Medicine by Sfakianakis Alexandros: 08/01/16

Δευτέρα 1 Αυγούστου 2016

How do you do? As a unit, -EMS-service. Team -EMS, Fire, Police..?

Torpomoen rescue and training-park: The better the crew knows the other members job, the better and faster they can work as a team ( like the pilot knowing when the doc. need a stetoscope, or need to stop a bleeding,while the "medical team" start airway, other... same with doc, and "Rednings"mann"" Rescueman ( -HEMS-Tec. ).( HEMS-Tec.= M i n i m u m Years as Norwegian PMT/ Nurse Anesthesists w. climbingskills, "private" pilot teori, "perfect" health/fittnes, mutch more. AFAIK more then 100 alply per job, around 6 to interwue, 2 for test, taking weeks, -Then the training starts. Landings, Mountain, Advanced medical procedures, Water, Mutch more. The unit,-the ( Specialist system -Fire, Police, EMS Internally ) - And at scene. TOGETHER: As one Team ! How do you do ... This Video full screne: https://youtube/JatMLD2A-QU ExEMTNor

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How do you do? As a unit, -EMS-service. Team -EMS, Fire, Police..?

The distally based, venous supercharged anterolateral thigh flap

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Teaching EMTs requires balancing art and science

In the movie "Dead Poets Society," Robin Williams' character, Professor John Keating, introduces himself to his students by having them read the opening essay of their "Introduction to Poetry" textbook, by the fictional J. Evans Pritchard, PhD:

"To fully understand poetry, we must first be fluent with its meter, rhyme and figures of speech, then ask two questions:

1. How artfully has the objective of the poem been rendered and

2. How important is that objective"

Question one rates the poem's perfection; question two rates its importance. And once these questions have been answered, determining the poem's greatness becomes a relatively simple matter."

The essay continues on in stultifying, boring fashion, as if the beauty of poetry, and the emotion it invokes, can be measured and quantified like an algebraic formula. Keating allows his students to finish reading the essay, pauses for dramatic effect, and then quietly pronounces, "Excrement."

He goes on to an impassioned and funny soliloquy on the beauty and art of poetry, and how the measure of a poem's greatness is not a plot on a graph, but rather what it awakens in the reader's soul.

A lot of us who teach EMS could stand to be a lot more John Keating, and a lot less J. Evans Pritchard.

That's not to say that J. Evans Pritchard's technical essay didn't have merit. In fact, it was taken nearly word-for-word from a commonly used AP English textbook called "Sound and Sense: An Introduction to Poetry."

Appreciation of a writer's artistry requires a working knowledge of the technique of writing; the rhyme, meter, and figures of speech are important. The same is true of the science of medicine.

But many of us focus too much on the science, and too little on the art.

Buy-in prevails over facts
That point was driven home to me in one of my frequent debates with Nancy Magee on one of her favorite topics, "buy-in." Magee points out in her columns that the vast majority of management initiatives fail because of a lack of buy-in from employees.

Good ideas fail because the field personnel don't share management's vision. Either the employees are unwilling to change their way of thinking, or management wasn't charismatic enough to sell the idea properly.

In other words, too much J. Evans Pritchard, and not enough John Keating.

The example Magee used was the director of a large volunteer EMS organization firmly entrenched in the early 1990s and reflexively opposed to any increase in EMS educational standards. His stock answer to calls for more training was, "Where's the proof that all this extra education our volunteers have to obtain is going to help our patients""

My reply was, well… forceful.

I went into an impassioned rant about willful ignorance in EMS, our continuously evolving understand of medicine, and how one of the problems with lack of knowledge was not being able to perceive your lack of knowledge; the embodiment of the Dunning-Kruger effect. I provided concrete examples like oxygen administration, IV fluid therapy, antiarrhythmic therapy and spinal immobilization.

Magee let my blood pressure subside a little bit and my hands to unclench from the steering wheel, and she asked mildly, "Good rationale. So, how many EMS instructors you know would have delivered it that way, rather than just 'you need more education, for education's sake'""

And I was forced to admit, "Not many."

She paused for effect, winked, and then, in her best John Keating fashion, pronounced, "Buy-in."

I also realized I'd been guilty of the same in my EMT class. I've always told new EMT instructors, "Be what the material isn't. Provide what the textbook does not."

For example, I've always used Joe Mistovich's EMT textbook, "Prehospital Emergency Care," from Brady Publishing, even though my teaching style is more akin to Dan Limmer, author of Brady's other EMT textbook. Joe is cerebral, while Dan is enthusiastic and animated. But my students didn't need a double dose of Dan Limmer or Joe Mistovich, they needed a teacher whose delivery balanced the textbook.

In teaching my hybrid EMT course, with most of the work done in online self-study, I allowed myself to forget that admonition. Since I wasn't directly providing all that essential technical information, and I didn't trust my students to grasp it without my supervision, I wasted valuable classroom time repeating material the textbook already covered nicely.

I was boring my students to death. I was focusing on the science of EMS, and ignoring the art.

Instructors facilitate synthesis and application
So at the very next class, I abandoned the lecture and started using more critical thinking exercises and clinical scenarios. I taught standing over a manikin or a patient assessment victim, rather than in front of a SMART Board.

I realized that, if I made my expectations clear through assessment and testing, my students would get the necessary technical details on their own. My job became exactly what was written in the syllabus, that I had previously neglected to do: the synthesis and application of knowledge.

I let Mistovich be my J. Evans Pritchard, leaving me to be John Keating. He had the science, I handled the art. That was immensely more fun, and more effective.

Remember that in the next class you teach: more Mr. Keating, and less J. Evans Pritchard. If you're good enough, you may have a generation of EMTs address you as "O' Captain, my captain."

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Predictive Biomarkers in Colorectal Cancer: From the Single Therapeutic Target to a Plethora of Options

Colorectal cancer (CRC) is one of the most frequent cancers and is a leading cause of cancer death worldwide. Treatments used for CRC may include some combination of surgery, radiation therapy, chemotherapy, and targeted therapy. The current standard drugs used in chemotherapy are 5-fluorouracil and leucovorin in combination with irinotecan and/or oxaliplatin. Most recently, biologic agents have been proven to have therapeutic benefits in metastatic CRC alone or in association with standard chemotherapy. However, patients present different treatment responses, in terms of efficacy and toxicity; therefore, it is important to identify biological markers that can predict the response to therapy and help select patients that would benefit from specific regimens. In this paper, authors review CRC genetic markers that could be useful in predicting the sensitivity/resistance to chemotherapy.

