Coronary Microvascular Disease in Women: Epidemiology, Mechanisms, Evaluation, and Treatment

Coronary microvascular dysfunction (CMD) involves functional or structural abnormalities of the coronary microvasculature resulting in dysregulation of coronary blood flow (CBF) in response to myocardial oxygen demand. This perfusion mismatch causes myocardial ischemia, which manifests in patients as microvascular angina (MVA). CMD can be diagnosed non-invasively via multiple imaging techniques or invasively using coronary function testing (CFT), which assists in determining the specific mechanisms involving endothelium-independent and dependent epicardial and microcirculation domains. Unlike traditional coronary artery disease (CAD), CMD can often occur in patients without obstructive atherosclerotic epicardial disease, which can make the diagnosis of CMD difficult. Moreover, MVA due to CMD is more prevalent in women and carries increased risk of future cardiovascular events. Successful treatment of symptomatic CMD is often patient-specific risk factor and endotype targeted. This article aims to review newly identified mechanisms and novel treatment strategies for managing CMD, and outline sex-specific differences in the presentation and pathophysiology of the disease.

Racial differences in low natriuretic peptide levels: Implications for heart failure clinical trials

BACKGROUND

Some patients with heart failure (HF) have low natriuretic peptide (NP) levels. It is unclear whether specific populations are disproportionately excluded from participation in randomized clinical trials (RCT) with inclusion requirements for elevated NPs. We investigated factors associated with unexpectedly low NP levels in a cohort of patients hospitalized with HF, and the implications on racial diversity in a prototype HF RCT.

METHODS

We created a retrospective cohort of 31,704 patients (age 72 ± 16 years, 49% female, 52% Black) hospitalized with HF from 2010 to 2020 with B-type natriuretic peptide (BNP) measurements. Factors associated with unexpectedly low BNP levels (<50 pg/mL) were identified using multivariable logistic regression models. We simulated patient eligibility for a prototype HF trial using specific inclusion and exclusion criteria, and varying BNP cut-offs.

RESULTS

Unexpectedly low BNP levels were observed in 8.9% of the cohort. Factors associated with unexpectedly low BNP levels included HFpEF (aOR 3.76, 95% CI: 3.36, 4.20), obesity (aOR 1.96, 95% CI: 1.73, 2.21), self-identification as Black (aOR 1.53, 95% CI: 1.36, 1.71), and male gender (aOR 1.45, 95% CI: 1.31, 1.60). Applying limited clinical inclusion and exclusion criteria from PARAGLIDE-HF disproportionately excluded Black patients, with impairment in renal function having the greatest impact. Adding thresholds for BNP of ≥35, ≥50, ≥67, ≥100, and ≥150 pg/mL demonstrated the risk of exclusion was higher for Black compared to non-Black patients (RR = 2.03 [95% CI: 1.73, 2.39], 1.90 [95% CI: 1.68, 2.15], 1.63 [95% CI: 1.48, 1.81], 1.38 [95% CI: 1.28, 1.50], and 1.23 [95% CI: 1.15, 1.31], respectively).

CONCLUSIONS

Nearly 10% of patients hospitalized with HF have unexpectedly low BNP levels. Simulating inclusion into a prototype HFpEF RCT demonstrated that requiring increasingly elevated NP levels disproportionately excludes Black patients.

Enabling chronic obstructive pulmonary disease diagnosis through chest X-rays: A multi-site and multi-modality study

PURPOSE

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic illnesses in the world. Unfortunately, COPD is often difficult to diagnose early when interventions can alter the disease course, and it is underdiagnosed or only diagnosed too late for effective treatment. Currently, spirometry is the gold standard for diagnosing COPD but it can be challenging to obtain, especially in resource-poor countries. Chest X-rays (CXRs), however, are readily available and may have the potential as a screening tool to identify patients with COPD who should undergo further testing or intervention. In this study, we used three CXR datasets alongside their respective electronic health records (EHR) to develop and externally validate our models.

METHOD

To leverage the performance of convolutional neural network models, we proposed two fusion schemes: (1) model-level fusion, using Bootstrap aggregating to aggregate predictions from two models, (2) data-level fusion, using CXR image data from different institutions or multi-modal data, CXR image data, and EHR data for model training. Fairness analysis was then performed to evaluate the models across different demographic groups.

RESULTS

Our results demonstrate that DL models can detect COPD using CXRs with an area under the curve of over 0.75, which could facilitate patient screening for COPD, especially in low-resource regions where CXRs are more accessible than spirometry.

CONCLUSIONS

By using a ubiquitous test, future research could build on this work to detect COPD in patients early who would not otherwise have been diagnosed or treated, altering the course of this highly morbid disease.

Associations between remote patient monitoring programme responsiveness and clinical outcomes for patients with COVID-19

Objective

To assess whether engagement in a COVID-19 remote patient monitoring (RPM) programme or telemedicine programme improves patient outcomes.

Methods

This is a retrospective cohort study analysing patient responsiveness to our RPM survey or telemedicine visits and outcomes during the COVID-19 pandemic. Daily text message surveys and telemedicine consultations were offered to all patients who tested positive for SARS-CoV-2 at our institutional screening centres. Survey respondents with alarm responses were contacted by a nurse. We assessed the relationship between virtual engagement (telemedicine or RPM survey response) and clinical outcomes using multivariable logistic regression.

Results

Between 10 July 2020 and 2 January 2021, 6822 patients tested positive, with 1230 (18%) responding to at least one survey. Compared with non-responders, responders were younger (49 vs 53 years) and more likely to be white (40% vs 33%) and female (65% vs 55%) and had fewer comorbidities. After adjustment, individuals who engaged virtually were less likely to experience an emergency department visit, hospital admission or intensive care unit–level care.

Conclusion

Telemedicine and RPM programme engagement (vs no engagement) were associated with better outcomes, but this was likely due to differences in groups at baseline rather than the efficacy of our intervention alone.

