Contemporary approach to cardiogenic shock care: a state-of-the-art review

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Design and Rationale for the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices (DOAC LVAD) Study

Implantable left ventricular assist devices (LVAD) therapy is used to improve quality of life, alleviate symptoms, and extend survival in patients with advanced heart failure (HF). LVAD patients require chronic anticoagulation to reduce the risk of thromboembolic complications and frequently experience bleeding events. Apixaban is a direct oral anticoagulant which has become first-line therapy for patients with non-valvular atrial fibrillation and venous thromboembolism; however, its safety in LVAD patients has not been well-characterized. The evaluation of the hemocompatibility of the Direct Oral Anti-Coagulant apixaban in Left Ventricular Assist Devices (DOAC LVAD) trial is a Phase 2, open label trial of LVAD patients randomized to either apixaban or warfarin therapy. Patients randomized to apixaban will be started on a dose of 5 mg twice daily, while those randomized to warfarin will be managed to an INR goal of 2.0-2.5. All patients will be treated with aspirin 81mg daily. We plan to randomize and follow up to 40 patients for 24 weeks to evaluate the primary outcome of freedom from death or hemocompatibility related adverse events (HRAEs) (stroke, device thrombosis, bleeding, aortic root thrombus, and arterial non-CNS thromboembolism). DOAC LVAD will establish the feasibility of apixaban anticoagulant therapy in LVAD patients. Clinicaltrials.gov: NCT04865978.

Cardiovascular disease, surgery and outcomes in women: are they any different

PURPOSE OF REVIEW

Cardiovascular disease is a leading cause of death for women worldwide and continues to be a major determinant of significant morbidity. Several studies have investigated the marked differences in diagnosis, treatment and etiology in cardiovascular disease and how it relates to gender. In this review, several key studies highlight the stark differences and bring light to the disparity and potential opportunities for further research.

RECENT FINDINGS

One noted area of gender disparity is ischemic cardiac disease as it relates to surgical management. Women have historically had delays in diagnosis, inferior surgical revascularization techniques, and inadequate postoperative care when compared to men.

SUMMARY

By highlighting the disparities in cardiovascular ischemic care, the hope is to bring attention and future research to a population group that is currently undertreated for their ischemic disease and suffering high mortality rates.

Statins for Patients Undergoing Thoracic Aortic Aneurysm Repair Surgery: What to Do?

Statins may be associated with improved outcomes in patient with thoracic aortic aneurysms but there is little data on the role of statins in patients who have undergone thoracic aortic aneurysm repair.

Deglutition Syncope Treated With Peroral Endoscopic Myotomy

Deglutition syncope is a rare, neurally mediated reflex syncope associated with swallowing. It is typically associated with pharyngoesophageal disorders with secondary abnormal vagal reflex causing atrioventricular cardiac block and cerebral hypoperfusion. Diagnosis can be delayed and challenging. Various treatment options have been reported, including withholding cardiac blocker agents, diet modifications, and pacemaker placement. We present a case of persistent deglutition syncope secondary to esophagogastric junction outflow obstruction that failed medical therapy and was managed successfully with peroral endoscopic myotomy with excellent long-term outcome.

Prevalence and predictors of parental concern for children's weight from 2002 to 2012

OBJECTIVES

Public health initiatives to increase parental awareness about children's obesity have become more prominent in the past decade. These initiatives may contribute to increased concern in parents for their children's weight, even if their children are at a healthy weight. The aim of the present study was to document trends in parental (N = 365; 67.9% female) concern for their children's weight from 2002 to 2012 using surveys on health and eating behaviors.

STUDY DESIGN

Participants (N = 365) were parents who completed surveys in 2002 and were followed up in 2012 as part of a longitudinal epidemiological study of eating attitudes and behavior.

METHODS

McNemar's test and logistic regression models estimated changes in and predictors of parental concern.

RESULTS

In 2002, 36.5% of participants indicated concern for their children's weight, which rose to 54.4% in 2012. Parents of overweight children were more likely to report concern than parents of average-weight children at baseline and 10-year follow-up. However, concern increased significantly even among parents of average-weight children, rising from 28.7% to 41.6% (McNemar's test statistic: 8.20, P = .002). Secondary analyses revealed that parents' baseline drive for thinness predicted increased likelihood of concern in these parents (odds ratio: 1.10, P = .04).

