Search

Background Sleep inversion is sleeping during the day and waking up at night; a depart from the normal sleeping time between 10:00 PM to 5:00 AM. The aim of this study was to detect subtle changes in left ventricular (LV) systolic function caused by sleep inversion using strain imaging in young healthy individuals free of cardiovascular risk factors. Methods 100 healthy persons (18 to 35 years of age) with an inverted sleep pattern, and a normal LV systolic function by conventional 2D echocardiography were compared with 100 healthy individuals from the same age group with normal sleep timings. Conventional and speckle tracking echocardiography were performed. Results Male gender, smoking, less exercise, social media overuse, and junk food were significantly more common in the sleep inversion group. They had lower mean GLS than the controls (-20.90% ± 3.45 vs -22.87% ± 3.67, p < 0.0001). By multivariate analysis, sleep inversion was found to be independently associated with low GLS (Odds ratio: 2.02, 95% confidence interval (CI): 1.07–3.82, p = 0.03). Conclusion Sleep inversion is associated with subclinical left ventricular systolic dysfunction detected by speckle tracking in young healthy individuals. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Introduction Computed Tomography (CT) scan is a helpful tool to assess the coronary arteries and the great vessels. However, its routine use in the assessment of patients with suspected prosthetic valve dysfunction (PVD) has not been studied thoroughly. Objective To determine the impact of routine cardiac computed tomography angiography (CCTA) on diagnostic and therapeutic decisions in patients with suspected PVD. Methods and results This was a prospective cohort study that was conducted on 50 consecutive patients with suspected PVD who underwent both 64-slice ECG-gated CT and transesophageal echocardiography (TEE). The gold standard was the intraoperative findings. Surgery was performed in forty-six patients. ECG-gated CT showed findings that were not detected by TEE in sixteen patients (32%) namely aortic root abscess, aortic pseudoaneurysm, paravalvular leakage (PVL), sclero-calcific disruption of sutures as cause of PVL, mechanical prosthesis occluder malfunction, an underlying thrombus as cause of malfunction and finally presence of aortic dissection. Furthermore, CTA findings dictated treatment changes in fourteen patients (28%). Conclusion This study demonstrates that ECG-gated CTA has a complementary role to TEE in patients with suspected PVD. CCTA is more accurate in diagnosis of periannular complications (Aortic root abscess and Pseudo-aneurysm) and in delineating their anatomical relation to surrounding cardiac structures. Therefore CCTA can have important role in deciding and planning the method of correction whether surgical or percutaneous and has to be considered after TEE in patients with a high suspicion on PVD.

Susan Labib, Hussein Heshmat Kassem, Hossam Kandil Department of Cardiology, Cairo University, Cairo, EgyptCorrespondence: Susan LabibDepartment of Cardiology Cairo University, Kasr Alainy University Hospital, 23, Second Floor, Manial, Cairo, EgyptTel +201006928590Email dr.suzanlabib@gmail.comBackground: Peri-procedural blood-pressure (BP) changes were investigated and correlated to Major adverse cardiovascular events (MACE) as predictor of outcome for patients undergoing percutaneous coronary intervention (PCI); whether acute coronary syndrome (Unstable angina, or MI; STEMI or NSTEMI) or scheduled for elective PCI.Methods: Resting BP in the 204 recruited patients undergoing PCI throughout 2018 was measured thrice – in the ward before transferring to the cardiac catheterization lab (cath lab), in the cath lab, and after transfer to the recovery room. Patients were categorized based on their systolic and diastolic BP peri-procedural difference as systolic (SBP): with a large difference (> 20 mmHg, n=47), with a small difference (≤ 20 mmHg, n=157) (shock patients excluded); diastolic (DBP): with a large difference (> 10 mmHg, n=65), and with a small difference (≤ 10 mmHg, n=139). The primary end-points were MACE including all-cause mortality, non-fatal myocardial infarction, and stroke during the hospital stay. The Mann–Whitney U and Chi-square tests were used to analyze the data accordingly (p< 0.005).Results: Within the category of MACE, cardiac mortality was the only adverse cardiac event encountered in the study sample. Cardiac mortality was significantly higher in both the large SBP-difference group versus the other group (10.6% vs 0.6%, p=0.003) and the large DBP-difference group versus the small-difference group (7.7% vs 0.7%, p=0.013).Conclusion: Peri-procedural systolic and diastolic BP differences, greater than 20 mmHg and 10 mmHg, respectively, correlated with MACE in all patients undergoing PCI.Keywords: percutaneous coronary intervention, major adverse cardiovascular events, peri-procedural BP changes

Background Aortic root abscess (ARA) is a major complication of infective endocarditis that is associated with increased morbidity and mortality. Limited data are present about patient characteristics and outcomes in this lethal disease. We aimed to study the clinical and echocardiographic characteristics of patients with ARA compared to patients with left-sided infective endocarditis without ARA. We included patients with a definite diagnosis of left-sided infective endocarditis according to modified Duke’s criteria. The patients were classified into two groups according to the presence of ARA (ARA and NO-ARA groups). All the patients were studied regarding their demographic data, clinical characteristics, laboratory and imaging data, and complications. Results We included 285 patients with left-sided infective endocarditis. The incidence of ARA was 21.4% (61 patients). Underlying heart disease, mechanical prosthesis, bicuspid aortic valve, and prior IE were significantly higher in ARA. The level of CRP was higher in ARA (p = 0.03). ARA group showed more aortic valve vegetations (73.8% vs. 37.1%, p < 0.001), more aortic paravalvular leakage (26.7% vs. 4.5%, p < 0.001), and less mitral valve vegetations (21.3% vs. 68.8%, p < 0.001). Logistic regression analysis showed that the odds of ARA increased in the following conditions: aortic paravalvular leak (OR 3.9, 95% CI 1.2–13, p = 0.03), mechanical prosthesis (OR 3.6, 95% CI 1.5–8.7, p = 0.005), aortic valve vegetations (OR 3.0, 95% CI 1.2–8.0, p = 0.02), and undetected organism (OR 2.3, 95% CI 1.1–4.6, p = 0.02), while the odds of ARA decreased with mitral valve vegetations (OR 0.2, 95% CI 0.08–0.5, p = 0.001). We did not find a difference between both groups regarding the incidence of major complications, including in-hospital mortality. Conclusion In our study, ARA occurred in one fifth of patients with left-sided IE. Patients with mechanical prosthesis, aortic paravalvular leakage, aortic vegetations, and undetected organisms had higher odds of ARA, while patients with mitral vegetations had lower odds of ARA.