Creation and Validation of a Novel Sex-Specific Mortality Risk Score in LVAD Recipients

Background

Prior studies have shown that women have worse 3‐month survival after receiving a left ventricular assist device compared with men. Currently used prognostic scores, including the Heartmate II Risk Score, do not account for the increased residual risk in women. We used the IMACS (International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support) registry to create and validate a sex‐specific risk score for early mortality in left ventricular assist device recipients.

Methods and Results

Adult patients with a continuous‐flow LVAD from the IMACS registry were randomly divided into a derivation cohort (DC; n=9113; 21% female) and a validation cohort (VC; n=6074; 21% female). The IMACS Risk Score was developed in the DC to predict 3‐month mortality, from preoperative candidate predictors selected using the Akaike information criterion, or significant sex × variable interaction. In the DC, age, cardiogenic shock at implantation, body mass index, blood urea nitrogen, bilirubin, hemoglobin, albumin, platelet count, left ventricular end‐diastolic diameter, tricuspid regurgitation, dialysis, and major infection before implantation were retained as significant predictors of 3‐month mortality. There was significant ischemic heart failure × sex and platelet count × sex interaction. For each quartile increase in IMACS risk score, men (odds ratio [OR], 1.86; 95% CI, 1.74–2.00; P<0.0001), and women (OR, 1.93; 95% CI, 1.47–2.59; P<0.0001) had higher odds of 3‐month mortality. The IMACS risk score represented a significant improvement over Heartmate II Risk Score (IMACS risk score area under the receiver operating characteristic curve: men: DC, 0.71; 95% CI, 0.69–0.73; VC, 0.69; 95% CI, 0.66–0.72; women: DC, 0.73; 95% CI, 0.70–0.77; VC, 0.71 [95% CI, 0.66–0.76; P<0.01 for improvement in receiver operating characteristic) and provided excellent risk calibration in both sexes. Removal of sex‐specific interaction terms resulted in significant loss of model fit.

Conclusions

A sex‐specific risk score provides excellent risk prediction in LVAD recipients.

Intercostal chest drain fixation strength: comparison of techniques and sutures

OBJECTIVE

The accidental removal of an intercostal chest drain (ICD) is common and may result in serious complications. A number of fixation techniques and suture material are in use, and the selection is often based on personal preferences and equipment availability. This study is designed to determine which of the common techniques provides the strongest ICD fixation.

METHODS

This study compared the mechanical strength of eight different ICD fixation techniques (purse string, 'Roman sandal', 'Jo'burg' (JO) technique, a suture through the tube, one and two passes through a locking plastic tie, tape fixation and a commercial disposable drainage tube holder) and two silk suture sizes using porcine cadavers and a digital push-pull dynamometer to simulate accidental removal of an ICD. A total of 14 different experimental set-ups produced 280 measurements.

RESULTS

Significant differences in ICD fixation strength were observed. A modified JO technique using a size 1 silk suture was nearly three times stronger than a purse-string fixation using a size 0 silk and 10 times stronger from a commercial, adhesive-based device (180, 70 and 22, respectively).

CONCLUSION

In situations where the mechanical strength of ICD fixation is important, using a size 1 silk and a modified JO technique may provide the strongest fixation.

[Gudden's diagnosis on Louis II from a contemporary and current psychiatric perspective]

BACKGROUND

Not only the circumstances of the simultaneous death of King Louis II and his psychiatrist Bernhard von Gudden on Pentecost 1886 are still the subject of controversial discussion but also the nature of Louis' mental illness and the expert report that formed the basis for removing Louis from power.

RESULTS

When one considers the psychiatric knowledge of the time, however, it becomes clearer how the four experts who assessed Louis reached a diagnosis of paranoia (madness). Gudden left behind no textbook. Nevertheless, a comparison of the structure and symptom weighting of the expert report with the classification system used in the Compendium, the first edition of the textbook published in 1883 by Gudden's long-time pupil Emil Kraepelin, provides insight into Gudden's school of thought. The experts' interpretation of Louis' illness is an outstanding document in the history of psychiatry. Even after the death of Louis and Gudden, the three remaining experts did not change their views before the parliamentary committees investigating the incident.

CONCLUSION

If we use the knowledge of the time as the basis for our assessment, there is no justification for claiming that Gudden and his fellow experts wrongly diagnosed Louis.

Abstract 4954: Clinical validation of a cell-free DNA liquid biopsy approach for noninvasive molecular profiling

Clinical molecular profiling of advanced cancers enables the identification of actionable genomic alterations to guide therapeutic decisions. Although profiling of tissue samples is considered the gold standard, specimens may be unavailable or unsuitable for testing due to limited tumor purity or specimen quality. Further, genetically informed treatment decisions are increasingly necessary after disease progression and re-biopsy in this setting may not be feasible. Circulating tumor DNA (ctDNA) approaches for identification of genetic alterations in cancer patients may be more informative as the alterations reflect the current status of the tumor. ctDNA is representative of multiple tumor sites within a patient and may aid in the detection of alterations throughout the course of therapy. However, the fraction of ctDNA obtained from a blood sample is often very low (&lt;1.0%) and difficult to detect. Additionally, many methods to evaluate ctDNA interrogate single hotspot or a few mutations. The next generation of ctDNA assays must identify clinically actionable genetic alterations and novel biomarkers with high precision and accuracy. To address these issues, we have developed and validated PlasmaSelect64, a ctDNA approach to comprehensively detect genetic alterations at low allele frequencies in the circulation of cancer patients. Utilizing digital genomic approaches, we demonstrated robust sensitivity and specificity in our CLIA laboratory in 64 well-established cancer genes that were identified based on clinical actionability. In addition to the evaluation of exons in 58 genes that are frequently mutated in cancer for sequence mutations, we performed a comprehensive genomic analysis of translocations in 18 genes and copy number analyses in 19 genes. We have also developed a novel approach for identification of microsatellite instability (MSI) using these error correction methodologies. To evaluate the PlasmaSelect64 approach, we developed and optimized the pre-analytical conditions for sample collection and processing with K2EDTA and Streck blood collection tubes. Analytical validation studies were performed with clinical samples and contrived cell-line mixtures containing known alterations determined by orthogonal methods. We robustly identified sequence mutations at 0.50% mutant allele frequency (MAF) with a limit of detection of 0.05% MAF, corresponding to a per-base specificity of 99.9997% and a sensitivity of 99.4%. For detection of focal amplifications and translocations, analytical method validation studies demonstrated sensitivity of 97.2% and 94.4% and specificity of &gt;99% at MAFs of ≥20% and ≥0.50%, respectively. PlasmaSelect64 provides a non-invasive platform to enable detection of clinically relevant genetic alterations across a large number of genomic regions to aid in the therapeutic management of cancer patients.

