Two 'firsts' in a patient with tricuspid valve infective endocarditis following edge-to-edge repair: a case report

Background

Tricuspid regurgitation (TR) is associated with increased morbidity and mortality. As many elderly TR patients are deemed inoperable, transcatheter edge-to-edge repair (T-TEER) is arising as a viable treatment option. Though procedural safety aspects seem excellent, long-term risks cannot be ignored, including the feasibility of cardiac pacing by endovascular lead implantation at a later time, as well as T-TEER device-related infective endocarditis (IE), in the context of systemic infection.

Case summary

We present the case of an 80-year-old man with recurrent admissions for right heart failure due to massive TR, despite successful percutaneous mitral valve repair. The patient was turned down for surgery and eventually underwent T-TEER, with successful TR reduction to mild-to-moderate and improvement in quality of life. Five months later, the patient was admitted for symptomatic bradycardia and the first reported pacemaker implantation after T-TEER with a specific tricuspid valve device was performed. Lead implantation was guided by transoesophageal echocardiography, and did not worsen residual TR. Two years later, the patient presented with device-related tricuspid valve IE, again a 'first' following T-TEER. Despite antimicrobial therapy, the vegetation embolized through the atrial septal defect caused by prior mitral-TEER and triggered an ischaemic stroke. Furthermore, sepsis led to multiorgan failure and eventually death.

Discussion

Tricuspid regurgitation is an individual predictor of morbidity and mortality, frequently found in elderly, and should be addressed in symptomatic inoperable patients. With the rise of interventional treatment, new challenges face long-term follow-up and treatment after percutaneous repair. This case report underscores the feasibility of endovascular pacemaker lead implantation after T-TEER, while it points to the risk of device-related tricuspid valve IE.

Transthoracic guidance of percutaneous tricuspid valve repair: a case report

Background

Percutaneous tricuspid valve (TV) repair for tricuspid regurgitation (TR) is arising as a viable treatment option in high-risk patients and can lead to symptom control an improvement in quality of life (QoL). Newest devices have greatly increased safety and efficacy of interventional TR therapy. However, as with any emerging medical procedure, safety aspects need to be considered and procedural risks gradually reduced.

Case summary

We present the case of an 87-year-old woman with massive TR despite successful percutaneous mitral valve repair. The patient was turned down for surgery and eventually underwent percutaneous TV repair using the TriClip™ (Abbott Medical) device. Significant TR reduction with sustained procedural success at 30-day follow-up were associated with functional and clinical improvement. Transthoracic echocardiographic guidance of the procedure, thanks to excellent parasternal TV visualization, is highlighted, while the complex anatomy of the TV is pointed out.

Discussion

Tricuspid regurgitation is an individual predictor of morbidity but frequently found in elderly patients who are deemed very high risk for surgical treatment. This case underscores the use of modern interventional techniques and devices for addressing TR and improving QoL, whether as a stand-alone procedure or as part of complete interventional therapy of the atrioventricular valves.

Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry

AIMS

Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes.

METHODS AND RESULTS

Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In-hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long-term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long-term mortality (hazard ratio 2.12, 95% confidence interval 1.33-3.38; P = 0.002).

CONCLUSIONS

The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in-hospital course and a worse long-term outcome.

[Treatment of Heavily Calcified Coronary Lesions]

Treatment of Heavily Calcified Coronary Lesions Abstract. In Switzerland and other industrialized nations, coronary heart disease (CHD) is the most common cause of death in adulthood. CHD is a chronic disease in which stenoses of the epicardial coronary arteries usually cause a deficit in blood supply to the heart muscle tissue, which can lead to chest pain, myocardial infarction, heart failure or cardiac arrhythmia and ultimately to significant morbidity and mortality. Since the first percutaneous coronary intervention (PCI) on 16th September 1977 at the University Hospital of Zurich by Andreas Grüntzig, the field of interventional cardiology has seen remarkable progress in the treatment of coronary artery disease, especially with the development and evolution of coronary stents. Nonetheless, calcified coronary stenoses pose a challenge in everyday interventional practice because they prevent stent implantation or correct expansion or are associated with a higher rate of complications. Unfortunately, to date, there are no established interventions to prevent calcification of the coronary arteries. However, there are some therapeutic approaches that allow PCI in calcified vessels, and these are the focus of this work.