Background The aorta is the largest and strongest artery in the body that plays an important role in the control of systemic vascular resistance and heart rate. Aortic diseases contribute to the wide spectrum of arterial diseases that may be diagnosed after a long period of subclinical development. Multidetector computed tomographic scanners (≥ 64 detector rows) for aortic imaging remain one of the most preferred imaging techniques for diagnosis and follow-up of aortic conditions in acute as well as chronic presentations. The aim of this study is to establish a normal reference values for aortic diameters among Egyptian population and to find which of the cardiovascular risk factors could be an independent determinant of the aortic diameters. Results Five hundred and sixteen Egyptian individuals were enrolled in our study, the mean age was 53.5 ± 10.9, and males comprised 61.4% of the study population. Aortic root diameters measured at the annulus, sinus and STJ were 23.09 ± 2.55 mm, 33.75 ± 3.93 mm and 26.13 ± 3.05 mm, respectively. The BSA-indexed diameters were 11.70 ± 1.39, 17.10 ± 2.10 and 13.25 ± 1.65, respectively. The diameter of the tubular part of ascending aorta was 30.97 ± 4.16 mm, and the BSA-indexed diameter was 15.71 ± 2.28. The aortic diameters measured at the level of the pulmonary bifurcation were 24.56 ± 2.95 mm and 23.79 ± 2.96 mm at systolic and diastolic phases, respectively. The BSA-indexed diameters were 12.44 ± 1.52 and 12.05 ± 1.52 at systolic and diastolic phases, respectively. At the diaphragmatic level, the mean diameters were 22.39 ± 2.72 mm and 21.49 ± 2.79 mm at systolic and diastolic phases, respectively. The BSA-indexed diameters were 11.34 ± 1.43 and 10.98 ± 1.48 at systolic and diastolic phases, respectively. Age, gender, BSA, BMI and hypertension were statistically significant independent predictors of ascending and descending aortic diameters. Conclusions Our study established a normal reference value for thoracic aortic diameters among Egyptians using contrast enhanced MSCT aortography. Age, Gender, BSA, BMI and hypertension are the major determinants of aortic diameters.

Background: Although cardiovascular imaging techniques are widely used to diagnose myocardial ischemia in patients with suspected stable coronary artery disease (CAD), they have limitations related to lack of specificity, sensitivity and “late” diagnosis. Additionally, the absence of a simple laboratory test that can detect myocardial ischemia in CAD patients, has led to many patients being first diagnosed at the time of the development of myocardial infarction. Nourin is an early blood-based biomarker rapidly released within five minutes by “reversible” ischemic myocardium before progressing to necrosis. Recently, we demonstrated that the Nourin-dependent miR-137 (marker of cell damage) and miR-106b-5p (marker of inflammation) can diagnose myocardial ischemia in patients with unstable angina (UA) and also stratify severity of ischemia, with higher expression in acute ST-segment elevation myocardial infarction (STEMI) patients compared to UA patients. Minimal baseline-gene expression levels of Nourin miRNAs were detected in healthy subjects. Objectives: To determine: (1) whether Nourin miRNAs are elevated in chest pain patients with myocardial ischemia suspected of CAD, who also underwent dobutamine stress echocardiography (DSE) or ECG/Treadmill stress test, and (2) whether the elevated levels of serum Nourin miRNAs correlate with results of ECHO/ECG stress test in diagnosing CAD patients. Methods: Serum gene expression levels of miR-137, miR-106b-5p and their corresponding molecular pathway network were measured blindly in 70 enrolled subjects using quantitative real time PCR (qPCR). Blood samples were collected from: (1) patients with chest pain suspected of myocardial ischemia (n = 38) both immediately “pre-stress test” and “post-stress test” 30 min. after test termination, (2) patients with acute STEMI (n = 16) functioned as our positive control, and (3) healthy volunteers (n = 16) who, also, exercised on ECG/Treadmill stress test for Nourin baseline-gene expression levels. Results: (1) strong correlation was observed between Nourin miRNAs serum expression levels and results obtained from ECHO/ECG stress test in diagnosing myocardial ischemia in CAD patients, (2) positive “post-stress test” patients with CAD diagnosis showed upregulation of miR-137 by 572-fold and miR-106b-5p by 122-fold, when compared to negative “post-stress test” patients (p &lt, 0.001), (3) similarly, positive “pre-stress test” CAD patients showed upregulation of miR-137 by 1198-fold and miR-106b-5p by 114-fold, when compared to negative “pre-stress test” patients (p &lt, and (4) healthy subjects had minimal baseline-gene expressions of Nourin miRNAs. Conclusions: Nourin-dependent miR-137 and miR-106b-5p are promising novel blood-based biomarkers for early diagnosis of myocardial ischemia in chest pain patients suspected of CAD in outpatient clinics. Early identification of CAD patients, while patients are in the stable state before progressing to infarction, is key to providing crucial diagnostic steps and therapy to limit adverse cardiac events, improve patients’ health outcome and save lives.

