Novel insights on acute myocarditis in pediatric patients

Acute myocarditis (AM) is an inflammatory affliction of the heart muscle characterized by recent onset with a broad spectrum of clinical manifestations that globally affect millions of individuals, notably children and young adults. The absence of distinct patterns of onset or predictable progression poses a significant threat to survival, potentially leading to advanced heart failure and malignant arrhythmias. Myocardial fibrosis, a hallmark of myocardial remodeling, is increasingly recognized as a contributor to adverse outcomes in acute myocarditis cases. Advances in molecular and immunological techniques have highlighted the intricate interplay between viral infections, dysregulated immune responses, and genetic susceptibility. Currently, there is no clear consensus for diagnosis or ongoing follow-up in pediatric patients. The conventional diagnostic tool, endomyocardial biopsy (EMB), considered the gold standard, has been complemented by the effectiveness of cardiac magnetic resonance imaging (CMRI) techniques. Given the procedural complexities and associated complications, there is a pressing need to explore non-invasive alternatives. In this context, biomarkers emerge as promising contenders by evaluating both the inflammatory processes and cardiac remodeling, providing valuable observations into disease severity, progression, and treatment response. Therapeutic strategies in these cases, focusing on the specific pathways or immune components associated with the etiologies, have exhibited promise for better outcomes. Acute myocarditis in children remains a multifaceted clinical challenge, necessitating a comprehensive understanding of its pathophysiology, diagnosis, and management. This review aims to delve into novel insights surrounding the pathophysiology, diagnosis, and management of acute myocarditis in pediatric patients.

LONG-TERM IMPROVEMENT OF GLUCOSE HOMEOSTASIS AND BODY COMPOSITION IN PATIENTS UNDERGOING LAPAROSCOPIC SLEEVE GASTRECTOMY

CONTEXT

Laparoscopic sleeve gastrectomy (SG) has gained popularity as a metabolic procedure, but its long-term effectiveness for Romanian patients remains unclear.

OBJECTIVES

To assess the long-term efficacy of SG for Romanian patients and to evaluate the differences between 5 years and 1 year follow-up.

DESIGN

A longitudinal, prospective analysis of collected data from 68 patients undergoing SG between 2009 and 2014 was performed. Long-term outcomes at 5 years were analyzed in terms of total weight loss (%TWL), excess weight loss (%EWL), body composition and glucose homeostasis.

SUBJECTS AND METHODS

All patients meeting the standard criteria for SG before inclusion were prospectively enrolled in the study. Of the 68 patients, eight were lost to follow-up, therefore, 60 patients (41.7±12.5 years, baseline body mass index [BMI] 44.6±9.9Kg/m2) were analyzed.

RESULTS

The BMI decreased at 12 months with 30.7% from the preoperative BMI (p<0.001) and subsequently stabilized at 5 years.TWL and EWL were 30.6% and 83.1%, respectively at 1 year, with a slightly increase at 5 years.Therapeutic success rate (%EWL≥50) and diabetes remission rate (Buchwald criteria) were 93.3% and respectively 63.6% at 5 years. Insulin sensitivity index and metabolic clearance rate of glucose increased with 92.5% and 60.1% respectively, in the third month from baseline (p<0.001), while estimated second phase of insulin secretion decreased with 7.9% in the first month postoperatively (p=0.04), remaining stable afterwards.

CONCLUSIONS

SG was effective in terms of %EWL, body composition and glucose homeostasis improvement for Romanian patients, the outcomes stabilizing after 1 year follow-up.

CARDIOVASCULAR RISK ASSESSMENT IN THE ADULT (AGED 40-79 YEARS) ROMANIAN POPULATION

Atherosclerotic Cardiovascular Diseases are the leading cause of death worldwide.

Aim

To estimate the prevalence of cardiovascular risk (CVR) categories in the adult population (aged 40-79 years) of Romania.

