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Background Intravenous (IV) prostacyclin analogues infusion and balloon atrial septostomy (BAS) are two important treatment options for managing advanced right heart failure in patients with idiopathic pulmonary arterial hypertension (IPAH). References and protocols are rare for dose titrations and transitions between subcutaneous and IV prostacyclin in functional Class IV IPAH patients. Balloon atrial septostomy is rarely done in very few expert centres. Case summary A young female with IPAH who had received maximal medication including subcutaneous prostacyclin analogues injection was admitted due to advanced right heart failure. She received ascites drainage twice. Later, we directly switched the administration route of prostacyclin from subcutaneous to IV at a ratio of 1:1 instantly. Such rapid conversion led her into a state of profound hypotension and drowsy consciousness, which was resolved after escalating IV inotropics and reducing prostacyclin dosage. Five days later, she received BAS under the guidance of intracardiac echocardiography. Her urine output increased and dyspnoea improved gradually. Six months later, clinical worsening happened again with increase of ascites and dyspnoea. She underwent 2nd and 3rd session of graded BAS with relief of symptoms again. She received permanent transition to IV prostacyclin analogues infusions via a peripherally inserted central catheter after three sessions of BAS. Discussion Balloon atrial septostomy is effective in stabilizing the critical right heart failure in IPAH patients but should be intended as a bridge to lung transplant procedure. Transition from subcutaneous to IV prostacyclin is helpful but needs to be titrated in proper aliquots and time intervals to avoid abrupt haemodynamic changes.

Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.

Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown.\ud \ud Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy.\ud \ud Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response.\ud \ud Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting.\ud \ud Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening.\ud \ud Clinical trial registered with www.clinicaltrials.gov (NCT01560624).

Background: GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic t...

Despite growing evidence that an educational anaesthesia video can effectively reduce perioperative anxiety, the ideal medium for addressing perioperative anxiety is unclear.The purpose of this study was to investigate the effect of viewing an anaesthetic patient information video on anxiety levels in patients scheduled to undergo surgery.A randomised controlled trial.Pingtung Christian Hospital (PTCH), Taiwan.One hundred patients were randomised to either an experimental group (n = 50) or a control group (n = 50).At the preoperative clinic, the experimental group watched the an 8 minute educational anaesthetic video, whereas the control group received a standard 8-min verbal briefing on anaesthesia after preoperative assessment.The Chinese version of the Spielberger state trait anxiety inventory, which included a state scale (STAI-S) and a trait scale (STAI-T), was performed in the preoperative clinic (T1) before anaesthetic preassessment, at the preoperative holding area just before surgery (T2) and again on the third day after surgery (T3). Scores for overall satisfaction with medical care were obtained on the third day after surgery. For two time interval comparisons, effect size was used to standardise the extent of change as measured by STAI-S.After the educational intervention, state anxiety was lower in the experimental group than in the control group at both T2 (42.9 ± 6.5 vs. 45.0 ± 12.7) and T3 (40.2 ± 5.3 vs. 48.8 ± 8.5). Compared with control group, the experimental group had a larger effect size at T2 and T3 (-0.65 and -0.36, respectively). Overall satisfaction was significantly higher in the experimental group than in the control group (P 0.05).Perioperative anxiety was significantly reduced and overall patient satisfaction increased after viewing a preoperative educational anaesthesia video compared with a standard verbal briefing on anaesthesia.

Accidental bone fractures are a major cause of premature disabilities and death. Whether atrial fibrillation (AF) treated with or without antithrombotics correlates with occurrence of such events remains under-investigated.Patients ≥18 years with newly diagnosed AF between 2005 and 2009 without previous cancers or traffic injury were identified from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Research Institutes and served as the AF group. A fourfold number of age-, gender-, and comorbidity-matched patients but without AF served as the non-AF controls. Patients were followed, and cumulative incidence of hospitalization-requiring bone fractures was compared between groups. Predictors of accidental bone fractures were determined by Cox regression analysis.Within a mean follow-up of 3.6 years, bone fractures, especially those involving neck/trunk and lower limbs, were significantly more frequent in patients with AF (N=6925) than in those without (N=27,700) (7.0 vs. 3.8 per 1000 person-years, log-rank p=0.001, adjusted HR=1.85, 95% CI=1.50-2.30, p0.001). Cox models identified female gender, previous stroke, and CHA2DS2-VASc score≧1 as risk factors for bone fractures in AF patients, whereas oral anticoagulants (HR=0.62, 95% CI=0.35-0.91, p=0.034), especially when used in patients with CHA2DS2-VASc score≧1 but not antiplatelet therapy (p=0.39) as negative predictors.Patients with AF are more vulnerable to non-traffic-, non-cancer-related bone fractures especially when with specified characteristics. For those with higher CHA2DS2-VASc scores, the use of anticoagulant but not antiplatelet agents could be associated with lower risk of such events.