Background: Currently, no blood biomarkers exist that can diagnose unstable angina (UA) patients. Nourin is an early inflammatory mediator rapidly released within 5 min by reversible ischemic myocardium, and if ischemia persists, it is also released by necrosis. Nourin is elevated in acute coronary syndrome (ACS) patients but not in symptomatic noncardiac and healthy subjects. Recently, circulating microRNAs (miRNAs) have been established as markers of disease, including cardiac injury and inflammation. Objectives: To profile and validate the potential diagnostic value of Nourin-dependent miR-137 (marker of cell damage) and miR-106b-5p (marker of inflammation) as early biomarkers in suspected UA patients and to investigate the association of their target and regulating genes. Methods: Using Nourin amino acid sequence, an integrated bioinformatics analysis was conducted. Analysis indicated that Nourin is a direct target for miR-137 and miR-106b-5p in myocardial ischemic injury. Two linked molecular networks of lncRNA/miRNAs/mRNAs were also retrieved, including CTB89H12.4/miR-137/FTHL-17 and CTB89H12.4/miR-106b-5p/ANAPC11. Gene expression profiling was assessed in serum samples collected at presentation to an emergency department (ED) from: (1) UA patients (n = 30) (confirmed by invasive coronary angiography with stenosis greater than 50% and troponin level below the clinical decision limit), (2) patients with acute ST elevation myocardial infarction (STEMI) (n = 16) (confirmed by persistent ST-segment changes and elevated troponin level), and 3) healthy subjects (n = 16). Results: Gene expression profiles showed that miR-137 and miR-106b-5p were significantly upregulated by 1382-fold and 192-fold in UA compared to healthy, and by 2.5-fold and 4.6-fold in STEMI compared to UA, respectively. Healthy subjects showed minimal expression profile. Receiver operator characteristics (ROC) analysis revealed that the two miRNAs were sensitive and specific biomarkers for assessment of UA and STEMI patients. Additionally, Spearman’s correlation analysis revealed a significant association of miRNAs with the associated mRNA targets and the regulating lncRNA. Conclusions: Nourin-dependent gene expression of miR-137 and miR-106b-5p are novel blood-based biomarkers that can diagnose UA and STEMI patients at presentation and stratify severity of myocardial ischemia, with higher expression in STEMI compared to UA. Early diagnosis of suspected UA patients using the novel Nourin biomarkers is key for initiating guideline-based therapy that improves patients’ health outcomes.

Introduction: Nourin is an inflammatory mediator rapidly released by ischemic myocardium “before” necrosis, and by necrotic cells . It stimulates leukocyte “ chemotaxis ” and “ activates ” leukocytes and vascular endothelial cells to release several “ cytokine storm ” mediators. Using Nourin amino acid sequence, Bioinformatics analysis indicated that Nourin is likely regulated by miRNA-106b ; an inflammatory-signaling pathway linked to myocardial ischemia. Hypothesis: As an "initial" inflammatory marker, the Nourin-dependent miR-106b can early diagnose ischemia-induced injury in UA patients when Troponin levels are below the decision limit, and in STEMI patients. The underlying regulatory mechanism involves lncR-CTB89H12.4 and mRNA-ANAPC11; associated with ischemia. Methods: Gene expression of lncR-CTB89H12.4 / miR-106b and mRNA-ANAPC11 were measured in serum samples from UA (n=30 - confirmed by invasive coronary angiography and negative Troponin) and STEMI (n=16) patients at presentation, and healthy volunteers (n=16). Results: Gene expression of miR-106b was up-regulated by 150-fold in UA compared to healthy, and by 4.6-fold in STEMI compared to UA (Fig. 1). Receiving Operator Characteristics (ROC) analysis revealed a statistically significant difference in miR-106b that discriminated UA from healthy controls with a test sensitivity of 87% sensitivity & specificity of 88%. Diagnostic sensitivity was 86% and specificity was 90% for discriminating UA from STEMI. Additionally, Spearman’s correlation analysis revealed a significant association of miR-106b with lncR-CTB89H12.4 and mRNA-ANAPC11. The down regulation of lncR-CTB89H12.4 after ischemia resulted in the up-regulation of miR-106b and activation of mRNA-ANAPC11 . Conclusions: The Nourin-dependent miR-106b is a promising early inflammatory biomarker indicating UA patients and discriminating between UA and STEMI. Regulations appears to be from lncR-CTB89H12.4 and mRNA-ANAPC11 .