Citation Format: Monica Nesselbush, Samuel Angiuoli, Luis A. Diaz, Andrew Georgiadis, Shannon Glynn, Siân Jones, Laurel Keefer, Peter LoVerso, Derek Murphy, Sonya Parpart-Li, David Riley, Naomi Sengamalay, Manish Shukla, John Simmons, Snehal Talati, Rebecca Steinberg, Laura Tucker, Victor E. Velculescu, Ellen Verner, Angela Villarta, Mark Sausen. Clinical validation of a cell-free DNA liquid biopsy approach for noninvasive molecular profiling [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4954. doi:10.1158/1538-7445.AM2017-4954

The Effect of Preservative and Temperature on the Analysis of Circulating Tumor DNA

Purpose: Analysis of genomic alterations in cell-free DNA (cfDNA) is evolving as an approach to detect, monitor, and genotype malignancies. Methods to separate the liquid from the cellular fraction of whole blood for circulating tumor DNA (ctDNA) analyses have been largely unstudied, although these may be a critical consideration for assay performance.Experimental Design: To evaluate the influence of blood processing on cfDNA and ctDNA quality and yield, we compared the cfDNA levels in serum with those in plasma. Given the limitations of serum for ctDNA analyses, we evaluated the effects of two plasma processing approaches, K₂EDTA and Cell-Free DNA BCT (BCT) tubes, on cfDNA and ctDNA recovery. A total of 45 samples from nine patients with cancer were collected in both tube types. Once collected, blood was processed into plasma immediately or kept at room temperature and processed into plasma at 1, 3, 5, or 7 days.Results: As early as 24 hours after collection, plasma isolated from blood collected in K₂EDTA tubes contained an elevated level of cfDNA that increased over time compared with BCT tubes where no significant increase in cfDNA levels was observed. When samples from an additional six patients with cancer, collected in the same manner, were stored at 4°C in K₂EDTA tubes over the course of 3 days, total cfDNA and ctDNA levels were comparable between samples collected in BCT tubes. At day 3, there was a trend toward a decrease in ctDNA levels in both tubes that was more pronounced when measuring the mutant allele fraction for cases stored at 4°C in K₂EDTA tubes.Conclusions: In summary, methods of blood processing have a strong influence on cfDNA and ctDNA levels and should be a consideration when evaluating ctDNA in peripheral circulation. Clin Cancer Res; 23(10); 2471-7. ©2016 AACR.

Neuron-specific enolase as a marker of neuronal lesions during various comas in man

The detection of neuron-specific enolase in biological fluids has been investigated as an indirect marker of neuronal damage in man. This protein was measured by a sandwich enzymoimmunoassay in serums and cerebrospinal fluids from patients with consciousness disorders of various aetiologies. Neuron-specific enolase level was significantly increased in sera from patients with comas resulting from anoxemia, head injury, septic state, cirrhosis and fulminant hepatitis. On the other hand, patients with meningitis (affection not normally accompanied with neuronal lesion) exhibited no change of this marker level. The statistical analysis of our results suggests that, in neurological disorders, the neuron-specific enolase levels in cerebrospinal fluid could have some prognostic value. The correlation between its level in cerebrospinal fluid and in serum was also demonstrated. Neuron-specific enolase increase in biological fluids thus represents a useful and promising marker to biochemically characterize various strokes possibly resulting in neuronal damage.

Characterization of indoor bioaerosols from a hospital ward in a tropical setting

OBJECTIVES

Study was conducted to assess whether temporal variation exists in airborne microbial concentrations of a hospital ward (west-Chennai, India) using active and passive methods, and characterise the microorganisms.

METHODS

Air samples (duplicates) were collected simultaneously using exposed-plate, impingement (BioSampler) and filtration (personal sampling filter cassette loaded with gelatin filter) methods over different periods of the year. Bacterial plates were incubated at 37°C and observed for growth after 48h; fungal plates were incubated at 25°C and 37°C and observed upto 7 days. Microorganisms were identified using standard microbiological procedures.

RESULTS

Microbial loads were found to vary with the sampling method. Concentrations of bacteria were higher (exposed-plate: 45-150 CFU/plate; impingement: 1.12E+03-1.6856E+05 CFU/m(3); filtration: 3.788E+03-1.91111E+05 CFU/m(3)) than fungi (exposed-plate: 0-13 CFU/plate; impingement: 0-3.547E+03 CFU/m(3); filtration: 0-1.515E+04 CFU/ m(3)). Coagulase-negative Staphylococci and Micrococci were the predominant Gram-positive cocci in active and passive samples. Enterobacter and Pseudomonas were the predominant Gram-negative bacilli. Among fungi, Aspergillus niger was isolated throughout the year. There was no significant temporal variation in airborne microbial loads irrespective of methods.

CONCLUSIONS

Exposed-plate method was found to capture microorganisms efficiently with little variation in duplicate samples, suggesting its use in hospitals for preliminary assessment of indoor air quality and determine pathogenic microorganisms due to particle fall-out.

