Mauricio Rocha-e-Silva

Small volume hypertonic resuscitation of circulatory shock

Small volume hypertonic resuscitation is a relatively new conceptual approach to shock therapy. It was originally based on the idea that a relatively large blood volume expansion could be obtained by administering a relatively small volume of fluid, taking advantage of osmosis. It was soon realized that the physiological vasodilator property of hypertonicity was a useful byproduct of small volume resuscitation in that it induced reperfusion of previously ischemic territories, even though such an effect encroached upon the malefic effects of the ischemia-reperfusion process. Subsequent research disclosed a number of previously unsuspected properties of hypertonic resuscitation, amongst them the correction of endothelial and red cell edema with significant consequences in terms of capillary blood flow. A whole set of actions of hypertonicity upon the immune system are being gradually uncovered, but the full implication of these observations with regard to the clinical scenario are still under study. Small volume resuscitation for shock is in current clinical use in some parts of the world, in spite of objections raised concerning its safety under conditions of uncontrolled bleeding. These objections stem mainly from experimental studies, but there are few signs that they may be of real clinical significance. This review attempts to cover the earlier and the more recent developments in this field.

Small volume resuscitation with 3% hypertonic saline solution decrease inflammatory response and attenuates end organ damage after controlled hemorrhagic shock

BACKGROUND Recently, studies have been conducted examining the efficacy of 3% hypertonic saline solution (HS) for the treatment of traumatic brain injury; however, few studies have analyzed the effects of 3% hemorrhagic shock during hemorrhagic shock. The aim of this study was to test the potential immunomodulatory benefits of 3% hemorrhagic shock resuscitation over standard fluid resuscitation. METHODS Wistar rats were bled to a mean arterial pressure of 35 mm Hg and then randomized into 3 groups: those treated with lactated Ringers solution (LR; 33 mL/kg, n = 7), 3% HS (10 mL/kg, n = 7), and 7.5% HS (4 mL/kg, n = 7). Half of the extracted blood was reinfused after fluid resuscitation. Animals that did not undergo shock served as controls (n = 5). Four hours after hemorrhagic shock, blood was collected for the evaluation of tumor necrosis factor-alpha and interleukin-6 by enzyme immunoassay. Lung and intestinal samples were obtained for histopathologic analysis. RESULTS Animals in the HS groups had significantly higher mean arterial pressure than those in the LR group 1 hour after treatment. Osmolarity and sodium levels were markedly elevated in the HS groups. Tumor necrosis factor-alpha and interleukin-6 levels were similar between the control and HS groups but significantly higher in the LR group (P < .05). The lung injury score was significantly higher in the LR group compared with the 7.5% HS and 3% HS groups (5.7 +/- 0.7, 2.1 +/- 0.4, and 2.7 +/- 0.5, respectively). Intestinal injury was attenuated in the 7.5% HS and 3% HS groups compared with the LR group (2.0 +/- 0.6, 2.3 +/- 0.4, and 5.9 +/- 0.6, respectively). CONCLUSIONS A small-volume resuscitation strategy modulates the inflammatory response and decreases end-organ damage after HS. Three percent HS provides immunomodulatory and metabolic effects similar to those observed with conventional concentrations of HS.