Introduction: No blood biomarker exits that can diagnose Unstable Angina (UA) patients. Nourin is ischemia-dependent inflammatory mediator rapidly released by reversible ischemic myocardium “before” necrosis, and by necrotic cells. Using Nourin amino acid sequence, Bioinformatics analysis indicated that Nourin is likely regulated by miR-137; a marker of cell damage and a hypoxiaresponsive autophagy-signaling pathway linked to myocardial ischemia and coronary artery disease. Hypothesis: That the Nourin-dependent miR-137, is an early biomarker for UA patients when Troponin levels are below the decision limit. The underlying regulatory mechanism involves lncRCTB89H12.4 and mRNA-FTLH-17; also associated with ischemia. Methods: We measured serum gene expression profile of lnc-CTB89H12.4/miR-137 and mRNAFTHL- 17 in UA (n=30 - confirmed by invasive coronary angiography and negative Troponin) and STEMI (n=16) patients at presentation, and healthy volunteers (n=16). Results: Gene expression of miR-137 was up-regulated by 1,185-fold in UA (median=1,244.41) compared to healthy (1.05), and by 2.5-fold in STEMI (3,162.72) compared to UA (Fig. 1). Receiving Operator Characteristics (ROC) analysis revealed a statistically significant difference in miR-137 that discriminated UA from healthy controls with a test sensitivity & specificity of 96% & 93%, respectively. Diagnostic sensitivity was 75% & specificity was 83% for discriminating UA from STEMI. Additionally, Spearman’s correlation analysis revealed a significant association of miR-137 with lncRCTB89H12.4and mRNA-FTHL-17. The down-regulation of lncR-CTB89H12.4 after ischemia resulted in the up-regulation of miR-137 and activation of mRNA-FTLH-17. Conclusions: As a marker of cell damage, the Nourin-dependent miR-137 is a promising early diagnostic biomarker indicating UA patients and discriminating between UA and STEMI. Regulations appears to be from lncR-CTB89H12.4 and mRNA-FTLH-17.

Introduction Smoking and obesity are recognized as important modifiable risk factors for coronary artery disease (CAD). However, the general perception that smoking protects against obesity is a common reason for starting, and/or not quitting smoking. Purpose To detect the quantity, quality and relative distribution of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) estimated by abdominal computed tomography in smokers versus non- smokers. Methods The abdominal muscular wall was traced manually to calculate SAT and VAT areas (cm2) (outside and inside abdominal muscular wall respectively) as well as SAT density [Hounsfield units (HU)] at L4-L5 in 409 consecutive patients referred for evaluation of chest pain by multi-slice computed tomography coronary angiography (MSCT-CA). Results 26% of the studied patients (n=107) were current smokers, while the remaining 74% (n=302) never smoked. Coronary artery atherosclerosis was more prevalent in smokers compared to non-smokers (64.5% vs 55.0%; p=0.09). Smokers had statistically significantly lower body mass index (BMI) (31.2±4.3 vs. 32.5±4.7 kg/m2; p=0.015), hip circumference (HC) (98.6±22.5 vs. 103.9±20.9 cm; p=0.031), total fat area (441.62±166.34 vs. 517.95±169.51cm2; p Conclusion Smoking contributes to CAD and to the pathogenic redistribution of body fat towards VAT, through limiting SAT potential to expand. Funding Acknowledgement Type of funding source: None

Background Echocardiographic assessment of prosthetic mechanical valves is limited by shadows, artefacts and the need for cumbersome Doppler calculations. CT scan has the potential to overcome some of the limitations of echocardiography in assessment of prosthetic valves. Objectives Determine the incremental diagnostic value of cardiac computed tomographic angiography (CTA) over transesophageal echocardiography (TEE) in patients with suspected prosthetic valve dysfunction (PVD) and its impact on treatment decisions. Methods 50 consecutive patients with suspected PVD underwent both 64-slice ECG-gated CT and TEE and the results were compared. Imaging was compared against surgical findings (Reference standard). Echocardiographic evaluation focused on the detection of signs of PVD: vegetations, new or increased paravalvular leakage (PVL), aortic root pseudoaneurysms or abscesses and occluder malfunction. The CT interpreter was blinded to the findings of TEE. Results ECG-gated CT showed findings that were not detected by TEE in fifteen patients (30%). Additional aortic root abscess in four patients (8%), additional aortic root pseudoaneurysm in four patients (8%), and sclero-degenerative change across one of occluder of aortic prosthesis as cause of PVL in another patient (2%) not detected by TEE. CT negated the presence of aortic root abscess in one patient (2%), negated the presence of PVL in another patient (2%) both were detected by TEE. CT diagnosed occluder malfunction in one patient (2%) and underlying cause in two patients (4%) both were not detected by TEE. CT diagnosed presence of aortic arch dissection in one patient (2%) with large aortic root pseudoaneurysm. CT showed minor diagnostic change in six patients (12%). CT showed better delineation of site and periannular extension of aortic root abscess in four patients (8%). CT showed better assessment severity of PVL in one patient (2%) and cause of PVL across mechanical aortic prosthesis in another patient (2%). CT resulted in change of treatment strategy in 14 patients (28%). This included surgical excision of additional aortic root abscess or aortic root pseudoaneurysm in four patients (8%), surgical removal of prosthesis for underlying pathology (vegetation, malfunction due to underlying thrombus or PVL) in four patients (8%), aortic arch replacement with tubular graft and reimplantation of coronaries in one patient (2%) and conservative treatment with antibiotic therapy for small aortic root abscess not detected by TEE in 2 patients (4%), proper anticoagulation therapy and close monitor of INR in one patient (2%). Conclusion ECG-gated CT and TEE are complementary in patients with prosthetic valve dysfunction. Therefore, CT imaging has to be considered after clinical routine workup and TEE in patients with a high suspicion on prosthetic valve dysfunction.

