High output cardiac state: evaluating the incidence, plausible etiologies and outcomes

INTRODUCTION

The high output cardiac state (HOCS) [cardiac index (CI) >4 L/min/m2 ], primarily driven by abnormally low systemic vascular resistance (SVR), is a relatively under-recognized condition. Although, majority of these patients meet criteria for heart failure (HF), their treatment should be aimed at the primary pathology, as the majority of guideline directed HF therapies can reduce SVR further.

OBJECTIVES

To characterize patients with HOCS and provide valuable insight into the condition.

METHODS

Patients investigated by right heart catheterization (RHC) at the St. Boniface Hospital, Winnipeg, Canada between January 2009 and November 2021 were reviewed. Two groups of patients were included: 1) HOCS [CI >4 L/min/m2], and 2) pre-HOCS [CI between 3.8-4.0 L/min/m2]. Their medical records were reviewed to identify plausible etiologies, relevant investigations, and outcomes.

RESULTS

177/2950 (6 %) patients met criteria for inclusion: 144/177 (81 %) with HOCS [mean age 51 years (range 19 - 82); 67/144 (47 %) female] and 33/177 (19 %) with pre-HOCS [mean age 55 years (range 30 - 83); 6/33 (18 %) female]. The most common plausible etiologies for the HOCS included anemia (36 %), obesity (34 %), cirrhosis (17 %), and lung disease (32 %). Trans-thoracic echocardiography and magnetic resonance imaging findings were non-specific and predominantly described preserved left ventricular ejection fraction, and pulmonary hypertension. The population experienced high rates of hospitalization, and significantly high mortality [36/144 (25 %) of HOCS at a median follow-up of 31.5 months, and 13/33 (39 %) of pre-HOCS at a median follow-up of 17 months].

CONCLUSIONS

HOCS is not an uncommon condition and is associated with high mortality. Current HF guideline should incorporate such evaluation into the diagnostic criteria.

Antenatal diagnosis of bronchopulmonary sequestration: A case report and review of the literature

Congenital lung malformations are a constellation of pathologies that can be diagnosed antenatally by ultrasound and fetal MRI. Ultrasound is considered the modality of choice for a routine assessment of second-trimester scans worldwide. Bronchopulmonary sequestration (BPS) and congenital pulmonary airway malformation (CPAM) are the 2 most common echogenic chest masses discovered incidentally during routine ultrasound scans in the second trimester. This paper describes BPS and differentiates it from CPAM sonographically in utero. An extensive literature search involving antenatal ultrasound is undertaken to review the most up-to-date understanding of the BPS. Furthermore, a case study at our institution and the literature review will help better describe the salient features of BPS. A 41-year-old female G3P1 visits our department for a routine second-trimester ultrasound. An echogenic lesion with a cystic component is visualized in this scan. Based on the grayscale and color imaging, this complex echogenic lesion was reported as CPAM and was referred to fetal assessment for confirmation. The fetal assessment diagnosed the lesion as BPS because of the pathognomonic feeding vessel from the thoracic aorta. Regardless of the congenital lung mass, any large mass compromising fetal well-being is an indication for intervention. The prognosis of BPS in the absence of fetal hydrops is excellent. A robust collaboration among radiologists, obstetricians, and pediatricians is required for the best outcome for the pregnancy and the neonate.

CT perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients (CANCCAP): protocol for a prospective study

INTRODUCTION

Cardiac arrest remains one of the most common causes of death with the majority occurring outside of hospitals (out of hospital cardiac arrest). Despite advancements in resuscitation management, approximately 50% of comatose cardiac arrest patients (CCAP) will suffer a severe unsurvivable brain injury. To assess brain injury, a neurological examination is conducted, however, its reliability in predicting outcomes in the first days following cardiac arrest is limited. Non-contrast CT is the most employed scan to assess hypoxic changes, even though it is not sensitive to early hypoxic-ischaemic changes in the brain. CT perfusion (CTP) has shown high sensitivity and specificity in brain death patients, although its use in predicting poor neurological outcome in CCAP has not yet been explored. The purpose of this study is to validate CTP for predicting poor neurological outcome (modified Rankin scale, mRS≥4) at hospital discharge in CCAP.

