Transient Cortical Blindness After Cardiac Catheterization: A Case Report and Review of Possible Neurological Etiologies

Cardiac catheterization is a standard procedure performed approximately 1 million times per year. Transient cortical blindness is a rare complication of this procedure. Herein we report a case of complete bilateral vision loss after cardiac catheterization through right radial access, which, to our knowledge, has only been reported once before. Prompt identification of this complication is crucial for patient care. This report provides insight into the diagnostic difficulties, differential diagnosis, imaging findings, and management of transient cortical blindness.

Prevalence and risk factors of erectile dysfunction in cirrhotic patients: An observational study

Background

Erectile dysfunction (ED) is a prevalent complication observed in male patients with liver cirrhosis; however, there is limited understanding of the etiological determinants responsible for its occurrence. The objective of this investigation is to explore potential contributory factors that underlie the development of ED in male patients with liver cirrhosis.

Method

A cross-sectional study was conducted on 200 male patients with liver cirrhosis, who were divided into three groups according to the Child score. ED was studied using the International Index of Erectile Function (IIEF-5) Questionnaire and penile Doppler.

Results

The prevalence of ED among the cirrhotic patients was 80%, and it was more frequent in patients with advanced liver disease (Child C). Penile venous leakage was observed in 20% of cirrhotic patients, which increased to 28.6% in those with advanced liver cirrhosis. Multivariate logistic regression analysis showed that age, low albumin levels, elevated INR, high hemoglobin levels, and Child C were predictors of ED in cirrhotic patients.

Conclusion

Several clinical variables have been identified as potential contributors to the development of erectile dysfunction (ED) in patients with cirrhosis. These variables include advanced age, decreased levels of albumin, elevated INR, increased hemoglobin levels, and Child C classification. Early identification and treatment of these factors could potentially improve the quality of life for cirrhotic patients with ED. Notably, patients with ED in this population were observed to have elevated levels of INR, serum bilirubin, and hemoglobin, as well as reduced levels of serum albumin.

Pre-Transplant Marital Status and Hematopoietic Cell Transplantation Outcomes

Background

Evidence about the impact of marital status before hematopoietic cell transplantation (hct) on outcomes after hct is conflicting.

Methods

We identified patients 40 years of age and older within the Center for International Blood and Marrow Transplant Research registry who underwent hct between January 2008 and December 2015. Marital status before hct was declared as one of: married or living with a partner, single (never married), separated or divorced, and widowed. We performed a multivariable analysis to determine the association of marital status with outcomes after hct.

Results

We identified 10,226 allogeneic and 5714 autologous hct cases with, respectively, a median follow-up of 37 months (range: 1-102 months) and 40 months (range: 1-106 months). No association between marital status and overall survival was observed in either the allogeneic (p = 0.58) or autologous (p = 0.17) setting. However, marital status was associated with grades 2-4 acute graft-versus-host disease (gvhd), p < 0.001, and chronic gvhd, p = 0.04. The risk of grades 2-4 acute gvhd was increased in separated compared with married patients [hazard ratio (hr): 1.13; 95% confidence interval (ci): 1.03 to 1.24], and single patients had a reduced risk of grades 2-4 acute gvhd (hr: 0.87; 95% ci: 0.77 to 0.98). The risk of chronic gvhd was lower in widowed compared with married patients (hr: 0.82; 95% ci: 0.67 to 0.99).

Conclusions

Overall survival after hct is not influenced by marital status, but associations were evident between marital status and grades 2-4 acute and chronic gvhd. To better appreciate the effects of marital status and social support, future research should consider using validated scales to measure social support and patient and caregiver reports of caregiver commitment, and to assess health-related quality of life together with health care utilization.

Venous Ablation

Chronic venous insufficiency is a common and a highly prevalent vascular disorder, that occurs as a result of venous reflux owing to defective venous valves, which in turn causes venous hypertension with significant symptom burden that can interfere with quality of life. Therapeutic strategy involves lowering the venous pressure by lifestyle changes, compression therapy, and conventional catheter-based thermal ablation and novel nonthermal, nontumescent techniques of ablating the affected veins.

