Impact of cannabis use in patients with implantable cardiac defibrillators admitted with acute heart failure: a national perspective

Background

Cannabis is the most popular recreational drug in the United States but knowledge about its health implications remain limited. Cannabis use has been linked to acute myocardial infarction and congestive heart failure. The effect of cannabis use in acute decompensated heart failure in patients with Implantable Cardiac Defibrillators (ICDs) is not known.

Objective

In this study, we sought to explore the impact of cannabis use in patients with Implantable Cardiac Defibrillators (ICDs) admitted with acute decompensated heart failure.

Methods

We queried the 2019 National Inpatient Sample (NIS) database for all patients aged ≥18 with ICD devices admitted with acute heart failure. Patients were stratified into two groups based on Cannabis use. We excluded patients with opioid, amphetamine, psychostimulants, cocaine, sedative, and hallucinogen abuse disorders to eliminate the effect of polysubstance use.

Results

Of the 174,295 hospitalization events for acute decompensated heart failure with ICDs, 1824 were noted to have diagnosis of cannabis use (CU). Patients with CU were younger (mean age 52.4y vs 68.5y) and mostly male (81.1% vs 18.9%). CU group had lower prevalence rates for anemia, atrial fibrillation, coronary artery disease, diabetes, cirrhosis, chronic kidney disease and hypothyroidism. They had higher rates of alcoholism, tobacco use and depression. The primary outcome studied was inpatient mortality. Secondary outcomes include cardiac arrest, myocardial infarction, cardiogenic shock, ventricular tachycardia, ventricular fibrillation, stroke, respiratory failure, pleural effusion, acute kidney injury, length of stay (LoS) and hospital charges. Patients in CU group were noted to have decreased length of stay (reduction in adjusted mean LoS: 2.14 days, P=0.000), mortality (adjusted OR: 0.14, P=0.006) and respiratory failure (adjusted OR: 0.53, P=0.009).

Conclusion

Among patients with implantable cardiac defibrillator admitted for acute decompensated heart failure, cannabis users were younger and mostly male. These patients were noted to have decreased length of stay, inpatient mortality, and respiratory failure.

Funding Acknowledgement

Type of funding sources: None.

Viruses, parkinsonism and Parkinson's disease: the past, present and future

Parkinsonism secondary to viral infections is not an uncommon occurrence and has been brought under the spotlight with the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A variety of viruses have been described with a potential of inducing or contributing to the occurrence of parkinsonism and Parkinson's disease (PD), although the relationship between the two remains a matter of debate originating with the description of encephalitis lethargica in the aftermath of the Spanish flu in 1918. While some viral infections have been linked to an increased risk for the development of PD, others seem to have a causal link with the occurrence of parkinsonism. Here, we review the currently available evidence on viral-induced parkinsonism with a focus on potential pathophysiological mechanisms and clinical features. We also review the evidence on viral infections as a risk factor for developing PD and the link between SARS-CoV-2 and parkinsonism, which might have important implications for future research and treatments.

Treatment Response following Radioactive Iodine Therapy in Miliary versus Macronodular Pulmonary Metastases in Papillary Thyroid Carcinoma

Background  Pulmonary metastases in papillary thyroid carcinoma have two common presentations—micro/miliary (MM) and macronodular metastases (MN). The mainstay of treatment, posttotal thyroidectomy, is multiple radioactive iodine ablations (RAIA) every 6 to 12 months. Response assessment is determined by decline in stimulated serum thyroglobulin levels (sTg), disease regression on chest x-ray (CXR), computed tomography thorax, or whole body iodine scintigraphy (TWBS).

Aim  This study aims to assess the difference in response to RAIA based on the pattern of presentation.

Methodology  Retrospective analysis of patients from January 2008 to July 2017 was done. Patients with pulmonary metastases treated with RAIA (3700MBq per therapy as opposed to theAmerican Thyroid Association recommendation of 7400MBq per therapy) and a minimum follow-up of 8 months were included. The initial and the final sTg, TWBS, and CXR were analyzed for both groups. Final outcome in terms of complete response, disease regression, static disease, and disease progression was determined.