O novo Qualis, ou a tragédia anunciada

Para marcianos recem-desembarcados, Qualis e definido pela CAPES como uma lista de veiculos utilizados para a divulgacao da producao intelectual dos programas de pos-graduacao stricto sensu (mestrado e doutorado). Ate recentemente estes veiculos eram classificados quanto ao âmbito de circulacao (Local, Nacional, Internacional) e quanto a qualidade (A, B, C), para cada area de avaliacao. Serve para fundamentar o processo de avaliacao do Sistema Nacional de Pos-Graduacao da CAPES. Esta classificacao foi de grande importância como primeira medida de qualidade do produto da pos-graduacao. Praticamente todos concordam que ela ja esgotou seu ciclo de validade e deve ser substituida. O evidente crescimento em qualidade da producao cientifica brasileira extrapolou os limites deste metro, que perdeu seu poder discriminativo. Uma nova tabela Qualis esta em vias de ser ativada. Nao me sinto capacitado a avalia-la para outras areas, mas o produto oferecido a consideracao da comunidade medica merece comentarios. As premissas em que se baseia sao tres. A primeira e que a distribuicao de frequencia de conceitos dos programas brasileiros de pos-graduacao deve ser normal, ou Gaussiana. Poder-se-ia aqui indagar como foi que se chegou a conclusao de que essa distribuicao e naturalmente normal. A segunda premissa estabelece que apenas 25% dos programas podem ter conceito maximo (6 ou 7) em qualquer area de avaliacao. Caso o numero de programas merecedores de conceito maximo supere o limite, as normas de avaliacao serao automaticamente “apertadas” para manter o limite. Igualmente, pode-se perguntar se nao e absurdo mudar as regras do jogo no meio da partida para rebaixar o conceito de programas que a primeira vista pareciam excelentes. A terceira premissa diz respeito a nova tabela Qualis para periodicos, que passa a ter sete niveis conforme a Tabela 1. Esta vale para todas as areas do conhecimento, devendo cada area estabelecer os niveis especificos de corte de tal modo a assegurar que apenas 25% dos periodicos estejam no nivel mais alto (Qualis A) e que haja maior numero de periodicos A2 que A1. Embora isso nao seja explicito, parece evidente que estes 25% derivam diretamente dos 25% do conceito anterior.

Potassium in hemorrhagic shock: a potential marker of tissue hypoxia.

BACKGROUND This study was designed to evaluate serum potassium level variation in a porcine model of hemorrhagic shock (HS). METHODS Eight pigs were studied in a controlled hemorrhage model of HS. Blood withdrawal began at a 50 mL/min to 70 mL/min rate, adjusted to reach a mean arterial pressure (MAP) level of 60 mm Hg in 10 minutes. When MAP reached 60 mm Hg, the blood withdrawal rate was adjusted to maintain a MAP decrease rate of 10 mm Hg every 2 minutes to 4 minutes. Arterial and mixed venous blood samples were collected at MAP levels of 60 mm Hg, 50 mm Hg, 40 mm Hg, 30 mm Hg, 20 mm Hg, and 10 mm Hg and analyzed for oxygen saturation, Po2, Pco2, potassium, lactate, bicarbonate, hemoglobin, pH, and standard base excess. RESULTS Significant increase in serum potassium occurred early in all animals. The rate of rise in serum potassium and its levels accompanied the hemodynamic deterioration. Hyperkalemia (K >5 mmol/L) incidence was 12.5% at 60 mm Hg and 50 mm Hg, 62.5% at 40 mm Hg, 87.5% at 30 mm Hg, and 100% at 20 mm Hg. Strong correlations were found between potassium levels and lactate (R = 0.82), SvO2 (R = 0.87), DeltapH (R = 0.83), and DeltaPco2 (R = 0.82). CONCLUSIONS Serum potassium increase accompanies the onset of HS. The rise in serum potassium was directly related to the hemodynamic deterioration of HS and strongly correlated with markers of tissue hypoxia.

IMPACT FACTOR, SCIMAGO INDEXES AND THE BRAZILIAN JOURNAL RATING SYTEM: WHERE DO WE GO FROM HERE?

collection. The Science Citation Edition for 2008 includes 6620 journals, of which 6567 (99.2% of the total) from 72 countries (where England, Scotland and Wales are counted as three separate countries much as they would be for Rugby and Football, although I did miss Northern Ireland) exhibited an IF > 0. The Social Sciences Citation Edition comprises 1985 journals from 45 countries (including England and Scotland, but not Wales), of which 1974 (99.4% of the total) have an IF > 0. Thus, the entire JCR-ISI collection totaled 8,541 in 2008. The SCImago collection is considerably larger, comprising 16,032 journals from 233 countries, of which 14,649 journals (91.3% of the total) boast a C/D > 0. It is thus a more comprehensive index, covering twice as many journals from thrice as many countries. Two other differences should be mentioned: (a) SCImago is freely accessible, whereas the JCR-ISI can only be accessed by fee-paying subscribers, and (b) JCR-ISI has a bias in favor of English-speaking countries, while SCImago has a broader base. However, it must be noted that JCR-ISI has been broadening its non-English speaking base over recent years. The obvious questions are as follows: what do these indexes measure and how reliable are they? Given that it is generally believed that citations of articles are an indirect measure of quality, it is generally assumed that both IF and C/D reflect quality. However, no gold standard has ever been described that effectively measures journal quality. Consequently, no proof exists to show that IF or C/D truly reflect quality, even though there is a general gut feeling that they do. Generally speaking, journals with a high IF or C/D are desirable places to publish scientific findings; it is also true that most (but certainly not all) of the truly relevant

In the February 2009 issue of Clinics.

