Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/ depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

We present a case of extensive thrombosis in the jugular vein and sigmoid, transverse, superior sagittal sinuses with partial deep venous thrombosis. The patient had acute severe headache but had neither focal neurological deficit nor consciousness change. Emergency endovascular thrombolysis through transfemoral approach was performed with successful restoration of venous drainage. There was no hemorrhagic complication. Several days later, the patient had a focal seizure attack due to focal venous infarction despite of continuous systemic anticoagulation therapy.
Colon, Sigmoid ; Consciousness ; Drainage ; Emergencies ; Headache ; Humans ; Infarction ; Jugular Veins ; Seizures ; Sinus Thrombosis, Intracranial* ; Superior Sagittal Sinus ; Thrombosis ; Urokinase-Type Plasminogen Activator ; Venous Thrombosis

To date, there are limited data and little consensus on treatment strategies for huge hepatocellular carcinoma (HCC). Surgical resection provides significantly better survival than other modalities for single large HCC regardless of tumor stage. Recently, with technological advances in radiation therapy, stereotactic body radiation therapy (SBRT) is considered an alternative treatment option for HCC. Herein, we present a case of huge HCC that was successfully managed by SBRT. Transarterial embolization, previously performed in Russia, was incomplete. It was also not suitable for resection and transarterial chemoembolization. Although the rationale for radiotherapy in huge HCC was insufficient, SBRT was performed because no other treatment options were available. Additional radiofrequency ablation was performed for small HCC in a different segment, and radiological complete response (CR) was achieved. The CR was maintained over 4 years. Therefore, SBRT may be an alternative treatment option for large HCC that is not suitable for curative treatment.

BACKGROUND AND OBJECTIVES: Although elevations of plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) concentration have been shown to be prognostically significant in patients with non-ST elevation acute coronary syndrome (ACS), the relation between the plasma level of NT-proBNP and the severity of coronary disease remains unknown. SUBJECTS AND METHODS: The NT-proBNP concentration was analyzed in 50 patients with non-ST elevation ACS. We compared plasma NT-proBNP levels and treatment method (medical treatment vs. percutaneous coronary intervention [PCI]). RESULTS: In patients with non-ST elevation ACS, NT-proBNP levels were significantly higher in the PCI (n=37) group than in the medical treatment (n=13) group (296.6 vs. 76.3 pg/mL;p<.001). In patients with unstable angina (UA), NT-proBNP levels were significantly higher in the PCI (n=22) group than in the medical treatment (n=12) group (147.6 vs. 64.5 pg/mL;p<.001). Elevated NT-proBNP level predicted PCI in patient with non-ST elevation ACS. A NT-proBNP level >125.9 pg/mL had sensitivity, specificity, positive predictive value and negative predictive value of 75.7%, 92.3%, 96.6% and 57.1%, respectively. In patients with UA, a NT-proBNP level >123.8 pg/mL had equivalent results of 68.2%, 91.7%, 93.8% and 61.1%, respectively. The area under the curve was 0.891 in non-ST elevation ACS and 0.907 in UA. Elevated NT-proBNP level was also correlated with the severity of culprit artery stenosis and multi-vessel disease. CONCLUSION: Elevated plasma NT-proBNP concentrations were associated with the severity of coronary artery disease in patients with non-ST elevation ACS. In combination with clinical factors, NT-proBNP level will provide a highly discerning tool for early risk stratification and further clinical decisions.
Acute Coronary Syndrome* ; Angina, Unstable ; Angioplasty ; Arteries ; Constriction, Pathologic ; Coronary Artery Disease ; Coronary Disease ; Coronary Stenosis* ; Coronary Vessels* ; Humans ; Natriuretic Peptide, Brain ; Percutaneous Coronary Intervention ; Plasma* ; Sensitivity and Specificity

BACKGROUND/AIMS: A moderate dose of statin/ezetimbe combination therapy reduced the LDL-C (low density lipoprotein-cholesterol) in a fashion comparable to high dose statin without increasing the adverse events in patients with primary hypercholesterolemia. Yet there is no data on the effectiveness and safety of statin/ezetimbe combination therapy in patients suffering with acute myocardial infarction (AMI). METHODS: We retrospectively compared the lipid profiles and clinical variables of 82 patients who were admitted to our institution with AMI. These patients were successfully treated with emergent coronary intervention within 12 hours after the chest pain onset and they were prescribed a single statin (statin group) or statin/ezetimibe combination therapy (dual inhibition group) for treating their hyperlipidemia within 72 hours after the admission. We compared the initial lipid profiles, the % reduction of total cholesterol (TC), the LDL-C at 1 and 6 months and the safety profiles between the two therapeutic groups. RESULTS: Although the initial TC and LDL-C levels were significantly higher in the dual inhibition group than the statin group, one month later, the % reduction of the TC was 27.9+/-13.1% and 17.0+/-15.0% (p=0.004) and the % reduction of the LDL-C was 38.5+/-12.5% and 25.1+/-18.9% (p=0.001) in each group, respectively. One patient in the dual inhibition group showed CPK elevation more than 3 times the upper normal limit and ALT elevation more than 2 times of upper normal limit was observed in one patient in the statin group. CONCLUSIONS: Cholesterol dual inhibition therapy is superior to single statin therapy for the aspect of cholesterol reduction and safety in successfully reperfused AMI patients.
Chest Pain ; Cholesterol ; Humans ; Hypercholesterolemia ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Hyperlipidemias ; Myocardial Infarction ; Retrospective Studies ; Stress, Psychological