Background: Cardiovascular disease is a leading cause of death worldwide. Aging is an unavoidable coronary risk factor and is associated with dermatological signs that could be a marker for increased coronary risk. We tested the hypothesis that hair graying as a visible marker of aging is associated with risk of coronary artery disease (CAD) independent of chronological age. Methods: This cross-sectional study included 545 males who underwent a computed tomography coronary angiography (CTCA) for suspicious of CAD, patients were divided into subgroups according to the percentage of gray/white hairs (Hair Whitening Score, HWS: 1–5) and to the absence or presence of CAD. Results: CAD was prevalent in 80% of our studied population, 255 (46.8%) had 3 vessels disease with mean age of 53.2 ± 10.7 yrs. Hypertension, diabetes and dyslipidemia were more prevalent in CAD group (P = 0.001, P = 0.001, and P = 0.003, respectively). Patients with CAD had statistically significant higher HWS (32.1% vs 60.1%, p

Increased sympathetic tone and use of bronchodilators increase heart rate and this may worsen functional capacity in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to look at the short-term effect of the heart rate lowering drug ivabradine on clinical status in COPD patients.We randomised 80 COPD patients with sinus heart rate ≥90 bpm into either taking ivabradine 7.5 mg twice per day or placebo for two weeks. We assessed all patients using the modified Borg scale and 6-minute walk test at baseline and then again 2 weeks after randomisation.There were no significant differences in age, sex, severity of airway obstruction (measured using forceful exhalation), severity of diastolic dysfunction or pulmonary artery systolic pressure between the two groups. The ivabradine group showed significant improvement in 6-minute walk distance (from 192.6±108.8 m at baseline to 285.1±88.9 m at the end of the study) compared with the control group (230.6±68.4 at baseline and 250.4±65.8 m at the end of study) (p0.001). This improvement in the drug group was associated with significant improvement of dyspnea on modified Borg scale (p=0.007).Lowering heart rate with ivabradine can improve exercise capacity and functional class in COPD patients with resting heart rate90 bpm.

In dentistry, 3D printing already has diverse applicability, and holds a great deal of promise to make possible many new and exciting treatments and approaches to manufacturing dental restorations. Better availability, shorter processing time, and descending costs have resulted in the increased use of RP. Concomitantly the development of medical applications is expanding. (Zaharia et al., 2017)Many different printing technologies exist, each with their own advantages and disadvantages. Unfortunately, a common feature of the more functional and productive equipment is the high cost of the equipment, the materials, maintenance, and repair, often accompanied by a need for messy cleaning, difficult post-processing, and sometimes onerous health and safety concerns (Dawood et al., 2015)Low-cost 3D printers represent a great opportunity in the dental and medical field, as they could allow surgeons to use 3D models at a very low cost and, therefore, democratize the use of these 3D models in various indications. However, efforts should be made to establish a unified validation protocol for low-cost RP 3D printed models, including accuracy, reproducibility, and repeatability tests. Asaumi et al., suggested that dimensional changes may not affect the success of surgical applications if such changes are within a 2% variation .However, the proposed cut-off of 2% should be furthermore discussed, as the same accuracy may be not required for all types of indications. (Silva et al., 2008; Maschio et al., 2016)This aim of the present study is to evaluate the dimensional accuracy of the 3D printed mandibular models fabricated by two different additive manufacturing techniques, using highly precise one as selective laser sintering (SLS) and a low-cost one as fused filament fabrication and whether they are both comparable in terms of precision. In addition to evaluation of dimensional accuracy of linear measurements of the mandible in CBCT scans.7 mandibular models will be recruited. Radio-opaque markers of gutta-percha balls will be applied on the model to act as guide pointsTen linear measurements (5 long distances: Inter-condylar, inter-coronoidal, inter-mandibular notch, length of left ramus, length of right ramus; as well as 5 short distances: Length of the body of the mandible at midline, length of the body of the mandible in the area of last left molar, as well as that of the last right molar, the distance between the tip of right condyle to the tip of the right coronoid, as well as that of their left counterparts) will be obtained using digital calliper, to act as the reference standard later. Scanning of the model by CBCT will be next , 3D printing of the scanned image using SLS and FFF printers will be done. Recording of same linear measurment will be done on printed models. Comparison of the recorded values vs reference standard is the last step

Aim: To assess the interdental alveolar bone density within specific regions of interest in the mandible of bruxers, mild bruxers and non-bruxers in absence or presence of influencing factors, such as orthodontia and impaction. Materials and methods: The study consisted of 104 subjects (64 bruxers and 40 controls) from the female students in the Faculty of Dentistry. Students were classified into bruxers, non-bruxers, and mild bruxers. The presence of modifying factors, such as impacted mandibular third molars and/or current or recent orthodontic treatment were identified. Panoramic radiographs were obtained, and the mean bone density values of interdental alveolar bone were measured using ImageJ software. Results: Non-bruxers had the highest mean bone density in all measured regions. The mesial aspect of the second premolar was an area of higher mean bone density in bruxers and in mild bruxers, compared to non-bruxers. In the presence of orthodontic treatment, the mean bone density in non-bruxers surpassed that of bruxers and mild bruxers. Conclusion: Bruxism, whether mild or severe decreased the interdental mean bone density in the studied regions of interest. The presence of influencing factors affected the interdental mean bone density.

Introduction: Distribution of abdominal fat is more detrimental in the pathogenesis of coronary artery atherosclerosis (CAA) than its amount. Purpose: To detect the value of the amount of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT), and their distribution by abdominal computed tomography in the detection of CAA as assessed by multi-slice computed tomography coronary angiography (MSCT-CA). Methods: The abdominal muscular wall was traced manually to calculate SAT and VAT areas (cm²) (outside and inside abdominal muscular wall respectively) at L4-L5 in 63 consecutive patients with no risk factors for coronary artery disease (CAD) referred for evaluation of chest pain by MSCT-CA. Results: 40% of the studied patients (n=25) had CAA (Group 1), while the remaining 60%(n=38) had no CAA (Group 2). There was no statistically significant difference between both groups as regards weight, body mass index (BMI), waist circumference (WC), waist-to hip ratio (W/H ratio), VAT area, SAT area, and total fat area. Group 1 patients were predominantly males (53% vs 24%; p=0.023), with statistically significantly increased VAT/ SAT area ratio (0.40 ± 0.23 vs 0.29 ± 0.16; p=0.028), and increased age (55.7 ± 7.9 vs 44.0 ± 11.1; p