In this issue of CLINICS we are publishing the first report on organ transplants from Hospital das Clinicas, covering the period of 2002 to 2007. We intend to follow up this article with annual reports starting early 2010. In this article Azeka et al. report on a total of 3,321 solid organ and tissue transplants at the institution. The 5-year survival curve ranged from 53% to 88%, and shows that solid organ and tissue transplants are feasible within the institution, and leads one to expect that the quality of transplantants should improve over the coming years. We are also publishing an Editorial commenting on a review article published in our January 2009 issue, eight more original clinical science articles, and one basic research article, as well as 3 case reports. Salluh et al. describe outcomes and thrombotic events in a series of 18 critically ill cancer patients positive for antiphospholipid antibodies. Measurements were performed up to 48 hours after the occurrence of acrocyanosis or arterial/venous thrombotic events. All patients developed MOF during the ICU stay, and intra-hospital death occurred in 13/18 (72%) of the patients. Of the 5 discharged patients, 3 were alive 90 days later. Authors conclude that the coexistence of sepsis or SIRS and aPL antibodies was often associated with MOF and death. Furtado et al. developed and validated a Brazilian-Portuguese version of the Gesture Behavior Test for patients with non-specific chronic low back pain. Translation into Portuguese was performed by a rheumatologist fluent in the language of origin (French), and skilled in the validation of questionnaires. The translated version was back-translated into French by a native-speaking teacher of the language. The two translators then created a final consensual version in Portuguese. They conclude that the Brazilian version proved to be a reproducible and valid instrument. In addition, according to the questionnaire results, more disabled patients were found to exhibit more protective gesture behavior related to low-back. Ruano et al. report on their experience using selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of 19 monochorionic diamniotic twin pregnancies complicated by severe twin-twin transfusion syndrome. A 1.0 mm fetoscopic laser was employed for this therapy and showed results similar to those reported in the literature for larger endoscopes. Greve et al. compared radial shockwaves and conventional physiotherapy for treating plantar fasciitis in 32 patients equally divided between conventional treatment (10 physiotherapy sessions each, consisting of ultrasound, kinesiotherapy and instruction for stretching exercises at home) and a test group (undergoing 3 applications of radial shockwaves, once a week, plus instruction for stretching exercises at home). They found that both treatments were effective for pain reduction and for improving the functional abilities of patients with plantar fasciitis, but that the effect of the shockwaves appeared sooner than physiotherapy after the onset of treatment. Torquato et al. quantified the interaction between intra-abdominal pressure and positive-end expiratory pressure in 30 mechanically ventilated ICU patients with a fixed tidal volume; respiratory system plateau and abdominal pressure were measured at a Positive-End Expiratory Pressure level of zero and 10 cm H2O, with and without a 5 kg weight placed over their stomachs. They conclude that the addition of the weight onto the abdomen increased both abdominal pressure and airway plateau pressure, confirming that intra-abdominal hypertension elevates the plateau pressure. However, they add, plateau pressure should not be taken as a good detector of elevated intra-abdominal pressure in patients under mechanical ventilation using PEEP, adding that intra-abdominal pressure must also be measured. Bacarin et al. investigated and compared the influence of a previous history of foot ulcers on plantar pressure variables during gait of patients with diabetic neuropathy. The study included 20 controls; 17 diabetic neuropathy patients without foot ulcers, and 10 diabetic neuropathy patients with at least one healed foot ulcer within the last year, and concludes that foot ulcers in the clinical history of diabetic neuropathy influenced plantar pressure distribution, resulting in an increased load under the midfoot and rearfoot and an increase in the variability of plantar pressure during barefoot gait, whereas the progression of diabetic neuropathy was not found to influence plantar pressure distribution. Lopes et al. compared self-report and interview administration methods of the Western Ontario Rotator Cuff Index and the Disabilities of Arm, Shoulder and Hand Questionnaires in 30 male and female patients with rotator cuff disorders in 30 male and female patients over 18 years of age with rotator cuff disorders (tendinopathy or rotator cuff tear) and Brazilian Portuguese as their primary language. The majority (n=26) had a complete college degree or higher. Mean questionnaire scores and administration times were not significantly different (p<0.05) between the two groups procedures. There were statistically significant correlations (p<0.05) between the 2 procedures and strong correlations were found between the questionnaires in both groups, with no differences between them with regard to administration time or correlations between the 2 questionnaires. Duarte et al. measured the prevalence of thyroid dysfunction in 399 elderly cardiology patients with mild excessive iodine intake in the urban area of Sao Paulo. They found that elderly patients have a higher prevalence of both hypo- and hyperthyroidism as well as thyroid nodules when compared with the general population; about one-third of the older patients had elevated urinary secretion of iodine and a higher prevalence of chronic Hashimoto’s thyroiditis. Authors recommend that ultrasonographic studies, tests for thyroid function and autoimmunity should be performed in elderly patients. Ýrkorucu et al. analyzed the formation of adherences in 50 Wistar male rats undergoing median laparotomy and standardized abrasion of the visceral and parietal peritoneum, Phosphatidylcholine, Seprafilm II, and t-PA alone and phosphatidylcholine and t-PA in combination were tested. Seven days after surgery, a relaparotomy for adhesion grading showed that adhesion was less pronounced in the study groups, even more so in the combination group. In the t-PA group and the combination group, six and two rats, respectively, developed hematomas locally on the cecum.