Design

The present study was part of the epidemiological, cross-sectional PREDATORR study (PREvalence of DiAbeTes mellitus, prediabetes, overweight, Obesity, dyslipidemia, hyperuricemia and chronic kidney disease in Romania).

Subjects and Methods

Exclusion criteria: age <40/or>79 years old and diagnosis of ischemic vascular disease. The CVR was evaluated using charts developed by the World Health Organization/ International Society of Hypertension (WHO/ISH) available for Europe B (epidemiological sub-region where Romania was included). The CVR was divided into 5 categories: <10%, 10-20%, 20-30%, 30-40%, > 40%.

Results

A total of 1631 subjects (57.0±10.7 years, 45.1% males) were included in the present study.The age and sex-adjusted prevalence of CVR >40% was 2.9% (95%CI 2.8-3.1%), CVR 30-40% was 1.85% (95%CI 1.8-1.9%), CVR 20-30% was 5.8% (95%CI 5.6-6.0%) and 13.0% (95%CI 12.8-13.3%) of the adult Romanian population has a 10-20% CVR, these CVR categories being more frequent in male and older age. Diabetes, overweight/obesity and smoking were associated with high CVR categories.

Conclusion

Romania is one of the countries with high CVR, requiring CVD prevention measures.

Prevalence of overweight/obesity, abdominal obesity and metabolic syndrome and atypical cardiometabolic phenotypes in the adult Romanian population: PREDATORR study

PURPOSE

The objectives were to assess the prevalence of overweight/obesity, abdominal obesity and metabolic syndrome (MetS), and to evaluate the characteristics of the metabolically unhealthy lean (MUHL) and metabolically healthy overweight/obese (MHO) phenotypes in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological study with a stratified, cross-sectional, cluster random sampling design. Participants were classified into four cardiometabolic phenotypes based on the BMI, the cut-off value being 25 kg/m(2), and the presence of MetS (defined according to the Harmonization definition 2009): MUHL, MHO, metabolically healthy lean (MHL) and metabolically unhealthy overweight/obese (MUHO).

RESULTS

Overall, 2681 subjects aged 20-79 years were included in the analysis. The overall age and sex-adjusted prevalence of obesity was 31.90 %, overweight was 34.7 %, abdominal obesity was 73.90 % and MetS was 38.50 %. The age- and sex-adjusted prevalence of MHO phenotype was 31.60 %, while MUHL phenotype prevalence was 3.90 %. MUHL and MHO participants had a cardiometabolic profile, kidney function and CVD risk intermediary between MHL and MUHO. MUHL had higher odds of being associated with CVD risk (OR 5.8; p < 0.001), abdominal obesity, prediabetes, diabetes, hypertriglyceridemia and hypo-HDL cholesterolemia than MHL, while MHO phenotype was associated with hypo-HDL cholesterolemia (OR 3.1; p = 0.002), prediabetes (OR 2.9; p < 0.001) and abdominal obesity.

CONCLUSIONS

PREDATORR study showed a high prevalence of obesity/overweight, abdominal obesity and MetS in the adult Romanian population, and their association with kidney function and several cardiometabolic factors.

Study of the decomposition pathway of 12-molybdophosphoric acid in aqueous solutions by micro Raman spectroscopy