METHODS AND ANALYSIS

The CT Perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients study is a prospective cohort study funded by the Manitoba Medical Research Foundation. Newly admitted CCAP receiving standard Targeted Temperature Management are eligible. Patients undergo a CTP at the same time as the admission standard of care head CT. Admission CTP findings will be compared with the reference standard of an accepted bedside clinical assessment at the time of admission. Deferred consent will be used. The primary outcome is a binary outcome of good neurological status, defined as mRs<4 or poor neurological status (mRs≥4) at hospital discharge. A total of 90 patients will be enrolled.

ETHICS AND DISSEMINATION

This study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed at the end of the study.

TRIAL REGISTRATION NUMBER

NCT04323020.

Assessment of magnetic resonance imaging (MRI)-fusion prostate biopsy with concurrent standard systematic ultrasound-guided biopsy among men requiring repeat biopsy

INTRODUCTION

The role of magnetic resonance imaging (MRI)-fusion biopsy (FB) remains unclear in men with prior negative prostate biopsies. This study aimed to compare the diagnostic accuracy of FB with concurrent systematic biopsy (SB) in patients requiring repeat prostate biopsies.

METHODS

Patients with previous negative prostate biopsies requiring repeat biopsies were included. Those without suspicious lesions (≥Prostate Imaging-Reporting and Data System [PI-RADS] 3) on MRI were excluded. All patients underwent FB followed by SB. The primary outcome was the sensitivity for clinically significant prostate cancer (Gleason score ≥7). The secondary objective was identification of potential predictive factors of biopsy performance.

RESULTS

A total of 53 patients were included; 41 (77%) patients were found to have clinically significant prostate cancer. FB had a higher detection rate of significant cancer compared to SB (85% vs. 76%, respectively, p=0.20) and lower diagnosis of indolent (Gleason score 3+3=6) cancer (10% vs. 27%, respectively, p=0.05). FB alone missed six (15%) clinically significant cancers, compared to 10 (24%) with SB. SB performance was significantly impaired in patients with anterior lesions and high prostate volumes (p<0.05). There was high degree of pathological discordance between the two approaches, with concordance seen in only 34% of patients.

CONCLUSIONS

In patients with prior negative biopsies and ongoing suspicion for prostate cancer, a combined approach of FB with SB is needed for optimal detection and risk classification of clinically significant disease. Anterior tumors and large prostates were significant predictors of poor SB performance and an MRI-fusion alone approach in these settings could be considered.

Complete resolution of chylopericardium after chemotherapy for chronic lymphocytic leukemia

Nontraumatic chylous pleural effusions (chylothorax) and pericardial effusions (chylopericardium) are rare. They can, however, accompany intrathoracic malignancies and, most commonly, lymphomas. An association of chronic lymphocytic leukemia (cll) with chylopericardium has rarely been reported. A 68-year-old woman with cll, previously treated with single-agent fludarabine in the community, developed pleuritic chest pain and a new pericardial effusion. Computed tomography (ct) imaging of her chest revealed a large pericardial effusion with progressive lymphadenopathy. Pericardiocentesis identified a chylous effusion, and complete evacuation was achieved by catheter drainage. The cll was not treated. An asymptomatic pericardial effusion subsequently recurred. Pericardiocentesis was not repeated. Lymph node biopsy and flow cytometry revealed no evidence of large-cell lymphoma transformation. The patient was treated with 6 cycles of chlorambucil and obinutuzumab. Imaging of her chest by ct between cycles 2 and 3 revealed a marked resolution of the intrathoracic lymphadenopathy, with complete disappearance of the pericardial effusion. Repeat imaging at 5 months and again at 3 years after completion of chemotherapy demonstrated no recurrence of either the lymphadenopathy or the pericardial effusion. The mechanism of production and the treatment of chylous effusions are poorly defined. In this case, resolution of the pericardial effusion with effective chemotherapy is postulated to have alleviated obstruction of anterograde lymphatic flow facilitating drainage into the systemic venous system and allowing for spontaneous complete resolution of the pericardial effusion without surgical intervention.

