Jui-Peng Tsai

Factors Associated With Leisure Participation Among the Elderly Living in Long-term Care Facilities

SUMMARY Background: A lack of participation in leisure activities often leads to depression in the elderly. This study investigated the factors impacting leisure participation among the elderly living in long-term care facilities. Methods: This cross-sectional study recruited 309 individuals older than 65 years from six long-term care facilities located in the Taipei area. Structured in-person questionnaires were administered to assess their demographic characteristics, general self-rated health status, leisure constraints, and leisure participation. Results: The average frequency of leisure participation was 27.20 ± 12.48 points. The top five most popular leisure activities were watching television, walking, chatting, reading, and participating in religious activities. Elderly subjects who tended to be female, have religious beliefs, have a high school education level, be married, perceive themselves in better health, demonstrate better cognitive function and have higher scores on activities of daily living and instrumental activities of daily living scales were more likely to participate in leisure activities (p < 0.05). In contrast, those who were older, had stayed in the facility for a longer time period and had more leisure constraints were less likely to participate in leisure activities (p < 0.05). Overall, the predictive factors for leisure participation included religious beliefs, educational level, cognitive skill, instrumental activities of daily living score, depression, personal inner constraints, and structural constraints. The entire model was significant (F = 11.03, p < 0.001). Conclusion: Based on the self-reported interests, health status and level of cognitive skill of elderly residents, long-term care facilities should arrange appropriate leisure activities to prevent depression and to improve quality of life. [International Journal of Gerontology 2010; 4(2): 69–74]

Large aortic aneurysm mimicking a cardiac tumor

IntroductionExtrinsic left atrial compression caused by a displaced, crooked descending thoracic aorta is rare. This anomaly may mimic primary cardiac tumors or metastatic neoplasms from the first look.Case presentationWe reported a 78-year-old woman presented to our emergency room with back pain, increased exercise intolerance and intermittent angina. She also had one syncopal event 1 month ago and gastric cancer post gastrectomy history. Subsequent chest plain film showed no mediastinum widening.Two-dimensional echocardiography was performed and revealed a heterogeneous mass as large as 2.3 × 2.4 cm occupying the left atrium (LA). Three-dimensional echocardiography vividly demonstrated that LA was constrained between the aortic valve (AV) and a luminal structure with pulsatile character suggestive of the aorta.ConclusionsWe successfully demonstrated the detailed structure and location of an anomalous descending aorta on the oblique imaging plane of RT-3DE, which may not be readily available by traditional 2D method.

Efficacy and tolerability between an olmesartan/amlodipine fixed-dose combination and an amlodipine double dose in mild to moderate hypertension

Fixed‐dose combinations (FDCs) are one of the options for improving blood pressure (BP) goal attainment. We enrolled 141 patients and evaluated the efficacy and safety between a fixed dose of olmesartan/amlodipine (OA) and a double dose of amlodipine (DA) for treating mild to moderate hypertension after amlodipine monotherapy failure. After at least 2 weeks of monotherapy failure, the patients were randomized to receive either OA or DA for 8 weeks. We compared the systolic blood pressure (SBP)‐lowering efficacy of the OA and DA using both an office BP and an ambulatory blood pressure monitoring (ABPM) device. The intent‐to‐treat analysis found that the early (2nd week) and final visit (8th week) SBP reductions were significantly greater in those patients receiving OA (n = 70) than DA (n = 71) (17.57 ± 15.49 vs. 10.46 ± 13.36 and 24.89 ± 14.09 vs. 17.03 ± 13.27 mmHg, p = 0.002 and 0.001, respectively). Among those using ABPM, the patients with 8‐week OA had a greater SBP‐lowering effect in comparison with those on DA (14.08 ± 10.74 vs. 6.32 ± 10.21, p = 0.018). Both treatment strategies were well tolerated. This study showed that an OA FDC is more effective than DA in reducing SBP for mild to moderate hypertension after the failure of amlodipine monotherapy.

A meta-analysis comparing SPECT with PET for the assessment of myocardial viability in patients with coronary artery disease.

ObjectiveThe aim of this meta-analysis was to examine the diagnostic accuracy of single-photon emission computed tomography (SPECT) for the assessment of myocardial viability in patients with coronary artery disease as compared with PET. Materials and methodsThe literature was searched using the following keywords: single-photon emission computed tomography, positron emission tomography, perfusion, viability, myocardial infarction. Studies involving patients with coronary artery disease, left ventricular dysfunction, or a history of myocardial infarction and that compared SPECT and PET for the assessment of myocardial viability were included in the analysis. ResultsEight studies including 310 patients were included in the meta-analysis. The total number of myocardial segments analyzed was 3580. The sensitivity and specificity of SPECT for the eight studies ranged from 59 to 95% and from 79 to 100%, respectively. The pooled sensitivity of SPECT was 82% [95% confidence interval (CI): 81–84%]. The pooled specificity of SPECT was 88% (95% CI: 86–90%). For all studies, the pooled diagnostic odds ratio was 62.60 (95% CI: 19.29–203.15) and the area under the receiver-operating characteristic curve was 0.945, indicating that SPECT could accurately assess myocardial viability. ConclusionThe meta-analysis indicated that SPECT can accurately assess myocardial viability, as compared with PET, and supports the use of SPECT for the assessment of myocardial viability in patients with coronary artery disease.