A young female patient was referred for pulmonary arterial hypertension (PAH). Catheterization revealed a large sinus venosus interatrial communication (SVIAC), partial anomalous pulmonary venous return (PAPVR), pulmonary vascular resistance (PVR) 15 Wood units, and bidirectional shunting. She was then put on target medication for PAH. Two years later, she had angina and underwent computed tomography examination, which showed pulmonary arterial aneurysm compressing the left main coronary. Coronary stenting was performed, which successfully relieved the compression and angina. Meanwhile, PVR lowered to 3.5 Wood units after medical therapy. Surgical correction for SVIAC and PAPVR was done successfully 5 years after diagnosis.

Traffic accidents account substantially for premature disability and deaths in the modern world. Whether atrial fibrillation complicates the outcome of traffic injury remains under-investigated.From 1998 to 2010, all inpatient records stored in the Taiwan National Health Insurance database were screened. Those related with traffic accidents were aggregated to individuals and enrolled. The medical expenses and hospital outcomes were compared between patients with atrial fibrillation (AF group) and either the rest patients (No-AF group) or the propensity-matched patients without atrial fibrillation (No-AF-matched group). Prognostic predictive variables for adverse in-hospital events were further identified by multivariate regression analysis.Within the 13-year time span, of the 776,620 individuals ever admitted for traffic accidents, there were 1233 patients with AF. Compared with No-AF and No-AF-matched groups respectively, AF patients stayed longer in hospital (10.9 ± 10.6 vs. 6.8 ± 7.2 and vs. 8.2 ± 8.7 days, both p0.001), more often required surgical operations (73.2% vs. 69.5%, p = 0.006 and vs. 68.9%, p = 0.021), and consumed larger medical expenses (US$ 2384 ± 3174 vs. 1246 ± 2024, or 91.3% higher; and vs. 1406 ± 2172, or 69.6% higher, both p0.001), yet developed more postoperative complications (8.8% vs. 1.2% and vs. 3.2%, both p0.001) and deaths (2.5% vs. 0.9%, p0.001 and vs. 1.6%, p = 0.015). Identified by regression analysis, CHA2DS2-VASC score and representative demographic/injury-related variables predict in-hospital adverse events in these AF group patients.For patients suffering traffic accidents, those with AF consume more surgical resources and medical expenses yet end up with poorer hospital outcome, especially those with higher CHA2DS2-VASC scores and other relevant variables.

Rationale: Few studies had reported syndromes that include patent ductus arteriosus (PDA) with Eisenmenger syndrome and congenital deafness clustered in male siblings without facial, skeletal, or mental abnormalities. Patient concerns: Two brothers, who were deaf and had PDA with Eisenmenger complex, were first seen at our Cardiology clinic at the ages of 25 and 41, respectively. They presented with progressive dyspnea on exertion. Upon physical examination, both brothers had clubbing and/or cyanotic toes, normal fingers, and without facial, skeletal, ophthalmological, or mental abnormalities. Diagnoses and interventions: Echocardiography and multidetector computed tomography revealed large PDAs in both brothers. Cardiac catheterization showed bidirectional shunting via the PDA. Outcomes and lessons: Familial clustering of Eisenmenger PDA and congenital deafness is rare. Further studies are warranted to define possible genetic links.

This paper incorporates principal component analysis (PCA) with support vector machine-particle swarm optimization (SVM-PSO) for developing real-time face recognition systems. The integrated scheme aims to adopt the SVM-PSO method to improve the validity of PCA based image recognition systems on dynamically visual perception. The face recognition for most human-robot interaction applications is accomplished by PCA based method because of its dimensionality reduction. However, PCA based systems are only suitable for processing the faces with the same face expressions and/or under the same view directions. Since the facial feature selection process can be considered as a problem of global combinatorial optimization in machine learning, the SVM-PSO is usually used as an optimal classifier of the system. In this paper, the PSO is used to implement a feature selection, and the SVMs serve as fitness functions of the PSO for classification problems. Experimental results demonstrate that the proposed method simplifies features effectively and obtains higher classification accuracy.

Diarrhea with secondary decompensation is the main cause of morbidity and mortality in captive young rhesus macaque (Macaca mulatta) colonies. Approximately 25% of diarrhea cases with secondary decompensation are considered to be idiopathic chronic diarrhea. The purpose of this study was to investigate the suspected but not systematically examined association between rotavirus infection and diarrhea with secondary decompensation among young rhesus macaques at the California National Primate Research Center (CNPRC). Blood and stool samples were collected from 89 randomly selected young animals (age range: 6 months to 1.5 years) and were tested for the presence of rotavirus antibody, and rotavirus antigen, respectively, using enzyme-linked immunosorbent assays (ELISA’s). Test and clinical data were analyzed using Fisher’s exact tests and multivariate logistic regression model. Our analysis indicates that rotavirus is endemic among young outdoor-housed rhesus macaques at the CNPRC. Although the relationship between detectable rotavirus antigen in stool and symptomatic diarrhea with secondary decompensation was not significant, there was a significant association between rotavirus seropositivity and a history of diarrhea with secondary decompensation within the past 6 months. While our cross-sectional and case-control study suggests an association between rotavirus infection and diarrhea with secondary decompensation among captive rhesus macaques, more extensive longitudinal studies on larger cohorts and with more intensive sample collection are needed to confirm these findings.