Background Clostridium difficile infection (CDI) has recently markedly increased, incurring greater health care–associated costs and hospitalizations especially in vitamin D deficient patients. Accordingly, the aim of this study was to evaluate the relationship between low vitamin D levels and the severity and recurrence of CDI. Methods A retrospective case-control study evaluated patients hospitalized between 2007 and 2013 with CDI and a positive C. difficile toxin assay. Severe complicated CDI was defined based on (1) laboratory or radiological criteria correlated clinically and (2) sepsis requiring intensive care unit admission. Recurrent CDI (RCDI) was defined as a new episode of diarrhea occurring within 90 days of resolution of the initial episode for at least 10 days after discontinuing therapy and confirmed by positive stool C. difficile toxin assay or polymerase chain reaction. Patients were divided into 4 groups based on vitamin D level (ng/mL): severely deficient (Results Two hundred seventy-one patients were diagnosed with CDI, of which 48 had RCDI distributed as 5 (12.5%), 15 (16.1%), 10 (15.6%), and 13 (17.5%) patients in each of the aforementioned groups, respectively ( P= 0.55). Severe complicated CDI was identified in 7 (17.5%), 17 (18.2%), 9 (14%), and 3 (4%) patients, respectively ( P = 0.04). Thirty-day mortality was 1 of 40, 1 of 93, 2 of 64, and 2 of 74 patients, respectively ( P = 0.43). Conclusions Normal vitamin D level has a protective effect against severe CDI, and low vitamin D is associated with greater severity of CDI but not with an increased risk of RCDI or 30-day mortality.

Background Closure of atrial septal defect (ASD) among adults under transthoracic echocardiography (TTE) guidance using devices other than the Amplatzer Septal Occluder has not been extensively tested. Aim of work Assessment of the safety and efficiency of secundum ASD closure using the Occlutech Figulla ASD Occluder under TTE guidance in adult patients with hemodynamically significant secundum ASD. Methods Twenty patients (mean age, 32.9 ± 9.7, 75% of them females) were enrolled in the study. All patients underwent TTE and transoesophageal echocardiography (TEE) to assess the characteristics of the ASD prior to percutaneous closure. Procedures were performed using the Figulla Occluder device under both fluoroscopic and TTE guidance. Follow-up clinical and TTE examinations were done at 1, 3, and 6 months following the procedure. Results TTE estimated mean ASD size was 21.7 ± 7.3 mm with adequate rims except for the aortic rim (deficient in one third of cases). Mean device size was 28.1 ± 8.6 mm with mean procedure and fluoroscopic times of 46.2 ± 16.4 and 15.7 ± 5.4 minutes respectively. ASD was successfully closed in all patients. Two patients showed a small residual shunt immediately after the device placement that disappeared by the end of the 2nd followup TTE examination. Transient complications were detected in 2 patients. All patients were asymptomatic during the follow-up period. Conclusion Transcatheter closure of secundum ASD in adults under TTE guidance using the Occlutech Figulla ASD occluder device is safe and effective when performed in a tertiary center and by expert echocardiographers and interventional cardiologists.

Objectives: This study sought to examine the immediate and short term outcome (6 months) of percutaneous coronary interventions (PCIs) in patients with advanced chronic kidney disease (CKD). Background: PCI is established as a safe and effective option to treat patients with coronary artery disease. Difficulties and complications are known to be higher during PCI in patients with chronic kidney disease (CKD). Few data exist on the immediate and short term outcome of PCI in patients with advanced chronic kidney disease (creatinine clearance (Cr Cl) 70, Group 2, Cr Cl 30, Group 3, Cr Cl 93%) in all groups, as compared to patients in group 1 and 2, patients in group 3 had higher in-hospital morbidity (61% vs 0.9% and 8% for groups 3, 1 and 2 respectively P

Objective: We examined weight changes during chronic hepatitis C (CHC) therapy and association with virologic response. Methods: Weight changes were compared between subjects achieving rapid, early, and sustained virologic response rates (RVR, EVR, and SVR). RVR, EVR and SVR were compared among patients with or without weight loss of = 0.5 body mass index (BMI) units (kg/m2) at 4, 12, 48 weeks. Results: CHC therapy was initiated in 184 cases. Median pretreatment BMI was 27.7 (18.4-51.3) with 38% overweight and 31% obese (BMI =25 and = 30, respectively). Among patients with liver biopsies (n = 90), steatosis was present in 31.6%; fibrosis grade of 1-2/6 in 46%, 3-4 in 37.3% and 5-6 in 14.7%. Mean weight loss at 4, 12, 24 and 48 weeks of therapy were 1.2, 2.6, 3.8 and 3.3 kg, respectively. After 4 and 12 weeks of treatment, 38% and 54.3% had a BMI decrement of = 0.5 kg/m2. For genotype 1, weight loss at 4 weeks was associated with significantly higher EVR (90.0% vs. 70%, p = 0.01) and a tendency towards better RVR and SVR (42.9% vs. 26.0% and 55.2% vs. 34.8%, respectively, p = 0.08). In multivariate analysis, weight loss at 4 weeks was independently associated with EVR (OR 6.3, p = 0.02) but was not significantly associated with RVR or SVR Conclusions: Spontaneous weight loss at 4 and 12 weeks of CHC therapy was associated with improved EVR. Weight loss at 4 weeks was an independent predictor of EVR but not SVR.