Regional Blood Flow Distribution and Oxygen Metabolism During Mesenteric Ischemia and Congestion

BACKGROUND Acute mesenteric ischemia is a potentially fatal vascular emergency with mortality rates ranging between 60% and 80%. Several studies have extensively examined the hemodynamic and metabolic effects of superior mesenteric artery occlusion. On the other hand, the cardiocirculatory derangement and the tissue damage induced by intestinal outflow obstruction have not been investigated systematically. For these reasons we decided to assess the initial impact of venous mesenteric occlusion on intestinal blood flow distribution, and correlate these findings with other systemic and regional perfusion markers. METHODS Fourteen mongrel dogs were subjected to 45 min of superior mesenteric artery (SMAO) or vein occlusion (SMVO), and observed for 120 min after reperfusion. Systemic hemodynamics were evaluated using Swan-Ganz and arterial catheters. Regional blood flow (ultrasonic flow probes), intestinal O(2)-derived variables, and mesenteric-arterial and tonometric-arterial pCO(2) gradients (D(mv-a)pCO(2) and D(t-a)pCO(2)) were also calculated. RESULTS SMVO was associated with hypotension and low cardiac output. A significant increase in the regional pCO(2) gradients was also observed in both groups during the ischemic period. After reperfusion, a progressive reduction in D(mv-a)pCO(2) occurred in the SMVO group; however, no improvement in D(t-a)pCO(2) was observed. The histopathologic injury scores were 2.7 +/- 0.5 and 4.8 +/- 0.2 for SMAO and SMVO, respectively. CONCLUSIONS SMV occlusion promoted early and significant hemodynamic and metabolic derangement at systemic and regional levels. Additionally, systemic pCO(2) gradient is not a reliable parameter to evaluate the local intestinal oxygenation. Finally, the D(t-a)pCO(2) correlates with histologic changes during intestinal congestion or ischemia. However, minor histologic changes cannot be detected using this methodology.

Hypertonic saline solution increases cerebral perfusion pressure during clinical orthotopic liver transplantation for fulminant hepatic failure: preliminary results