CONCLUSION

Findings support the need for future research to examine consequences of societal messages about pediatric obesity.

Topiramate, nutrition and weight change: a prospective study

PURPOSE

To evaluate prospectively the relationship between appetite, food composition, nutritional habits and weight loss following administration of topiramate (TPM) and to identify predictors for TPM induced weight loss.

METHODS

22 patients with epilepsy who were started on TPM were prospectively followed for 6 months and contacted again after a mean follow-up time of 37.1 months.

RESULTS

Body mass index (BMI) loss occurred in 59% of patients, with a mean weight loss of 9.5 kg after 6 months while receiving TPM without further weight loss at the long term follow-up. Weight loss was associated with reduction in appetite without affecting food composition. Predictors for BMI loss after 6 months were high initial BMI and body fat. After 3 weeks of treatment with TPM, the recorded parameters did not predict BMI loss but at 3 months, weight loss, reduction of appetite and amount of food intake were predictive for the amount of BMI loss after 6 months.

Intravenous levetiracetam in the treatment of benzodiazepine refractory status epilepticus

In 2006, levetiracetam was approved as the first of the newer anticonvulsive drugs as an intravenous formulation (ivLEV) for patients with epileptic seizures who are unable to take oral medication. We report our experience with the use of ivLEV for the treatment of 18 episodes of benzodiazepine refractory focal status epilepticus (SE) in 16 patients, including four patients with secondary generalised SE. SE was controlled in all patients by the given combination of drugs; application of further antiepileptic medications after ivLEV was necessary in two episodes. No severe side effects occurred. Our data suggest that ivLEV may be an alternative for the treatment of SE in the future, even in patients that did not respond to benzodiazepines. A large prospective, randomised, controlled study is warranted to investigate the efficacy and safety of ivLEV for the treatment of SE.

The ischemic preconditioning paradox in deceased donor liver transplantation-evidence from a prospective randomized single blind clinical trial

While animal studies show that ischemic preconditioning (IPC) is beneficial in liver transplantation (LT), evidence from few smaller clinical trials is conflicting. From October 2003 to July 2006, 101 deceased donors (DD) were randomized to 10 min IPC (n = 50) or No IPC (n = 51). Primary objective was efficacy of IPC to decrease reperfusion (RP) injury. Both groups had similar donor risk index (DRI) (1.54 vs. 1.57). Aminotransferases on days 1 and 2 were significantly greater (p < 0.05) in IPC recipients. In multivariate analyses, IPC had an independent effect only on day 2 aspartate transferase. Prothrombin time, bilirubin and histological injury were similar in both groups. IPC had no significant effect on plasma TNF-alpha, IL-6 and IL-10 in the donor and TNF-alpha and IL-6 in the recipient. In contrast, IPC recipients had a significant rise in systemic IL-10 levels after RP (p < 0.05) and had fewer moderate/severe rejections within 30 days (p = 0.09). Hospital stay was similar in both groups. One-year patient and graft survival in IPC versus No IPC were 88% versus 78% (p = 0.1) and 86 versus 76% (p = 0.25), respectively. IPC increases RP injury after DDLT, an 'IPC paradox'. Other potential benefits of IPC are limited. IPC may be more effective in combination with other preconditioning regimens.

Pregabalin-induced generalized myoclonic status epilepticus in patients with chronic pain

Pregabalin is often used for the treatment of chronic pain syndromes. We here describe two patients with chronic pain and pregabalin-induced myoclonic status epilepticus. Patients treated with pregabalin who experience sudden behavioral changes or mycloni should be investigated for this possible side effect, and pregabalin should be reduced or discontinued if myocloni or status epilepticus occurs.

Troglitazone-induced fulminant hepatitis: report of a case with autopsy findings

Troglitazone is an insulin-sensitizing agent used to treat type 2 diabetes mellitus. Several cases have been reported of troglitazone-induced hepatic injury; some requiring transplantation, others resulting in death. We here present a case of troglitazone-induced fulminant hepatic necrosis that led to the death of the patient.