Aims We directly compared TomTec and QLAB software packages for the three-dimensional echocardiographic (3DE) assessment of left ventricular (LV) dyssynchrony including their ability to predict response to cardiac resynchronization therapy (CRT) in patients with ischaemic and non-ischaemic cardiomyopathy. Methods and results A total of 140 heart failure patients with the LVEF ≤35% and 60 healthy volunteers underwent 3DE. A subgroup of 60 patients underwent CRT and were evaluated before and 6–12 months after implantation. The systolic dyssynchrony index (SDI) was derived from the dispersion of time to minimum regional volume for all 16 LV segments and measured with both software packages and compared using Pearson's correlation and Bland–Altman analysis. Measurements of SDI were significantly higher using TomTec compared with QLAB in both patients (10.9 ± 3.8 vs. 9.7 ± 3.9, P < 0.001) and healthy volunteers (4.1 ± 0.8 vs. 2.4 ± 1, P < 0.001), with large biases and wide limits of agreement. A moderate correlation ( r = 0.65, P < 0.001) was observed between both software packages in patients while their inter-observer and intra-observer reliability were good. Of the 60 patients undergoing CRT, reverse remodelling as a measure of response was observed in 41 patients (68%). The optimal SDI cut-off value to predict response to CRT was higher for TomTec than for QLAB (8.8 vs.7.3%, P < 0.001) and demonstrated better sensitivity and specificity (93 and 61%, respectively) compared with QLAB (88 and 33%, respectively). Response prediction in patients with non-ischaemic cardiomyopathy was excellent with a sensitivity and specificity of 95 and 100% for TomTec and 70 and 83% for QLAB using similar cut-off values of 9.1 and 9.2%, respectively. Conclusion Different 3DE software packages for the assessment of mechanical dyssynchrony should not be used interchangeably until better software standardization is achieved. Dyssynchrony assessment with 3DE for the prediction of response to CRT seems particularly useful in patients with non-ischaemic cardiomyopathy.

Aims In a time of controversy regarding the use of echocardiography for assessment of left ventricular (LV) dyssynchrony and prediction of response to cardiac resynchronization therapy (CRT), this meta-analysis aimed to evaluate the feasibility and reliability of LV dyssynchrony assessment by three-dimensional echocardiography (3DE), determine clinically useful reference values in healthy subjects and heart failure patients, and examine the accuracy of 3DE to predict response to CRT. Methods and results A total of 73 studies that evaluated the assessment of LV dyssynchrony by 3DE were eligible. The systolic dyssynchrony index (SDI) for 16 segments, being the predominant 3DE dyssynchrony parameter, was used for data pooling. Results demonstrated that LV dyssynchrony assessment by 3DE is feasible in 94% of studied subjects [95% confidence interval (CI): 92-95%)]. Pooled estimates of intraclass correlation coefficients (ICC) and limits of agreement (LoA) demonstrated that SDI has good interobserver (ICC: 0.92, LoA: 4.07%) and intraobserver reliability (ICC: 0.95, LoA: 2.10%). Reference values of SDI in healthy subjects, heart failure patients in general, and patients eligible for CRT were 2.7±0.9%, 9.8±3.9%, and 10.7±3.6%, respectively. Meta-regression analysis demonstrated that reference values of SDI in healthy subjects significantly differed between different software [1.80% (95% CI: 0.55-3.05%), P < 0.001]. In patients eligible for CRT, SDI had good accuracy to predict treatment response with a weighted mean cut-off value of 9.8% and pooled estimates for sensitivity and specificity of 93% (95% CI: 89-97%) and 75% (95% CI: 58-93%), respectively. Conclusion 3DE is a feasible and reliable tool for assessment of LV dyssynchrony and may have additional value to current selection criteria for accurate prediction of response to CRT. © The Author 2012.

Compared with parenteral nutrition, enteral nutrition reduces infectious complications and mortality in patients with severe acute pancreatitis (SAP). This study used clinical outcomes to investigate the association between time to initiation of distal jejunal feeding (DJF) and time to achievement of goal enteral feeding with clinical outcomes.A retrospective chart review was performed on all patients with SAP admitted to the medical intensive care unit (ICU) during a 1-year period. Collected data included demographic information, body mass index (BMI; kg/m(2)), Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, time of onset of DJF, time to goal feeding, ICU length of stay, and mortality.Time to starting DJF was longer in nonsurvivors (n = 4) than in survivors (n = 12) (17 vs 7 days, P.05). All nonsurvivors had BMI30 kg/m(2) (50% had BMI50 kg/m(2)). ICU length of stay was significantly associated with achievement of goal feeding. Three patients never reached goal feeding and spent 45.3 ± 19.6 days in the ICU; 7 patients reached goal feeding within 3 days of initiating DJF and spent 18 ± 1.7 days in the ICU; and 4 patients reached goal feeding within 3 days and spent 10.5 ± 3.5 days in the ICU. APACHE II scores were not significantly different among the 3 groups (16.7 ± 1.5, 12 ± 0.7, and 16.2 ± 1.2, respectively, P.05).Early initiation of DJF in the ICU was associated with reduced mortality in this cohort of patients with SAP. Early achievement of jejunal feeding goal early was associated with a shorter ICU length of stay, irrespective of the severity of SAP.