We compared midterm prognostic predictors of peripheral artery disease (PAD) with or without diabetes mellitus (DM) presenting with critical lower limb ischemia (CLI). A total of 172 patients with PAD (109 DM; 63 non-DM) were enrolled. The major adverse events (MAEs) were death or amputation. The diabetic group had a higher MAE rate (39% vs 22%, P = .042) with a mean follow-up duration of 30 ± 19 months. In a multivariate binary logistic regression analysis, revascularization (odds ratio = 0.289, P = .006) and higher serum cholesterol (odds ratio=0.988, P = .027) predicted a lower MAE rate in the DM group. In contrast, the presence of severe chronic kidney disease (stage 4 or 5, odds ratio = 5.238, P = .025) was a positive predictor of MAEs in the nondiabetic group. In conclusion, the prognostic predictors of MAE in diabetic and nondiabetic patients with PAD and CLI were different.

Tracheal intubation of anaesthetised rats for laboratory experiments remains an essential yet challenging procedure.We aimed to investigate whether tracheal intubation can be safely and securely accomplished in laboratory rats employing only handy instruments and with minimal experience.The feasibility and safety of a modified orotracheal intubation method was evaluated in rats undergoing open-chest surgery as part of another research protocol, and compared with an existing technique.The study was carried out in a tertiary medical centre-affiliated animal laboratory.Eighty-five rats weighing 250 to 350 g anaesthetised with intraperitoneal pentobarbital (60 mg kg(-1)).Orotracheal intubation was performed on 35 animals (group Jou) using a previously reported technique and then on another 50 rats (group New) using the modified method employing a 3-ml syringe-derived intubation wedge, a 0.025-inch guidewire and a 16-gauge 45-mm-long intravenous catheter.The time for completion, the number of attempts and the incidence of difficulties and complications were recorded. The intubated tracheas were subsequently examined macroscopically and microscopically to determine position of the intubation catheter and the integrity of epithelial lining.Compared with the previous technique, the new method was completed more rapidly (1 ± 0.2 vs. 5 ± 2.4 min; P0.001), more smoothly (difficulties encountered in 8 vs. 74%; P0.001), with greater overall success (100 vs. 86%; P=0.022) and with fewer attempts [1 (1 to 1) vs. 2 (2 to 4); P0.001) for the new and Jou techniques, respectively, and with a lower incidence of procedure-related complications. Postmortem analysis confirmed there was no microscopic injury to the tracheal epithelial lining with the new technique in contrast to 57% in those using the Jou technique (P0.001).Tracheal intubation for laboratory rats can be securely and safely completed with the modified method employing a short learning curve and easily available devices.

Aim: Information regarding the effects of omega-3 fatty acid on hypertriglyceridemic patients in Chinese is still limited. This study aimed to investigate the efficacy and safety of Omacor®, a prescription ethyl-ester omega-3 fatty acid for the treatment of hypertriglyceridemia, administered at doses of 2 g/day and 4 g/day to Taiwanese hypertriglyceridemic patients. Methods: A multicenter, randomized, double-blind, placebo-controlled, parallel study in adults with hypertriglyceridemia was conducted. After a five-week diet lead in period patients with triglycerides = 200–1000 mg/dL were randomized to receive Omacor®, a concentrated preparation of omega-3 eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) in a dose of 1 g twice daily (2 g Omacor ®), 2 g twice daily (4 g Omacor®) or placebo, for eight weeks. The primary endpoint was the percentage change in triglyceride serum levels from baseline to the end of treatment. Results: A total of 253 Taiwanese patients were randomized, of which 65.6% (166) were men. At the end of the treatment, the percentage change in triglyceride serum levels in both the Omacor® 4 g/day (−32.1%) and 2 g/day (−29.7%) groups was larger than in the placebo group (−5.4%) (p < 0.001). The incidence of drug-related adverse events was as follows: 0.0%, 1.2%, and 0.0% in Omacor ® 4 g/day, Omacor® 2 g/day, and placebo groups, respectively. No drug-related serious adverse events were reported during the study. Conclusions: Omacor® may be a feasible option to treat hypertriglyceridemia in Taiwanese patients.