In vivo 1 H MRS of human gallbladder bile in understanding the pathophysiology of primary sclerosing cholangitis (PSC): Immune-mediated disease versus bile acid-induced injury

Primary sclerosing cholangitis (PSC) has been considered to be either an "autoimmune disease" or a "bile acid-induced injury." In vitro MRS studies on PSC patients have limitations due to the contamination of bile with contrast agent (commonly administered during endoscopic retrograde cholangiopancreatography) and/or the use of patient cohorts with other diseases as controls. The objective of this study was to quantify biliary metabolites using in vivo ¹ H MRS and gain insight into the pathogenesis of PSC. Biliary metabolites in 10 PSC patients and 14 healthy controls were quantified in vivo using ¹ H MRS on a 3 T MR scanner. The concentrations of total bile acids plus cholesterol, glycine-conjugated bile acids, taurine-conjugated bile acids, and choline-containing phospholipids (chol-PLs) were compared between the two groups. There were statistically significant decreases in the levels of the above mentioned biliary metabolites in the PSC patients compared with controls. The reduction in bile acid secretion in bile of PSC patients indicates accumulation of bile acids in hepatocytes. Moreover, reduction in the levels of chol-PLs in bile may increase the toxic effects of bile acids. Our findings suggest that the bile duct injury in PSC patients is most likely due to "bile acid-induced injury."

In vivo 1H MRS of human gallbladder bile at 3 T in one and two dimensions: detection and quantification of major biliary lipids

In vitro (1)H MRS of human bile has shown potential in the diagnosis of various hepatopancreatobiliary (HPB) diseases. Previously, in vivo (1)H MRS of human bile in gallbladder using a 1.5 T scanner demonstrated the possibility of quantification of choline-containing phospholipids (chol-PLs). However, other lipid components such as bile acids play an important role in the pathophysiology of the HPB system. We have employed a higher magnetic field strength (3 T), and a custom-built receive array coil, to improve the quality of in vivo (1)H MRS of human bile in the gallbladder. We obtained significant improvement in the quality of 1D spectra (17 healthy volunteers) using a respiratory-gated PRESS sequence with well distinguished signals for total bile acids (TBAs) plus cholesterol resonating at 0.66 ppm, taurine-conjugated bile acids (TCBAs) at 3.08 ppm, chol-PLs at 3.22 ppm, glycine-conjugated bile acids (GCBAs) at 3.74 ppm, and the amide proton (-NH) arising from GCBAs and TCBAs in the region 7.76-8.05 ppm. The peak areas of these signals were measured by deconvolution, and subsequently the molar concentrations of metabolites were estimated with good accuracy, except for that of TBAs plus cholesterol. The concentration of TBAs plus cholesterol was overestimated in some cases, which could be due to lipid contamination. In addition, we report the first 2D L-COSY spectra of human gallbladder bile in vivo (obtained in 15 healthy volunteers). 2D L-COSY spectra will be helpful in differentiating various biliary chol-PLs in pathological conditions of the HPB system.

The double helix angiography of right coronary arteries: false lumen stenting of a type F right coronary artery spiral dissection with late recanalization of the true lumen and occlusion of the stented false lumen

Guide catheter induced dissection of coronary arteries is an uncommon, but serious complication of coronary angioplasty. Treatment can include emergent coronary artery bypass grafting to the affected vessel or percutaneous intervention including wiring the true lumen and exclusion stenting of the dissection flap to prevent further propagation. Detailed descriptions have been published of techniques of intentional passage of guide wires into the false lumen and reentry into the true lumen with chronic total occlusions. We present an unusual case of what appeared to be successful intentional false lumen stenting with reentry into the true lumen of an iatrogenic dissection of the right coronary artery with restoration of TIMI III coronary flow which, one year later, was complicated by recanalization of the true lumen and occlusion of the stented false lumen causing symptomatic angina.