Therapy of Respiratory Complications in Myasthenia Gravis

Myasthenia gravis is responsible for damaging the neurosurgical structures in charge of producing and supporting the breathing process. Plasmapheresis is the procedure that non selectively removes the potentially pathological elements from the blood.It is done extracorporeally, and has multiple clinical applications, especially in situations when intensive care is required. In patients with moderate or severe forms, or with no favourable therapeutic response to cholinesterase inhibitors, corticosteroids and / or immunosuppressive therapy are administered.

Value of Autopsies in the Study of Diagnostic Errors in Respiratory Medicine

Diagnostic errors are real and are causing harm to patients on a global scale. However, the methods for measuring diagnostic errors are underdeveloped. One very important tool in this regard is the use of autopsies, in order to point out the cases where the actual affliction was missed and to quantify the incidence of such mistakes. We have carried out a study to compare the clinical diagnostic with the post mortem autopsy report in 119 patients who have died at the Pulmonology Hospital in Iasi, Romania, between January 2nd 2016 and January 2nd 2017. The purpose of this research is to determine the incidence of diagnostic errors and to identify the most missed or overlooked respiratory diseases.

The Contribution of Stress Level in Modifying the Cardiometabolic Risk in a Population Cohort from North-East Romania

The cardiometabolic risk is used to assess the probability of developing a cardiovascular disease in association with diabetes. The research of stress factor represents a breakthrough in assessing this risk. The study aim was to evaluate the importance of cardiometabolic risk measurement instruments in the context of psycho-behavioral factors expressed by individual stress level. The cross-sectional study consisted of applying a PSL assessment questionnaire to a group of 254 individuals. Quantification of the PSL was achieved by a previously validated standardized questionnaire (PSS Scale). The research involved completing the questionnaire and corroborating clinical and paraclinical data (LDL-cholesterol, glycemia, glycosylatedhemoglobin - HbA1c). Data were analyzed using the SPSS V.21 software (IBM). The calculation of global cardiovascular risk score (SCORE) highlighted that 75% of cases presented a risk for a cardiovascular event over the next 10 years of lower than 3 (30%). Fasting glycemia values showed significant differences compared to glycosylated hemoglobin values (tvalue= 8.68, p[[0.01, 95% CI). It is noted the absence of significant differences between the calculated mean value and the normal LDL maximum threshold (tvalue = 0.96, p = 0.336). Mean values of females perceived stress score (MPSS/female = 20.9 � 6.43SD) are significantly higher (F = 30.7, p [0.05, 95% CI) versus males (MPSS/male = 16.5 � 5.92SD), but there is no correlation between patient�s age and perceived stress score (r = 0.028, p = 0.651, 95% CI). Correlation of socio-economic factors with PSL reveals that low educational level (r = -0.203, p = 0.001) and low income (r = -0.204, p = 0.001) significantly increase the PSL. The results indicate that there is no correlation between perceived stress score and cardiovascular risk score (r = -0.0936, p = 0.137, 95% CI). Aspects revealed by study results highlight the need for monitoring stress factor in actions of clinical management in patients at high cardiometabolic risk.

Reducing the Duration and Improving Hospitalisation Time by Using New Surgical Tehniques and Psychotherapy

As far as surgical techniques are concerned, video-assisted thoracoscopy comes with lot of improved results compared to classical surgical techniques. This technique seems to reduce the parameters reflecting the period of hospitalization, exposure to analgesics, patient�s recovery rate, and the level of pain felt. Studies have been conducted that have demonstrated that, hypnosis can significantly improve the duration of pain exposure as well as the intensity perceived by the patient. In domain literature report cases in which hypnosis has been proven effective is in the preoperative preparation of surgical patients. furthermore, by applying hypnosis, positive results are found during the postoperative care of patients. This study aims at the results of video-assisted surgical techniques, and at the opportunity of integrating complementary therapeutic elements such as hypnosis to improve the parameters interested in perioperative care of the surgical patient.