Results  Of the total of 1,793 patients, 71 were included. There were 43 females and 28 males. The median age was 39 years and the range was 14 to 79 years. Forty-five (63.3%) patients had MM and 26 (36.6%) patients had MN disease. The average number of therapies was three and maximum follow-up period was 15 years. Of the 45 MM patients, 1 had progression, 7 were static, 23 had regression, and 14 had complete response. Of the 26 MN patients, 22 had progression, 2 were static, 1 had regression, and 1 had complete response.

Conclusion  MM metastases, when compared with MN disease, respond to RAIA with a better outcome. In addition to achieving comparable response with a lower dose per therapy, there were no radiation-related long-term complications reported.

Covid-19, nervous system pathology, and Parkinson's disease: Bench to bedside

Coronavirus disease 2019 (Covid-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is primarily regarded as a respiratory disease; however, multisystemic involvement accompanied by a variety of clinical manifestations, including neurological symptoms, are commonly observed. There is, however, little evidence supporting SARS-CoV-2 infection of central nervous system cells, and neurological symptoms for the most part appear to be due to damage mediated by hypoxic/ischemic and/or inflammatory insults. In this chapter, we report evidence on candidate neuropathological mechanisms underlying neurological manifestations in Covid-19, suggesting that while there is mostly evidence against SARS-CoV-2 entry into brain parenchymal cells as a mechanism that may trigger Parkinson's disease and parkinsonism, that there are multiple means by which the virus may cause neurological symptoms.

Clinical Spectrum, Therapeutic Outcomes and Prognostic predictors in Paraneoplastic Neurological Syndromes - Experiences from a Tertiary Care Center in India

Background:

Paraneoplastic Neurological Syndromes (PNSs) are a heterogeneous group of immune-mediated disorders that often precede tumor diagnosis. There are few systematic studies on the spectrum and follow-up of PNSs.

Objective:

To analyze the clinical spectrum, associated tumors, antibody profile, outcomes, and prognostic predictors in a cohort of PNSs admitted in a tertiary care center.

Methods:

This retrospective study included 97 patients (2008-2019). PNSs were further classified as “classical,” “nonclassical,” “definite,” and “possible.” Clinical profile, diagnostic strategies, therapeutic options, and predictors of outcomes were identified.

Results:

The median age was 54 years (range 17–81). Thirty-nine (40.2%) had classical PNS, and 58 (59.8%) had nonclassical PNS, 74 (76.3%) had “Definite” PNS while 23 (23.7%) had “Possible” PNS. Cerebellar degeneration, peripheral neuropathy, and encephalopathy were the three most common neurological syndromes. Tumors were diagnosed in 66 (68%) patients; Lung cancer was the most common primary tumor. Antibodies were positive in 52 (53.6%). Anti-Yo antibody and anti-Ma2 antibody were the most common antibodies. The majority (57.7%) received immunotherapy in addition to definitive treatment for the tumor. A good outcome was seen in 53 (54.6%). Factors associated with good outcome were: early diagnosis, mRS <3 at presentation, absence of metastatic disease, and adjuvant immunotherapy.

Conclusion:

A high index of clinical suspicion is essential for early diagnosis and prompt management of PNS, especially the nonclassical syndromes. Multimodality diagnostic imaging techniques and antibody profiling play a crucial role in the diagnosis. A favorable prognosis can be expected with the judicious use of immunotherapy and definitive treatment of malignancy.

Clinical Spectrum and Outcome of Neurosarcoidosis: A Retrospective Cohort Study from a Teaching Hospital in India

Context:

Neurosarcoidosis (NS) is a chronic disease with a diverse clinical spectrum, therapeutic response, and outcome. There is scarce literature from our country regarding the same.

Aims:

The aim of this study was to evaluate the clinical spectrum, therapeutic responses, and outcomes of NS in an Indian cohort.

Settings and Design:

In a cross-sectional study, we included all patients with NS treated at a quaternary care teaching hospital in India from January 2007 to October 2019.