[Bernhard von Gudden on the occasion of the 125th anniversary of his death]

Bernhard von Gudden died 125 years ago together with King Ludwig II of Bavaria, his royal patient. The prominence of the "Fairy Tale King", the circumstances surrounding the deprivation of his power and his psychiatric internment as well as the establishment of Luitpold's reign and above all the catastrophic ending of the Bavarian royal drama still outshine Gudden's importance for the scientific development of the new subject of Nervenheilkunde (psychiatry and neurology), particularly Bernhard von Gudden's importance and integrity as a physician. Not only was he a much sought-after academic teacher, but he was also a patient-focused advocate of the principle of no restraint. As director of mental institutions, Gudden gave vital impulses for the improvement of mental health treatment. For 14 years he treated Prince Otto, the mentally ill brother of Ludwig II. Gudden rendered an expert opinion together with three other Bavarian psychiatrists resulting in Ludwig's legal incapacitation. Concerning the justification for the King's ousting there have been very different and controversial arguments from the constitutional and psychiatric point of view even in recent times. There is, however, a growing conviction that Ludwig II was incapable of reigning, the deprivation of his power followed the path prescribed by the constitution, and Gudden and his colleagues carried out a reviewing procedure considered valid by today's standards and appropriate under the circumstances. The royal disaster ending with the patient's and reviewer's death, however, has to be attributed to a misjudgement by Gudden that is based on the role diffusion between reviewer and treating physician.

[Responsible dealing with sexuality. Recommendations in a clinical institution]

Sexuality is excluded in house regulations, guidelines, instructions and regulations in German hospitals. The English literature does not show much more, but more often the wish for clear guidelines is formulated. Under the guidance of the clinical Ethics Committee a paper with recommendations was prepared, which comprises regulations for responsible handling of sexuality in the Pfalzklinikum. This includes sexuality of acute patients in psychiatry, nursing home inhabitants, forensic patients and above all patients in the department of child and youth psychiatry. The right of self-realization on the one hand, the staff's responsibility for patients with limitations in the determination of one's intent on the other hand and the rules for staff members define the range of the paper.

The efficacy and safety of valganciclovir vs. oral ganciclovir in the prevention of symptomatic CMV infection in children after solid organ transplantation

Routine prophylaxis for CMV with valganciclovir is common in adult recipients but data to support its use in children are scarce. The aim of this study was to compare the efficacy and safety of valganciclovir vs. ganciclovir in a pediatric cohort. We performed a retrospective analysis of 92 children after KTx and/or LTx. All children have received IV ganciclovir for two wk, and then oral ganciclovir (TID; n = 41) before 2004, or valganciclovir (OD; n = 51) thereafter. Treatment was given for three months in R+/D+ or R+/D- recipients and for six months in R-/D+. Patients were followed for one yr post transplant. Both groups were comparable in their demographic and transplant-related history. Symptomatic CMV infection/disease developed in 13.7% vs. 19.5% of valganciclovir and ganciclovir groups, respectively (P-NS). Time-to-onset of CMV infection was comparable in both groups (P-NS); rates of acute allograft rejection were similar in both groups (3.9% vs. 9.8%). Risk factors for CMV infection included young age, serostatus of R-/D+, and allograft from cadaver donor. No significant side effects were noted in both groups. As in adults, valganciclovir appears to be as efficacious and safe as oral ganciclovir. Valganciclovir should be considered as a possible prophylactic treatment for CMV in pediatric recipients of KTx or LTx.

Pooled nasopharyngeal and oropharyngeal samples for the identification of respiratory viruses in adults

A pooled sample of oropharyngeal swabs, nasopharyngeal swabs and nasopharyngeal washings, taken from each of 1,000 subjects, was compared to separate specimens from the same sampling. Multiplex real-time polymerase chain reaction (mqRT-PCR) was used to identify 12 respiratory viruses. Two hundred and forty-three (97%) of the 251 viruses identified in the separate samples were also identified in the mixed samples. The sensitivity rate was identical at 100% for all virus groups except coronaviruses. This sensitivity rate clearly justifies the use of pooled samples instead of separate samples for clinical and epidemiological purposes. The reduction in costs attained from the use of pooled samples may represent a critical advantage when considering its use in extensive clinical and epidemiological studies.

Effects of the vasopressin (V1b) receptor antagonist, SSR149415, and the corticotropin-releasing factor 1 receptor antagonist, SSR125543, on FG 7142-induced increase in acetylcholine and norepinephrine release in the rat

Arginine vasopressin and corticotropin-releasing factor are two neuroactive peptides that regulate hypothalamic-pituitary-axis and associated stress response. While the potential antidepressant and anxiolytic profiles of corticotropin-releasing factor 1 antagonists have been well studied, the concept of blockade of vasopressin system as another approach for the treatment of emotional processes has only been made available recently by the synthesis of the first non-peptide antagonist at the V1b receptor, SSR149415. In the present study SSR149415 has been compared with the corticotropin-releasing factor 1 antagonist SSR125543 and with anxiolytic and antidepressant drugs on the response of hippocampal cholinergic and cortical noradrenergic systems to the anxiogenic benzodiazepine receptor inverse agonist FG 7142. Acute (0.3-10 mg/kg, i.p.) and long-term administration (10 mg/kg, i.p., 21 days) of SSR149415 and SSR125543 reduced the FG 7142-induced increase in extracellular concentrations of acetylcholine in the hippocampus of anesthetized rats measured by microdialysis. By contrast acute and long-term administration of SSR149415 failed to reduce the FG 7142-induced increase in the release of norepinephrine in the cortex of freely moving rats. The present results demonstrate that the two compounds have similar profiles in a model of activation by an anxiogenic drug of the hippocampal cholinergic system and they suggest that SSR149415 and SSR125543 may have anti-stress anxiolytic and antidepressant effects via a mechanism of action different from classical benzodiazepine ligands and noradrenergic antidepressants.