Micro Raman spectroscopy was applied to investigate the speciation of heteropoly and isopoly molybdates in 0.05 and 0.005 M aqueous solutions of 12-molybdophosphoric acid at pH values between 1 and 6. For comparative purposes, (31)P NMR spectroscopy was applied too. It is shown that stability of Keggin anion is influenced both by pH and concentration of solution. The Keggin structure is stable in acidic solutions (pH<1.6) while defective Keggin structures are formed with further alkalization (up to pH5.6). Monolacunary anion PMo11O(39)(7-) is the main component in the pH region from 1.6 to 3.4. Further removal of molybdenyl species causes the appearance of other vacant Keggin structures such as PMo9O31(OH)(3)(6-) and PMo6O(25)(9-) at about pH4. At pH5.0, anion PMo6O(25)(9-) is the main species. In solutions with pH greater than 5.0, heteropolymolybdates disappear completely and isopolymolybdates Mo7O(24)(6-) and MoO(4)(2-) are formed in higher amounts. In more diluted solution of 0.005 M, the decomposition scheme of 12-molybdophosphoric acid solution with increasing of pH takes place without observation of significant amounts of Mo7O(24)(6-) species. If alkalinization is performed with 0.5 M instead of 5 M NaOH, there are no significant changes in the Raman spectra of solutions. It is shown that the spectra of evaporated samples may be used for the identification of molecular species in corresponding concentrated solutions. However, Raman spectra of dry residues of more diluted solutions differ from spectra of corresponding solutions due to the reactions performed during the process of drying and cannot be used for unambiguous identification of species in solution. Acidification of 0.05 M solution of Na2MoO4 shows that at pH>5.6, molybdate anion MoO(4)(2-) dominates, while in the pH range between 5.6 and 1, heptamolybdate anion Mo7O(24)(6-) is preferentially formed.

A pharmacokinetic drug interaction study between nebivolol and paroxetine in healthy volunteers

WHAT IS KNOWN AND OBJECTIVE

Nebivolol is a highly selective beta-blocker with additional vasodilator properties, widely used in the clinical practice for the treatment of hypertension and heart failure. Paroxetine is a second-generation antidepressant and a potent inhibitor of CYP2D6, the same isoenzyme involved in the metabolism of nebivolol. The objective of this study was to investigate the effect of multiple-dose paroxetine intake on the pharmacokinetics of nebivolol in healthy volunteers and its potential consequences upon nebivolol pharmacodynamics.

METHODS

The study included 23 healthy subjects and was designed as an open-label, single-centre, non-randomized, two-period clinical trial. During period 1 (reference), each volunteer received a single dose of 5 mg nebivolol, whereas during period 2 (test), each volunteer received a single dose of 5 mg nebivolol and 20 mg paroxetine, after a pretreatment regimen with paroxetine (20-40 mg/day for 6 days). The pharmacokinetic parameters of nebivolol and its active metabolite were analysed by non-compartmental modelling. The pharmacodynamic parameters (blood pressure and heart rate) were assessed at rest, after each nebivolol intake.

RESULTS AND DISCUSSION

Pretreatment with paroxetine increased the mean peak plasma concentrations (Cmax ) for unchanged nebivolol (1·78 ± 1·17 vs. 4·24 ± 1·67 ng/mL) and for its active metabolite (0·58 ± 0·21 vs. 0·79 ± 0·24 ng/mL) compared to nebivolol alone. The time (tmax ) to reach Cmax was 1·37 ± 0·88 (h) and 3·11 ± 1·76 (h) for the parent compound and its active metabolite after nebivolol administered alone and 3·96 ± 1·76 (h), respectively, 7·33 ± 7·84 (h) after pretreatment with paroxetine. Also, the total areas under the curve (AUC0-∞ ) were significantly increased from 17·26 ± 43·06 to 106·20 ± 65·56 h ng/mL for nebivolol unchanged and 13·03 ± 11·29 to 74·56 ± 88·77 h ng/mL for its hydroxylated metabolite, before and after paroxetine intake. All the pharmacokinetic parameters presented statistically significant differences when paroxetine was administered with nebivolol. Nonetheless, statistical analysis did not show a significant difference between the vital signs measured during the two periods.

WHAT IS NEW AND CONCLUSION

After pretreatment with paroxetine, the exposure to nebivolol was increased by 6·1-fold for the parent drug and 5·7-fold for the hydroxylated active metabolite. Paroxetine influenced nebivolol pharmacokinetics in healthy volunteers, but it did not have a significant effect on nebivolol pharmacodynamic parameters measured at rest, although the clinical relevance of this drug interaction needs further investigation.

