Accelerated treatment with rtPA for pulmonary embolism induced circulatory arrest

Patients with circulatory arrest due to pulmonary embolism (PE) should be treated with fibrinolytics. Current guidelines do not specify which regimen to apply, and it has been suggested that the regimen of 100 mg rtPA/2 h should be used, because this is recommended for hemodynamic instable PE in the ESC/ERS Guideline. This two hour regimen, however, is incompatible with key principles of cardiopulmonary resuscitation (CPR), such as employment of interventions that allow fast evaluation of effectiveness, and limitation of the total duration of CPR to avoid poor neurological outcomes. Additionally, the low flow-state during CPR has important consequences for the pharmacokinetic properties of rtPA. Arguably, the volume of distribution is lower, the metabolism reduced and the half life time longer. Therefore, these changes largely discard the rationale to use high dosages of rtPA over a prolonged period of time. More importantly, these changes highlight that the guideline recommendations, based on studies in patients without circulatory arrest, cannot be easily translated to the situation of circulatory arrest. An accelerated regimen of rtPA (0.6 mg/kg/15 min., max 50 mg) is mentioned by the 2019 ESC/ERS Guideline. However, empirical support or a rationale is not provided. Due to the rarity of the situation and ethical difficulties associated with randomizing unconscious patients, a randomized head-to-head comparison between the two regimens is unlikely to ever be performed. With this comprehensive overview of the pharmacokinetics of rtPA and current literature, a strong rationale is provided that the accelerated protocol is the regimen of choice for patients with PE-induced circulatory arrest.

[Treating black hypertensive patients: limited applicability of the guideline recommendations]

Self-identified black patients respond better to calcium channel blockers and diuretics, than to renin-angiotensin-system inhibiting agents. This has been translated into sensitive guideline recommendations to treat black patients differently than others. We argue that such recommendations have limited applicability. Studies that shaped these recommendations selected patients on the basis that they self-identify as Black. This self-identification is often considered synonymous to having an African ancestry, but ancestry is but one of the many factors that constitutes one's self-identification. Moreover, if any, the African roots of these patients are often many generations old. Patients that self-identify as Black are likely to have ancestors from other races that co-determine their response to antihypertensive medications. The ancestry of black Dutch patients is diverse, and incomparable to black American or African patients. Therefore it is ill-advised to treat Dutch patients based on associations found in these populations. Studies in more comparable populations are scarce and contradictory.

Ascending Cholangitis due to Heavy Lifting

Gallstone disease is the most common risk factor for cholangitis. In an anatomically normal bile duct system, cholangitis does not occur without the presence of stones. Endoscopic retrograde cholangiography with papillotomy and stone extraction is a well-established curative therapy for gallstones in the common bile duct. More important, papillotomy prevents recurrent episodes. The present case report describes a 73-year-old male with recurring cholangitis in a clear bile duct system after previous papillotomy. An etiology of duodenal reflux into the common bile duct due to heavy lifting is proposed.

[A woman with symptoms of an ileus]

An 84-year-old woman was seen with symptoms of an obstructive ileus. CT imaging revealed a volvulus of her intrathoracic stomach. This was successfully treated with gastroscopic detorsion. The patient recovered well.

Incremental diagnostic value of epicardial adipose tissue for the detection of functionally relevant coronary artery disease

BACKGROUND AND AIM

To determine the incremental diagnostic value of epicardial adipose tissue (EAT) volume in addition to the coronary artery calcium (CAC) score for detecting hemodynamic significant coronary artery disease (CAD).

METHODS AND RESULTS

122 patients (mean age 61 ± 10 years, 61% male) without a previous cardiac history underwent a non-contrast CT scan for calcium scoring and EAT volume measurements. Subsequently all patients underwent invasive coronary angiography (ICA) in conjunction with fractional flow reserve (FFR) measurements. A stenosis >90% and/or a FFR ≤0.80 were considered significant. Mean EAT volume and CACscore were 128 ± 51 cm(3) and 418 ± 704, respectively. The correlation between EAT volume and the CACscore was poor (r = 0.11, p = 0.24). Male gender (odds ratio [OR] 2.86, p = 0.01), CACscore ([cut-off value 100] OR 3.31, p = 0.003, and EAT volume ([cut-off value 92 cm(3)] OR 4.28, p = 0.01) were associated with flow-limiting disease. The multivariate model revealed that only male gender (OR 2.50, p = 0.045), CAC score (OR 3.60, p = 0.005), and EAT volume (OR 4.95, p = 0.02) were independent predictors of myocardial ischemia. Using the cut-off values of 100 (CAC score) and 92 cm(3) (EAT volume), sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for detecting functionally relevant CAD as indicated by FFR were 71, 57, 77, 50 and 63% and 91, 29, 85, 44 and 52% for the CACscore and EAT volume, respectively. Adding EAT volume to the CAC score and cardiovascular risk factors did not enhance diagnostic performance for the detection of significant CAD (p = 0.57).