Safety of outpatient autologous hematopoietic cell transplantation for multiple myeloma and lymphoma

Autologous hematopoietic cell transplantation (Auto-HCT) is commonly an in-patient procedure. However, Auto-HCT is increasingly being offered on an outpatient basis. To better characterize the safety of outpatient Auto-HCT, we compared the outcome of 230 patients who underwent Auto-HCT on an in-patient vs outpatient basis for myeloma or lymphoma within a single transplant program. All outpatient transplants occurred in a cancer center day hospital. Hematopoietic recovery occurred earlier in the outpatient cohort, with median time to neutrophil recovery of 10 vs 11 days (P<0.001) and median time to platelet recovery of 19 vs 20 days (P=0.053). Fifty-one percent of the outpatient cohort never required admission, with this percentage increasing in later years. Grade 3-4 non-hematologic toxicities occurred in 29% of both cohorts. Non-relapse mortality at 1 year was 0% in the outpatient cohort and 1.5% in the in-patient cohort (P=0.327). Two-year PFS was 62% for outpatient vs 54% for in-patient (P=0.155). One- and two-year OS was 97% and 83% for outpatient vs 91% and 80% for in-patient, respectively (P=0.271). We conclude that, with daily outpatient evaluation and aggressive supportive care, outpatient Auto-HCT can result in excellent outcomes for myeloma and lymphoma patients.

Alternative donors extend transplantation for patients with lymphoma who lack an HLA matched donor

Alternative donor transplantation is increasingly used for high risk lymphoma patients. We analyzed 1593 transplant recipients (2000 to 2010) and compared transplant outcomes in recipients of 8/8 allele human leukocyte antigen (HLA)-A, -B, -C, and DRB1 matched unrelated donors (MUD; n=1176), 7/8 allele HLA-matched unrelated donors (MMUD; n=275) and umbilical cord blood donors (1 or 2 units UCB; n=142). Adjusted 3-year non-relapse mortality of MMUD (44%) was higher as compared to MUD (35%; p=0.004), but similar to UCB recipients (37%; p=0.19), although UCB had lower rates of neutrophil and platelet recovery compared to unrelated donor groups. With a median follow-up of 55 months, 3-year adjusted cumulative incidence of relapse was lower after MMUD compared with MUD (25% vs 33%, p=0.003) but similar between UCB and MUD (30% vs 33%; p=0.48). In multivariate analysis UCB recipients had lower risks of acute and chronic graft versus host disease compared with adult donor groups (UCB vs MUD: HR=0.68, p=0.05; HR=0.35; p<0.001). Adjusted 3-year overall survival was comparable (43% MUD, 37% MMUD and 41% UCB). Data highlight that patients with lymphoma have acceptable survival after alternative donor transplantation. MMUD and UCB can expand the curative potential of allotransplant to patients who lack suitable HLA-matched sibling or MUD.

Clinical outcomes of patients with desmoplastic small round cell tumor of the peritoneum undergoing autologous HCT: a CIBMTR retrospective analysis

Desmoplastic small round cell tumor of the peritoneum (DSRCTP) is a rare, frequently fatal tumor. This retrospective study, based on CIBMTR registry data, describes the largest reported cohort of DSRCTP patients who have undergone Auto-SCT. The probabilities of disease-free survival (DFS) at 1 year for patients in CR and not in CR were 75% (95% confidence interval: 48-94%) and 35% (15-59%), respectively. The probability of OS at 3 years was 57% (29-83%) and 28% (9-51%) for patients in CR and not in CR, respectively. Median survival for the entire cohort was 31 months (36 months and 21 months for those in CR and not in CR, respectively). Engraftment at 42 days was 97% (88-100%). Treatment-related mortality was low, with only one death in the first 100 days. Auto-SCT is a tolerable approach in patients with DSRCTP, with the greatest benefit seen in those patients who obtain CR. For those not in CR, the median OS in this series is greater than previously reported (21 months vs 17 months), suggesting Auto-SCT is useful in prolonging DFS and OS, even in patients with residual or persistent disease pre-transplant.

Risk factors for catheter-related thrombosis (CRT) in cancer patients: a patient-level data (IPD) meta-analysis of clinical trials and prospective studies

BACKGROUND

Knowledge of independent, baseline risk factors for catheter-related thrombosis (CRT) may help select adult cancer patients who are at high risk to receive thromboprophylaxis.

OBJECTIVES

We conducted a meta-analysis of individual patient-level data to identify these baseline risk factors.