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How do you do? As a unit, -EMS-service. Team -EMS, Fire, Police..?

Exhaustion of Activated CD8 T Cells Predicts Disease Progression in Primary HIV-1 Infection

Hoffmann, M; Pantazis, N; Martin, GE; Hickling, S; Hurst, J; Meyerowitz, J; Willberg, CB; Hoffmann, M; Pantazis, N; Martin, GE; Hickling, S; Hurst, J; Meyerowitz, J; Willberg, CB; Robinson, N; Brown, H; Fisher, M; Kinloch, S; Babiker, A; Weber, J; Nwokolo, N; Fox, J; Fidler, S; Phillips, R; Frater, J; SPARTAC and CHERUB Investigators, .; - view fewer (2016) Exhaustion of Activated CD8 T Cells Predicts Disease Progression in Primary HIV-1 Infection. PLoS Pathogens , 12 (7) , Article e1005661. 10.1371/journal.ppat.1005661 . Green open access

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Working on the Argument Pipeline: Through Flow Issues between Natural Language Argument, Instantiated Arguments, and Argumentation Frameworks

Hunter, A; Wyner, A; van Engers, T; (2016) Working on the Argument Pipeline: Through Flow Issues between Natural Language Argument, Instantiated Arguments, and Argumentation Frameworks. (In press).

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On Partial Information and Contradictions in Probabilistic Abstract Argumentation

Hunter, A; Thimm, M; (2016) On Partial Information and Contradictions in Probabilistic Abstract Argumentation. In: Proceedings of the 15th International Conference on Principles of Knowledge Representation and Reasoning (KR 2016). Association for the Advancement of Artificial Intelligence: Cape Town, South Africa. (In press).

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Motor Versus Body Awareness: Voxel-based Lesion Analysis in Anosognosia for Hemiplegia and Somatoparaphrenia Following Right Hemisphere Stroke

Moro, V; Pernigo, S; Tsakiris, M; Avesani, R; Edelstyn, NMJ; Jenkinson, P; Fotopoulou, A; (2016) Motor Versus Body Awareness: Voxel-based Lesion Analysis in Anosognosia for Hemiplegia and Somatoparaphrenia Following Right Hemisphere Stroke. Cortex 10.1016/j.cortex.2016.07.001 . (In press).

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The Potentialities and Limitations of Reactive Law Making: A Case Study in Terrorism Suppression

Trapp, KN; (2016) The Potentialities and Limitations of Reactive Law Making: A Case Study in Terrorism Suppression. UNSW Law Journal , 39 (3) (In press).

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The under reporting of recruitment strategies in research with children with life threatening illnesses: A systematic review

Hudson, B; Oostendorp, L; Candy, B; Vickerstaff, VH; Jones, C; Lakhanpaul, M; Bluebond-langner, M; Hudson, B; Oostendorp, L; Candy, B; Vickerstaff, VH; Jones, C; Lakhanpaul, M; Bluebond-langner, M; Stone, P; - view fewer (2016) The under reporting of recruitment strategies in research with children with life threatening illnesses: A systematic review. Palliative Medicine (In press).

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Wavelet reconstruction of E and B modes for CMB polarisation and cosmic shear analyses

Leistedt, B; McEwen, JD; Buttner, M; Peiris, HV; (2016) Wavelet reconstruction of E and B modes for CMB polarisation and cosmic shear analyses. Monthly Notices of the Royal Astronomical Society (In press). Green open access

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A commmentary on selected fragments of middle comedy.

Papachrysostomou, A.; (2006) A commmentary on selected fragments of middle comedy. Doctoral thesis, University of London. Green open access

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The Cost-effectiveness of Pixantrone for Third/Fourth-line Treatment of Aggressive Non-Hodgkin's Lymphoma

Muszbek, N; Kadambi, A; Lanitis, T; Hatswell, AJ; Patel, D; Wang, L; Singer, JW; Muszbek, N; Kadambi, A; Lanitis, T; Hatswell, AJ; Patel, D; Wang, L; Singer, JW; Pettengell, R; - view fewer (2016) The Cost-effectiveness of Pixantrone for Third/Fourth-line Treatment of Aggressive Non-Hodgkin's Lymphoma. Clinical Therapeutics , 38 (3) pp. 503-515. 10.1016/j.clinthera.2016.01.004 . Green open access

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Comparing the impacts of Miocene–Pliocene changes in inter-ocean gateways on climate: Central American Seaway, Bering Strait, and Indonesia

Brierley, CM; Fedorov, AV; (2016) Comparing the impacts of Miocene–Pliocene changes in inter-ocean gateways on climate: Central American Seaway, Bering Strait, and Indonesia. Earth and Planetary Science Letters , 444 pp. 116-130. 10.1016/j.epsl.2016.03.010 .

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Assembly and activation of dynein-dynactin by the cargo adaptor protein Hook3

Metazoan cytoplasmic dynein moves processively along microtubules with the aid of dynactin and an adaptor protein that joins dynein and dynactin into a stable ternary complex. Here, we examined how Hook3, a cargo adaptor involved in Golgi and endosome transport, forms a motile dynein–dynactin complex. We show that the conserved Hook domain interacts directly with the dynein light intermediate chain 1 (LIC1). By solving the crystal structure of the Hook domain and using structure-based mutagenesis, we identify two conserved surface residues that are each critical for LIC1 binding. Hook proteins with mutations in these residues fail to form a stable dynein–dynactin complex, revealing a crucial role for LIC1 in this interaction. We also identify a region of Hook3 specifically required for an allosteric activation of processive motility. Our work reveals the structural details of Hook3's interaction with dynein and offers insight into how cargo adaptors form processive dynein–dynactin motor complexes.

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A program to reduce inequality

<p>During development, cells must differentiate to form diverse tissues, a process that is often set in motion by the unequal segregation of key factors during mitosis. Once a tissue has been specified, however, its constituent cells must remain similar...

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Frederic Bard: The sweet side of traffic

At the age of seven, Frederic Bard's father taught him about the atomic composition of water molecules. Bard was flabbergasted to learn that water is not simply "made of water." He became fascinated by the idea that deeper truths...