Contribution of Imaging Techniques in the Management of Cutaneous Pathology

The management of skin pathology of tumors and inflammatory disorders is difficult due to the existence of constantly changing diagnostic and treatment algorithms. The incidence of cutaneous melanoma and other melanocytic or non-melanoma tumors is currently increasing. Melanoma is difficult to treat in advanced stages due to its aggressiveness, and early diagnosis is required to improve the prognosis of these patients. Imaging techniques, such as classical and digital dermatoscopy can provide information on structure, vascular pattern, prognostic factors and detailed morphological analysis that can lead to improved individual management. This article presents a retrospective study that aims to analyze the contribution of imaging techniques to clinical and histological data.

Non-invasive evaluation of the relationship between electrical and structural cardiac abnormalities in patients with myotonic dystrophy type 1

BACKGROUND

Cardiac involvement in myotonic dystrophy type 1 (MD1) includes conduction disease, arrhythmias, and left-ventricular (LV) systolic dysfunction leading to an increased sudden cardiac death risk. An understanding of the interplay between electrical and structural myocardial changes could improve the prediction of adverse cardiac events. We aimed to explore the relationship between signs of cardiomyopathy by conventional and advanced cardiovascular magnetic resonance (CMR), and electrical abnormalities in MD1.

METHODS

Fifty-seven MD1 patients (43 ± 13 years, 46% male) and 15 matched controls (41 ± 7 years, 53% male) underwent CMR including cine-imaging with feature-tracking strain analysis, late gadolinium enhancement (LGE), and native/post-contrast T1-mapping with extracellular volume calculation. Standard 12-lead and long-term ECG monitoring were performed as screening for rhythm and/or conduction abnormalities.

RESULTS

Abnormal ECGs were recorded in 40% of MD1; a pathologic CMR was found in 44%: 21% had an impaired LV-EF and 32% showed non-ischemic LGE. When looking at MD1 patients with available long-term ECG monitoring (n = 39), those with atrial fibrillation (Afib)/flutter(Afl) episodes had lower LV-EF (52 ± 7 vs. 60 ± 5%, p = 0.002), lower global longitudinal strain (- 17 ± 3 vs. - 20 ± 3%, p = 0.034), a trend to lower left atrial emptying fraction (LA-EF) (44 ± 14 vs. 55 ± 8%, p = 0.08), and higher prevalence of LGE (88% vs. 23%, p = 0.001) with an intramural (75% vs. 23%, p = 0.01) and septal (63% vs. 13%, p = 0.009) pattern. In a model including LV-EF (OR 0.8, 95% CI 0.7-1.0, p = NS) and LGE presence (OR 14.8, 95% CI 1.4-159.0, p = 0.026), only LGE was independently associated with the occurrence of Afib/Afl episodes.

CONCLUSION

Myocardial abnormalities depicted by non-ischemic LGE-CMR were the only independent predictor for the occurrence of Afib/Afl on ECG monitoring, previously shown to predict adverse cardiac events in MD1.

Identification of Cardiomyopathy-Associated Circulating miRNA Biomarkers in Muscular Dystrophy Female Carriers Using a Complementary Cardiac Imaging and Plasma Profiling Approach

Background: Different from males with Duchenne/Becker muscular dystrophy (DMD/BMD) in whom overt myopathy is the rule, muscular dystrophy (MD) female carriers are mostly free of skeletal muscle symptoms. However, similar to MD males, these females are also prone to cardiomyopathy. Since circulating microRNAs (miRNAs) have been proposed as diagnostic biomarkers for various cardiovascular diseases, the aim of the current study was to identify specific circulating miRNAs in the plasma of female DMD/BMD carriers that may allow an early and accurate diagnosis of cardiac involvement in these cases.

Methods: Twenty-nine female MD carriers and 24 age-matched healthy female controls were prospectively enrolled. All MD carriers and controls underwent comprehensive cardiovascular magnetic resonance (CMR) studies as well as venous blood sampling on the same day.