Background Clostridium difficile infection (CDI) has increased in incidence and severity worldwide, causing direct costs estimated to range from US $3.2 billion to $4.8 billion. The aim of this study was to investigate and identify factors that predict recurrence of CDI. Methods This was a retrospective case-control study between 2007 and 2013 on patients admitted with CDI. Recurrent CDI is defined as a new episode of diarrhea within 90 days confirmed by a positive stool C. difficile toxin assay or polymerase chain reaction, after resolution of the initial CDI episode for at least 10 days and after discontinuation of the CDI therapy. Results Three thousand twenty patients were diagnosed with CDI between January 2007 and December 2013. Two hundred nine of 2019 patients in the study had a recurrence of CDI within 90 days of the end of the initial CDI episode (10.3%). Multivariate analysis showed that most of the recurrences occurred in patients with comorbidities, particularly chronic kidney disease (odds ratio, 1.3; 95% confidence interval [CI], 1.0–2.4; P = 0.039). In addition, a higher percentage of patients in the recurrence group were prescribed proton-pump inhibitors (odds ratio, 1.65; 95% CI, 1.0–1.7; P = 0.002) and steroids (odds ratio, 1.65; 95% CI, 1.0–1.5; P = 0.047). Conclusions Our data suggest that the use of glucocorticoids, use of proton-pump inhibitors, and having end-stage renal disease are significant risk factors associated with recurrent CDI.

The effects of different dietary oils on the development of colitis-associated colon cancer have not been studied. The present study examined the effect of different dietary oils on the severity of chronic colitis, development of colitis-associated premalignant changes, and colonic expression of cyclooxygenase-2 (COX-2) in interleukin-10 knockout (IL-10-/-) mice.IL-10-/- mice were fed chow supplemented with corn oil (CO; control, n=28), olive oil (OO; n=29), or fish oil (FO; n=35) for 12 wk and their colons were studied for colitis score, premalignant changes, and COX-2 expression.The average colitis score was higher in the FO than in the CO group. Similarly, the incidence of severe colitis (scoreor=3) was significantly higher in the FO than in the CO and OO groups (50% versus 7.7% and 3.7%, respectively, P0.05). Dysplasia was more frequent in the FO and less frequent in the OO than in the CO group (47% and 4% versus 15%, respectively, P0.05). Conversely, aberrant crypt foci and crypt index were significantly higher in the FO than in the CO group. Colitis score, aberrant crypt foci, and crypt index did not differ between the OO and CO groups. COX-2 immunostaining was significantly lower in the OO than in CO group (P0.05) but not different between the FO and CO groups.In IL-10-/- mice, fish oil exacerbates chronic colitis and colitis-associated premalignant changes. Conversely, olive oil inhibits COX-2 immunostaining and decreases the risk of neoplasia associated with chronic colitis.

The field of short bowel syndrome and gastrointestinal failure has recently evolved, particularly after the clinical introduction of intestinal and multivisceral transplantation. For nearly three decades, the management of short bowel syndrome was limited to the natural adaptation process and lifelong intravenous supplementation. However, recent clinical availability of intestinal transplantation as an alternative to total parenteral nutrition, has fueled the field with relentless efforts to enhance intestinal adaptation and gut rehabilitation with the achievement of full nutritional autonomy. Intestinal and multivisceral transplantation has added new dimensions as a creative therapy to short bowel syndrome patients, as well as those with extensive abdominal pathology that could not be treated with conventional methods. With continuous improvement in the survival outcome, the procedure has become more widely applicable and commonly utilized, with more than 65 intestinal transplant centers worldwide. With the procedure currently showing improvement in therapeutic indices, including cost effectiveness and quality of life, we believe intestinal and multivisceral transplantation should promptly be offered to short bowel syndrome patients who fail conventional rehabilitation as well as those with complex abdominal pathology.

Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.

Nonsteroidal anti-inflammatory drugs decrease sporadic colorectal carcinoma and adenomas in patients with familial adenomatous polyposis and in rodent models of sporadic colon cancer and familial adenomatous polyposis. Similarly, selective cyclooxygenase 2 inhibitors decrease adenomas in humans and rodents. However, their effects on chronic colitis and colitis-associated neoplasia are unknown. Interleukin 10-/- mice (C57/B6) were fed regular chow (n = 20) or chow with celecoxib (1,500 ppm, n = 18) or rofecoxib (75 ppm, n = 20) for 12 weeks. Twenty-eight percent of the celecoxib group died versus 5% of the control and rofecoxib groups (p < 0.05 compared with control). Celecoxib and rofecoxib increased the incidence of colitis (26% vs. 92% and 68%, p < 0.01), colitis score (0.4 +/- 0.2 vs. 2.5 +/- 0.3 and 2 +/- 0.4, p < 0.01), aberrant crypt foci (0.5 +/- 0.3 vs. 3.7 +/- 2.6 and 2.8 +/- 0.7, p < 0.01), aberrant crypts per mouse (4.11 +/- 2.1 vs. 41.2 +/- 9.7 and 27.1 +/- 7.5, p < 0.01) and dysplasia (11% vs. 54% and 42%, p < 0.01). Similarly, indomethacin (9 ppm, n = 15) increased colitis score, aberrant crypt foci, and dysplasia after 27 days of treatment. Two selective cyclooxygenase 2 inhibitors exacerbate colitis and premalignant changes in the interleukin 10-/- mouse model of chronic colitis and colitis-associated colon carcinoma.

Primary duodenal adenocarcinoma accounts for less than 0.5% of all gastrointestinal cancers. We report a case of duodenal adenocarcinoma with highly divergent growth patterns consisting of poorly differentiated adenocarcinoma and neuroendocrine carcinoma proven to arise as a single neoplasm of monoclonal origin, as demonstrated by microdissection-based mutational profiling. Multicomponent growth patterns, as seen in this case, can occasionally be encountered in gastrointestinal malignancies and have led to speculation about the pathogenesis. The methods used to clearly establish monoclonal origin based on the unique profiling of mutational damage can address fundamental issues related to tumor development and progression, while providing cogent clinical information. Our findings confirm the great potential for intestinal epithelial cells to differentiate along different histogenetic lines during tumor progression.