PATIENTS/METHODS

MEDLINE, EMBASE, CINAHL, CENTRAL, DARE and the Grey literature databases were searched in all languages from 1995 to 2008. Prospective studies and randomized controlled trials (RCTs) were eligible. Studies were included if original patient-level data were provided by the investigators and if CRT was objectively confirmed with valid imaging. Multivariate logistic regression analysis of 17 prespecified baseline characteristics was conducted. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

RESULTS

A total sample of 5636 subjects from five RCTs and seven prospective studies was included in the analysis. Among these subjects, 425 CRT events were observed. In multivariate logistic regression, the use of implanted ports as compared with peripherally implanted central venous catheters (PICCs), decreased CRT risk (OR, 0.43; 95% CI, 0.23-0.80), whereas past history of deep vein thrombosis (DVT) (OR, 2.03; 95% CI, 1.05-3.92), subclavian venipuncture insertion technique (OR, 2.16; 95% CI, 1.07-4.34) and improper catheter tip location (OR, 1.92; 95% CI, 1.22-3.02), increased CRT risk.

CONCLUSIONS

CRT risk is increased with use of PICCs, previous history of DVT, subclavian venipuncture insertion technique and improper positioning of the catheter tip. These factors may be useful for risk stratifying patients to select those for thromboprophylaxis. Prospective studies are needed to validate these findings.

Outpatient hysteroscopy: a routine investigation before assisted reproductive techniques?

OBJECTIVE

To evaluate the importance of subjecting the patient to an outpatient (office) hysteroscopy (OH) before assisted reproductive techniques (ART) and patient compliance, possible side effects, and complications of the procedure.

DESIGN

Comparative observational cross-sectional study.

SETTING

University hospital.

PATIENT(S)

One hundred fifty-two patients attending the outpatient infertility clinic for pre-ART (IVF/intracytoplasmic sperm injection [ICSI]-ET) investigations, with normal uterine findings on hysterosalpingography (HSG).

INTERVENTION(S)

Transvaginal sonography (TVS) and OH (using a rigid, 30-degree, 4-mm hysteroscope) by the vaginoscopic "no touch" technique.

MAIN OUTCOME MEASURE(S)

Diagnostic value and compliance of OH.

RESULT(S)

The procedure was successful in 145 patients (95.4%); 51 of them (35.2%) had previous ART failures. Abnormal hysteroscopic findings were observed in 48 women (33.1%), in which endometrial polyp, submucous myoma, and intrauterine adhesions were the most common findings. The TVS was specific (100%) but not sensitive (41.7%) compared with OH. Abnormal hysteroscopic findings were significantly higher in patients with previous ART failure(s). The procedure was acceptable in almost all patients with no reported complications.

CONCLUSION(S)

The OH should be part of the infertility workup before ART even in patients with normal HSG and/or TVS. This is especially relevant in cases with prior failed ART cycles.

Human actin mutations associated with hypertrophic and dilated cardiomyopathies demonstrate distinct thin filament regulatory properties in vitro

Two cardiomyopathic mutations were expressed in human cardiac actin, using a Baculovirus/insect cell system; E99K is associated with hypertrophic cardiomyopathy whereas R312H is associated with dilated cardiomyopathy. The hypothesis that the divergent phenotypes of these two cardiomyopathies are associated with fundamental differences in the molecular mechanics and thin filament regulation of the underlying actin mutation was tested using the in vitro motility and laser trap assays. In the presence of troponin (Tn) and tropomyosin (Tm), beta-cardiac myosin moved both E99K and R312H thin filaments at significantly (p<0.05) slower velocities than wild type (WT) at maximal Ca(++). At submaximal Ca(++), R312H thin filaments demonstrated significantly increased Ca(++) sensitivity (pCa(50)) when compared to WT. Velocity as a function of ATP concentration revealed similar ATP binding rates but slowed ADP release rates for the two actin mutants compared to WT. Single molecule laser trap experiments performed using both unregulated (i.e. actin) and regulated thin filaments in the absence of Ca(++) revealed that neither actin mutation significantly affected the myosin's unitary step size (d) or duration of strong actin binding (t(on)) at 20 microM ATP. However, the frequency of individual strong-binding events in the presence of Tn and Tm, was significantly lower for E99K than WT at comparable myosin surface concentrations. The cooperativity of a second myosin head binding to the thin filament was also impaired by E99K. In conclusion, E99K inhibits the activation of the thin filament by myosin strong-binding whereas R312H demonstrates enhanced calcium activation.