Subjects and Methods:

Patients older than 18 years of age fulfilling the diagnostic criteria for NS from the Neurosarcoidosis Consortium Consensus Group were included in the study. The therapeutic response and the degree of disability at last follow-up were assessed.

Results:

We identified 48 patients, among them 3 were categorized as having definite NS, 30 probable NS, and 15 possible NS. Cranial neuropathy was the most common presentation (47.9%), followed by myelopathy (25%). Systemic involvement was identified in 95.83% and mediastinal lymph nodes were the most common site. Clinical improvement was seen in 65.8% and disease stabilized in 28.9%, while 5.26% deteriorated. Fifty percent recovered without any residual disability, while 26.3% had minor and 23.7% had major residual sequelae.

Conclusions:

NS is a diverse illness, with a heterogeneous spectrum of clinical presentation, treatment response, and outcome. Cranial neuropathy is the most common presenting feature and has a good prognosis while myelopathy has an unfavorable prognosis. Meningeal and brain parenchymal disease is difficult to diagnose accurately unless systemic involvement is present. The diagnosis of NS should be clinically suspected in the appropriate clinical setting, the presence of systemic involvement should be investigated, and histologic confirmation should be attempted.

Imaging and clinical features of breast tuberculosis: a review series of 62 cases

AIM

To outline the disease burden of breast tuberculosis (TB) as a quantitative analysis amongst three tertiary hospitals in South Africa, with correlation to their clinical, demographic, and imaging features.

MATERIALS AND METHODS

A retrospective analysis was undertaken over an 18-month period (01/01/2017-30/06/2018) of all patients undergoing laboratory investigations for breast disease at the mammography departments of these three tertiary centres.

RESULTS

The prevalence of breast TB was 2.5% (n=62) of 2,516 patients. The median age of presentation was 38.5 years (interquartile range [IQR] 33-45). HIV status was known in 45 patients, of whom 36 were HIV infected (80%, 95% CI: 0.65-0.90, p<0.0001). Based on the ultrasound and/or mammogram findings, the patients were classified into five categories: TB breast abscess (40.3%), inflammatory/disseminated (24.2%), isolated TB lymphadenitis (22.6%), nodular (11.3%), and sclerosing form (1.6%). Histology demonstrated necrotising granulomatous inflammation in 57 cases (92%). Acid-fast bacilli (AFB) were positive in 8.1% (n=5) of the cytology and 16.1% (n=10) of the histology specimens. Culture for Mycobacterium tuberculosis was positive in 27% (17 cases), and in 12.9% (n=8). AFB were detected histologically using polymerase chain reaction (PCR) testing.

CONCLUSION

Knowledge of the varied clinical and radiological features is necessary to maintain a high degree of suspicion to prevent misdiagnoses, inappropriate management, and complications. Ultrasound-guided core biopsy rather than fine-needle aspiration (FNA) is advocated as the first-line intervention in diagnosing or excluding this disease, as it yields a better tissue sample and more often a positive diagnosis.

Inflammatory adipocyte-derived extracellular vesicles promote leukocyte attachment to vascular endothelial cells

BACKGROUND AND AIMS

Obesity is associated with an increased risk of cardiovascular disease, but the mechanisms involved are not completely understood. In obesity, the adipocyte microenvironment is characterised by both hypoxia and inflammation. Therefore, we sought to determine whether extracellular vesicles (EVs) derived from adipocytes in this setting might be involved in mediating cardiovascular disease, specifically by promoting leukocyte attachment to vascular endothelial cells.

METHODS

Mature 3T3-L1 adipocytes were incubated for 24 h under control, TNF-α (30 ng/mL), hypoxia (1% O₂), or TNF-α+hypoxia (30 ng/mL, 1% O₂) conditions. EVs were isolated by differential ultracentrifugation and analysed by nanoparticle tracking analysis. Primary human umbilical vein endothelial cells (HUVECs) were treated with EVs for 6 h before being lysed for Western blotting to investigate changes in adhesion molecule production, or for use in leukocyte attachment assays.