CONCLUSION

EAT volume measurements have no diagnostic value beyond calcium scoring and cardiovascular risk factors in the detection of hemodynamic significant CAD.

The impact of obesity on the relationship between epicardial adipose tissue, left ventricular mass and coronary microvascular function

Purpose

Epicardial adipose tissue (EAT) has been linked to coronary artery disease (CAD) and coronary microvascular dysfunction. However, its injurious effect may also impact the underlying myocardium. This study aimed to determine the impact of obesity on the quantitative relationship between left ventricular mass (LVM), EAT and coronary microvascular function.

Methods

A total of 208 (94 men, 45 %) patients evaluated for CAD but free of coronary obstructions underwent quantitative [¹⁵O]H₂O hybrid positron emission tomography (PET)/CT imaging. Coronary microvascular resistance (CMVR) was calculated as the ratio of mean arterial pressure to hyperaemic myocardial blood flow.

Results

Obese patients [body mass index (BMI) > 25, n = 133, 64 % of total] had more EAT (125.3 ± 47.6 vs 93.5 ± 42.1 cc, p < 0.001), a higher LVM (130.1 ± 30.4 vs 114.2 ± 29.3 g, p < 0.001) and an increased CMVR (26.6 ± 9.1 vs 22.3 ± 8.6 mmHg×ml⁻¹×min⁻¹×g⁻¹, p < 0.01) as compared to nonobese patients. Male gender (β = 40.7, p < 0.001), BMI (β = 1.61, p < 0.001), smoking (β = 6.29, p = 0.03) and EAT volume (β = 0.10, p < 0.01) were identified as independent predictors of LVM. When grouped according to BMI status, EAT was only independently associated with LVM in nonobese patients. LVM, hypercholesterolaemia and coronary artery calcium score were independent predictors of CMVR.

Conclusion

EAT volume is associated with LVM independently of BMI and might therefore be a better predictor of cardiovascular risk than BMI. However, EAT volume was not related to coronary microvascular function after adjustments for LVM and traditional risk factors.

Electronic supplementary material

The online version of this article (doi:10.1007/s00259-015-3087-5) contains supplementary material, which is available to authorized users.

Objective analysis versus subjective assessment of vowels pronounced by deaf and normal-hearing children

Objective whole-spectrum and formant analyses have been performed on all 15 Dutch vowels pronounced in /C1VC2/ words by 24 deaf and 24 normal-hearing children, in order to develop a model of pronunciation quality for evaluating (deaf) speech; the results as obtained for adult males by Bakkum et al. [J. Acoust. Soc. Am. 94, 1989-2004 (1993)] have been verified and extended. Spectral representations of the vowels were created by determining the output levels of a bank of 16 filters (90-7200 Hz), with 1/3-oct bandwidths and logarithmic spacing of their center frequencies. Spectral differences agree well with subjective differences in pronunciation quality obtained from magnitude estimation and identification experiments. Spectral differences not related to pronunciation quality judgments arise as a consequence of physiological interspeaker differences and variation in fundamental frequency, but these differences can be compensated for by speaker-normalization and F0-compensation procedures. Using principal components analysis (PCA), the vowel spectra can be described by a limited number of dimensions, without losing much information; a description in a two-dimensional PCA subspace still agrees well with the subjective judgments and it also agrees with a description by the first two formants. The whole-spectrum approach provides a determinate, readily interpretable model of pronunciation quality for evaluating vowels. As a practical advantage, its computational requirements are modest and, in conjunction with PCA, the vowel dynamics can be visualized, which makes the approach suitable for vowel training and diagnostics.

Objective analysis versus subjective assessment of vowels pronounced by native, non-native, and deaf male speakers of Dutch

An objective analysis has been performed on all 15 Dutch vowels pronounced in /hVt/ words by nine native Dutch, nine non-native, and six deaf males. Spectral representations of the vowel segments were created by determining the mean output levels of a bank of 16 filters (90-7200 Hz), with 1/3-oct bandwidths and logarithmic spacing of their center frequencies. The adequacy of the objective analysis is determined by the extent to which spectral information provides an accurate description of pronunciation quality. Spectral distances between the 24 utterances of each monophthong agree rather well with subjective distances obtained by listeners in an elaborate paired-comparisons experiment. For the various monophthongs, the correlation coefficients are within the range 0.63 to 0.88; averaging across all 12 monophthongs of each speaker results in a coefficient of 0.94. Furthermore, it appeared that the objective spectral analysis is as reliable as a subjective assessment by magnitude estimation by two to three listeners. Using principal components analysis (PCA), the number of dimensions by which the vowel spectra are described can be reduced. For the various monophthongs the range of the correlation coefficients between subjective distances and objective distances in a two-dimensional PCA subspace is 0.30-0.93. The three groups of speakers can still be distinguished in this subspace. In the extreme case of the deaf speakers all vowels are strongly "neutralized," whereas the different vowels of the native speakers are well separated, especially after speaker normalization; results are less clear for the non-natives.