Cardiac myosin binding protein-C modulates actomyosin binding and kinetics in the in vitro motility assay

The modulatory role of whole cardiac myosin binding protein-C (cMyBP-C) on myosin force and motion generation was assessed in an in vitro motility assay. The presence of cMyBP-C at an approximate molar ratio of cMyBP-C to whole myosin of 1:2, resulted in a 25% reduction in thin filament velocity (P<0.002) with no effect on relative isometric force under maximally activated conditions (pCa 5). Cardiac MyBP-C was capable of inhibiting actin filament velocity in a concentration-dependent manner using either whole myosin, HMM or S1, indicating that the cMyBP-C does not have to bind to myosin LMM or S2 subdomains to exert its effect. The reduction in velocity by cMyBP-C was independent of changes in ionic strength or excess inorganic phosphate. Co-sedimentation experiments demonstrated S1 binding to actin is reduced as a function of cMyBP-C concentration in the presence of ATP. In contrast, S1 avidly bound to actin in the absence of ATP and limited cMyBP-C binding, indicating that cMyBP-C and S1 compete for actin binding in an ATP-dependent fashion. However, based on the relationship between thin filament velocity and filament length, the cMyBP-C induced reduction in velocity was independent of the number of cross-bridges interacting with the thin filament. In conclusion, the effects of cMyBP-C on velocity and force at both maximal and submaximal activation demonstrate that cMyBP-C does not solely act as a tether between the myosin S2 and LMM subdomains but likely affects both the kinetics and recruitment of myosin cross-bridges through its direct interaction with actin and/or myosin head.

Does chronic ST segment elevation following Q wave myocardial infarction exclude tissue viability?

PURPOSE

Electrocardiographic (ECG) ST segment elevation lasting 2 or more weeks following Q wave myocardial infarction has been associated with 'ventricular aneurysm' and absence of tissue viability. Regional systolic dysfunction may reflect either viable myocardium or scar. Positron emission-tomographic (PET) imaging can distinguish viable from nonviable tissue. We hypothesized that patients with chronic ST segment elevation after Q wave infarction might demonstrate salvageable myocardium in the infarct region.

METHODS

The ECGs of 1,229 sequential patients undergoing PET scans for viability assessment were reviewed by an electrocardiographer to identify individuals with chronic anteroseptal Q wave infarctions with persistent ST segment elevation exceeding 1 mV. Patients with QRS duration longer than 0.14 ms or rhythm other than sinus were excluded. Viability was considered present if either a reversible stress-induced perfusion defect (ischemia) or a resting perfusion-metabolism mismatch (hibernation) was identified.

RESULTS

Anteroseptal ECG Q wave infarction was identified in 132 subjects (74% male, age 61 +/- 12 years). Chronic ST segment elevation was present in 84 subjects (64%) and absent in 48. Baseline clinical characteristics and left ventricular systolic function were similar in both groups. 63% of those with and 56% of those without chronic ST elevation had viable myocardium. No relationship was noted between chronic ST segment elevation and the presence or absence of myocardial viability.

CONCLUSIONS

Chronic ST segment elevation after anteroseptal Q wave myocardial infarction does not exclude myocardial viability in the 'infarct zone'. Evaluation of residual tissue viability is indicated to assess the benefit of revascularization in patients with Q wave infarction and chronic ST segment elevation.

A 65-year-old factory worker with dyspnea on exertion and a normal chest x-ray

Chronic beryllium disease is an occupationally acquired granulomatous lung disease similar to sarcoidosis. It is caused by exposure to beryllium in genetically susceptible persons. It should be suspected in patients with beryllium exposure who present with pulmonary symptoms or have a positive screening blood beryllium-specific lymphocyte proliferation test. The diagnosis is confirmed by the finding of granulomas on transbronchial biopsy in the appropriate clinical and epidemiologic setting. Although there is no cure, treatment with corticosteroids is usually beneficial. In view of the potential side effects, treatment is reserved for patients with symptoms or a decline in pulmonary function.

Transseptal approach for mitral valve surgery. A safe alternative when the need calls

Within a 40-month period ending in June 1992, we used the transseptal approach in performing mitral valve surgery on 18 patients. The patients selected had 1 or more of the following indications: small left atrium; adhesions from previous cardiac surgery or rheumatic activity; large, organized left atrial thrombus: the need for concomitant tricuspid valve surgery; or any combination of these factors. We made the septal incision in the long axis of the fossa ovalis and extended it anteriorly and posteriorly, taking care not to injure either the aortic root or the coronary sinus. In 15 patients, we easily obtained good mitral exposure; in 3, exposure was still difficult. One patient died, but the cause of death was not related to the surgical approach. Although none of our patients had early postoperative cardiac arrhythmias, the small number in our series and the short follow-up time prevent us from predicting the effect of this incision on late postoperative cardiac arrhythmias. Therefore, we recommend limiting the transseptal approach to complex reoperations and to operations necessitating right atriotomy for concomitant procedures. It is also very useful in patients with a large, organized left atrial thrombus. Under these conditions, we conclude that using the transseptal approach for mitral valve surgery is a simple, safe, and time-saving technique.