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mito-QC illuminates mitophagy and mitochondrial architecture in vivo

Autophagic turnover of mitochondria, termed mitophagy, is proposed to be an essential quality-control (QC) mechanism of pathophysiological relevance in mammals. However, if and how mitophagy proceeds within specific cellular subtypes in vivo remains unclear, largely because of a lack of tractable tools and models. To address this, we have developed "mito-QC," a transgenic mouse with a pH-sensitive fluorescent mitochondrial signal. This allows the assessment of mitophagy and mitochondrial architecture in vivo. Using confocal microscopy, we demonstrate that mito-QC is compatible with classical and contemporary techniques in histochemistry and allows unambiguous in vivo detection of mitophagy and mitochondrial morphology at single-cell resolution within multiple organ systems. Strikingly, our model uncovers highly enriched and differential zones of mitophagy in the developing heart and within specific cells of the adult kidney. mito-QC is an experimentally advantageous tool of broad relevance to cell biology researchers within both discovery-based and translational research communities.

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The importance of serine metabolism in cancer

Serine metabolism is frequently dysregulated in cancers; however, the benefit that this confers to tumors remains controversial. In many cases, extracellular serine alone is sufficient to support cancer cell proliferation, whereas some cancer cells increase serine synthesis from glucose and require de novo serine synthesis even in the presence of abundant extracellular serine. Recent studies cast new light on the role of serine metabolism in cancer, suggesting that active serine synthesis might be required to facilitate amino acid transport, nucleotide synthesis, folate metabolism, and redox homeostasis in a manner that impacts cancer.

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BLOC-1 and BLOC-3 regulate VAMP7 cycling to and from melanosomes via distinct tubular transport carriers

Endomembrane organelle maturation requires cargo delivery via fusion with membrane transport intermediates and recycling of fusion factors to their sites of origin. Melanosomes and other lysosome-related organelles obtain cargoes from early endosomes, but the fusion machinery involved and its recycling pathway are unknown. Here, we show that the v-SNARE VAMP7 mediates fusion of melanosomes with tubular transport carriers that also carry the cargo protein TYRP1 and that require BLOC-1 for their formation. Using live-cell imaging, we identify a pathway for VAMP7 recycling from melanosomes that employs distinct tubular carriers. The recycling carriers also harbor the VAMP7-binding scaffold protein VARP and the tissue-restricted Rab GTPase RAB38. Recycling carrier formation is dependent on the RAB38 exchange factor BLOC-3. Our data suggest that VAMP7 mediates fusion of BLOC-1–dependent transport carriers with melanosomes, illuminate SNARE recycling from melanosomes as a critical BLOC-3–dependent step, and likely explain the distinct hypopigmentation phenotypes associated with BLOC-1 and BLOC-3 deficiency in Hermansky–Pudlak syndrome variants.

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Novel role for the midbody in primary ciliogenesis by polarized epithelial cells

The primary cilium is a membrane protrusion that is crucial for vertebrate tissue homeostasis and development. Here, we investigated the uncharacterized process of primary ciliogenesis in polarized epithelial cells. We show that after cytokinesis, the midbody is inherited by one of the daughter cells as a remnant that initially locates peripherally at the apical surface of one of the daughter cells. The remnant then moves along the apical surface and, once proximal to the centrosome at the center of the apical surface, enables cilium formation. The physical removal of the remnant greatly impairs ciliogenesis. We developed a probabilistic cell population–based model that reproduces the experimental data. In addition, our model explains, solely in terms of cell area constraints, the various observed transitions of the midbody, the beginning of ciliogenesis, and the accumulation of ciliated cells. Our findings reveal a biological mechanism that links the three microtubule-based organelles—the midbody, the centrosome, and the cilium—in the same cellular process.

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Tissue homogeneity requires inhibition of unequal gene silencing during development

Multicellular organisms can generate and maintain homogenous populations of cells that make up individual tissues. However, cellular processes that can disrupt homogeneity and how organisms overcome such disruption are unknown. We found that ~100-fold differences in expression from a repetitive DNA transgene can occur between intestinal cells in Caenorhabditis elegans. These differences are caused by gene silencing in some cells and are actively suppressed by parental and zygotic factors such as the conserved exonuclease ERI-1. If unsuppressed, silencing can spread between some cells in embryos but can be repeat specific and independent of other homologous loci within each cell. Silencing can persist through DNA replication and nuclear divisions, disrupting uniform gene expression in developed animals. Analysis at single-cell resolution suggests that differences between cells arise during early cell divisions upon unequal segregation of an initiator of silencing. Our results suggest that organisms with high repetitive DNA content, which include humans, could use similar developmental mechanisms to achieve and maintain tissue homogeneity.

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Syntaxin-17 delivers PINK1/parkin-dependent mitochondrial vesicles to the endolysosomal system

Mitochondria are considered autonomous organelles, physically separated from endocytic and biosynthetic pathways. However, recent work uncovered a PINK1/parkin-dependent vesicle transport pathway wherein oxidized or damaged mitochondrial content are selectively delivered to the late endosome/lysosome for degradation, providing evidence that mitochondria are indeed integrated within the endomembrane system. Given that mitochondria have not been shown to use canonical soluble NSF attachment protein receptor (SNARE) machinery for fusion, the mechanism by which mitochondrial-derived vesicles (MDVs) are targeted to the endosomal compartment has remained unclear. In this study, we identify syntaxin-17 as a core mitochondrial SNARE required for the delivery of stress-induced PINK1/parkin-dependent MDVs to the late endosome/lysosome. Syntaxin-17 remains associated with mature MDVs and forms a ternary SNARE complex with SNAP29 and VAMP7 to mediate MDV–endolysosome fusion in a manner dependent on the homotypic fusion and vacuole protein sorting (HOPS) tethering complex. Syntaxin-17 can be traced to the last eukaryotic common ancestor, hinting that the removal of damaged mitochondrial content may represent one of the earliest vesicle transport routes in the cell.

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Shifts in frequency-modulated pulses recorded during an encounter with Blainville's beaked whales (Mesoplodon densirostris)

Echolocation signals produced by beaked whales (family: Ziphiidae) include frequency-modulated (FM) pulses that appear to have species-specific characteristics. To date there has been no established evidence that a single species of beaked whale might produce more than one type of FM pulse. In 2014 a group of Blainville's beaked whales (Mesoplodon densirostris) were sighted off of Southern California; recordings included FM pulses with significant increases in peak frequency, center frequency, and −10 dB bandwidth relative to FM pulses previously attributed to this species. This research suggests there may be greater variation in received beaked whale FM pulses than previously understood.