Non-Asian hepatocellular carcinoma: correlation between histologic features and echogenicity

Studies of hepatocellular carcinoma in Asia have revealed a correlation between lesion hyperechogenicity and five histologic features: nonliquefied necrosis, sinusoidal dilatation, hemorrhage, fatty metamorphosis, and fibrosis. However, this correlation has not been investigated for non-Asian hepatocellular carcinoma, despite substantial differences between the Asian and non-Asian forms of this carcinoma. We retrospectively reviewed records of 29 patients seen at one United States institution who had hepatocellular carcinoma lesions that were either completely hyperechoic or completely hypoechoic. Tissue specimens obtained surgically (n = 7) or percutaneously (n = 22) were evaluated microscopically for the presence of nonliquefied necrosis, sinusoidal dilatation, hemorrhage, fatty metamorphosis, and fibrosis. A statistically significant correlation was identified between the number of histologic features identified and lesion diameter (P = 0.04) but not between the number of histologic features identified and the likelihood of hyperechogenicity (P = 0.11). Two lesions (50%) with three histologic features, four lesions (40%) with two histologic features, and six lesions (55%) with one histologic feature were hypoechoic. The echogenicity of non-Asian hepatocellular carcinoma lesions cannot be attributed to the histologic features that are believed to underlie echogenicity of the Asian type of hepatocellular carcinoma.

Solitary fibrous tumor of the orbit: CT and pathologic correlation

We report the CT findings of a solitary fibrous tumor of the orbit. The radiologic features included relatively homogeneous contrast enhancement and smooth remodelling of the bones of the orbit, findings consistent with the benign nature of this relatively rare tumor.

Echogenicity of hepatic versus portal vein walls revisited with histologic correlation

The portal vein wall typically is hyperechoic over a wide range of beam-vessel angles, whereas the hepatic vein wall is hyperechoic only when the incident beam and the vessel are perpendicular. This has been attributed to marked discrepancies in mural thickness, collagen content, or perivascular fat between portal and hepatic veins. We evaluated histologically the walls of portal and hepatic veins using three cadaveric livers. For vessels with luminal diameter above 2 to 3 mm, hepatic vein and portal vein wall thicknesses were similar such that portal vein walls were not more than 50% thicker than those of hepatic veins of comparable size. Hepatic vein walls were mostly composed of parallel, tightly packed collagen fibers. In contrast, portal vein walls were composed of loosely arrayed, nonparallel connective tissue fibers which were separated by multiple intervening spaces and only a minority of which were collagenous. Perivascular fat was not identified adjacent to intrahepatic vessels beyond the liver hilus. The marked differences in echogenicity between portal vein and hepatic vein walls typically observed at ultrasonography thus cannot be attributed to differences in mural thickness, collagen content, or perivascular fat between these vessels. Rather, the distinct composition of the hepatic vein wall renders it a specular reflector, which is hyperechoic only when the angle between the ultrasound beam and the vessel wall is close to 90 degrees, whereas the composition of the portal vein wall enables it to appear hyperechoic at a wide range of beam-vessel angles.

Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease

Four Puerto Rican sisters had recurrent prolonged cholestasis of pregnancy without preexisting or intercurrent hepatic disorders. Available information was reviewed on the course, mechanism, and sequelae of prolonged recurrent cholestasis after 14 pregnancies in the 4 sisters. Etiologic, clinical, laboratory, radiological, and morphological studies of the liver and biliary tract were assessed. Each sister had contraceptive pill-induced pruritus. Prolonged recurrent cholestasis in the eldest sister was followed by cirrhosis and death. The second and third sisters had biopsy evidence of portal triaditis and fibrosis after five and three pregnancies, respectively. Intrahepatic cholestatic cirrhosis was present after three pregnancies in the youngest sister, necessitating an orthotopic liver transplantation; a posttransplantation pregnancy was also associated with prolonged cholestasis. Recurrent prolonged intrahepatic cholestasis of pregnancy was followed by periportal fibrosis or cirrhosis in 4 sisters. This finding suggests that patients with prolonged cholestasis after pregnancy should be followed up for evidence of ongoing liver disease, should be counseled on the potential of recurrence and disease progression in future pregnancies, and should alert family members at risk of possible occurrence of the syndrome.