Whether patients with atrial fibrillation (AF) and liver disease are also prone to cerebrovascular events and respond similarly favorably to antithrombotic therapy remains under-investigated.Patients ≥18years with newly-diagnosed AF in the period 2005 to 2009 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute. Patients were categorized into the Liver (N=433) or the Non-liver (N=3490) cohort according to whether they had a diagnosis of advanced liver disease. Patients were then followed to determine cumulative incidence of hospitalization-requiring cerebrovascular events, preventive effects of antithrombotics, and predictors of cerebrovascular events by Cox regression analysis.Within a mean follow-up of 3.3±1.4years, ischemic stroke (89.2 vs. 50.3 per 1000 person-years, adjusted HR 1.502, 95% CI 1.207-1.868, p0.001) and overall cerebrovascular events (102.3 vs. 56.4 per 1000 person-years, adjusted HR 1.535, 95% CI 1.251-1.883, p0.001) occurred significantly more often in the Liver than in the Non-liver cohort. Cox models identified aging (≥65years), DM, and CHA2DS-VASc score≥2 points as risk factors for overall cerebrovascular events in the Liver cohort, whereas antiplatelet agents (HR 0.932, 95% CI 0.128-6.803, p=NS) and vit-K antagonistic anticoagulants (HR 1.087, 95% CI 0.150-7.862, p=NS) showed no correlation.AF patients comorbid with advanced liver disease are more vulnerable to ischemic and therein overall cerebrovascular events, especially in those with old age, DM, or high CHA2DS-VASc scores. This propensity to cerebrovascular events, however, can't be altered by antithrombotic therapy.

The atheroprotective role of high-density lipoprotein (HDL-C) particles as measured by HDL-C level in coronary arterial disease (CAD) remains unsettled. The aim of our study was to ascertain whether HDL-C was associated with the development and severity of coronary artery disease in Chinese patients who underwent coronary angiogram with low background Low-density lipoprotein (LDL-C) levels, which has not been previously investigated.Between March 1995 and May 2000, 566 consecutive patients (408 males, 66.7 ± 11.3 years of age) with background LDL-C less than 100 mg/dl who underwent coronary artery angiography at our cath lab for suspected CAD were retrospectively recruited into the study. The severity of coronary lesions was measured by conventional coronary angiography and modified Gensini scores.In those subjects with significant coronary lesions, there were more males and conventional CAD risk factors of diabetes mellitus, smoking, and chronic renal disease. They were also older compared to those in the control group. However, total cholesterol, LDL-C, HDL-C, triglyceride levels and use of statins were similar in both groups. In those subjects with significant coronary lesions, there was no difference in conventional coronary lesion severity or modified Gensini score between the quartered HDL-C subgroups. Furthermore, there was no significant correlation between serum HDL-C level and modified Gensini scores. In linear regression analysis, HDL-C was not an independent predictor for modified Gensini scores. Furthermore, HDL-C was also not an independent risk factor for the presence of significant coronary lesions in low LDL-C patients in logistic regression analysis.In Chinese patients with low background LDL-C, serum HDL-C was not associated with development of CAD or lesion severity in patients with suspected CAD. Therefore, HDL-C did not appear to be atheroprotective in these patients.Coronary artery disease; Gensini score; High-density lipoprotein cholesterol.

Atrial fibrillation is a common heart rhythm disorder in older adults, and its prevalence has increased rapidly in recent years. The health issues associated with atrial fibrillation are not limited to physiological problems, as it also contributes to an increased risk of falls, which may be related to cardiovascular co-morbidities and medication use. The aim of this study was to determine which cardiovascular co-morbidities and medication use are associated with falls in older adults with atrial fibrillation.Four hundred and one patients 75 years of age or older (82.2 ± 0.2 years) were enrolled in a geriatric evaluation and management unit in Taiwan. Events associated with patient falls and medication use were recorded, and comprehensive geriatric assessment was conducted during admission.Among the study participants, 66 (16.5%) patients had atrial fibrillation and 234 (58.4%) patients had a history of fall. We found a significantly higher prevalence of falls in patients with atrial fibrillation [odds ration (OR) 1.98, 95% confidence interval (CI) 1.08-3.63, p = 0.026] compared with those without atrial fibrillation. Using multivariate logistic regression, we found that benzodiazepine use (OR 18.22, 95% CI 2.71-122.38, p = 0.003), a history of paroxysmal atrial fibrillation (OR 12.18, 95% CI 1.37-108.70, p = 0.025) and hypertension (OR 9.49, 95% CI 1.19-75.57, p = 0.034) were independent factors for falls in atrial fibrillation patients.A diagnosis of atrial fibrillation in elderly patients is associated with falls. Benzodiazepine use, history of paroxysmal atrial fibrillation, and hypertension were associated with a high falling prevalence among patients with atrial fibrillation.Atrial fibrillation; Benzodiazepine; Falls; Hypertension.