Results: An impaired left ventricular (LV) systolic function was detected in 4 (14%) MD carriers while late gadolinium enhancement (LGE) indicative of myocardial fibrosis was present in 13 female patients (45%)—with an exclusively non-ischemic pattern. Among the circulating miRNAs examined, six were significantly up-regulated in MD carriers compared to female controls: miR-206 (103-fold increase, p < 0.0001), miR-222 (41-fold, p < 0.0001), miR-26a (fourfold, p = 0.029), miR-342 (27-fold, p < 0.0001), miR-378a-3p (minimum 3,600-fold; almost undetectable in controls, p = 0.013), miR-378a-5p (64-fold, p < 0.0001); only two miRNAs were substantially down-regulated in MD carriers: miR-144 (p < 0.0001) and miR-29a (p = 0.002) (both undetectable in carriers). A significant down-regulation of the miR-29c (<0.001-fold, p = 0.006) was observed in MD carriers with abnormal CMR findings (comprising functional and/or structural abnormalities) compared to those with normal CMR examinations. Univariable analyses regarding the presence of abnormal CMR findings resulted in four significant variables: LV end-diastolic volume index (EDVi), LV end-systolic volume index (ESVi), an elevated plasma creatine kinase (CK), and decreased serum miR-29c levels. In subsequent multivariable analysis, the only independent predictor for an abnormal CMR among MD carriers was circulating miR-29c (OR 0.99, 95% CI 0.98–0.99, p = 0.037). Moreover, an elevated CK and/or a downregulated miR-29c level (<0.05 × 10^-3) resulted in an improved AUC value of 0.79 (0.62–0.97, p = 0.007) (79, 80 and 80%, sensitivity, specificity and overall accuracy) for the CMR-based diagnosis of cardiomyopathy in MD carriers when compared to using the two parameters individually.

Conclusion: In female MD carriers, down-regulation of circulating miR-29c relates to the presence of functional and/or structural cardiac abnormalities (as detected by CMR) and appears to be a promising novel biomarker—in addition to conventional CK plasma levels—for an early diagnosis of cardiomyopathy.

Use of Immunohistochemistry to Establish Ethiology in the Case of Primary Spontaneous Pneumotorax Patients

Primary spontaneous pneumothorax has a complex morphopathological substrate, in which active smoking plays an essential etiopathogenic role. Inflammation of the distal airways, bronchial anomalies, perivascular eosinophilic infiltrate associated with hereditary factors and physiognomy (longilli patients) lead to obstruction of distal airwayswhich is the essential element in the emergence of emphysematous changes. Immunohistochemistry (IHC) is a technique used to identify cellular or tissue (antigens) constituents by Ag-Ac, the Ac link site being identified either by direct labeling of the antibody or by a secondary labeling method. IHC reactions are based on tissue-antibody antigen binding, the latter being evidenced by direct conjugation to tracer molecules (direct reaction) or by another chain of other labeled free antibody linkages. We can consider the immunohistochemical method as having a potential utility, especially in selected patients, where there are sufficient clinical and epidemiological reasons to suspect a pneumothorax-causing disease but where the classical investigations did not provide diagnostic performance.

Influence of Environmental Factors on the Primary Spontaneous Pneumotorax

Pneumothorax is the presence of air between the two pleural effusions, making the pleural space from a virtual cavity to a real one. At present, we are facing a particular phenomenon: trying to establish with certainty the mechanisms underlying the occurrence of primary spontaneous pneumothorax and how to find and implement the best strategies for the application of treatment methods. Considering the classical conception that the incidence of spontaneous pneumothorax has a seasonal variability, we followed its distribution after the season, calendar month, by checking the statistical significance of the data obtained. Regardless of the dynamics factor involved and the likely mechanism of action, it seems to have an influence on the average duration of hospitalization and the length of time elapsed from intervention to discharge.