UNLABELLED During orthotopic liver transplantation for fulminant hepatic failure, some patients may develop sudden deterioration of cerebral perfusion and oxygenation, mainly due to increased intracranial pressure and hypotension, which are likely responsible for postoperative neurological morbidity and mortality. In the present study, we hypothesized that the favorable effects of hypertonic saline solution (NaCl 7.5%, 4 mL/kg) infusion on both systemic and cerebral hemodynamics, demonstrated in laboratory and clinical settings of intracranial hypertension and hemorrhagic shock resuscitation, may attenuate the decrease in cerebral perfusion pressure that often occurs during orthotopic liver transplantation for fulminant hepatic failure. METHODS 10 patients with fulminant hepatic failure in grade IV encephalopathy undergoing orthotopic liver transplantation with intracranial pressure monitoring were included in this study. The effect on cerebral and systemic hemodynamics in 3 patients who received hypertonic saline solution during anhepatic phase (HSS group) was examined, comparing their data with historical controls obtained from surgical procedure recordings in 7 patients (Control group). The maximal intracranial pressure and the corresponding mean arterial pressure values were collected in 4 time periods: (T1) the last 10 min of the dissection phase, (T2) the first 10 minutes at the beginning of anhepatic phase, (T3) at the end of the anhepatic phase, and (T4) the first 5 minutes after graft reperfusion. RESULTS Immediately after hypertonic saline solution infusion, intracranial pressure decreased 50.4%. During the first 5 min of reperfusion, the intracranial pressure remained stable in the HSS group, and all these patients presented an intracranial pressure lower than 20 mm Hg, while in the Control group, the intracranial pressure increased 46.5% (P < 0.001). The HSS group was the most hemodynamically stable; the mean arterial pressure during the first 5 min of reperfusion increased 21.1% in the HSS group and decreased 11.1% in the Control group (P < 0.001). During the first 5 min of reperfusion, cerebral perfusion pressure increased 28.3% in the HSS group while in the Control group the cerebral perfusion pressure decreased 28.5% (P < 0.001). Serum sodium at the end of the anhepatic phase and 3 hours after reperfusion was significantly higher in the HSS group (153.00 +/- 2.66 and 149.00 +/- 1.73 mEq/L) than in the Control group (143.71 +/- 3.30 and 142.43 +/- 1.72 mEq/L), P = 0.003 and P < 0.001 respectively. CONCLUSION Hypertonic saline solution can be successfully used as an adjunct in the neuroprotective strategy during orthotopic liver transplantation for fulminant hepatic failure, reducing intracranial pressure while restoring arterial blood pressure, promoting sustained increase in the cerebral perfusion pressure.

Pentoxifylline attenuates leukocyte-endothelial interactions in a two-hit model of shock and sepsis.

BACKGROUND This study investigated the effects of pentoxifylline (PTX) combined with resuscitation fluids on microcirculatory dysfunctions in a two-hit model of shock and sepsis. MATERIALS AND METHODS Male Wistar rats (250 g) were submitted to hemorrhagic shock and reperfusion followed by sepsis induced by cecal ligation and puncture. For the initial treatment of shock, rats were randomly divided into: sham, no injury, no treatment; hypertonic saline solution (HS) (7.5%, 4 mL/kg); lactated Ringers solution (LR, 3 × shed blood volume); HS + PTX (4 mL/Kg + 25 mg/kg PTX); and LR + PTX (3 × shed blood volume + 25 mg/kg PTX). After 48 h of being exposed to the double injury, leukocyte-endothelial interactions were assessed by intravital microscopy of the mesentery. Endothelial expression of P-selectin and intercellular adhesion molecule-1 (ICAM-1) was evaluated by immunohistochemistry, as well as lung neutrophil infiltration by histology. RESULTS Lactated Ringers solution induced marked increases (P < 0.001) in the number of rolling leukocytes per 10 min (two-fold), adherent leukocytes per 100 μm venule length (six-fold), migrated leukocytes per 5000 μm(2) (eight-fold), P-selectin and ICAM-1 expression (four-fold), and lung neutrophil infiltration (three-fold) compared with sham. In contrast, PTX attenuated leukocyte-endothelial interactions, P-selectin and ICAM-1 expression at the mesentery when associated with either LR (P < 0.001) or HS (P < 0.05). Neutrophil migration into the lungs was similarly reduced by PTX (P < 0.05). CONCLUSIONS Data presented showed that pentoxifylline attenuates microcirculatory disturbances at the mesenteric bed with significant minimization of lung inflammation after a double-injury model of hemorrhagic shock and reperfusion followed by sepsis.