Segmental liver transplantation from non-heart beating donors--an early experience with implications for the future

We report our experience of pediatric liver transplantation with partial grafts from non-heart beating donors (NHBD). Controlled donors less than 40 years of age with a warm ischemia time (WI) of less than 30 min were considered for pediatric recipients. Death was declared 5 min after asystole. A super-rapid recovery technique with aortic and portal perfusion was utilized. Mean donor age was 29 years and WI 14.6 min (range 11-18). Seven children, mean age 4.9 years (0.7-11), median weight 20 kg (8.4-53) received NHBD segmental liver grafts. Diagnoses included seronegative hepatitis, neonatal sclerosing cholangitis, familial intrahepatic cholestasis, hepatoblastoma, primary hyperoxaluria and factor VII deficiency (n=2). The grafts included four reduced and one split left lateral segments, one left lobe and one right auxiliary graft. Mean cold ischemia was 7.3 h (6.2-8.8). Complications included one pleural effusion and one biliary collection drained percutaneously. At 20 months (10-36) follow-up all children are alive and well with functioning grafts. Donation after cardiac death is a significant source of liver grafts for adults and children with careful donor selection and short cold ischemic times.

Ex vivo liver surgery for extraadrenal pheochromocytoma

A case of a 15-year-old girl with a malignant extraadrenal pheochromocytoma situated between the inferior vena cava and the portal triad is described. Using ex vivo technique, the tumour was successfully resected on the bench, as a previous attempt to remove the tumour in situ had been abandoned. The surgical aspects and implications of ex vivo surgery are discussed, highlighting the increased operative risk, perioperative mortality, and poor long-term results in patients with malignant tumours.

Infectious complications of implantable ports and Hickman catheters in paediatric haematology–oncology patients

The aim of this study was to define and compare the infectious and non-infectious complications associated with Hickman catheters and implantable ports in children. The study was conducted over a three-year period in the Department of Haematology-Oncology at the Schneider Children's Medical Center of Israel. All patients who required a central venous catheter (CVC) were included in the study. For each episode of catheter-associated bloodstream infection, demographic, clinical and microbiology data were recorded. During the study period, 419 tunnelled CVCs (246 implantable ports and 173 Hickman) were inserted in 281 patients. Compared with implantable ports, Hickman catheters were associated with a significantly higher rate of bloodstream infections (4.656 vs 1.451 episodes per 1000 catheter-days), shorter time to first infection (52.31 vs 108.82 days, P < 0.001), shorter duration of catheterization (140.75 vs 277.28 days, P < 0.001), and higher rate of removal because of mechanical complications (P < 0.005). Gram-positive bacterial infections were more prevalent in the implantable port group (63.6% vs 41.6%), whereas Gram-negative rods, polymicrobial infections and mycobacterial infections were more prevalent in the Hickman group (31.4% vs 50.9%, 17% vs 36% and 0% vs 4.4%, respectively; P < 0.05 for all). Haematopoietic stem cell transplantation was identified as an independent risk factor for infection [odds ratio (OR) -1.68, P = 0.005] and for catheter removal due to complications (OR -2.0, P < 0.001). Implantable ports may be considered the preferred device for most paediatric oncology and stem cell transplantation patients.

2-Chloro-N-[(S)-phenyl [(2S)-piperidin-2-yl] methyl]-3-trifluoromethyl benzamide, monohydrochloride, an inhibitor of the glycine transporter type 1, increases evoked-dopamine release in the rat nucleus accumbens in vivo via an enhanced glutamatergic neurotransmission

2-Chloro-N-S-phenyl 2S-piperidin-2-yl methyl]-3-trifluoromethyl benzamide, monohydrochloride (SSR504734) is a potent and selective inhibitor of the glycine transporter type 1, which increases central N-methyl-D aspartate glutamatergic tone. Since glutamate has been shown to play a role in the regulation of the dopaminergic system in dopamine-related disorders, such as schizophrenia, we investigated the possibility that SSR504734 may modify the basolateral amygdala-elicited stimulation of dopamine release in the nucleus accumbens via an augmentation of glutamate receptor-mediated neurotransmission. First, our data confirmed that SSR504734 is an inhibitor of GlytT1. In the nucleus accumbens of anesthetized rat, SSR504734 (10 mg/kg, i.p.) induced an increase of extracellular levels of glycine as measured by microdialysis coupled with capillary electrophoresis with laser-induced fluorescence detection. Second, the data demonstrated that SSR504734 (10 mg/kg, i.p.) enhanced the facilitatory influence of glutamatergic afferents on dopamine neurotransmission in the nucleus accumbens. Using an electrochemical technique, we measured dopamine release in the nucleus accumbens evoked by an electrical stimulation of the basolateral amygdala. SSR504734 facilitated dopamine release evoked by a 20 or a 40 Hz frequency basolateral amygdala stimulation. This facilitatory effect was dependent on glutamatergic tone, as intra-nucleus accumbens application of 6-7-dinitroquinoxaline-2,3-dione (10(-3) M) or DL-2-amino-5-phosphonopentanoic acid (10(-3) M), alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid and N-methyl-D aspartate receptors antagonists, respectively, inhibited dopamine release evoked by basolateral amygdala stimulation. Furthermore DL-2-amino-5-phosphonopentanoic acid co-administrated with SSR504734 hampered the dopamine-evoked release facilitation. These data underline the in vivo implication of the glycine uptake mechanism in the control of subcortical glutamate/dopamine interactions.

Difficulties in making the diagnosis of Hirschsprung disease in early infancy

This study highlights the less common presentations of Hirschsprung disease (HD) and HD-associated enterocolitis (HAE) in neonates and infants. We present three infants whose diagnosis was delayed because of atypical presenting features, especially with failure to gain weight, decreased appetite, episodes of diarrhoea and vomiting and hypoalbuminaemia. The reported incidence of HAE ranges from 0 to 16.2%. To avoid complications of life-threatening HAE, primary care physicians require a high index of suspicion of the more unusual presentations of HD in neonates and infants.