RESULTS

EVs from adipocytes treated with TNF-α and TNF-α+hypoxia increased vascular cell adhesion molecule (VCAM-1) production in HUVECs compared to basal level (4.2 ± 0.6 and 3.8 ± 0.3-fold increase, respectively (p < 0.05)), an effect that was inhibited by an anti-TNF-α neutralising antibody. Production of other adhesion molecules (E-selectin, P-selectin, platelet endothelial cell adhesion molecule and VE-Cadherin) was unchanged. Pre-incubating HUVECs with TNF-α+hypoxia EVs significantly increased leukocyte attachment compared to basal level (3.0 ± 0.4-fold increase (p < 0.05)).

CONCLUSIONS

Inflammatory adipocyte EVs induce VCAM-1 production in vascular endothelial cells, accompanied by enhanced leukocyte attachment. Preventing adipocyte derived EV-induced VCAM-1 upregulation may offer a novel therapeutic target in the prevention of obesity-driven cardiovascular disease.

Nutrient availability in the Setiu Wetland Lagoon, Malaysia: trends, possible causes and environmental impacts

The objective of this study was to identify the spatial and temporal variabilities of selected nutrients in the Setiu Wetlands Lagoon (SWL), Malaysia. Water samples were collected quarterly at ten monitoring sites. This study presents results from a 10-year field investigation (2003 to 2010 and 2014 to 2015) of water quality in the SWL. For the spatial pattern, four clusters were identified with hierarchical cluster analysis. Analysis of the temporal trend shows that the high total suspended solid loading in 2010 was due to large-scale land clearing upstream of the SWL. The enrichment of ammonium after 2010 could plausibly be due to land-based aquaculture diffuse discharges. In 2005-2007, expansion of oil palm plantations within the Setiu catchment had doubled the phosphorus concentration in the SWL. The natural and anthropogenic alterations of the lagoon inlets profoundly influenced the spatial distribution patterns of nutrients in the SWL. These results suggest that intense anthropogenic disturbances close to the SWL accounted for the water quality deterioration.

Evidence for Adipocyte-Derived Extracellular Vesicles in the Human Circulation

Adipocyte-derived extracellular vesicles (EVs) may serve as novel endocrine mediators of adipose tissue and impact upon vascular health. However, it is unclear whether adipocyte-derived EVs are present in the human circulation. Therefore, the purpose of this study was to seek evidence for the presence of adipocyte-derived EVs in circulating plasma. Size-exclusion chromatography of platelet-free plasma identified fractions 5 to 10 as containing EVs by a peak in particle concentration, which corresponded with the presence of EV and adipocyte proteins. Pooling fractions 5 to 10 and subjecting to ultracentrifugation yielded a plasma EV sample, as verified by transmission electron microscopy (TEM) showing EV structures and Western blotting for EV (e.g., CD9 and Alix) and adipocyte markers. Magnetic beads and a solid-phase assay were used to deplete the EV sample of the four major families of circulating EVs: platelet-derived, leukocyte-derived, endothelial-derived, and erythrocyte-derived EVs. Postdepletion samples from both techniques contained EV structures as visualized by TEM, as well as CD9, Alix, and classic adipocyte proteins. Postdepletion samples also contained a range of other adipocyte proteins from an adipokine array. Adipocyte proteins and adipokines are expressed in optimally processed plasma EV samples, suggesting that adipocyte-derived EVs are secreted into the human circulation.

In silico, in vitro and in vivo analysis identifies a potential role for steroid hormone regulation of FOXD3 in endometriosis-associated genes

STUDY QUESTION

Can bioinformatics analysis of publically available microarray datasets be utilized in identifying potentially important transcription factors (TF) in the hormonal regulation of the endometrium?

SUMMARY ANSWER

Systems integration and analysis of existing complex (published) datasets, predicted a role for the novel transcription factor, Forkhead Box D3 (FOXD3) in healthy endometrium and in endometriosis, which was followed by the demonstration of decreased levels of the protein upon decidualisation of normal human endometrial stromal cells in vitro and differential endometrial expression in the stroma in endometriosis.