In the January 2010 issue of Clinics

As Clinics opens its sixth year of existence, its second as a monthly periodical, we shall be expecting our first posting of an Impact Factor by the ISI Journal of Citations report. Over this period, CLINICS gradually evolved from a publisher of articles originating mainly from the Medical College of Sao Paulo University to a more cosmopolitan Brazilian and International publisher of science. This trend, illustrated in Fig. 1, strongly suggests that the posting of our first impact factor will enhance the trend towards a truly cosmopolitan journal. In this issue, we publish eight Clinical Science reports. Hovnanian et al. endeavored to determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in 244 patients with advanced left ventricular dysfunction and found that for selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting it may be possible to implement preoperative clinical/functional parameter measurements for predicting outcome, such as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise or at rest. Tiryakioglu et al. examined the frequency of Cushing’s syndrome (CS) in 150 obese patients devoid of specific clinical symptoms of Cushing’s syndrome and found that a significant proportion (9.33%) of patients with simple obesity had Cushing’s syndrome; they argue that obese patients should be routinely screened for Cushing’s syndrome. Barbosa et al. propose to improve the transmission of information between requiring physicians and radiologists by means of a structured report for thyroid sonography developed according to information gathered from radiologists and endocrinologists working in the field. They found that implementation of the structured report in a university hospital was viable, and that radiologists and endocrinologists preferred the structured report when compared to free text, and both agreed that the former improved the transmission of information. Dantas et al. evaluated the kinetics with which a cholesterol-rich emulsion (called a low-density emulsion) binds to low-density lipoprotein receptors in a group of 10 patients with grade III obesity, versus 10 non-obese healthy control individuals by the fractional clearance rate, and found that grade III obese subjects exhibited normal low-density lipoprotein removal from plasma as tested by the nanoemulsion method, but triglyceride removal was slower. Horasanli et al. compared the efficacy of combined lumbar plexus-sciatic nerve blocks versus epidural anesthesia in 40 patients per group undergoing total knee surgery, and found that the lumbar plexus-sciatic nerve blocks provide effective unilateral anesthesia and may offer a beneficial alternative to epidural anesthesia in patients undergoing total kneesurgery. Scorleze-Ferrer et al. examined causes of admission in the public health system for children from zero to nine years of age in the city of Sao Paulo during the years 2002 to 2006 and compared these results to those from the national data, and found a paradoxical increase in the number of hospitalizations during an expansion of primary attention, indicating that the rise was not associated with a significant improvement in the quality of service. Ramos et al. determined differences in cardiac vagal tone values in non-obese healthy, adult men with and without unfavorable anthropometric characteristics, and found that non-obese and healthy adult men with unfavorable anthropometric characteristics tend to present lower cardiac vagal tone levels. They claim that early identification of this trend by simple protocols that are non-invasive and risk-free, using select anthropometric characteristics, may be clinically useful in a global strategy to prevent cardiovascular disease. Melotti et al. evaluated the value and limitations of clonality analysis in the diagnosis of primary cutaneous B-cell lymphomas (PCBCL) and B-cell pseudolymphomas (B-PSL). The study included 29 cases of B-cell lymphoproliferative processes classified as primary cutaneous B-cell lymphomas (13), B-PSL (6) and inconclusive cases (10) using histology and immunohistochemistry, and concludes that the use of the two protocols, IgH FR3-trad and IgL-Kappa (IgL-K) Biomed protocols for clonality analysis improved diagnostic accuracy. We also publish four Basic Science papers Morais Silva et al. analyzed the effects of fluoxetine, a selective serotonin re-uptake inhibitor, on the enamel organ of rats and found no structural changes in the experimental group compared to the controls, suggesting that, at the dose used, fluoxetine did not interfere with serotonin-mediated development of the enamel organ or the process of amelogenesis. Sallum et al. evaluated transcapillary refill in a model of retroperitoneal uncontrolled, treated hemorrhage in dogs and concluded that despite the rebleeding observed in treated groups, the utilization of hypertonic saline solution with dextran proved to be effective in the initial reanimation, producing evident transcapillary refill, while the Lactated Ringer’s solution produced capillary extravasation and was ineffective in the initial volume replacement in this model of uncontrolled hemorrhage. Subhash et al. describe the normal and variant anatomy of the coronary artery ostia in Indian subjects and find that the preferential location of the ostia was within the sinus and above the cusps, but below the sinutubular ridge. On occasion, normal variants such as multiple ostia, vertical or circumferential shift in the position, and slit-like ostia may create confusion in interpreting the images and pose a difficulty during procedures like angiography, angioplasty, and coronary artery bypass grafting. Norhazlia et al. describe the effect of eurycoma longifolia on spermatogenesis in estrogen-treated adult male rats and claim that the extract acts as a potential agent for reversing the effects of estrogen by increasing spermatogenesis and sperm counts in rats after fourteen consecutive days of treatment. We also publish a review on coronary heart disease in women and 3 case reports.