Antibody penetration of tumor GS-7 xenografts in nude mice: a model for mucinous adenocarcinoma of the colon

A new cell line derived from a human adenocarcinoma of the colon, GS-7, was propagated as a s.c. tumor in nude mice. This tumor histologically is a mucinous adenocarcinoma (also designated mucoid or colloid) with characteristic large mucin pools that are not lined by an epithelial layer but may contain scattered, randomly distributed cancer cells. Ten to 20% of human colorectal adenocarcinomas are of this histological type, but rapidly growing xenografts with this histology have been rarely used experimentally. This tumor, therefore, constitutes a useful model for similar human tumors. The mucin pools contain large amounts of carcinoembryonic antigen and tumor-associated glycoprotein 72, and the cells express epithelial glycoprotein 2 on their surface. The ability of antibodies injected i.v. to penetrate this tumor was investigated, using both biotinylated and radioiodinated antibodies (Abs). The results demonstrate that Abs can effectively penetrate the mucin pools, and that large amounts of Ab can localize there. This tumor type may have advantages as a target for certain forms of experimental immunotherapy.

Inhibitory effect of arginine restriction on hepatoma growth

The potential effects of arginine depletion on promotion of hepatocarcinogenesis and the proliferation of hepatoma cells was investigated. A promotional effect of an arginine-free diet on tumor incidence in liver and kidney was not detected in rats and mice treated with N-nitrosodimethylamine. Inhibitory effects of an arginine-deficient diet on the growth of transplanted hepatomas were observed. Relative to the effect on body weight, the inhibition was greater in mice than rats. The inhibitory effects of an arginine-deficient diet were not correlated with the arginase activity in the tumors. Studies with hepatoma cells treated with polyethyleneglycol-modified arginase indicated that the inhibitory effects of arginine-deprivation on DNA synthesis need not be related to depletion of polyamine precursors.

Transformation of immortal, non-tumorigenic osteoblast-like human osteosarcoma cells to the tumorigenic phenotype by nickel sulfate

Epidemiological studies have indirectly linked compounds of chromium, nickel and arsenic to human carcinogenesis. However, there is no evidence that metal compounds can transform human cells to the tumorigenic phenotype in culture. We show here that exposure to 36 microM NiSO4 for 48-96 h results in transformation of an immortal, nontumorigenic, osteoblast-like cell line, HOS TE85, to the tumorigenic phenotype. Continuous passaging following treatment leads to the formation of a few dense foci. The cells isolated and expanded from the foci are morphologically transformed, and form anchorage-independent colonies of the size and abundance comparable to that formed by Kirsten murine sarcoma virus transformed HOS TE85 cells. The transformed cells from tumors in nude mice, have enhanced levels of plasminogen activators and have lost the ability to form model bone matrix on extended culture in the presence of ascorbic acid and beta-glycerophosphate. A number of cell lines have been established from nude mouse tumors. Cytogenetic analysis reveals 16 marker chromosomes and an aberrant chromosome 16. This is the first report of the transformation of a human cell line to tumorigenic phenotype by a metal carcinogen.

A new murine monoclonal antibody against human hepatoma

A murine monoclonal antibody (MAb 336) reactive with human hepatocellular carcinoma has been raised after immunizing BALB/c mice with whole HepG2 cells. MAb 336 (IgG1) was reactive with HepG2 (whole cells and membrane fractions), but not normal liver or peripheral blood cells. Immunohistological studies indicated that 12/16 hepatocellular carcinoma and 6/11 cirrhotic livers expressed MAb 336-associated antigen, and most normal human tissues and tissues derived from other cancers were unstained. Direct and competitive binding assays ruled out the possibility that this MAb reacts with alpha-fetoprotein, carcinoembryonic antigen, or ferritin. Western blot analysis indicated that MAb 336 reacts with an antigen of approximately 30,000 daltons. This MAb may be potentially useful for studying antigenic expression in hepatocellular carcinoma and as a targeting agent for radioimmunodetection and immunoconjugate therapy.

Role of protein kinase A in tax transactivation of the human T-cell leukemia virus type I long terminal repeat

The human T-cell leukemia virus type I (HTLV-I) long terminal repeat (LTR) is inducible both by the retroviral tax gene product and by cyclic AMP in the murine thymoma S49 cell line. The cis-acting sequences that control transcriptional induction by tax and by cyclic AMP are in close proximity within the HTLV-I promoter. By using a protein kinase A (PKA)-deficient S49 mutant cell line, the response of the viral promoter to cyclic AMP was shown to depend on PKA, whereas the response to tax did not require the activity of this enzyme. Transactivation of the HTLV-I LTR by tax, however, decreased in PKA-deficient and adenylate cyclase-deficient cells. The evidence presented supports largely independent mechanisms of promoter induction by cyclic AMP and tax but also suggests a role for PKA-mediated phosphorylation in the regulation of HTLV-I LTR-driven gene expression by tax.