Severe hypothermia (SH, 30 °C) increases the risk of pacing-induced ventricular fibrillation (PIVF) by enhancing spatially discordant alternans (SDA). Whether moderate hypothermia (MH, 33 °C), which is clinically used for therapeutic hypothermia, also facilitates SDA remains unclear. We hypothesized that MH attenuates SDA occurrence compared with that achieved by SH, and decreases the susceptibility of PIVF.Using an optical mapping system, action potential duration (APD)/conduction velocity restitutions and thresholds of APD alternans were determined by S1 pacing in Langendorff-perfused isolated rabbit hearts. In the MH group (n = 7), S1 pacing was performed at baseline (37 °C), after 5-min MH, and after 5-min rewarming (37 °C). In the SH group (n = 9), pacing was also performed at baseline (37 °C), after 5-min SH, and after 5-min rewarming (37 °C). The thresholds of APD alternans were defined as the longest S1 pacing cycle length at which APD alternans were detected.Although the thresholds of APD alternans were not different between the MH (273 ± 46 ms) and the SH (300 ± 35 ms) (p = 0.281) groups, SDA threshold was shorter (at a faster heart rate) during MH (228 ± 33 ms) than that during SH (289 ± 42 ms) (p = 0.028). At APD alternans threshold, SH hearts showed more SDA than that during MH (SH: 7 hearts, MH: 2 hearts, p = 0.049). SDA could be induced in all 9 SH hearts (100%), while only 4 MH hearts (57%) had SDA (p = 0.029). The PIVF inducibility during SH (44 ± 53%) was higher than that during MH (0%) (p = 0.043).Compared with SH, the MH group showed greater attenuation of SDA and decreased the susceptibility of PIVF. Therefore, MH is safer as a procedural guideline for use in clinical therapeutic hypothermia than SH.Cardiac alternans; Conduction velocity; Hypothermia; Optical mapping.

Background Tracheal intubation of laboratory mice remains essential yet challenging for most researchers. The aim of this study was to investigate whether this procedure can be more efficiently and safely accomplished by a novel method using slim and torqueable guidewires to guide access to the trachea. Methods This study was carried out in an animal laboratory affiliated to a tertiary medical center. Mice weighing 22 to 28 g were subjected to various open-chest experiments after being anesthetized with intraperitoneal ketamine (100 mg/kg) and lidocaine hydrochloride (10 mg/kg). The oropharyngeal cavity was opened with angled tissue forceps, and the trachea was transilluminated using an external light. The vocal cords were then crossed using either the Conventional method with a 38-mm-long, end-blunted stiff needle as a guide for insertion of a 22-gauge, 25-mm-long intravenous catheter into the trachea, or the Modified method utilizing using a 0.014-inch-thin torqueable wire as the guide to introduce an identical tube over it into the trachea. The epithelial integrity of the trachea was later examined histologically when the animals were sacrificed either immediately after the surgery or at 28 days post-surgery, depending on the corresponding research protocols. Results Orotracheal intubation was successfully completed in all mice using either the Conventional (N = 42) or the Modified method (N = 50). With the Modified method, intubation took less time (1.73 vs. 2.17 min, Modified vs. Conventional, p

Background Propofol is an anesthetic with pluripotent cytoprotective properties against various extrinsic insults. This study was designed to examine whether this agent could also ameliorate the infamous toxicity of doxorubicin, a widely-used chemotherapeutic agent against a variety of cancer diseases, on myocardial cells. Methods Cultured neonatal rat cardiomyocytes were administrated with vehicle, doxorubicin (1 μM), propofol (1 μM), or propofol plus doxorubicin (given 1 h post propofol). After 24 h, cells were harvested and specific analyses regarding oxidative/nitrative stress and cellular apoptosis were conducted. Results Trypan blue exclusion and MTT assays disclosed that viability of cardiomyocytes was significantly reduced by doxorubicin. Contents of reactive oxygen and nitrogen species were increased and antioxidant enzymes SOD1, SOD2, and GPx were decreased in these doxorubicin-treated cells. Mitochondrial dehydrogenase activity and membrane potential were also depressed, along with activation of key effectors downstream of mitochondrion-dependent apoptotic signaling. Besides, abundance of p53 was elevated and cleavage of PKC-δ was induced in these myocardial cells. In contrast, all of the above oxidative, nitrative and pro-apoptotic events could be suppressed by propofol pretreatment. Conclusions Propofol could extensively counteract oxidative/nitrative and multiple apoptotic effects of doxorubicin in the heart; hence, this anesthetic may serve as an adjuvant agent to assuage the untoward cardiac effects of doxorubicin in clinical application.