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A parametric vocal fold model based on magnetic resonance imaging

This paper introduces a parametric three-dimensional body-cover vocal fold model based on magnetic resonance imaging (MRI) of the human larynx. Major geometric features that are observed in the MRI images but missing in current vocal fold models are discussed, and their influence on vocal fold vibration is evaluated using eigenmode analysis. Proper boundary conditions for the model are also discussed. Based on control parameters corresponding to anatomic landmarks that can be easily measured, this model can be adapted toward a subject-specific vocal fold model for voice production research and clinical applications.

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Seafloor sound-speed profile characterization with non-parallel layering by the image source method: Application to CLUTTER'09 campaign data

The image source method was originally developed to estimate sediment sound speed as a function of depth assuming plane-layered sediments. Recently, the technique was extended to treat dipping, i.e., non-parallel layers and was tested using synthetic data. Here, the technique is applied to measured reflection data with dipping layers and mud volcanoes. The data were collected with an autonomous underwater vehicle towing a source (1600–3500 Hz) and a horizontal array of hydrophones. Data were collected every 3 m criss-crossing an area about 1 km². The results provide a combination of two-dimensional sections of the sediment sound-speeds plotted in a three-dimensional picture.

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On the completeness and the linear dependence of the Cartesian multipole series in representing the solution to the Helmholtz equation

The (Cartesian) multipole series, i.e., the series comprising monopole, dipoles, quadrupoles, etc., can be used, as an alternative to the spherical or cylindrical wave series, in representing sound fields in a wide range of problems, such as source radiation, sound scattering, etc. The proofs of the completeness of the spherical and cylindrical wave series in these problems are classical results, and it is also generally agreed that the Cartesian multipole series spans the same space as the spherical waves: a rigorous mathematical proof of that statement has, however, not been presented. In the present work, such a proof of the completeness of the Cartesian multipole series, both in two and three dimensions, is given, and the linear dependence relations among different orders of multipoles are discussed, which then allows one to easily extract a basis from the multipole series. In particular, it is concluded that the multipoles comprising the two highest orders in the series form a basis of the whole series, since the multipoles of all the lower source orders can be expressed as a linear combination of that basis.

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Guest Post: preventing sexual assualt

- Yalda Jabbarpour, MD

"You don't know me, but you've been inside me, and that's why we're here today." So began the statement of Brock Turner's victim at his sentencing this spring. Turner, a former Stanford University student, was found guilty of three counts of sexual assault, but his 6 month sentence sparked outrage. Although this case brought renewed interest to the problem of sexual assault, the sad truth is that it is not unique. A recent poll conducted by the Washington Post and Kaiser Family Foundation found that 20 percent of young women reported being sexually assaulted on their college campuses in the past four years. 1 in 5 women. As a mother and family physician who cares for adolescents, these statistics are frightening, especially considering the life-long physical and psychological consequences for the victims.

According to a 2010 article in AFP, sexual assault is associated with sexually transmitted infections (STIs), posttraumatic stress disorder, anxiety, depression, chronic pain syndromes, drug and alcohol abuse, irritable bowel syndrome, headaches, fibromyalgia and sexual dysfunction. Sexual assault is a true public health crisis. What can family physicians do to curb this epidemic?

Much of the literature on the physician's role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it's unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.

Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.

Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: "Lighthouses don't go running all over an island looking for boats to save; they just stand there shining." It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.

Dr. Jabbarpour is the Robert L. Phillips, Jr. Health Policy Fellow at Georgetown University School of Medicine.

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Diminishing return for mechanistic therapeutics with neurodegenerative disease duration?

The conventional approach to developing disease-modifying treatments for neurodegenerative conditions has been to identify drivers of pathology and inhibit such pathways. Here we discuss the possibility that the efficacy of such approaches may be increasingly attenuated as disease progresses. This is based on experiments using mouse models of spinocerebellar ataxia type 1 and Huntington's disease (HD), where expression of the dominantly acting mutations could be switched off, as well as studies in human HD, which suggest that the primary genetic driver of age-of-onset of disease is a much weaker determinant of disease progression in affected individuals. The idea that one may approach a point in the disease course where such rational therapeutic strategies based on targets which determine onset of disease have minimal efficacy, suggests that one needs to consider other approaches to therapies and clinical trial design, including initiation of therapies in presymptomatic individuals.

Different factors may determine the onset of a neurodegenerative disease versus its progression. Thus, treatments aiming to slow progression based on targets which determine onset may have less efficacy with increased disease duration.

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Optimal cue combination and landmark-stability learning in the head direction system

Maintaining a sense of direction requires combining information from static environmental landmarks together with dynamic information about self-motion. This is accomplished by the head direction system, whose neurons – head direction cells – encode specific head directions. When the brain integrates information in sensory domains, this process is almost always "optimal" – that is, inputs are weighted according to their reliability. Evidence suggests cue combination by head direction cells may also be optimal. The simplicity of the head direction signal, together with the detailed knowledge we have about the anatomy and physiology of the underlying circuit, therefore makes this system a tractable model with which to discover how optimal cue combination occurs at a neural level. In the head direction system, cue interactions are thought to occur on an attractor network of interacting head direction neurons, but attractor dynamics predict a winner-take-all decision between cues, rather than optimal combination. However, optimal cue combination in an attractor could be achieved via plasticity in the feedforward connections from external sensory cues (i.e., the landmarks) onto the ring attractor. Short-term plasticity would allow rapid re-weighting that adjusts the final state of the network in accordance with cue reliability (reflected in the connection strengths), while longer term plasticity would allow long-term learning about this reliability. Although these principles were derived to model the head direction system, they could potentially serve to explain optimal cue combination in other sensory systems more generally.

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Cost variation study of antidepressant drugs

2016-08-01T06-49-56Z
Source: International Journal of Basic & Clinical Pharmacology
Ajay Kumar Shukla, Parag Sharma.
Background: Depression and anxiety disorders are the most common mental illnesses, each affecting in excess of 10-15% of the population at some time in their lives. Approximately 10-15% of those with severe depression attempt suicide at some point of time. Thus, it is important that symptoms of depression be recognized and treated appropriately. Methods: The prices of 15 antidepressant drugs, available in 43 different formulations were analyzed. Costs of different brands of a particular generic antidepressant drug being manufactured by different companies, in the same strength and dosage forms were used to calculate cost ratio and percentage cost variation. Results: This study shows that there is a wide variation in the prices of different brands of same antidepressant drug in Indian market. The highest cost ratio and percent cost variation was found for amitriptyline 50 mg, followed by bupropion 25 mg, amitriptyline 75 mg and dosulepin 50 mg. Highest number of brands of antidepressant drugs available in Indian market are for escitalopram 10 mg followed by escitalopram 5 mg and 20 mg. Conclusions: There is wide price variation of different brands of the same generic antidepressant drug in Indian market. Cost of a drug plays an important role in treatment of depression as it follows a long course and adherence to the treatment is related with drug cost. To decrease the wide cost variation among different brands of antidepressant drugs; it is high time to generate physician awareness about impact of cost effectiveness of drug regimen and for regulation of drug prices by the concerned agencies.