Characterization of the Serum a1-Antitripsine Level in Primary Spontaneous Pneumotorax Patients

Diagnosis of primary or idiopathic spontaneous pneumothorax is one of exclusion, and in fact defines an entity that may have a difficult or impossible cause to be highlighted by current means, we consider it appropriate to study these etiopathogenic aspects. There is a definite association between alpha-1 antitrypsin deficiency and pulmonary emphysema and indirect spontaneous pneumothorax secondary to an emphysematous pulmonary lesion. Dose of alpha-1 antitrypsin is an immunoturbinimetric method for in vitro determination of alpha-1 antitrypsin in human serum and plasma. This product is calibrated to be used for the Daytona RX analyzer. The serum level of alpha-1-antitrypsin is not a determining factor in the postoperative evolution characterized by the interval until air loss disappears, but certainly exerts some influence, the exact level of which remains to be determined.

The Importance of Modified Budin Incidence in the Radiological Diagnosis in Patients with Aseptic Necrosis of the Femoral Head

This study included 56 patients who presented hip pain occurring spontaneously without any trauma history. A new radiological protocol was initiated for all the patients suspected of NACF. A pelvis, Dunlop profile and modified Budin at both hips scan was performed. In order to emphasize the effectiveness of the new radiological protocol, the following indicators were analyzed: the mobility of the affected hip, the radiological changes typical to the aseptic necrosis of the femoral head, the extension angle of the necrosis area on every incidence after Kerboul [1,2], the surface area covering the necrosis zone on every incidence and the coverage on every patient. The modified Budin profile has a greater diagnostic value for the early stages of NACF than the Dunlop profile and the radiography. The Budin incidence is important in order to differentiate stage III of NACF from stage IV by highlighting the degenerative changes in the acetabular cavity.

Bipolar Hemiarthroplasty vs Total Arthroplasty of the Patients with Aseptic Necrosis of the Femoral Head - 20 year retrospective study

We evaluated 1541 patients with aseptic necrosis of the femoral head who underwent prosthetic surgery over a period of 20 years and assessed each implant survival rate depending on the surgucal technique used. The patients were divided into two groups. The first group contained patients with stage II and III of aseptic necrosis, while the second group contained patients with coxarthrosis secondary to the aseptic necrosis of the femoral head. In 20 years, the revision of the bipolar prosthesis in patients with NACF stage III was rated at 1.65%, p=0.0005 and the total prosthesis was rated 7.41%, in patients with secondary NACF coxarthrosis, in spite of 3.98% which was in patients with NACF, p=0.002. The cotyloid was the most frequent cause for the bipolar prosthesis revision and the aseptic loosening of the cup was the most common cause for the total prosthesis revision in patients with secondary NACF coxarthrosis.

The Importance of Immunohistochemistry Techniques in Assessing the Prognosis of Multimodally Treated Breast Cancer

The identification of prognostic factors in the invasive breast cancer is particularly important for the therapeutic approach appropriate to the aggression of neoplasia. Determining the impact of multiple prognostic factors and correlating clinical and immunohistochemical factors allow the treatment to be adjusted so as to avoid the over-treatment of less aggressive neoplasms and to select the optimal multimodal neoadjuvant and adjuvant treatment in cancers with increased aggressiveness. Tissue samples obtained by breast tumor biopsy were studied by classical histopathology methods and by immunohistochemistry techniques, followed by the determination of the histological type, degree of tumor differentiation, status of estrogenic and progesterone receptors, Her2 status. Subsequently, the analysis of the particularities of the prognostic factors associated with the cases with aggressive, metastatic evolution was performed.

Use of Gentian Violet in the Treatment of Severe Radiodermatitis Secondary to Adjuvant Radiotherapy in Breast Cancer

Adjuvant radiotherapy is indicated for patients with conservatively or radically operated breast cancer, demonstrating the benefit of this type of treatment for local recurrence rate and survival. Radiodermatitis are radiation-induced skin reactions, a significant side effect of cumulative ionizing radiation in significant doses at the skin level during the treatment of various tumor localizations. This study presents aspects regarding prevention and treatment of radiodermatitis in patients with adjuvant irradiated breast cancer treated in the Regional Institute of Oncology Iasi. In the study group, use of gentian violet has helped to alleviate these side effects of irradiation, both in intensity and duration, with an important impact on the quality of life of the patients.