WHAT IS KNOWN ALREADY

The reported endometriosis-associated endometrial aberrations are most pronounced in the progesterone-dominant secretory phase and progesterone resistance is a proposed causative factor.

STUDY DESIGN, SIZE, DURATION

The study was initially an 'in silico' study, with confirmatory 'wet lab' data from western blotting (WB), qPCR and Immunohistochemistry (IHC) on endometrial biopsies obtained from 142 women undergoing gynaecological surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a University Research Institute. Bioinformatic analysis of selected published microarray datasets identified differentially regulated genes for the early and mid-secretory phases relative to the proliferative phase. Diseases and Functions categories were identified with Ingenuity (IPA) 'core analysis' software. The key transcription factors controlling secretory phase gene changes were revealed with oPOSSUM software. FOXD3 expression levels were examined in human endometrial samples from women aged 18-55 years by WB, IHC, and qPCR. The progesterone regulation of endometrial FOXD3 levels was examined in vivo and in cultured primary human endometrial stromal cells in vitro.

MAIN RESULTS AND THE ROLE OF CHANCE

Initial data mining and subsequent bioinformatics analysis of human endometrial microarray datasets identified FOXD3 to be a key regulator of gene expression specific to secretory phase/endometriosis. FOXD3 was dynamically expressed in healthy endometrium and differentially expressed in endometriosis. In vitro decidualisation of primary endometrial stromal cells significantly decreased FOXD3 protein (P = 0.0005) and progestagen (Levonorgestrel) treatment also reduced the high endometrial FOXD3 protein (P = 0.0001) and mRNA levels (P = 0.04) seen in untreated women with endometriosis, with a shift of FOXD3 from the nucleus to the cytoplasm.

LIMITATIONS, REASONS FOR CAUTION

The quality of Bioinformatics analysis and results depends on the published micro-array data.

WIDER IMPLICATIONS OF THE FINDINGS

An in depth analysis of FOXD3 function and its relationship with estrogen and progesterone might provide insights into its potential deregulation in proliferative disorders of the endometrium including endometrial cancer where its expression is also deregulated. Further, FOX transcription factors are increasingly seen as novel therapeutic targets in disease.

STUDY FUNDING/COMPETING INTERESTS

We acknowledge the support by Wellbeing of Women project grant RG1073 (D.K.H., A.J.V.). We also acknowledge the support of Liverpool Women's Hospital Foundation Trust (J.A.D.), Institute of Translational Medicine (D.M., A.J.V., D.K.H.) and the Institute of Integrative Biology (O.V.), University of Liverpool. All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Patient dose monitoring in Dubai in radiography and interventional procedures

This paper presents ongoing actions in Dubai on patient dose monitoring in digital radiographic examinations, mammography, interventional procedures, and dental radiological procedures. The aim of Dubai Health Authority (DHA) is to move towards the establishment of local diagnostic reference levels. DHA has participated in national and regional projects under the umbrella of the International Atomic Energy Agency. The need for local radiation protection educational programmes and wider patient dosimetry monitoring and recording emerged from this work.

Application of a quartz crystal microbalance to evaluate biodegradability of starch by Bacillus subtilis

Biodegradation of solution-cast starch films by Bacillus subtilis was monitored using a quartz crystal microbalance (QCM). A starch film was formed on the crystal by solution casting and exposed to the Bacillus subtilis culture in a bioreactor. The high sensitivity of the QCM could monitor small weight changes of the starch films on the crystal in the initial stages of biodegradation by secreted exo-enzymes of the bacterium. The feasibility of this approach as a means of quantification and characterisation of biodegradability of different polymeric materials by selected organisms is discussed.

