine were significantly decreased whereas glutamate, alanine, and arginine were significantly increased relative to the reference group. Throughout time, tryptophan levels were significantly lower in the general anesthesia group versus the awake craniotomy group. The general anesthesia group had a significantly higher phenylalanine/tyrosine ratio, which may suggest higher oxidative stress than the awake group throughout time. Between experimental groups, a significant increase in large neutral amino acids was found postoperatively in awake craniotomy patients, pain was also less and recovery was faster. A significant difference in mean hospitalization time was also found, with awake craniotomy patients leaving after 4.53 +/- 2.12 days and general anesthesia patients after 3.17 +/- 1.62 days; P=0.012. This study demonstrates that awake craniotomy is likely to be physically and emotionally less stressful than general anesthesia and that amino acid profiling holds promise for monitoring postoperative pain and recovery.

Background: Early initiation of continuous positive airway pressure (CPAP) applied by face mask benefits patients with acute cardiogenic pulmonary oedema (ACPE). The simple disposable Boussignac CPAP (BCPAP) has been used in ambulances by physicians. In the Netherlands, ambulances are manned by nurses and not physicians. It was hypothesised that ambulance nurses are able to identify patients with ACPE and can successfully apply BCPAP. A prospective case series of patients with presumed ACPE treated with BCPAP by ambulance nurses is described.Methods: After training of ambulance nurses, all 33 ambulances in the region were equipped with BCPAP. ACPE was diagnosed on clinical signs and pulse oximetry saturation (Spo(2)) 80%) was generated with an oxygen flow of 15 l/min. The physiological responses, experiences and clinical outcomes of the patients were collected from ambulance and hospital records, and ambulance nurses and patients received a questionnaire.Results: From March to December 2006, 32 patients (age range 61-94 years) received BCPAP during transport to six different regional hospitals. In 26 patients (81%) a diagnosis of ACPE was confirmed. With BCPAP, median (IQR) Spo(2) increased from 79% (69-94%) to 96% (89-98%) within 20 min. The median (IQR) duration of BCPAP treatment was 26 min (21-32). The patients had no negative recollections of the treatment. Ambulance personnel were satisfied with the BCPAP therapy.Conclusion: When applied by ambulance nurses, BCPAP was feasible and effective in improving oxygen saturation in patients with ACPE. Although survival benefit can only be demonstrated by further research, it is considered that BCPAP can be implemented in all ambulances in the Netherlands.

Aims: To assess safety and efficacy of off-site percutaneous coronary intervention (PCI) in The Dutch invasive cardiovascular system.Methods and results: Descriptive single centre registry of elective and emergency PCI. Setting is a Dutch community hospital, 40 km north of Amsterdam, with an adherent population of 400,000 people. A Clinical follow up of Major Adverse Cardiac and Cerebral Events (MACCE) at 30 days post PCI is performed. The total number of participants eligible for PCI was 781 of whom 545 were men and 236 women.During a two-year period 781 PCI's were performed of which 298 were emergency and 483 elective. Acute complications occurred in 2.1% of participants. MACCE-free was 86.9% in the group with AMI and 95.8% in the elective group.Conclusions: Off-site PCI is feasible and safe in The Netherlands on the condition that specific key factors for success are taken into consideration. (C) 2007 Elsevier Ireland Ltd. All rights reserved.