Patterns of antigen distribution in human carcinomas

Ten epithelial-specific monoclonal antibodies, including monoclonal antibodies to antigens that have been used extensively in immunodiagnosis and immunotherapy experiments, were tested for reactivity with 20 human carcinomas each of the colon, lung, and breast. The antibodies tested included B72.3, OC125, and antibodies to carcinoembryonic antigen, the 17-1A antigen, and the milk fat globule mucin antigen (epithelial membrane antigen). Striking differences in the pattern of antigen distribution were seen, with each antibody having a fairly consistent staining pattern, which was dependent on the tumor type. Two antibodies reacted with most or all tumor specimens and, when positive, reacted homogeneously with apparently every cell in the specimen. Other antibodies consistently produced a variegated staining pattern, typically with areas of positive cells surrounded by areas of negative tumor cells. A third pattern was strong localization to the luminal edge and/or secretions of glandular tumors; this pattern was seen primarily in colon carcinomas which have more well-developed glandular structures than breast or lung carcinomas. A correlation with biochemical properties of the antigens was evident, in that mucins or mucin-related antigens generally produced variegated staining of lung and breast carcinomas and luminal edge/secretion staining of colon carcinomas. Such differences in antigen distribution are likely to be a major factor in developing methods for immunodiagnosis and immunotherapy.

Women in the Military Academies: US Navy (Part 1 of 3)

In brief: Women were admitted to the US Naval Academy in Annapolis, Maryland, a little more than a decade ago. To compensate for differences between men and women, some modifications were made in the physical training program, which originally had been designed for men. For example, the personal defense requirement includes judo, boxing, and wrestling for men and judo, hand-to-hand defense, and fencing for women; all these activities are believed to develop poise, fortitude, and combat strategy. The authors point out that athletic women have more success than nonathletes at the academy, probably because athletes tend to possess the stamina, strength, and self-discipline required to survive the academy's tough, uncompromising physical environment.

Teratologic evaluation of Alcide liquid in rats and mice. I

Alcide, a liquid sterilizer, was evaluated for teratogenic potential in rats and mice. Sodium chlorite and lactic acid, the active ingredients of this compound, form chlorine dioxide when mixed. Pregnant rats and mice were administered 1 ml and 0.1 ml, respectively, of Alcide liquid by gavage on days 6-15 of gestation. The general health of the dams was evaluated and the fetuses examined for external, visceral and skeletal malformations. There was no evidence of maternal toxicity among treated rats and mice. Fetal viability, weight, length and number of resorptions were comparable with control groups. Teratogenic toxicity was not detected in either species. There was some incidence of skeletal and visceral anomalies; however, these variances were not significantly different from control animals.

Pathologic pulmonary findings in children with the acquired immunodeficiency syndrome: a study of ten cases

Lung tissue and tissue from the lymphoreticular system obtained at open biopsy and/or autopsy were studied in ten children with the acquired immunodeficiency syndrome (AIDS). One or both parents of nine of the children had AIDS or risk factors for AIDS. The remaining child had hemophilia. The following pulmonary lesions were seen: 1) diffuse alveolar damage (DAD), 2) Pneumocystis carinii and/or cytomegalovirus pneumonitis, 3) lymphoid interstitial pneumonitis (LIP), and 4) desquamative interstitial pneumonitis (DIP). Combinations of such factors as mechanical ventilation, oxygen therapy, and opportunistic infection played a role in the pathogenesis of DAD. Opportunistic infections were related to the defective cell-mediated immunity in these children. The clinical, epidemiologic, immunologic, and pathologic features of the thymuses of these patients indicate that the immune deficiency was unlikely to have been of congenital origin. The immunologic abnormalities may also have been related to the pathogenesis of LIP and DIP. Neither LIP nor DIP has been described in adults with AIDS. Open lung biopsy is of practical importance in the diagnosis and treatment of pulmonary disease in children with AIDS.

Lip reconstruction following resection for an unusual basal-cell carcinoma

Basal-cell carcinoma most commonly occurs in men in the fifth to seventh decades of life. The area of the lesion is usually one that has frequent exposure to the sun: the middle third of the face and upper lip. An unusual case of basal-cell carcinoma occurring on the lower lip and involving the commissure in a 21-year-old woman is presented. The surgical procedures for resection of the tumor and reconstruction of the commissure are described.