Differenzialindikation atypischer Neuroleptika: Amisulprid, Clozapin, Olanzapin, Quetiapin und Risperidon

With the introduction of atypical neuroleptics, the therapy of schizophrenia has been improved by a group of antipsychotic substances characterized by better tolerability concerning extrapyramidal side effects and higher efficiency against negative symptoms. However, these atypical antipsychotics are not a homogeneous class of drugs but rather represent a group of substances with very different neurobiologic, pharmacologic, and clinical features. This fact and the growing variety of available atypical neuroleptics illustrate the difficulty in choosing the "right" antipsychotic drug for each patient. The aim of this investigation was to evaluate preliminary empirical data for possible differential indication of atypical neuroleptics by a questionnaire-based survey of 192 physicians in ten psychiatric hospitals active in the biological psychiatry work group of the German Federal Directors' Conference.

Unusual intestinal sequelae after operations for Ascaris lumbricoides infestation

Two children with severe bowel sequelae distal to the site of an Ascaris lumbricoides bowel obstruction are reported. It is postulated that these resulted from inflammatory reaction to toxic decomposition products of disintegrating worms. Surgery should be modified in the presence of bowel-wall injury distal to the site of ascarid worm - bolus obstruction.

Control by tachykinin NK(2) receptors of CRF(1) receptor-mediated activation of hippocampal acetylcholine release in the rat and guinea-pig

In vivo microdialysis was employed to explore the effects of different selective non-peptides NK(1),NK(2) and NK(3) receptor antagonists on the corticotropin releasing factor (CRF)-induced release of acetylcholine (ACh) in the hippocampus of rats and guinea-pigs. In both species, the intracerebroventricular (i.c.v.) administration of CRF produced a time- and dose-dependent increase in hippocampal ACh release that was totally suppressed by an intraperitoneally (i.p.) pretreatment with the selective non-peptide CRF(1) receptor antagonist antalarmin (30 mg/kg). Pretreatment with the selective NK(2) receptor antagonist SR48968 (1mg/kg, i.p.) significantly reduced the increase of ACh induced by CRF. In contrast, its low-affinity enantiomer SR48965 (1mg/kg, i.p.) or the NK(1) receptor antagonist, GR205171 (1mg/kg, i.p.) did not exert any antagonist effect. Moreover, administration of the selective NK(3) receptor antagonist SR142801 (1mg/kg, i.p.) did not significantly reduce the CRF-induced hippocampal ACh release in guinea-pigs (the only species studied). The selective activity of SR48968 versus GR205171 or SR142801 indicates that NK(2) receptors play a major role in the control of CRF-induced hippocampal ACh release. Moreover, in freely moving rats, two sessions of stroking of the neck and back of the rat for 30 min, at 90 min intervals, known to be a stressful stimulus, produced a marked and reproducible increase in hippocampal ACh release. This effect was prevented by the administration of the two selective non-peptide CRF1 and NK(2) receptor antagonists antalarmin (30 mg/kg, i.p.) and SR48968 (1mg/kg, i.p.), respectively. This suggests that stress-induced activation of the hippocampal ACh system may be under the control of both endogenously released CRF and NKA, and opens the possibility of the existence of a functional interplay between the pathways containing these peptides as we observed in our experiments on anaesthetized animals.

SR141716, a central cannabinoid (CB(1)) receptor antagonist, blocks the motivational and dopamine-releasing effects of nicotine in rats

The central CB(1) cannabinoid receptor has recently been implicated in brain reward function. In the present study we evaluated first the effects of the selective CB(1) receptor antagonist, SR141716, on the motivational effects of nicotine in the rat. Administration of SR141716 (0.3 and 1 mg/kg) decreased nicotine self-administration (0.03 mg/kg/injection). SR141716 (0.3-3 mg/kg) neither substituted for nicotine nor antagonized the nicotine cue in a nicotine discrimination procedure, but dose-dependently (0.01-1 mg/kg) antagonized the substitution of nicotine for D-amphetamine, in rats trained to discriminate D-amphetamine. Secondly, using brain microdialysis, SR141716 (1-3 mg/kg) blocked nicotine-induced dopamine release in the shell of the nucleus accumbens (NAc) and the bed nucleus of the stria terminalis. To investigate whether SR141716 would block the dopamine-releasing effects of another drug of abuse, we extended the neurochemical study to the effect of ethanol, consumption of which in rodents is reduced by SR141716. Dopamine release induced by ethanol in the NAc was also reduced by SR141716 (3 mg/kg). These results suggest that activation of the endogenous cannabinoid system may participate in the motivational and dopamine-releasing effects of nicotine and ethanol. Thus, SR141716 may be effective in reduction of alcohol consumption, as previously suggested, and as an aid for smoking cessation.

A rare case of colonic obstruction by 'cherry tomato' phytobezoar: A simple technique to avoid enterotomy

Small bowel obstruction is the most common complication of phytobezoar in children. The authors present a rare case of colonic obstruction caused by a cherry tomato phytobezoar in a 16-month-old child that was treated successfully during laparotomy after failure of external fragmentation.