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Degrading the male body: manhood and conflict in the high-medieval low countries

Recent studies of medieval manhood have prompted scholars to revisit the established research field of medieval conflict and have directed attention towards the role of gendered violence in (elite) political culture. However, symbolic impermanent defamations of the male body proper remain to be discussed. Drawing from the rich narrative sources from the high medieval Low Countries, the present article aims at remedying this blind spot by scrutinising specific forms of gendered violence, such as the enforced shearing of an elite man's beard or a public mocking of his chivalric manly fortitude. It also presents the argument that these practices, when used in contexts of conflict and punishment, not only tapped into the authority of ancient traditions and rituals but rather served clear contemporary interests relating to the pacification of society. Such gendered tactics would have helped to avoid feud in a world in which aristocratic manly honour regularly seemed to demand it, especially in a time when centralised and consolidated structures for conflict management were still lacking and a religiously inspired peace ideal influenced policy-making as well as day-to-day social dynamics.

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Prevalence, implication, and determinants of worsening renal function after surgery for congenital heart disease

Abstract

Accumulating data in adults indicate the prognostic importance of worsening renal function (WRF) during treatment of acute heart failure. Venous congestion appears to play a dominant role in WRF; however, data regarding WRF in children with congenital heart disease (CHD) are limited. The present study was conducted to elucidate the prevalence and characteristics of WRF after surgery for CHD in children. We also tested our hypothesis that, similar to adult heart failure, venous congestion is an important determinant of WRF independent of cardiac output in this population. Fifty-five consecutive pediatric patients who underwent cardiovascular surgery for CHD were studied (median age 0.7 years; range 3 days to 17 years). The degree of WRF was assessed by the difference between the maximum levels of postoperative serum creatinine (Cr) and preoperative serum Cr. There was a high prevalence of WRF in the present cohort: an increase in Cr level was observed in 47 patients (85 %) and a Cr increase ≥0.3 mg/dL was seen in 23 (42 %). Importantly, WRF was significantly associated with a worse clinical outcome of a longer stay in the intensive care unit and hospital (both p < 0.05), even after controlling for age and operative factors. In addition, multivariate regression analysis revealed that central venous pressure, rather than cardiac output, was an independent determinant of WRF. Postoperative management to relieve venous congestion may help ameliorate or prevent WRF and thereby improve outcomes in patients with CHD.

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Comparison of the performance of zotarolimus- and everolimus-eluting stents by optical coherence tomography and coronary angioscopy

Abstract

Overall stent performance should be characterized by geometric luminal gain acquisition, neointimal coverage of the stent struts, and stabilization of the underlying inflammatory neoatheroma. The aim of this study was to compare the performance of zotarolimus-eluting stent (ZES), everolimus-eluting stent (EES) and bare metal stent (BMS) using optical coherence tomography (OCT) and coronary angioscopy. For 36 stented coronary lesions (BMS, 12 lesions; ZES, 11 lesions; EES, 13 lesions) in 27 patients, we calculated neointimal area and uncovered stent strut rate based on OCT findings at 10 months after stent placement. The grades of neointimal coverage and yellow color, both of which were classified from 0 to 3, were also assessed by coronary angioscopy. The plaque area of the ZES lesions was larger than that of the EES lesions (P < 0.05) but smaller than that of the BMS lesions (P < 0.05). The OCT-based uncovered rate of the ZES lesions was less than that of the EES lesions (P < 0.01), but similar to that of the BMS lesions. The stent coverage grade by angioscopy was higher in the ZES lesions than in the EES lesions (P < 0.05), but similar to the BMS lesions. The yellow grade was less in the ZES lesions than in the EES lesions (P < 0.01), but similar to the BMS lesions. ZES might be better than BMS in terms of neointimal thickening, and better than EES in terms of neointimal coverage as well as prevention of neoatheroma formation. ZES may have superior performance compared with EES.

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Older age is associated with greater central aortic blood pressure following the exercise stress test in subjects with similar brachial systolic blood pressure

Abstract

Brachial systolic pressure (BSP) is often monitored during exercise by the stress test; however, central systolic pressure (CSP) is thought to be a more direct measure of cardiovascular events. Although some studies reported that exercise and aging may play roles in changes of both BSP and CSP, the relationship between BSP and CSP with age following the exercise stress test remains unclear. The aim of this study was to evaluate the effect of age on the relationship between BSP and CSP measured after exercise. Ninety-six subjects underwent the diagnostic treadmill exercise stress test, and we retrospectively divided them into the following 3 groups by age: the younger age group (43 ± 4 years), middle age group (58 ± 4 years), and older age group (70 ± 4 years). Subjects exercised according to the Bruce protocol, to achieve 85 % of their age-predicted maximum heart rate or until the appearance of exercise-associated symptoms. BSP, CSP, and pulse rate (PR) were measured using a HEM-9000AI (Omron Healthcare, Japan) at rest and after exercise. BSP, CSP, and PR at rest were not significantly different among the 3 groups (p = 0.92, 0.21, and 0.99, respectively). BSP and PR immediately after exercise were not significantly different among the groups (p = 0.70 and 0.38, respectively). However, CSP immediately after exercise was 144 ± 18 mmHg (younger age), 149 ± 17 mmHg (middle age), and 158 ± 19 mmHg (older age). CSP in the older age group was significantly higher than that in the younger age group (p < 0.01). Despite similar BSPs in all age groups after exercise, CSP was higher in the older age group. Therefore, older subjects have a higher CSP after exercise, which is not readily assessed by conventional measurements of BSP.