The study objectives were to evaluate outcomes in patients who have received dry needling treatments and to identify predictors of pain and disability.The study was a prospective cohort follow-up design.The study was conducted at the Pain Clinic at Pingtung Christian Hospital, Taiwan.Ninety-two (92) patients sick-listed for 3 months or longer for myofascial pain syndrome.From February to October 2008, participants were treated at the pain clinic with dry needling of trigger points and muscle stretches of the involved muscles.Data were collected by self-administered questionnaires to assess changes in pain intensity and pain interference. Data collection was performed at baseline and after 2, 4, and 8 weeks. Sociodemographic variables, symptom characteristics, and baseline outcome measures were analyzed using generalized estimating equation methodology.The proposed dry-needling protocol reduced pain intensity and pain interference. Long duration of pain symptoms, high pain intensity, poor quality of sleep, and repetitive stress were associated with poor outcomes.Dry needling is an effective treatment for reducing pain and pain interference. However, long pain duration, high pain intensity, poor quality of sleep, and repetitive stress are associated with poor outcomes. Treatment outcome depends not only on the dry needling protocol, but also on disease characteristics and patient demographic profile.

Background Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but transseptal puncture carries a certain risk of complications. Our previous report has shown the effectiveness of phase-array intracardiac echocardiography (ICE)-guided transseptal puncture in patients with dilated left atrium undergoing PTMC. However, there are few reports comparing the new-generation mechanical versus phase-array ICE-guided transseptal puncture in PTMC. Methods Between March 2007 and March 2008, 6 consecutive patients with symptomatic mitral stenosis with dilated left atrium (range, 4.1–6.1 cm) underwent transseptal puncture by mechanical ICE guidance in PTMC by the same experienced operator. The procedural, echocardiographic and clinical results were retrospectively retrieved and analyzed. In addition, phase-array ICE-guided transseptal cases ( n = 7), which included consecutive cases from May to December 2008, were compared. Results All 6 patients could have fossa ovalis visualized by ICE, and none of them had false transseptal puncture. Mechanical ICE provided a panoramic wider view of the interatrium septum, and offered better knowledge of the needle's geographic contact to the fossa ovalis than did the phase-array system. The fluoroscopic time of PTMC in the mechanical ICE-guided group (37 ± 9 minutes, n = 6) was similar ( p = 0.465) to that of phase-array guidance (31 ± 15 minutes, n = 7). Conclusion Mechanical ICE is effective in guiding transseptal puncture in PTMC.

The coexistence of idiopathic pulmonary artery hypertension with pulmonary arteriovenous malformation (PAVM) is challenging because although the PAVM causes hypoxia and polycythemia with potential thrombotic complications, closing the PAVM increases pulmonary artery pressure. We report on a lady with PAVM and idiopathic pulmonary artery hypertension who, within 2 years of diagnosis, had an ischemic stroke, PAVM enlargement from 20 × 20 × 30 mm to 30x × 40 × 40 mm and oximetry decrease to 90%. Transcatheter occlusion of PAVM with a vascular plug was successful. A year later, she had no flow via the PAVM and systemic oximetry improved to 97%, but pulmonary vascular resistance increased to 1.5-fold of baseline.

The purpose was to compare the findings of multi-detector computed tomography (MDCT) in prosthetic valve disorders using the operative findings as a gold standard. In a 3-year period, we prospectively enrolled 25 patients with 31 prosthetic heart valves. MDCT and transthoracic echocardiography (TTE) were done to evaluate pannus formation, prosthetic valve dysfunction, suture loosening (paravalvular leak) and pseudoaneurysm formation. Patients indicated for surgery received an operation within 1 week. The MDCT findings were compared with the operative findings. One patient with a Björk-Shiley valve could not be evaluated by MDCT due to a severe beam-hardening artifact; thus, the exclusion rate for MDCT was 3.2% (1/31). Prosthetic valve disorders were suspected in 12 patients by either MDCT or TTE. Six patients received an operation that included three redo aortic valve replacements, two redo mitral replacements and one Amplatzer ductal occluder occlusion of a mitral paravalvular leak. The concordance of MDCT for diagnosing and localizing prosthetic valve disorders and the surgical findings was 100%. Except for images impaired by severe beam-hardening artifacts, MDCT provides excellent delineation of prosthetic valve disorders.

This paper presents the application of a hybrid controller to the optimization of the movement of a mobile robot. Through hybrid controller processes, the optimal angle and velocity of a robot moving in a work space was determined. More effective movement resulted from these hybrid controller processes. The experimental scenarios involved a five-versus-five soccer game and a MATLAB simulation, where the proposed system dynamically assigned the robot to the target position. The hybrid controller was able to choose a better position according to the circumstances encountered. The hybrid controller that is proposed includes a support vector machine and a fuzzy logic controller. We used the method of generalized predictive control to predict the target position, and the support vector machine to determine the optimal angle and velocity required for the mobile robot to reach the goal. First, we used the generalized predictive control to predict the target position. Then, the support vector machine is used to classify the angle that must be followed by the mobile robot to reach the goal. Next, a fuzzy logic controller is designed to determine the velocity of the left and right wheels of the mobile robot. Thus generated, the velocity was optimized according to the measures obtained by the support vector machine. Finally, based on the optimal velocity of robot, the output membership function was modified. Consequently, the proposed hybrid controller allowed the robot to reach the goal quickly and effectively.