Mediastinal tumors in children: a single institution experience

Mediastinal masses in children are a heterogeneous group of asymptomatic or potentially life-threatening congenital, infectious, or neoplastic lesions that present complex diagnostic and therapeutic dilemmas. Some patients are asymptomatic; in others, the mass may compress mediastinal structures and cause sudden asphyxia. In these cases, close cooperation is needed among pediatric surgeons, anesthesiologists, intensivists, oncologists, and radiologists. The files of 45 children with mediastinal masses admitted between 1986 and 1999 to the Pediatric Intensive Care Unit (PICU) of Schneider Children's Medical Center of Israel were reviewed. Twenty-one were admitted for perioperative care, and 21 for emergency care, including 19 with respiratory distress. Five of the emergency care group had asphyxia and 10 needed assisted ventilation. Two children were admitted for evaluation and 1 for leukopheresis. The children admitted on an emergency basis had more clinical findings than the postoperative group: almost 80% had dyspnea and more than 45% had oxygen desaturation; 33% had cough and noisy breathing, and 25%, superior vena cava syndrome or hepatosplenomegaly. Eight patients (17.8%) had benign disease and 37 (82.2%) malignant disease. The patients with a benign mass were significantly younger than the patients with a malignant mass (p<0.005); in 5 cases (12.5%), a congenital anomaly presented as a mediastinal mass. Most of the malignant masses were of hematologic origin (40.5%), followed by neurogenic tumors (27%). Twenty-seven patients underwent surgery, including 6 emergency procedures (3 partial resections, 2 biopsies, 1 lymph node biopsy). There were no intraoperative or postoperative deaths. The present series emphasizes the complex care children with a mediastinal mass require. They should be treated in a tertiary center with a multidisciplinary approach.

Selective blockade of neurokinin-2 receptors produces antidepressant-like effects associated with reduced corticotropin-releasing factor function

The present study investigated the effects of the selective neurokinin-2 (NK2) receptor antagonist SR48968 in behavioral, electrophysiological, and biochemical tests sensitive to the action of prototypical antidepressants (fluoxetine, imipramine) or to corticotropin-releasing factor (CRF) receptor antagonists, which have been proposed recently as potential antidepressants. Results showed that SR48968 (0.3-10 mg/kg i.p.) produced antidepressant-like activity because it reduced immobility in the forced swimming test in both mice and rats, and decreased the amount of maternal separation-induced vocalizations in guinea pig pups. This latter effect appears to involve a reduction of stress-induced substance P release because SR48968 reduced the separation-induced increase in the number of neurons displaying neurokinin-1 receptor internalization in the amygdala. Furthermore, SR48968 increased the expression of the cAMP response-element binding protein mRNA in the rat hippocampus after repeated (1 mg/kg i.p., 21 days), but not acute administration. Finally, neuronal firing of the locus coeruleus (LC) and noradrenergic (NE) release in the prefrontal cortex both elicited by an uncontrollable stressor or an intraventricular administration of CRF were reduced by SR48968 (0.3-1 mg/kg i.p.). The finding that SR48968 (1 mg/kg i.p.) blocked the cortical release of NE induced by an intra-LC infusion of the preferential NK2 receptor agonist neurokinin A suggested the presence of NK2 receptors in this latter region. Importantly, SR48965 (1-10 mg/kg i.p.), the optical antipode of SR48968, which is devoid of affinity for the NK2 receptor, was inactive in all the models used. These data suggest that NK2 receptor blockade may constitute a novel mechanism in the treatment of depression and CRF-related disorders.

VEGF(165) requires extracellular matrix components to induce mitogenic effects and migratory response in breast cancer cells

The expression of VEGF and the relapse-free survival rate of breast cancer patients are inversely related. While VEGF induces the proliferation and migration of vascular endothelial cells, its function in breast cancer cells is not well studied. We reported previously that fibronectin increased VEGF-dependent migration in breast cancer cells. Since VEGF has an extracellular matrix (ECM)-binding domain and possesses binding affinity for heparin, we sought to determine the effects of VEGF in breast cancer cells and the role of heparin and/or fibronectin in VEGF-induced signaling. Cells grown on plastic were compared to those grown on fibronectin or to those grown on plastic in the presence of heparin, and analysed for intracellular signaling, proliferation and migration in response to VEGF(165). Both heparin and fibronectin enhanced the binding of VEGF to T47D cells. After treatment with VEGF, [(3)H]thymidine incorporation, c-fos induction, and the number of migrating cells were significantly higher ( approximately twofold) in cells grown on fibronectin or in cells grown on plastic in the presence of heparin when compared to those grown on plastic only. Likewise, tyrosine phosphorylation of VEGF receptors, MAPK activity and PI3-kinase activity were all several-fold higher in cells seeded on fibronectin or in the presence of heparin as compared to cells exposed to VEGF alone. VEGF-dependent c-fos induction was found to be regulated through a MAPK-dependent, but PI3-kinase-independent pathway. In contrast, the migration of T47D cells in response to VEGF, in the presence of ECM, was regulated through PI3-kinase. Therefore, VEGF requires ECM components to induce a mitogenic response and cell migration in T47D breast cancer cells.

Endogenous neurotensin down-regulates dopamine efflux in the nucleus accumbens as revealed by SR-142948A, a selective neurotensin receptor antagonist

SR-142948A belongs to the second generation of potent, selective, non-peptide antagonists of neurotensin receptors. It was used to investigate the role of endogenous neurotensin in the regulation of dopamine efflux in the nucleus accumbens and striatum of anaesthetized and pargyline-treated rats. All the data were obtained using in vivo electrochemistry. Electrically evoked (20 Hz, 10 s) dopamine efflux was monitored by differential pulse amperometry, whereas variations in basal (tonic) dopamine efflux were monitored by differential normal pulse voltammetry. Like the first-generation compound SR-48692, SR-142948A did not affect the tonic and evoked dopamine efflux, but dose-dependently enhanced haloperidol (50 microg/kg, i.p.) induced facilitation of the electrically evoked dopamine release in the nucleus accumbens. In contrast to SR-48692, SR-142948A dose-dependently potentiated haloperidol (50 microg/kg, i.p.) induced increase in the basal dopamine level in the nucleus accumbens. This potentiating effect did not appear in the striatum. When dopaminergic and/or neurotensinergic transmissions were modified by a higher dose of haloperidol (0.5 mg/kg, i.p.), apomorphine, amphetamine or nomifensine, SR-142948A pre-treatment affected only the effect of apomorphine on the basal dopamine level in the nucleus accumbens. These results strengthen the hypothesis that endogenous neurotensin could exert a negative control on mesolimbic dopamine efflux.