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Teneligliptin improves left ventricular diastolic function and endothelial function in patients with diabetes

Abstract

Incretin hormones have been reported to have cytoprotective actions in addition to their glucose-lowering effects. We evaluated whether teneligliptin, a novel dipeptidyl peptidase-4 (DPP-4) inhibitor, affects left ventricular (LV) function in patients with type 2 diabetes mellitus (T2DM). Twenty-nine T2DM patients not receiving any incretin-based drugs were enrolled and prescribed with teneligliptin for 3 months. Compared to baseline levels, hemoglobin A1c levels decreased (7.6 ± 1.0 % to 6.9 ± 0.7 %, p < 0.01) and 1,5-anhydro-d-glucitol levels increased (9.6 ± 7.2 μg/mL to 13.5 ± 8.7 μg/mL, p < 0.01) after treatment. Clinical parameters, including body mass index and blood pressure, did not show any difference before and after treatment. Three months after treatment, there were improvements in LV systolic and diastolic function [LV ejection fraction, 62.0 ± 6.5 % to 64.5 ± 5.0 %, p = 0.01; peak early diastolic velocity/basal septal diastolic velocity (E/e′) ratio, 13.3 ± 4.1 to 11.9 ± 3.3, p = 0.01]. Moreover, there was an improvement in endothelial function (reactive hyperemia peripheral arterial tonometry [RH-PAT] index; 1.58 ± 0.47 to 2.01 ± 0.72, p < 0.01). There was a significant negative correlation between changes in the E/e' ratio and RH-PAT values. Furthermore, circulating adiponectin levels increased (27.0 ± 38.5 pg/mL to 42.7 ± 33.2 pg/mL, p < 0.01) without changes in patient body weight. Teneligliptin treatment was associated with improvements in LV function and endothelial functions, and an increase in serum adiponectin levels. These results support the cardio-protective effects of teneligliptin in T2DM patients and increase in serum adiponectin levels.

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Implantable loop recorder monitoring after concomitant surgical ablation for atrial fibrillation (AF): insights from more than 200 continuously monitored patients

Abstract

Different follow-up methods have been used to report success rates after AF ablation. Recent studies have shown that intermittent rhythm monitoring underestimates the actual AF recurrence rate. We therefore report our experience with continuous rhythm monitoring by implantable loop recorder (ILR) in a large patient cohort. Between 09/2008 and 12/2012, 343 cardiac surgical patients underwent concomitant surgical AF ablation. ILR implantation was performed in 206 patients. ILR interrogation was accomplished at 3, 6 and 12 months postoperatively. Successful ablation was defined as AF Burden <0.5 %. Primary outcome of the study was freedom from AF at 12-month follow-up. Mean patient's age was 70.5 ± 7.4 years. No major ablation- or ILR-related complications occurred. In 4 patients (1.9 %) ILR had to be explanted due to ILR-related wound infection (n = 2) or chronic pain (n = 2). Survival rate at 1-year follow-up was 96.6 %. Freedom from AF rate after 1-year follow-up was 68.5 and 63.6 % off antiarrhythmic drugs, respectively. Statistically significant predictors for successful ablation at 1-year follow-up were smaller LA diameter, shorter duration of AF and preoperative paroxysmal AF. Demographic data, indication for surgery, lesion set and used energy source had no impact on freedom from AF after 1 year. Continuous ILR monitoring after concomitant surgical AF ablation was safe and feasible, with registered freedom from AF rate of 68.5 % at 1-year follow-up. Thus continuous rhythm monitoring provides reliable outcome data and helps to guide antiarrhythmic therapy.

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Comparison of clinical characteristics in patients with Takayasu arteritis with and without concomitant tuberculosis

Abstract

Because of frequent tuberculosis in patients with Takayasu arteritis (TA), a possible relationship between TA and tuberculosis has been proposed. However, there are no studies to date that have examined clinical manifestations in patients diagnosed with TA with or without tuberculosis. Two hundred sixty-seven patients were diagnosed with TA according to the 1990 American College of Rheumatology criteria between September 1994 and April 2014. Patients with TA were classified into groups with or without tuberculosis. Among the 267 patients with TA studied, 47 patients (17.7 %) who had a history of previous treatment of tuberculosis (34 patients), concurrent diagnosis of tuberculosis with TA (10 patients), or diagnosis of tuberculosis during the follow-up period for TA (3 patients) were included in the group with tuberculosis. The group with tuberculosis comprised of 33 patients (70.2 %) with pulmonary tuberculosis, 12 patients (25.5 %) with tuberculous lymphadenitis, and 2 patients (4.3 %) with tuberculosis of the skin and colon, respectively. Comorbid disease and patients' signs and symptoms were not significantly different between TA patients with and without tuberculosis. Additionally, the site of disease involvement in angiographic findings and distribution of angiographic type were similar between the two groups. In conclusion, tuberculosis including tuberculous lymphadenitis was frequently observed in patients with TA. Clinical features and angiographic findings in TA were not different according to the presence or absence of concomitant tuberculosis.

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Non-suppressive regulatory T cell subset expansion in pulmonary arterial hypertension

Abstract

Regulatory T cells (Tregs) have been reported to play a pivotal role in the vascular remodeling of pulmonary arterial hypertension (PAH). Recent studies have revealed that Tregs are heterogeneous and can be characterized by three phenotypically and functionally different subsets. In this study, we investigated the roles of Treg subsets in the pathogenesis of PAH in eight patients with PAH and 14 healthy controls. Tregs and their subsets in peripheral blood samples were analyzed by flow cytometry. Treg subsets were defined as CD4⁺CD45RA⁺FoxP3^low resting Tregs (rTregs), CD4⁺CD45RA⁻FoxP3^high activated Tregs (aTregs), and CD4⁺CD45RA⁻FoxP3^low non-suppressive Tregs (non-Tregs). The proportion of Tregs among CD4⁺ T cells was significantly higher in PAH patients than in controls (6.54 ± 1.10 vs. 3.81 ± 0.28 %, p < 0.05). Of the three subsets, the proportion of non-Tregs was significantly elevated in PAH patients compared with controls (4.06 ± 0.40 vs. 2.79 ± 0.14 %, p < 0.01), whereas those of rTregs and aTregs were not different between the two groups. Moreover, the expression levels of cytotoxic T lymphocyte antigen 4, a functional cell surface molecule, in aTregs (p < 0.05) and non-Tregs (p < 0.05) were significantly higher in PAH patients compared with controls. These results suggested the non-Treg subset was expanded and functionally activated in peripheral lymphocytes obtained from IPAH patients. We hypothesize that immunoreactions involving the specific activation of the non-Treg subset might play a role in the vascular remodeling of PAH.