Aims The objective of this study was to investigate whether a cytoprotective herb-derived agent, Ginkgo biloba extract (EGb) 761, could have a beneficial effect on doxorubicin-induced cardiac toxicity in vitro and in vivo . Methods and results Primary cultured neonatal rat cardiomyocytes were treated with the vehicle, doxorubicin (1 µM), EGb761 (25 µg/mL), or EGb761 plus doxorubicin. After 24 h, doxorubicin upregulated p53 mRNA expression, disturbed Bcl-2 family protein balance, disrupted mitochondrial membrane potential, precipitated mitochondrion-dependent apoptotic signalling, induced apoptotic cell death, and reduced viability of cardiomyocytes, whereas EGb761 pretreatment suppressed all the actions of doxorubicin. Similarly, rats treated with doxorubicin [3 mg/kg intraperitoneally (i.p.) three doses every other day] displayed retarded growth of body and heart as well as elevated apoptotic indexes in heart tissue at both 7 and 28 days after exposure, whereas EGb761 pretreatment (5 mg/kg i.p. 1 day before each dose of doxorubicin) effectively neutralized the aforementioned gross and cellular adverse effects of doxorubicin. Conclusion Doxorubicin impairs viability of cardiomyocytes at least partially by activating the p53-mediated, mitochondrion-dependent apoptotic signalling. EGb761 can effectively and extensively counteract this action of doxorubicin, and may potentially protect the heart from the severe toxicity of doxorubicin.

PROBLEM: In many resource-poor countries that are scaling up antiretroviral therapy (ART), 5-25% of patients are reported as "lost to follow-up". This figure is 9% in Malawi. There is no published information about the true outcome status of these patients. APPROACH: In four facilities in northern Malawi, ART registers and master cards were used to identify patients who had not attended the facility for 3 months or more and were thus registered as "lost to follow-up". Clinic staff attempted to trace these patients and ascertain their true outcome status. LOCAL SETTING: Of 253 patients identified as "lost to follow-up", 127 (50%) were dead, 58% of these having died within 3 months of their last clinic visit. Of the 58 patients (23%) found to be alive, 21 were still receiving ART and 37 had stopped treatment (high transport costs being the main reason for 13 patients). Sixty-eight patients (27%) could not be traced, most commonly because of an incorrect address in the register. Fewer patients were alive and more patients could not be traced from the central hospital compared with the peripheral hospitals. RELEVANT CHANGES:Better documentation of patients’ addresses and prompt follow-up of patients who are late for their appointments are required. LESSONS LEARNED: ART clinics in resource-poor countries should ensure that patients’ addresses are correct and comprehensive. Clinics should also undertake contact tracing as soon as possible in the event of non-attendance, consider facilitating access to ART clinics and take loss to follow-up into consideration when assessing death rates.

Background Whether and how mitral regurgitation impacts perioperative outcome of noncardiac surgery remains unclear. Methods From November 1999 to August 2004, all patients undergoing noncardiac operations and ever examined by echocardiography within prior 12 months were screened. Those with moderate-severe or severe mitral regurgitation were enrolled provided they were not already trachea-intubated and the surgery was not performed under local anesthesia. The perioperative outcomes of these patients were analyzed, and related prognostic predictors were investigated by multivariate logistic regression analysis. Results A total of 84 patients (43 men, mean age of 66 years, low surgical risk in 28 and intermediate in 56) complying with the inclusion criteria were included. Their surgery was complicated by frequent (31%) yet minor intraoperative adverse events of controllable hypotension and bradycardia. In contrast, the postoperative outcomes were seriously complicated with high morbidity (27.4%, mostly pulmonary edema and prolonged tracheal intubation) and mortality (11.9%). Atrial fibrillation was identified by multivariate logistic regression analysis as the predictor of inhospital death (OD 11.579, P = .003), whereas surgical risk level (OD 5.118, P = .021), left ventricular ejection fraction (OD 0.958, P = .026), and atrial fibrillation (OD 3.058, P = .045), as independent predictors of postoperative morbidity. Conclusions Under current anesthetic management, patients with advanced mitral regurgitation could go through fairly safe intraoperative course of noncardiac surgery despite minor complications. Their postoperative outcome was, however, complicated by extraordinarily high morbidity and mortality, especially in those with preexisting atrial fibrillation, higher surgical risk level, and lower left ventricular ejection fraction.