Severe Pulmonary Embolism in a Young Man Post Knee Arthroscopic Anterior Cruciate Ligament Repair: A Case Report and Literature Review

Thromboprophylaxis of post knee arthroscopy is a matter of debate. Herein, we report the case of a young man who developed a sub-massive pulmonary embolism following knee arthroscopic anterior cruciate ligament repair, with an initial presentation of syncope. Right sided electrocardiography revealed ST-segment elevation and mild elevation of troponin I. Emergent cardiac catheterization reveal a myocardial bridge at the left anterior descending artery, however no occlusion or thrombus was found. Echocardiography showed a D shaped left ventricle in the apical four chamber view. Computed tomography pulmonary angiography confirmed a pulmonary embolism at bilateral distal pulmonary arteries with involvement of the distal branches. We further discuss the need of thromboprophylaxis after knee arthroscopy. (J Intern Med Taiwan 2012; 23: 106-113)

Evaluation of the Accuracy of ECG Captured by CardioChip through Comparison of Lead I Recording to a Standard 12-Lead ECG Recording Device

Background Remote cardiac rhythm monitoring and recording, using hand-carried electrocardiogram (ECG) device had been widely used in telemedicine. The feasibility and accuracy analysis on the data recorded by a new miniature ECG system-on-chip (SoC) system has not been explored before. Methods This study evaluated the accuracy of the ECG recordings captured by CardioChip - a single-channeled, low-powered, miniature ECG SoC designed for mobile applications; comparing against Philips Pagewriter Trim III - a Food and Drug Administration certified, widely-used standard 12-lead ECG recording device, within Mackay Memorial Hospital in Taiwan. Results Total of 111 participants, age ranging from 39 to 87years old [mean age: 61.2 ± 13.4, 57 male (51.3%)] were enrolled. Two experienced cardiologists rated and scored the ECG morphology to be the same between the two devices, while CardioChip ECG was more sensitive to baseline noise. R-peak amplitudes measured both devices using single lead information (CardioChip ECG vs. Lead 1 in standard 12-lead ECG) showed statistical consistency. Offline analysis of signal correlation coefficients and coherence showed good correlation with both over 0.94 in average (0.94 ± 0.04 and 0.95 ± 0.04, respectively), high agreement between raters (94% agreement) for detecting abnormal cardiac rhythm with excellent R-peak amplitude (r = 0.98, p < 0.001) and PR interval (r = 0.91, p < 0.001) correlations, indicating excellent correlation between ECG recordings derived from two different modalities. Conclusions The results suggested that CardioChip ECG is comparable to medical industry standard ECG. The future implementation of wearable ECG device embedded with miniature ECG system-on-chip (SoC) system is ready for clinical use, which will potentially enhance efficacy on identifying subjects with suspected cardiac arrhythmias.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease- A Single Hospital Experience without On-Site Cardiac Surgery

BACKGROUND To investigate the safety and outcome of percutaneous coronary intervention for left main coronary artery disease in hospital without on-site cardiac surgery. METHODS Between January 2007 and December 2010, all patients diagnosed with left main coronary artery disease and refused coronary artery bypass graft surgery in our hospital or a tertiary center, were enrolled. Data including clinical course, angiographic characteristics, and 1- and 3-years outcomes were recorded and analyzed. RESULTS Seventy patients (mean age 73.4 ± 10.2 years, 47 male, 23 females) were treated with a mean SYNTAX score of 34.8 ± 12.6 and EuroSCORE of 6.7 ± 3.3. Thirty-two (45.7%) patients had stable angina, 35 (50.0%) had unstable angina/non ST-elevation myocardial infarction, and 3 (4.3%) had ST-elevation Myocardial infarction. Forty-three (61.4%) patients received a single-stent, 26 (37.1%) received two-stents, and 1 (1.4%) received balloon angioplasty. No procedure-related mortalities were noted and no emergency coronary artery bypass graft surgery was required. In the 3-year follow-up period, 2 (2.9%) patients had non-fetal myocardial infarction, 11 (15.7%) had left main target lesion revascularization. The major adverse cardiac and cerebrovascular events rates were 24.3% at 1 year and 37.1% at 3-years. The all-cause mortality rate was 41.4% (29 patients), including 18 (25.7%) cases of septic shock, 7 (10.0%) of sudden cardiac death, 2 (2.8%) of hypovolemic shock due to upper gastrointestinal bleeding, 1 (1.4%) of terminal stage malignancy, and 1 (1.4%) of suffocation at 3 years. CONCLUSIONS Percutaneous coronary intervention for patients with left main coronary artery disease was found to be a safe and effective strategy in our hospital without on-site cardiac surgery. KEY WORDS Incomplete revascularization; Left main coronary artery (LM); No cardiac surgery; Percutaneous coronary intervention (PCI).