[Emergency pancreatoduodenectomy for severe iatrogenic duodenal injury--case report]

We present the case of a male patient admitted for high flow biliary fistula (> 2000 ml/24h) as a consequence of a prior right nephrectomy by lumbar approach. The patient was operated after the failure of the medical conservative treatment and continous declining medical status. We noted the complete absence of the gastric antrum, duodenum I and II with the intraperitomeal direct display and opening of the Vater papilla, witch was difficult to identify unless common bile duct (CBD) was catheterized by supraduodenal choledocotomy. We performed emergency pancreatoduodenectomy with a good postoperative outcome , excepting a residual postnephrectomy abscess, witch was consequently evacuated and drained. The patient left the clinic 28 days postoperatively. The two years after follow up notes that the patient is in a good condition

Microcoil embolization for ablation of septal hypertrophy in hypertrophic obstructive cardiomyopathy

BACKGROUND

Percutaneous transcatheter occlusion with ethanol injection of septal arteries is an efficient treatment procedure of hypertrophic obstructive cardiomyopathy (HOCM). The aim of our study is to evaluate the feasibility and efficiency of septal artery embolization with microcoils.

METHODS

The microcoils were delivered through the guide-wire lumen of a 2mm-diameter coaxial balloon positioned inside the target vessel as distally as possible. One or more 0.018"-straight microcoils (Hilal straight coils, Cook, USA) were used for each target vessel until complete flow obstruction was noted. The intraventricular pressure gradient was measured before, during and after the procedure. Septal branch occlusion was finally documented by coronary angiography.

RESULTS

We treated 7 patients (pts) (male: 5 pts; mean age: 48 (10 years). All patients were symptomatic (NYHA class 3 or 4). The target vessels were successfully occluded in all patients, without complications. Moderate pain was recorded during and after the procedure and the CK level increased five- to ten-fold. The pressure gradient diminished during the procedure from 72 +/- 21 mm Hg to 30 +/- 15 mm Hg. The number of coils delivered ranged from 3 to 7 / patient. The embolized septal branches: 1 vessel in 5 patients; 2 vessels in 1 patient; 3 vessels in 1 case. After the procedure the pressure gradient, evaluated by transthoracic echocardiography, was 34 +/- 16 mm Hg and 42 +/- 12 mm Hg at 3 month-follow-up. Clinical improvement was recorded in all patients after the procedure (NYHA class 1 or 2). Temporary pacing was necessary in 3 patients during and immediately after the procedure but no patient needed permanent pacing.

CONCLUSIONS

Microcoil embolization is an efficient and safe approach for transcatheter ablation of septal hypertrophy in HOCM. This technique induced myocardial necrosis without the toxic effects of alcohol, reducing the risk of complications (permanent pace-maker implantation, ethanol flow to other myocardial regions).

Shoulder girdle abscess due to Streptococcus agalactiae complicating esophageal dilation

Bacteremia can result very unusually in significant complications after esophageal dilation. Procedure-related mucosal trauma may be a determinant, whereas pathogenic bacteria primarily originate from the patient's oropharyngeal flora. We describe an unusual case of Streptococcus agalactiae bacteremia and shoulder girdle abscess complicating esophageal bougienage. Consideration of specific risk factors and use of scrupulous procedural technique are warranted and will likely reduce pyogenic sequelae.

[The primary prevention of arterial hypertension. A meta-analysis of controlled clinical studies]

OBJECTIVE

To assess the efficacy of non pharmacological primary prevention of hypertension.

METHODS

Analysis of all the available trials with a minimal one-year follow-up and one recently study with 8 weeks follow-up. The outcomes consisted in blood pressure changes and incidence of hypertension at the end of the study.