Epidemiological Study of Femoral Head Osteonecrosis

In recent years, there has been an increase in the number of studies on the etiology of femoral head necrosis. We retrospectively reviewed all patients diagnosed with aseptic necrosis of the femoral in the period of 2010-2015. We recorded a total of 230 cases diagnosed with aseptic necrosis of the femoral head, group was composed of 65.7% men and 34.3% women, risk factors identified was 19.13% (post-traumatic), 13.91% (glucocorticoids), 26.52% (alcohol), 3.47% (another cause) and in 36 95% of the cases no risk factors were found. The results of the study based on the type of surgery performed on the basis of stages of disease progression, 8 patients (3.48%) benefited from osteotomy, 28 patients (12.17%) benefited of bipolar hemiarthroplasty prosthesis and 188 patients (81.74%) benefited of total hip arthroplasty. Osteonecrosis of the femoral head is characteristic to young patients between the age of 30-50 years old. Predisposing factors, alcohol and corticosteroid therapy remains an important cause of the disease. Total hip arthroplasty remains the best option for the patients with osteonecrosis of the femoral head.

Comprehensive Cardiovascular Magnetic Resonance Assessment in Patients With Sarcoidosis and Preserved Left Ventricular Ejection Fraction

BACKGROUND

Cardiac sarcoidosis (CS) may manifest as arrhythmia or even sudden cardiac death. Because patients with CS often present with nonspecific symptoms, normal electrocardiography, and preserved left ventricular ejection fraction, a reliable diagnostic tool for the work-up of CS is needed. Late gadolinium enhancement-cardiovascular magnetic resonance has proven diagnostic value in CS but has some limitations that may be overcome by adding newer cardiovascular magnetic resonance mapping techniques. The aim of our study was to evaluate a comprehensive cardiovascular magnetic resonance protocol, including late gadolinium enhancement and mapping sequences in sarcoid patients with no symptoms or unspecific symptoms and preserved left ventricular ejection fraction.

METHODS AND RESULTS

Sixty-one sarcoid patients were prospectively enrolled and underwent comprehensive cardiovascular magnetic resonance imaging. Twenty-six healthy volunteers served as control group. Mean left ventricular ejection fraction was 65%; late gadolinium enhancement was only present in sarcoid patients (n=15). Sarcoid patients had a higher median native T1 (994 versus 960 ms; P<0.001), lower post contrast T1 (491 versus 526 ms; P=0.001), expanded extracellular volume (28 versus 25%; P=0.001), and higher T2 values (52 versus 49 ms; P<0.001) compared with controls. Among patients with values higher than the 95% percentile of healthy controls, most significant differences were observed for native T1 and T2 values. Most of these patients were late gadolinium enhancement negative.

CONCLUSIONS

Patients with sarcoidosis demonstrate higher T1, extracellular volume, and T2 values compared with healthy controls, with most significant differences for native T1 and T2. While promising, the clinical significance of the newer mapping techniques with respect to early diagnosis and therapy of CS will have to be determined in future studies.

Detection and Assessment of Interleukin 6 in Irreversible Pulp Inflamation

The study aimed to assess the number, localization and distribution of interleukin 6 (IL-6) positive cells in healthy pulp, acute and chronic pulpitis. The study group included 48 patients aged between 18-72, treated in University of Medicine and Pharmacy Grigore T. Popa Iasi, Romania. The pulpectomy was performed on 42 patients diagnosed with acute and chronic pulpitis. The other 6 patients, without signs of dental caries or periodontal disease, were submitted to extractions of teeth for orthodontic purposes, with pulpectomy performed before extraction. The pulp samples were examined with optic microscope. The detection and assessment of IL-6 were performed using immunohistochemical technique. Data were statistically analysed using non-parametric tests. According to morphopathological criteria, 42.85% were classified as acute pulpitis and 57.14% as chronic pulpitis. The pulp samples in control group were not associated with IL-6 positive cells. The analysis of all samples with acute and chronic pulpitis identified 73.80% samples with IL-6 and 26.20% associated with the absence of IL-6. The highest frequency of IL-6 positive cells was recorded in rich-cell zone of crown dental pulp. The systemic distribution of IL-6 positive cells was mostly diffused without well-defined orientation. IL-6 release in acute and chronic pulpitis is significantly higher comparing with healthy pulp tissue.