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Effects of liraglutide, a glucagon-like peptide-1 analog, on left ventricular remodeling assessed by cardiac magnetic resonance imaging in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Abstract

The clinical efficacy of glucagon-like peptide-1 (GLP-1) analogs in patients with acute myocardial infarction (AMI) is uncertain. The purpose of the present study was to evaluate the effects of the GLP-1 analog liraglutide on left ventricular (LV) remodeling in patients with AMI. We retrospectively evaluated the effects of liraglutide on LV remodeling assessed by cardiac magnetic resonance imaging (CMRI) in 15 patients with type 2 diabetes who were successfully treated with primary percutaneous coronary intervention (PCI) for AMI. Patients were divided into two groups based on their hypoglycemic medication: liraglutide use (group L; n = 6) or standard therapy (group S; n = 9). The CMRI findings in the early phase and at the 6-month follow-up were compared. At the 6-month follow-up, group S showed increases in LV end-diastolic (from 64 to 74 mL/m², p = 0.08) and end-systolic (from 38 to 45 mL/m², p = 0.13) volume indexes, whereas no such increase was observed in group L. The LV mass index (LVMI) was significantly smaller in group L than in group S at baseline (64 vs. 75 g/m², p = 0.05) and at follow-up (56 vs. 78 g/m², p = 0.009). Multivariate regression analysis showed that liraglutide use was an independent negative predictor of LVMI (β = −0.720, p = 0.003). In conclusion, liraglutide may be able to prevent the progression of LV remodeling and is associated with a lower LV mass in diabetic patients with AMI undergoing primary PCI.

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Percutaneous retrieval of a radiolucent anchoring sleeve embolized in pulmonary artery during pacemaker implantation

Abstract

An 85-year-old female presented to our institution with symptomatic sick sinus syndrome. During pacemaker implantation, an anchoring sleeve in the right ventricular lead was embolized in the left pulmonary artery. Although the anchoring sleeve was radiolucent, digital subtraction angiography revealed an angiographic filling defect in the lower branch of the left pulmonary artery, and a snare catheter enabled the anchoring sleeve to be grasped and extracted.

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Aberrant serum polyunsaturated fatty acids profile is relevant with acute coronary syndrome

Abstract

Although a robust relationship between aberrant serum polyunsaturated fatty acids (PUFAs) profile and coronary artery disease (CAD) has been reported, the details concerning the association between aberrant PUFAs profile and clinical feature of CAD are not fully discovered. Therefore, we investigated the relationship between serum PUFAs and clinical profiles in CAD patients. We classified 595 consecutive CAD patients, who underwent coronary angiography into 3 groups according to the clinical profiles of CAD (group A: early phase ACS, n = 96; group B: stable CAD with previous history of ACS, n = 259; group C: stable CAD without previous history of ACS, n = 240) and measured serum n-3 [eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)] and n-6 [arachidonic acid (AA)] PUFAs. Serum EPA, DHA, and EPA/AA ratio were significantly low in the order of group A < B < C [EPA; 48.1 (34.1–60.3) μg/ml, 61.7 (41.2–94.5) μg/ml, and 74.4 (52.7–104.9) μg/ml, DHA; 113.1 (92.8–135.1) μg/ml, 125.8 (100.4–167.2) μg/ml, and 140.1 (114.7–177.0) μg/ml, EPA/AA ratio; 0.31 (0.22–0.45), 0.39 (0.26–0.62), and 0.44 (0.31–0.69), medians with interquartile range, p < 0.01]. Multiple regression analysis revealed that EPA (p = 0.009) and EPA/AA ratio (p = 0.023), but not DHA and DHA/AA ratio, were negatively associated with clinical profiles of ACS in CAD patients. Significant correlation was not observed between PUFAs profile and severity of coronary stenosis. Low serum EPA and EPA/AA ratio correlates with clinical profiles of ACS in patients with CAD, regardless of the extent and severity of coronary artery stenosis.

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Association between cholesterol efflux capacity and coronary restenosis after successful stent implantation

Abstract

The measurement of high-density lipoprotein (HDL) functionality could be useful for identifying patients who have an increased risk of coronary restenosis after stent implantation. In the present study, we elucidates whether HDL functionality can predict restenosis. The participants included 48 consecutive patients who had stable angina and were successfully implanted with a drug-eluting stent (DES) or bare-metal stent. Follow-up coronary angiography was performed after 6–8 months of stenting. Cholesterol efflux and the anti-inflammatory capacity of HDL were measured before stenting (at baseline) and at follow-up. The mean age was 64 ± 11 years and the body mass index was 24 ± 3 kg/m². While HDL cholesterol (HDL-C) significantly increased from baseline to follow-up, there was no significant association between HDL-C level at baseline and in-stent late loss. Cholesterol efflux capacity was significantly increased from baseline to follow-up. The efflux capacity at baseline was negatively correlated with in-stent late loss, whereas the anti-oxidative activity of HDL at baseline was not associated with in-stent late loss. We analyzed the predictors of in-stent late loss using independent variables (efflux capacity and anti-oxidative capacity at baseline in addition to age, gender, HDL-C and low-density lipoprotein cholesterol at baseline, hypertension, diabetes mellitus, smoking, lesion length and DES implantation, history of myocardial infarction and prior percutaneous coronary intervention) by a multiple regression analysis. The efflux capacity at baseline was only independently associated with in-stent late loss. In conclusion, cholesterol efflux capacity at baseline could predict coronary restenosis in patients with successful stent implantation.

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Optical coherence tomography analysis of the stent strut and prediction of resolved strut malapposition at 3 months after 2nd-generation drug-eluting stent implantation

Abstract

Our objective was to clarify whether thrombogenic problems with stent struts are resolved at 3 months after 2nd-generation drug-eluting stent implantation. Twenty-one patients with stable angina pectoris having 28 (22 zotarolimus-eluting, 6 everolimus-eluting) stents with optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) were evaluated. Stent strut coverage and malapposition were evaluated by OCT immediately after PCI and at 3-month follow-up. Acute strut malapposition was observed in 26 out of 28 analyzed stents (92.9 %). At 3-month follow-up, 7 (26.9 %) of those 26 stents with strut malapposition were completely resolved, and the mean percentages of uncovered struts and malapposed struts were 8.3 and 2.0 % when analyzed by each individual stent. When analyzing a total of 30,060 struts, 807 struts (2.7 %) demonstrated acute strut malapposition. Among these, 219 struts (27.1 %) demonstrated persistent strut malapposition. On the basis of receiver-operating characteristic curve analysis, a strut-to-vessel (S-V) distance ≤160 µm on post-stenting OCT images was the corresponding cutoff point for resolved malapposed struts (sensitivity 78.1 %, specificity 62.8 %, area under the curve 0.758). The S-V distance of persistent malapposed struts on post-stenting OCT images was longer than that of resolved malapposed struts (235 ± 112 vs. 176 ± 93 µm, p < 0.01). At 3 months after PCI, the prevalence rates of uncovered and malapposed struts were relatively low in 2nd-generation drug-eluting stent. Our results suggest that OCT-guide PCI with an S-V distance ≤160 µm may be recommended especially in patients with planed short-term DAPT.