RESULTS

Five reviewed randomized controlled trials with a minimal one year follow-up and one recently study with eight weeks follow-up assessed the following intervention: advice about sodium restriction, weight reduction, physical exercise and relaxation, a diet rich in fruits vegetables and low fat dairy foods. All the results were available according to the "intention to treat principle". The feasibility appeared to be initially good, but decreased with time, confirming the difficulty of long term prevention. The prevention effect was mild with a decrease in hypertension incidence of a few percent (2%) and blood pressure decrease of only a few mmHg reduction (mean of 3 mmHg). Three community studies were reviewed. The prevention interventions were carried out on entire populations. The feasibility was bad (great number of lost-follow-up). The results on the blood pressure incidence were available in only one study and the blood pressure decrease estimates were heterogeneous, so the results cannot be generalized.

CONCLUSION

The primary prevention of hypertension shows disappointing results when the intervention duration is above one year. It leaves little hope for a significant effect on blood pressure dependent cardiovascular events.

Osteopetrosis

Osteopetrosis is a rare hereditary bone disorder that presents in one of three forms: osteopetrosis tarda, osteopetrosis congenita and "marble bone" disease. Osteopetrosis tarda, the benign form, presents in adulthood, while the two more malignant variants, osteopetrosis congenita and marble bone disease, present in infancy and childhood, respectively. In all three forms, the main features are pathologic alteration of osteoclastic bone resorption and thickening of cortical and lamellar bones. Osteopetrosis tarda is usually discovered accidentally on routine radiographs and is often asymptomatic; however, patients may present because of related degenerative joint disease. Osteopetrosis congenita results in bone marrow failure and is almost always fatal. Marble bone disease causes short stature, cerebral calcification and mental retardation. Bone marrow transplant is the only chance for survival in patients with osteopetrosis congenita.

Morphophysiopathological correlations in pulmonary hypertension of cardiac origin

100 patients with congenital malformation and acquired cardiac diseases were studied on preoperatory pulmonary biopsies to estimate the pulmonary hypertension by correlating the data obtained by modern multidisciplinary investigation: histological, histoenzymological, ultrastructural, physiological and clinical techniques. The morphological pictures show a range of vascular lesions similar to those found in Heath and Edwards' classification and they are especially thickenings of the intima, hypertrophies of the media, narrowings of vascular lumen and later some plexiform lesions and hemosiderosis. Progressive fibrosis processes as well as immune pulmonary reactions were made evident. The electron microscopical examinations provided new data regarding the thickening of the capillary and alveolary basal lamina, the activity of pneumocytes and macrophages that were also certified from the histoenzymological point of view by increase of peroxidases and acid phosphatases activity. The investigation carried out proved the importance of the cardiac preoperatory catheterism in order to establish the grade of the pulmonary hypertension while the concordance index is more increased than in the cases that were investigated only by non-bleeding techniques.

[The incidence of chronic respiratory diseases in Hunedoara County and the cases of disease hospitalized in the Pneumophthisiology Department of Deva Hospital]

The structure of the incidence of chronic respiratory diseases is analysed within the district of Hunedoara for the last two decennia (1970-1991), and the low percentage of pulmonary tuberculosis as compared with the other respiratory diseases (8.75% for the last five years) is emphasized. A comparison is performed between the figures of Tb and of non-Tb disease cases hospitalized in the Pneumophysiology Department, District Hospital, Deva (27.6% non-Tb diseases) from 1987 to 1991. Attention is drawn to the obligation of pneumophysiologists to take over the medical assistance and follow up of non-Tb respiratory diseases, as a result of the Ministry of Health legislation on "pneumophysiology" (a specialty replacing the old "physiology").

Development of an irradiated vaccine that protects against enterotoxigenic Escherichia coli diarrhoea

In the pathogenesis of diarrhoea in man bacteria adhesion to enterocytes is mediated by specific CFA/I or CFA/II antigens. A perorally administered vaccine was prepared from E. coli H10407 (078:H11) by irradiation with electrons with high energy (EHE). Two hours after cimetidine administration rats were immunized per os with 5 irradiated vaccine doses at 4-day intervals. Seven days after the last immunization animals were infected by inoculating 1 x 10(9) germs in the ligated intestinal loop. Reduction of the intestinal secretion by over 50% 18 hours after inoculation was considered an efficient protection marker. The obtained results have proved a significant reduction of the intestinal secretion in immunized animals infected with serotypes 078:H11(63 +/- 4%) and 078:H12(59 +/- 5%) as compared to non-immunized animals. Experimental induction of the intestinal protection against Escherichia coli enterotoxigenic (ETEC) strains points to the possibility of using this type of irradiated vaccine in the prophylaxis of diarrhoea in man.