An evaluation of clinical and histopathological status in paucibacillary leprosy patients after completion of fixed duration therapy

The present study was carried out involving 25 patients with paucibacillary leprosy who attended the outpatient department of dermatology of Father Muller's Medical College Hospital during the period January 2001 to March 2002. All the patients were examined clinically and histopathologically at the beginning and at the end of six months of MDT and relevant data recorded. Clinicopathological correlation with histopathological classification before MDT was 72% and 68% at the end of MDT in our study. At the end of treatment 4 (16%) cases were clinically active and 8 (32%) were histopathologlcally active. The study showed that active cases were significantly reduced as a result of MDT, both clinically and histopathologically. The histopathological activity that outlasts MDT may be due to the bacillary fragments that persist; but clinical activity coupled with histopathological activity seen in 2 patients at the end of 6 months of MDT was possibly an indicator of relapse and these patients and similar others need to be followed up for a longer duration. In this study, resolution of granuloma and clinical activity after completion of MDT were assessed.

Telehealth and communication technologies in health: summary and action plan

INTRODUCTION

Rapid innovations and improvements in communication technologies have opened many new channels for health education and delivery, as well as disaster management. Theme 2 examined the role and applicability of these technologies to Disaster Medicine and Management and the various issues involved in their use.

METHODS

Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set Action Plans that then were reported to the collective group of all delegates.

RESULTS

Main points developed during the presentations and discussion included harnessing convergence, seeking interoperability, building partnerships and making it appropriate. This group identified four Principles of Action underlying its plan: (1) investigate possibilities, (2) identify stakeholders, (3) invite participation, and (4) involve discussants in activities.

DISCUSSION

Action plans were categorized into three areas that included "thinking globally, acting regionally", forming a telehealth advisory group, and increasing corporate partnerships.

CONCLUSIONS

Technology is opening many opportunities that have applications in disaster management. To optimize benefits, goals and standards must be agreed upon and implemented.

Physiologically based pharmacokinetics of cyclosporine A: extension to tissue distribution kinetics in rats and scale-up to human

The tissue distribution kinetics of i.v. Cyclosporine A (CyA) was investigated extensively in rats. The concentration-to-time data of 11 organs were analyzed separately using local physiologically based pharmacokinetic models, involving nonlinear plasma-to-blood cell distribution, membrane-permeability-limited plasma-to-tissue distribution and either linear or nonlinear tissue binding. Two global physiologically based pharmacokinetic models were then evaluated, each comprising arterial and venous pools together with the 11 organs, adopting either of the two local models. Both global models successfully described the blood and tissue distribution kinetics of CyA. In nonlinear model, the estimated dissociation constants (Kd) for the intracellular saturable binding ranged 0.2 to 60 ng/ml among the organs, which are comparable with values reported for cyclophilin-CyA binding in vitro. The predicted human pharmacokinetic profile using the physiologically based pharmacokinetic models, after scale-up of physiological parameters from rat to human, generally agreed with the observations following i.v. and oral administration, with moderate discrepancies due presumably to uncharacterized species differences and/or the effect of i.v. vehicle on the CyA binding in plasma. Nevertheless, the models allow reasonable prediction of drug exposure at the biological target, i.e., intracellular, unbound CyA, which may differ among various organs according to the local physiological elements, e.g., tissue cellular membrane permeability. As well as helping optimize the CyA regimen in patients, who are likely to exhibit a variety of physiological and pathological conditions, the modeling suggests possible insights into the known grafted-organ specific efficacy of CyA.

Managing the new NHS: breathing new life into the NHS reforms

The essence of the NHS reforms is that they bring market forces to bear on organisations providing public services, while allowing those organisations more freedom to respond in ways that will improve the efficiency, effectiveness, and appropriateness of their services. The new structural changes to the NHS--a leaner management executive and fewer, slimmer regions--could be used either to strengthen these features of the reforms or frustrate them by allowing ministers and top management to intervene even more at local level and "overmanage" the market. To ensure that the aims of the reforms are not frustrated ministers and the management executive must restrict themselves to laying down clear strategies and then allow purchasers and providers to meet those strategies in their own ways. They also need to ensure that the whole NHS can learn and benefit from local experimentation and devise ways of managing the crises that will inevitably arise; otherwise they might be tempted to become involved in managing the market at too local a level, and the NHS will suffer the worst of both worlds: stifling bureaucracy at the top and parochial self interest locally.