Role of vascular endothelial growth factor in the stimulation of cellular invasion and signaling of breast cancer cells

The expression of vascular endothelial growth factor (VEGF) by breast tumors has been previously correlated with a poor prognosis in the pathogenesis of breast cancer. Furthermore, VEGF secretion is a prerequisite for tumor development. Although most of the effects of VEGF have been shown to be attributable to the stimulation of endothelial cells, we present evidence here that breast tumor cells are capable of responding to VEGF. We show that VEGF stimulation of T-47D breast cancer cells leads to changes in cellular signaling and invasion. VEGF increases the cellular invasion of T-47D breast cancer cells on Matrigel/ fibronectin-coated transwell membranes by a factor of two. Northern analysis for the expression of the known VEGF receptors shows the presence of moderate levels of Flt-1 and low levels of Flk-1/KDR mRNAs in a variety of breast cancer cell lines. T-47D breast cancer cells bind 125I-labeled VEGF with a Kd of 13 x 10(-9) M. VEGF induces the activation of the extracellular regulated kinases 1,2 as well as activation of phosphatidylinositol 3'-kinase, Akt, and Forkhead receptor L1. These findings in T-47D breast cancer cells strongly suggest an autocrine role for VEGF contributing to the tumorigenic phenotype.

Comparative effects of neurotensin, neurotensin(8-13) and [D-Tyr(11)]neurotensin applied into the ventral tegmental area on extracellular dopamine in the rat prefrontal cortex and nucleus accumbens

Ejections of 10(-5)-10(-3)M neurotensin into the ventral tegmental area increased dopamine efflux measured by electrochemical approaches in the prefrontal cortex of anaesthetized rats. In the same conditions, the effects evoked on dopamine efflux by 10(-5)M neurotensin(8-13) and [D-Tyr(11)]neurotensin were different from each other and depended on the explored area: the prefrontal cortex and the caudal and rostral nucleus accumbens. In the prefrontal cortex, neurotensin(8-13) was as potent as neurotensin, whereas [D-Tyr(11)]neurotensin was ineffective. In the caudal nucleus accumbens, when considering the initial intensity of the effect, neurotensin(8-13) and neurotensin appeared more potent than [D-Tyr(11)]neurotensin. In contrast, in the rostral nucleus accumbens, neurotensin(8-13) was less potent than [D-Tyr(11)]neurotensin and neurotensin. These results support the differential involvement of two pharmacologically distinct neurotensin receptor entities on ventral tegmental area neurons in the modulation of mesolimbic and mesocortical dopaminergic activity.

High frequency of loss of heterozygosity for 1p35-p36 (D1S247) in Wilms tumor

We analyzed the loss of heterozygosity (LOH) for 1p in 18 Wilms tumors using a panel of 11 polymorphic markers. Loss of heterozygosity was identified in 56% of the tumors. The smallest region of overlap was defined for marker D1S247, underlying the 1p35-1p36.1 locus. This is the highest LOH frequency for 1p, or for the well-defined 11p13 and 11p15.5 loci. Based on the fact that tumors of all stages, with both favorable and unfavorable histology, exhibited LOH, we suggest that the 1p35-1p36.1 locus is involved in the etiology of Wilms tumor.

Small bowel obstruction and covered perforation in childhood caused by bizarre bezoars and foreign bodies

BACKGROUND

Small bowel obstruction with perforation is an unusual and rare complication of bezoars.

OBJECTIVE

To describe our use of emergency laparotomy to treat intestinal obstruction caused by bizarre bezoars.

CONCLUSIONS

An aggressive surgical approach to intestinal obstruction in the pediatric disabled or mentally retarded population is recommended.

Traumatic adrenal injury in children

BACKGROUND

Multiple organ injury in children is an increasingly frequent phenomenon in the modern emergency room. Adrenal hemorrhage associated with this type of trauma has received little attention in the past.

OBJECTIVES

Using computed tomography, we sought to determine the rate and nature of adrenal gland injury in children following blunt abdominal trauma due to motor vehicular accident.

METHODS

A total of 121 children with blunt abdominal trauma were examined and total body CT was performed in cases of multi-organ trauma or severe neurological injury.

RESULTS

Of all the children who presented with blunt abdominal trauma over a 51 month period, 6 (4.95%) had adrenal hemorrhage. In all cases only the right adrenal gland was affected. Coincidental injury to the chest and other abdominal organs was noted in 66.7% and 50% of patients, respectively.

CONCLUSIONS

Traumatic adrenal injury in the pediatric population may be more common than previously suspected. Widespread application of the more sophisticated imaging modalities available today will improve the detection of damage to the smaller organs in major collision injuries and will help in directing attention to the mechanism of trauma.

A simple method of intraoperative confirmation of intestinal patency

Routine intraoperative rectal temperature monitoring may serve in addition as a means of distal intestinal patency confirmation. A simple method, which is of immense importance especially when operating on infants and small children after NEC or intestinal atresia, is described.

A plea for incidental appendectomy in pediatric patients with malignancy

The evaluation of right lower quadrant (RLQ) abdominal pain in pediatric patients with malignancy can be difficult. However, since the mortality rate from peritoneal infections in these patients is very high, the differential diagnosis of RLQ peritoneal irritation, mainly of acute appendicitis (AA) versus neutropenic enterocolitis (NE), is crucial. Three cases of pediatric patients with malignancy demonstrating these difficulties are represented to enlighten this problem. The first patient died of multiorgan failure after operation for perforated appendicitis without generalized peritonitis. The second had a severe life-threatening postoperative complication because of delayed diagnosis of acute appendicitis. The third patient with malignant pelvic spread, underwent an unnecessary abdominal exploration for suspected AA. In all these cases and probably in many others, the clinical outcome could have been different if a previous incidental appendectomy had been performed during the primary abdominal operation. Incidental appendectomy in oncologic patients is recommended to facilitate the differential diagnosis of RLQ pain and to exclude the diagnosis of AA.