Probing the interplay between factors determining reaction rates on silica gel using termolecular systems

In this study we have compared energy and electron transfer reactions in termolecular systems using a nanosecond diffuse reflectance laser flash photolysis technique. We have previously investigated these processes on silica gel surfaces for bimolecular systems and electron transfer in termolecular systems. The latter systems involved electron transfer between three arene molecules with azulene acting as a molecular shuttle. In this study we present an alternative electron transfer system using trans β-carotene as an electron donor in order to effectively immobilise all species except the shuttle, providing the first unambiguous evidence for radical ion mobility. In the energy transfer system we use naphthalene, a structural isomer of azulene, as the shuttle, facilitating energy transfer from a selectively excited benzophenone sensitiser to 9-cyanoanthracene. Bimolecular rate constants for all of these processes have been measured and new insights into the factors determining the rates of these reactions on silica gel have been obtained.

The development of medical-manager roles in European hospital systems: a framework for comparison

A central motif of health reforms around the world has been the drive to persuade doctors and other clinical professionals to become more actively engaged in the management of services. Examples include moves to extend the commissioning role of primary care doctors (such as general practitioners in the UK) and the introduction of ‘clinical directorates’ in secondary care. This strategy has been seen as a means of controlling professionals, turning ‘poachers into game keepers’, especially with regard to resource allocation. However, there is also a mounting body of evidence pointing to how clinical leadership may play a role in stimulating quality improvement and new innovations inservice design, with positive consequences for patient safety and satisfaction (1). Focusing on the top 100 hospitals in the US Goodall (2) finds a strong positive association between the ranked quality of hospitals and whether the chief executive officer was a clinician. A survey of 1200 hospitals across seven countries (UK, US, Germany, France, Italy,Canada and Sweden) conducted by McKinsey and LSE also finds that clinically qualified managers improve both the effectiveness of management decisions and clinical performance of hospitals overall (3).

Activation energies of photoinduced unimolecular, bimolecular and termolecular processes on silica gel surfaces

Activation energies for energy and electron transfer have been measured in various systems on silica gel. In the case of ion-electron recombination, a facile technique involving fluorescence recovery is described which complements diffuse reflectance spectroscopy in the study of these systems. In bimolecular anthracene/azulene systems, activation energies have been shown to be independent of pre-treatment temperature in the range 25-210 °C, demonstrating that physisorbed water plays little role in determining diffusion rates on silica gel. In a ternary anthracene/azulene/perylene system, we have for the first time presented comparative activation energies for the diffusion of azulene and its radical cation, and have shown a greater activation energy for diffusion of the latter species.

Negative pressure pulmonary edema in the coronary care unit

A 63-year-old woman with no known cardiac history presented with pulmonary edema accompanied by electrocardiographic evidence of ischemia. Echocardiography demonstrated normal cardiac dimensions, normal wall motion and mild diastolic dysfunction. Despite repeat attempts at extubation following aggressive diuresis, the patient required ongoing ventilatory support. Although cardiac catheterization revealed normal coronary arteries, computed tomography revealed a 4 cm 9 cm multinodular goiter extending into the mediastinum and compressing the trachea. A diagnosis of negative pressure pulmonary edema should be considered in the differential diagnosis of any patient presenting with acute heart failure.

Delayed contrast enhancement cardiac magnetic resonance imaging in trastuzumab induced cardiomyopathy

BACKGROUND

Trastuzumab (Herceptin), an antagonist to the human epidermal growth factor 2 (HER2) receptor significantly decreases the rates of breast cancer recurrence and mortality by 50%. Despite therapeutic benefits, the risk of cardiotoxicity with trastuzumab ranges from 10-15% when administered sequentially following anthraycline chemotherapy. Little is known about the utility of cardiac magnetic resonance (CMR) in the assessment of trastuzumab mediated cardiomyopathy.

METHODS AND RESULTS

Between 2005-2006 inclusive, 160 breast cancer patients were identified at a single tertiary care oncology centre. Of the total population, 10 patients (mean age 40 +/- 8 years) were identified with trastuzumab induced cardiomyopathy, based on a LVEF less than 40% on serial MUGA or echocardiography. CMR was performed in all patients to determine LV volumes, systolic function and evidence of late gadolinium enhancement (LGE). At the time of diagnosis of trastuzumab induced cardiomyopathy, the mean LVEF was 29 +/- 4%. Subepicardial linear LGE was present in the lateral portion of the left ventricles in all 10 patients.