No abstract available.
Echocardiography ; Myocardial Infarction*

No abstract available.
Classification* ; Wounds and Injuries* ; Wounds, Gunshot*

BACKGROUND/AIMS: In spite of increasing interests about nonalcoholic steatohepatitis (NASH), there are few reports about the ultrastructure of hepatocyte in this disease. The aim of this study was to clarify abnormal electron microscopic (EM) findings and related factors in NASH. METHODS: Total of fourteen patients who underwent liver biopsy due to steatohepatitis were included. Precise personal history was taken and variable blood tests such as liver function test, lipid profile, and serum iron study were done. Pathologic examination with light and electron microscopy was done by single pathologist. RESULTS: Eleven men and three women were included and mean age was 33.7+/-12.8 years. Nine patients drinking less than 40 g/week was grouped as "NASH group" and other 5 patients drinking more than 40 g/week and body mass index less than 25 was grouped as "ASH (Alcoholic Steatohepatitis) group". Polymorphism of mitochondria such as megamitochondria or loss of cristae was major abnormal EM findings and was more common in "NASH group" than "ASH group" (p=0.027). There was no significant clinical or pathological factors related with the presence of these abnormal EM findings. CONCLUSIONS: Polymorphism of mitochondria is major abnormal EM finding of steatohepatitis and is more common in NASH than ASH. And there is no significant clinical or pathological factors which could predict the presence of these abnormal EM findings.
Adolescent ; Adult ; Fatty Liver/*pathology ; Female ; Hepatocytes/*ultrastructure ; Humans ; Liver Diseases, Alcoholic/*pathology ; Male ; Microscopy, Electron, Transmission ; Middle Aged ; Mitochondria, Liver/ultrastructure

BACKGROUND AND OBJECTIVES: Rapamycin has been shown to inhibit the vascular smooth muscle cell migration and proliferation that contributes to neointimal formation. We investigated whether the perivascular delivery of rapamycin in Pluronic gel could inhibit neointimal hyperplasia in a rat carotid artery model, and we tested the usefulness of carotid arteriography. MATERIALS AND METHODS: To assess the kinetics of rapamycin's release from Pluronic gel, a [3H] thymidine incorporation assay was performed with using the media exposed to rapamycin in Pluronic gel for 10, 20, 60 and 120 min. We applied 100 microgram of rapamycin in Pluronic gel to the perivascular space of the carotid artery after the balloon injury (n=9), whereas only gel was applied in a control group (n=9). We performed the carotid arteriography and the morphometric analysis 14 days after injury. RESULTS: The [3H] thymidine incorporation assay showed a reduction of uptake in a time-dependent manner (86%, 48%, 45% and 40% of the control, respectively, at 10, 20, 60 and 120 minutes). The inhibiting effect of rapamycin on neointimal hyperplasia was identified on the carotid arteriography (mean luminal diameter; 0.75+/-0.11 vs. 0.60+/-0.12 arbitrary units, respectively, p< 0.05) and on the morphometric analysis (neointima area: 0.09+/-0.03 vs. 0.17+/-0.06 mm(2), respectively, p< 0.05). CONCLUSION: This study demonstrated that perivascular delivery of rapamycin in Pluronic gel inhibits neointimal hyperplasia in a rat carotid injury model. This animal model combined with arteriography can be used for developing new drugs to treat restenosis. In addition, this technique might be useful for vascular surgery such as coronary artery bypass grafting, arteriovenous fistula formation and peripheral vascular bypass graft insertion.
Angiography ; Animals ; Arteriovenous Fistula ; Carotid Arteries ; Carotid Artery Injuries ; Cell Movement ; Coronary Artery Bypass ; Drug Delivery Systems ; Hyperplasia ; Kinetics ; Models, Animal ; Muscle, Smooth, Vascular ; Phenobarbital ; Rats ; Sirolimus ; Thymidine ; Transplants