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Surgical management of left ventricular thrombus following severe dehydration

Abstract

We experienced a case involving a left ventricular ball-like thrombus caused by severe following a 150 mile cycling road race. The patient had lower-limb arterial obstruction due to systemic thromboembolism on admission with no significant embolism, including the cerebral arteries, were detected. Left ventricular wall motion was good with no evidence of left and right coronary artery occlusion; therefore, we performed emergency left ventricular thrombectomy. Although there are many reports of left ventricular thrombus following acute myocardial infarction, dehydration is a very rare cause. Herein, we describe the surgical and management approaches to the treatment of left ventricular thrombectomy in this case.

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Larger low voltage zone in endocardial unipolar map compared with that in epicardial bipolar map indicates difficulty in eliminating ventricular tachycardia by catheter ablation

Abstract

Patients with ischemic and non-ischemic cardiomyopathy often have substrate for ventricular tachycardia (VT) in the endocardium (ENDO), epicardium (EPI), and/or intramural. Although it has been reported that the ENDO unipolar (UNI) voltage map is useful in detecting EPI substrate, its feasibility to detect intramural scarring and its usefulness in radiofrequency catheter ablation (RFCA) remain unclear. To assess the relationship between the left ventricle (LV) ENDO UNI voltage map and the LV EPI bipolar (BIP) voltage map, and to determine the usefulness of the ENDO UNI voltage map to guide RFCA for VT in patients with cardiomyopathy undergoing combined ENDO- and EPI RFCA. Eleven patients with VT undergoing detailed ENDO and EPI electroanatomical mapping of the LV were included (mean age 59 ± 11 years, 9 men). We assessed the value of the LV ENDO UNI voltage map in identifying EPI and/or intramural substrate in these 11 patients with non-ischemic or ischemic cardiomyopathy. The underlying heart disease was dilated cardiomyopathy in 4 patients, cardiac sarcoidosis in 3, hypertrophic cardiomyopathy in 2, and ischemic heart disease in 2 patients. The mean LV ejection fraction was 24 ± 7 %. The low voltage zone (LVZ) was defined as <1.5 mV for LV ENDO BIP electrograms (EGMs), <8.3 mV for LV ENDO UNI EGMs, and <1.0 mV for LV EPI BIP EGMs. The surface area of each LVZ was measured. We also measured the LVZ of the spatial overlap between ENDO UNI and EPI BIP voltage maps using the transparency mode on CARTO software. We performed RFCA at the ENDO and EPI based on activation and/or substrate maps, targeting the LVZ and/or abnormal EGMs. The LVZ was present in the LV ENDO BIP voltage map in 10 of 11 patients (42 ± 33 cm²), and in the LV ENDO UNI voltage map in 10 of 11 patients (72 ± 45 cm²). The LVZ was present in the EPI BIP voltage map in 9 of 11 patients (70 ± 61 cm²), and the LVZ in the ENDO UNI voltage map was also seen in all 9 patients. The location of the LVZ in the EPI BIP map matched that in 45 ± 28 % of ENDO UNI voltage maps. The LVZ in the ENDO UNI voltage map was larger than that in the EPI BIP voltage map in 6 of 11 patients, and RFCA failed in 5 of these 6 patients. In the remaining 5 patients with a smaller LVZ in the ENDO UNI voltage map compared with the EPI BIP voltage map or no LVZ both at ENDO UNI and EPI BIP voltage map, VT was successfully eliminated in 4 of 5 patients. The LV ENDO UNI voltage map is useful in detecting EPI substrate in patients with cardiomyopathy. A larger LVZ in the ENDO UNI voltage map compared to that in the EPI BIP voltage map may indicate the presence of intramural substrate, which leads to difficulty in eliminating VT, even with combined ENDO- and EPI RFCA.

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Antiplatelet therapy in Takotsubo cardiomyopathy: does it improve cardiovascular outcomes during index event?

Abstract

Plasma catecholamines may play an important role in Takotsubo cardiomyopathy (TCM) pathophysiology. Patients with disproportionately high catecholamine responses to stressful events are prone to worse clinical outcomes. Catecholamines stimulate platelet activation and, therefore, may determine the clinical presentation and outcomes of TCM. We conducted a retrospective, descriptive study TCM patients admitted between 2003 and 2013 to Einstein Medical Center, Philadelphia, PA, USA and Danbury Hospital, Danbury, CT, USA. A total of 206 patients met Modified Mayo TCM criteria. Using a multiple logistic model, we tested whether aspirin, dual antiplatelet therapy (DAPT) aspirin + clopidogrel, beta blocker, statin, or ACE inhibitor use were independent predictors of major adverse cardiovascular events (MACE) during the index hospitalization. MACE was defined as in-hospital heart failure, in-hospital death, stroke or respiratory failure requiring mechanical ventilation. Incidence of in-hospital heart failure was 26.7 %, in-hospital death was 7.3 %, stroke was 7.3 % and MACE was 42.3 %. In a multiple logistic regression model (adjusted for gender, race, age, physical stressor, hypertension, diabetes, hyperlipidemia, smoking history, body mass index, initial left ventricular ejection fraction, single antiplatelet therapy, DAPT, beta blocker, statin, and ACE inhibitor) aspirin and DAPT at the time of hospitalization were independent predictors of a lower incidence of MACE during the index hospitalization (aspirin: OR 0.4, 95 % CI (0.16–0.9), P = 0.04; DAPT: OR 0.23; 95 % CI (0.1–0.55); P < 0.01. Physical stressor itself was also found to be an independent predictor of worse MACE: OR 5.1; 95 % CI (2.4–11.5); P < 0.01. In our study, aspirin and DAPT were independent predictors of a lower incidence of MACE during hospitalization for TCM. Prospective clinical trials are needed to confirm the findings of this study.

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A Rare Case of Unusually Large Lower Ureter Calculus

Abstract

We report an unusual large and "s" shaped left lower ureteric calculus which has been never reported in any manuscript to the best of our knowledge. Calculus in genitourinary happen to occur in various shapes and sizes; here we report unusual shaped calculi.

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Αρχειοθήκη ιστολογίου

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Δευτέρα 1 Αυγούστου 2016

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