Multifocal Osteonecrosis Glucocorticoid Induced

The present study describes a 29 years old patient diagnosed with aseptic osteonecrosis with multiple localization occurred after a corticoid treatment for chronic toxic hepatitis. The clinical and para-clinical examinations determined the diagnosis of Wilson disease and avascular necrosis with multiple localizations. The evolution of the disease was favourable following the surgical treatment consisting of bilateral total hip arthroplasty with cementless prosthesis, hemi-arthroplasty of the left shoulder with cementless prosthesis, orthotopic hepatic transplantation with an entire liver from donor in cerebral death and immunosuppressive, anticoagulant, antiretroviral and gastro-protective treatment. There is an increase of the number of patients undergoing a glucocorticoids treatment for several months, years or lifelong periods. This type of treatment increases the risk of osteonecrosis depending on the dosage and the duration of the treatment.

T1 and T2 mapping for evaluation of myocardial involvement in patients with ANCA-associated vasculitides

BACKGROUND

Myocardial involvement in AAV patients might be silent, presenting with no or nonspecific symptoms, normal ECG, and preserved left-ventricular ejection fraction (LV-EF). Since up to 50% of deaths in these patients may be due to myocardial involvement, a reliable diagnostic tool is warranted. In contrast to LGE-CMR, which has its strengths in detecting focal inflammatory or fibrotic processes, recent mapping techniques are able to detect even subtle, diffuse inflammatory or fibrotic processes. Our study sought to investigate ANCA (antineutrophil cytoplasmic antibody) associated vasculitides (AAV) patients for myocardial involvement by a cardiovascular magnetic resonance (CMR) protocol, including late gadolinium enhancement (LGE) and mapping sequences.

METHODS

Thirty seven AAV patients were prospectively enrolled and underwent CMR imaging. Twenty healthy volunteers served as controls.

RESULTS

Mean LV-EF was 64%; LGE prevalence of the AAV patients was 43%. AAV patients had higher median native T1 (988 vs. 952 ms, p < 0.001), lower post-contrast T1 (488 vs. 524 ms, p = 0.03), expanded extracellular volume (ECV) (27.5 vs. 24.5%, p < 0.001), and higher T2 (53 vs. 49 ms, p < 0.001) compared to controls, with most parameters independent of the LGE status. Native T1 and T2 in AAV patients showed the highest prevalence of abnormally increased values beyond the 95% percentile of controls.

CONCLUSION

AAV patients demonstrated increased T1, ECV, and T2 values, with native T1 and T2 showing the highest prevalence of values beyond the 95% percentile of normal. Since these findings seem to be independent of LGE, mapping techniques may provide complementary information to LGE-CMR in the assessment of myocardial involvement in patients with AAV.

Evaluation of myocardial involvement in patients with connective tissue disorders: a multi-parametric cardiovascular magnetic resonance study

BACKGROUND

Severe arrhythmias or heart failure may be surrogates of myocardial involvement in patients with connective tissue disorders (CTD). However, most patients present with unspecific symptoms, normal ECG, and preserved left ventricular ejection fraction (LV-EF). Therefore, timely diagnosis by an accurate technique is crucial. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has proven value for the detection of focal processes, but due to the often diffuse character of fibrosis/inflammation in CTD patients, CMR mapping techniques might be of incremental value for the assessment of myocardial involvement. Purpose of this study was to evaluate a multi-parametric CMR protocol as a screening tool for myocardial involvement in CTD patients.

METHODS

Forty CTD patients were prospectively enrolled and underwent CMR, twenty healthy volunteers served as control group.

RESULTS

Mean LV-EF was 62 %; LGE prevalence was low (18 %). CTD patients had higher native T1 (1008 vs. 962 ms, p = 0.001), lower post contrast T1 (494 vs. 526 ms, p = 0.008), expanded extracellular volume (ECV) (28 vs. 25 %, p = 0.001), and higher T2 values (53 vs. 49 ms, p < 0.001) compared to controls. Among patients with values higher than the 95 % percentile of healthy controls, native T1 and T2 values seem to be the most promising discriminators.