In vitro effects of pulsed near-ultraviolet laser exposure on human larynx carcinoma cells

Effects of pulsed near-ultraviolet laser beam on structural characteristics and macromolecular synthesis of carcinoma HEp2 cells were investigated. Laser irradiation damage induced in these eukaryotic cells could be characterized by two development stages: a) a reversible stage with minor morphological damages (1.5 kJ/m2) and 2) an irreversible one, at higher fluences, characterized by cellular membrane damage, necrobiosis and cells detachment from the substrate (4.5 kJ/m2). A. Studies performed referring to macromolecular syntheses of low laser fluences (1.5 kJ/m2)--irradiated HEp2 cells showed the following aspects: a) syntheses inhibiton phase in the first cycles of cellular replication and b) syntheses stimulation phases in the following cycle with total repair of laser-induced molecular lesions. B. At high laser fluences (3-4.5 kJ/m2), metabolic lesions repair was partially or totally blocked after prolonged culturing at 37 degrees C. Ths paper suggests some mechanisms of laser action on macromolecular synthesis and correlates them with morphological changes induced by laser exposure of carcinoma cells.

Myocardial ultrastructural lesions in septic valvulopathies

The electron microscopic aspect of the myocard fragments was examined during surgical extirpation and prosthesis of some septic valvulopathies. Various and disseminated lesions were observed. We remarked the range of mitochondrial lesions, glycogenic deletions, lysosomal activations, the intensity of interstitial and intrasarcoplasmatic oedema that disintegrate sarcolemal structures and intercalary disks. The difficulties concerning the surgical valve prosthesis on the severe toxicoseptic and hypoxic myocardial alterations were mentioned.

[The surgical treatment of nonrheumatic mitral valvulopathies]

The present paper analyzed the indications and surgical treatment in 505 patients with lesions of the mitral valve. 350 lesions were of rheumatic nature and 148 with nonrheumatic etiology. 31 patients with infectious endocarditis with mitral localization were operated; 3 deaths and 56 cases wits aggravation of the lesions after endocarditis with a mortality of 6%, were recorded. The severity factors, the complications and characteristics of the intervention in these patients were analyzed. 48 patients had dysfunctions of the mechanical prosthesis with disk and 11 with Edwards Carpentier's prosthesis. The dysfunction types, the diagnosis methods and the evolution were investigated. 16 emergency cases with dysfunctions of the prostheses were operated wits good results. The cooperation among cardiologist, surgeon, explorer and anesthesiologist is an essential condition for the best solution of the new and complex pathology.

Contributions to the biology of the hypoxic liver. Note II. Histologic, electron microscopic and biochemical aspects in the course of open heart surgery under extracorporeal circulation

A study was carried out on the evolution of histological and ultrastructural lesions of liver fragments harvested at different time intervals in the course of extracorporeal circulation in 62 patients operated for acquired and congenital heart disease, as well as that of serologic tests, pre-, intra- and postoperatively up to seven days. Morphologically, it is only the ultrastructural examination that detects the accentuation of preexisting hypoxic lesions within the framework of a state of "controlled shock", noting especially accentuated dilation of the endoplasmic reticulum, lysosomal activation, mitochondrial lesions and a tendency to ribosomal and glycogenic depletion. The lesions did not exceed the limits of reversibility, excepting the cases with advanced heart failure and cardiac cirrhosis. Lending support to these data is the decrease of proteinemia and the dynamics of LDH, SDH, G1DH, gamma GT and transaminases increase after 24 h, then fall to normal values within seven days.