The Clinical Role of CT-Based Morphologic Description in Severely Calcified Coronary Arteries Ectasia Encountering Acute Coronary Syndrome.

Diffuse coronary arteries ectasia combined with calcification is seldom reported. Acute coronary syndrome, a potentially life-threatening disease, accompanied with coronary ectasia and diffuse calcification, made percutaneous coronary intervention difficult and risky owing to increasing complications rate. Dual-source computed tomography and three-dimensional volume rendering images help cardiovascular surgeon easier to localize the ideal site and facilitate the procedure.

A mimicker of acute myocardial infarction

In April, 2009, a 33-year-old man visited our emergency room complaining of sudden chest tightness, dyspnoea, left shoulder pain, and cold sweats while sleeping. He had intermittent chest discomfort, mild fever, and fl u-like symptoms about 1 month ago and had visited the outpatient clinic at that time. During the previous visit, his electrocardiogram (ECG) showed widespread borderline ST elevation over praecordial and inferior leads, but echocardiography showed no typical fi ndings of pericarditis. His medical history was otherwise unremarkable. On examination, blood pressure was 123/75 mmHg and heart rate was 70 beats per min. Compared with previous data, ECG showed progressive ST elevation, particularly over inferior leads. Chest radiography showed a mass superimposed over the left hilum. 3D echocardiography showed a large heterogeneous mass encroaching on the lateral aspect of the left ventricle and pulmonary artery (fi gure A). To exclude acute coronary syndrome, emergency coronary angiography was done, which showed patent vessels. CT of the chest showed a 7cm×5 cm×6 cm lobulated heterogeneous mass occupying the left anterior mediastinum adjacent to the pericardium with multifocal central-low density. Laboratory tests were all within normal range except for high concentratons of α-fetoprotein (13 ng/ml) and βHCG (57 mIU/ml). Thoracotomy showed direct tumour invasion from the mediastinum into the left lung, aorta, anterior chest wall, and main pulmonary arterial trunk. Excisional biopsy (fi gure B, C) confi rmed seminoma. We started bleomycin, etoposide, platinum (BEP) chemotherapy at the 20th day of hospitalisation. Follow-up echocardiogram 2-days later showed partial shrinkage of the tumour. ECG showed no more ST elevation. Six more courses of BEP chemotherapy were given from June to August, 2009. Follow-up chest CTs at 4 and 6 months after initial diagnosis showed no recurrent tumour. When seen in December, 2009, the patient was symptom-free and there was no evidence of recurrence. The mediastinum is the most common extragonadal primary site for germ cell tumours. The most common type of mediastinal germ cell tumour is mature teratoma, followed by seminoma, the latter accounting for most of the malignant subtypes (25–40%). Symptomatic patients can experience substernal chest pain, dyspnoea, weight loss, dysphagia, or fever. Tumour extension to the pericardium or mediastinum can produce pericardial eff usions along with changes on ECG. Although the radiology and pathology of primary cardiac tumours are well known, detailed understanding of extracardiac masses have mostly been limited to single case reports. The echocardiographic features of mediastinal tumours has been reveiwed, although there was no reference to germ cell tumours. Transthoracic and transoesophageal echocardiography are the mainstay in identifying mediastinal masses. A quick diagnosis by bedside echocardiography is crucial in emergency situations where the tumour causes compression or even pericardial tamponade. More complete imaging by CT or MRI is usually required. In cases of uncertain fi ndings, 3D echocardiography might be used to further identify the texture of the tumour and its association with adjacent structures. With advances in multidimensional echocardiographic imaging, visualisation of cardiovascular structure, function, and haemodynamics has greatly improved. Our patient had a primary mediastinal seminoma with extension to major cardiac structures. In our case, we successfully showed the detailed texture, character, and associations of the seminoma. Although treatable, therapeutic recommendations for this class of germ cell tumour are in constant evolution. Early diagnosis is paramount to long-term survival.

Intracoronary Stenting for Acute Myocardial Infarction Caused by Myocardial Bridging: A Case Report

Myocardial bridging is a benign condition with a favorable long-term outcome. However, some serious complications can be caused by myocardial bridges, such as myocardial infarction, sudden death, or serious arrhythmia, but such reports are rare. We report on a 61-year-old woman who experienced sudden onset of retrosternal chest tightness with radiation to the back lasting over 60 minutes and who came to our hosp ital for help. She had difficulty breathing and chest tightness, and an interoapical infarction on the EKG and elevated cardiac enzymes were found. Cardiac catheterization was performed and revealed myocardial bridging in the left anterior descending coronary artery, resulting in an estimated dynamic stenosis of 90% during systole and complete recovery during diastole. We successfully deployed an intracoronary stent to treat this patient, and she was asymptomatic without complications after 6 months of follow-up. We review the literature and discuss the clinical practice and methods in treating myocardial bridging. We feel we must remind physicians that even benign disease may need invasive intervention when serious complications occur. Intracoronary stenting causes little suffering, has few complications, and is an easy procedure as a first choice before an operation.