CONCLUSION

CTD patients showed higher T1, ECV, and T2 values compared to controls, with most significant differences for native T1 and T2, which seem to be independent of the presence of LGE. Our data suggest that CMR mapping techniques are of incremental value in the detection of myocardial involvement in CTD patients.

Blood Loss Management in Primary Hip Surgery: Is Reinfusion drain A Feasible Option in Maintaining Hemoglobin Levels?

The management of blood loss in primary hip arthroplasty is a controversial topic. Aim: To evaluate the efficacy of reinfusion drains in terms of hemoglobin levels and volume of red blood cell transfused postoperatively. Material and Methods: 295 patients who underwent primary hip arthroplasty were retrospectively assessed. After applying the exclusion criteria, 94 patients were included in the study and were divided into two groups: 45 patients received a reinfusion drain and 49 a suction drain. The following were analyzed: demographic characteristics of patients, preoperative hemoglobin level, 12-h and 24-h postoperative hemoglobin levels and their variations, number of transfused units of packed red blood cells, and postoperative complications. Results: Kruskal Wallis analysis revealed the homogeneity of the study groups (Chi-square=2.40, df=2, p=0.301). A statistically significant lower decline in mean Hb24 was found in suction drain group (p=0.001). Kruskal Wallis test revealed a significantly more frequent postoperative use of a higher number of packed red blood cell units in the suction drain group (Chi-square=28.70, df=2, p=0.001) compared to reinfusion drain group. Conclusions: We failed to demonstrate the superiority of reinfusion drains versus suction drains in maintaining hemoglobin levels.

Identification of cardiomyopathy associated circulating miRNA biomarkers in patients with muscular dystrophy using a complementary cardiovascular magnetic resonance and plasma profiling approach

BACKGROUND

Duchenne and Becker muscular dystrophy (DMD and BMD) are X-chromosomal recessive neuromuscular disorders that are caused by mutations in the dystrophin gene and characterized by cardiac involvement. Circulating microRNAs (miRNAs) have been proposed as diagnostic biomarkers for various cardiovascular diseases. However, circulating miRNAs reflecting the presence and/or disease severity of cardiac involvement in DMD/BMD patients have not been described so far.

METHODS

Sixty-three male patients with known MD and 26 age-matched healthy male controls were prospectively enrolled. All MD patients and controls underwent comprehensive cardiovascular magnetic resonance (CMR) studies as well as venous blood sampling on the same day.

RESULTS

An impaired left ventricular (LV) systolic function (defined as LV-EF <55 %) was detected in 29 (46 %) and presence of late gadolinium enhancement (LGE) indicative of myocardial fibrosis in 48 (76 %) MD patients with an exclusively non-ischemic pattern. Whereas no significant differences were observed for the 27 selected circulating miRNAs in MD patients with abnormal CMR findings (comprising structural and/or functional impairments) compared to those with completely normal CMR studies, a significant up-regulation of three miRNAs was observed in LGE-positive MD patients compared to LGE-negative ones: miR-222 (1.8-fold, p = 0.035), miR-26a (2.1-fold, p = 0.03) and miR-378a-5p (2.4-fold, p = 0.026). A signature of these three miRNAs (miR-26a, miR-222 and miR-378a-5p) resulted in an area under the curve (AUC) value of 0.74 for the diagnosis of LGE-positive MD patients. In a multivariable model, three independent predictors for LGE presence were identified comprising not only clinical and laboratory markers (LV-EF: OR 0.47, 95 % CI 0.24-0.89, p = 0.021 and elevated hs-Trop: OR 2559, 95 % CI 2.97-22.04*10(5), p = 0.023) but also the circulating miR-222 (OR 938, 95 % CI 938.46, 3.56-24.73*10(4), p = 0.016).

CONCLUSIONS

Up-regulation of circulating miRNAs miR-222, miR-26a and miR-378a-5p indicates the presence of myocardial scars in MD patients. Plasma miR-222 appears to be a promising novel biomarker reflecting structural - but not functional - cardiac alterations in MD patients.