CONCLUSION

LGE-CMR is a novel way of detecting early changes in the myocardium due to trastuzumab induced cardiotoxicity.

Bimolecular processes on silica gel surfaces: energetic factors in determining electron-transfer rates

Triplet state and radical cation formation is observed following laser excitation of anthracene, phenanthrene and naphthalene (and their derivatives) adsorbed on silica gel. Energy- and electron-transfer reactions of these compounds with co-adsorbed azulene have been studied using a time-resolved diffuse reflectance laser flash photolysis technique. Triplet energy transfer from the arene derivative to azulene and electron transfer from azulene to the arene radical cation have been investigated in order to distinguish between diffusional and energetic control in these systems. Energy and electron transfer can be studied independently due to differing absorption properties and energy dependencies of production of the triplet states and radical cations. Transient decay kinetics for both electron and energy transfer have been modelled using two different rate constant distributions: a log Gaussian and a symmetrical Levy stable distribution. The latter model has also been demonstrated to be applicable to the decay of radical cations in the absence of an electron donor, which cannot be adequately described by the Gaussian model. Energy-transfer rates between the arene derivatives and azulene have been found to be close to the diffusion-controlled limit; however, in most cases, the rate of electron transfer is considerably lower. A correlation between the bimolecular rate constant and free energy of electron transfer has been found, indicating a Marcus inverted region. Compounds with bulky substituents show a further reduction in the rate of electron transfer, suggesting that an additional steric factor is involved in this process.

Mammographic density is related to stroma and stromal proteoglycan expression

BACKGROUND

Mammographic density and certain histological changes in breast tissues are both risk factors for breast cancer. However, the relationship between these factors remains uncertain. Previous studies have focused on the histology of the epithelial changes, even though breast stroma is the major tissue compartment by volume. We have previously identified lumican and decorin as abundant small leucine-rich proteoglycans in breast stroma that show altered expression after breast tumorigenesis. In this study we have examined breast biopsies for a relationship between mammographic density and stromal alterations.

METHODS

We reviewed mammograms from women aged 50-69 years who had enrolled in a provincial mammography screening program and had undergone an excision biopsy for an abnormality that was subsequently diagnosed as benign or pre-invasive breast disease. The overall mammographic density was classified into density categories. All biopsy tissue sections were reviewed and tissue blocks from excision margins distant from the diagnostic lesion were selected. Histological composition was assessed in sections stained with haematoxylin and eosin, and the expression of lumican and decorin was assessed by immunohistochemistry; both were quantified by semi-quantitative scoring.

RESULTS

Tissue sections corresponding to regions of high in comparison with low mammographic density showed no significant difference in the density of ductal and lobular units but showed significantly higher collagen density and extent of fibrosis. Similarly, the expression of lumican and decorin was significantly increased.

CONCLUSION

Alteration in stromal composition is correlated with increased mammographic density. Although epithelial changes define the eventual pathway for breast cancer development, mammographic density might correspond more directly to alterations in stromal composition.

Controlling factors in electron and energy transfer reactions on silica gel surfaces

Energy and electron transfer reactions between co-adsorbed molecules on silica gel have been studied using nanosecond time-resolved diffuse reflectance laser flash photolysis. The systems under investigation are anthracene and 9-carboxylic acid anthracene co-adsorbed with azulene, which undergo both triplet-triplet energy transfer and electron transfer from azulene to the anthracene radical cation following laser excitation. The decay traces have been analysed using a model which assumes a log gaussian distribution of rate constants and the methodology behind the optimisation of the fitting parameters is described. Bimolecular rate constants for energy and electron transfer between anthracene (and its derivative) and azulene have been obtained. Ground state association between anthracene and azulene has been observed, and an equilibrium constant for the process determined. The kinetic data is corrected for these ground state association effects which reduce the free azulene concentration. For both systems and for both the energy and electron transfer processes, analysis of the quenching data yields the same quenching constant. This indicates that the rate of reaction of anthracene (and the 9-carboxylic acid anthracene) on silica gel is predominantly governed by the rate of diffusion of the quencher.