Background Cardiac syndrome X (CSX) is characterized by angina pectoris but with patent coronary arteries. Our previous study showed that CSX subjects had decreased serum adiponectin but higher leptin and insulin resistance (IR). However, few studies have investigated circulating adipokines and IR in subjects with combined metabolic syndrome X (MetX) and CSX. Methods Fifty-nine subjects with CSX were retrospectively enrolled from our cardiac catheterization patient databank. Fifty-four subjects with valvular heart disease or arrhythmia and with normal coronary angiograms were recruited as the non-CSX comparison group. The study subjects were reclassified according to the presence or absence of MetX. Circulating adipokines and degree of IR were measured. Results Subjects with combined MetX and CSX had a significantly higher HOMA-IR, a higher circulating leptin level (median 8.7 vs. 3.3 ng/mL, p

Background Traffic accidents account for a substantial proportion of premature disabilities and deaths. Whether atrial fibrillation (AF) provokes while antithrombotics prevent from such events remains un-investigated. Methods All patients ≥40years with newly diagnosed AF in 2005 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute as the AF group. Four-fold number of age-, gender-, and comorbidity-matched patients but without AF served as the Non-AF controls. Patients were followed till occurrence of hospitalization-requiring traffic injury, death, withdrawal from insurance, or the end of 2010. Cumulative incidence of traffic accidents was compared between groups, and predictors and preventive role of antithrombotics for these accidents were identified by Cox regression analysis. Results Within a mean follow-up of 4.3years, traffic injury occurred significantly more often in patients with AF (N=1724) than those without it (N=6896) (5.4 vs. 4.9 per 1000 person-years, log-rank p=0.012, HR 1.110, 95% CI 1.013–1.572). Cox models identified age ≧65years, hypertension, coronary artery disease, stroke, liver cirrhosis and CHADS2VASC score≧1 as risk factors for traffic injury in AF patients, whereas oral anticoagulants (HR 0.576, 95% CI 0.285–0.791, p=0.002) used in patients with CHADS2VASC score ≧1 but not antiplatelet therapy (p=0.197) as negative predictors. Conclusion Patients with AF are more vulnerable to traffic accidents especially when with higher CHADS2VASC scores and other comorbidities. This tendency to traffic accidents, however, could be ameliorated by oral anticoagulation in specialized cases but not by antiplatelet therapy.

Pulmonary arterial hypertension (PAH) is a rare disease but with significant morbidity and high mortality. There is no specific way to diagnose PAH. Thus, an easy used with good sensitivity and specificity biomarker of PAH is highly desirable to aid in the screening, diagnosis, and follow-up. Caveolin-1 (Cav1) is the structural protein of caveolae and is highly expressed in type I pneumocytes. Lungs tissues from idiopathic PAH (IPAH) patients showed decreased expression of Cav1 in vascular endothelial cells. Therefore, we developed a direct sandwich immunoassay for the determination of Cav1 in IAPH patient’s serum. The result disclosed serum Cav1 level was significantly lower in IPAH than control groups. Using serum Cav1, 17.17 pg/mL as a cutoff value, the sensitivity was 0.59 and the specificity was 1.0. There were two major findings in our results. First, serum Cav1 might be a novel biomarker in the diagnosis of IPAH with fare sensitivity and good specificity. Second, Cav1 might be used to make differential diagnosis between COPD-PH and IPAH group.

Optimal endovascular therapy for isolated superior mesenteric artery (SMA) dissection remains undetermined. Here, we report a 56-year-old male with ischemic bowel syndrome caused by such a serious vascular disease. He was treated with endovascular true lumen stenting yet got aggravated in bowel ischemia from unexpected jail of major intestinal branches perfused by the false lumen, requiring subsequent complex rewiring and dilatation procedures to resolve at the cost of excessive fluoroscopic and contrast medium exposure. Thus, when treating patients with isolated SMA dissection with a functioning false lumen, true lumen stenting may inadvertently compromise crucial intestinal branches and should not be indiscriminately considered as the prime therapeutic option.

the drug. Therefore, one should always have in mind that during treatment of systemic inflammatory, neoplastic or hematological diseases with monoclonal antibodies the production of anti-drug antibodies is a reality. These antibodies can cause hypersensitivity reactions, worsen overt or incipient heart failure [11] and induce myocardial infarction manifesting as Kounis syndrome [3]. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

A 58-year-old man with acute type B aortic dissection presented with right lower limb cyanosis, mesenteric ischemia, and acute renal failure. He was treated with extraanatomic right axillofemoral bypass surgery alone, recovered completely from renal, mesenteric, and lower extremity malperfusion shortly thereafter, and lived free of symptoms for the following year. Follow-up computed tomography angiograms documented adequate expansion of the true aortic lumen and good perfusion of visceral organs. Thus, managing such patients with coexisting visceral and extremity malperfusion may be accomplished with axillofemoral bypass exclusively, which can relieve ischemia of upstream abdominal organs and downstream lower extremities effectively and durably.