Long-term culture of Japanese human embryonic stem cells in feeder-free conditions

Human pluripotent embryonic stem cells (hESCs) have great promise for research into human developmental biology, development of cell therapies for the treatment of diseases, toxicology, and drug discovery. Traditionally, undifferentiated hESCs are maintained on mouse embryonic fibroblasts (MEFs), which impede the clinical applications of hESCs. Here we have examined the long-term stability of the Japanese hESC line (KhES-1) in feeder-free culture. KhES-1 cells were cultured with MEF conditioned medium (CM) and different doses of basic fibroblast growth factor (bFGF) in six-well-plates of which the surface was coated with Matrigel. KhES-1 cells were maintained for at least 40 passages. In this culture system, the cells maintained stable proliferation rates and steadily expressed Oct-4, Nanog, and alkaline phosphatase. In addition, KhES-1 cells maintained without direct feeder contact formed embryonic bodies with expression of markers from the three germ layers. Here we demonstrated that Japanese human embryonic stem cells KhES-1 were cultured long term in a feeder-free method, while retaining pluripotency in vitro.     

Gastric corpus polyps associated with Proton Pump Inhibitors therapy

The prevalence of Gastroesophageal Reflux Disease (GERD) is rapidly rising in Asia. We describe here a case of 51 years old man who had surgery for esophageal leiomyoma and received long-term therapy with Proton Pump Inhibitors (PPIs) for persisting reflux symptoms. On Esophago-Gastroduodenoscopy (EGD) several sessile polyps were seen in the gastric corpus. Earlier EGD done 15 years back had not demonstrated those polyps. Sections revealed polypoid fragments of glandular epithelium with dilated glands and negative histology for H. pylori. Polymerase chain reaction for 16S ribosomal RNA gene (16S rRNA PCR) of H. pylori was also negative. This is the first report originating from an Asian country describing Fundal Gland Polyps (FGPs) in the corpus of stomach rather than fundus in a patient on long-term PPI therapy.     

Should surgical pleurectomy for spontaneous pneumothorax be always thoracoscopic?

Fifty-seven patients were studied over a period of three years to analyse the efficacy of surgical pleurectomy for spontaneous pneumothorax. Thirty-one and 26 patients underwent open and video-assisted thoracoscopic surgery (VATS) pleurectomy, respectively. VATS was the main modality used for primary spontaneous pneumothorax (PSP) (21 vs. 8). However, secondary spontaneous pneumothorax (SSP) was mainly managed with open pleurectomy (23 vs. 5). The median operating time was significantly longer in open group (72.4 vs. 55 min; P=0.005). The amount of analgesia required in the first five days was significantly more in open group (108 mg vs. 46.9 mg; P=0.02). Chest drainage was significantly more in open group (1027.1 ml vs. 652.8 ml; P=0.04). However, chest drain duration and hospital stay had no significant difference. VATS emerged as a cost-effective modality (1770 pounds vs. 3226 pounds). The ability to return to work was significantly earlier in VATS group in PSP patients (6 weeks vs. 10 weeks; P=0.007). There were 3 (5.27%) recurrences in VATS group for patients with SSP. This experience suggests that VATS pleurectomy is an appropriate modality for PSP. However, open pleurectomy is a viable alternative to treat SSP.     

Urinary tract injuries during obstetrics and gynaecological surgical procedures at the Aga Khan University Hospital Karachi, Pakistan: a 20-year review

OBJECTIVE: To determine the prevalence of urinary tract injuries, identification of risk factors and methods employed for repair and their outcomes. STUDY DESIGN: Cross-sectional study of patients who had urinary tract injuries during major obstetric and gynaecological surgeries at the Aga Khan University Hospital (AKUH) from 1985 to 2004. MATERIAL AND METHODS: Computer-generated discharge summaries of patients who underwent major obstetric and gynaecological procedures during the 20 years of study period were retrieved. Information was collected on data collection form, and entered in SPSS version 13 and analysed. RESULTS: During the study period 12,567 obstetrics and 5,966 gynaecological procedures were performed. There were 3,910 abdominal hysterectomies, 984 myomectomies, 591 ovarian/adenexal surgeries and 481 vaginal hysterectomies. Out of these 110 urinary tract injuries were identified, 71 (64.5%) were of the urinary bladder and 39 (35.5%) were ureteric in origin, 31 (43.6%) bladder injuries were sustained during caesarean sections while 40 (56.3%) were during gynaecological procedures. In obstetric cases there were two ureteric injuries, the other ureteric injuries were sustained during surgeries for benign gynaecological conditions. The prevalence of bladder and ureteric injuries in obstetric surgeries was 0.25 and 0.02%, respectively, whereas in gynaecological surgeries the prevalence was 0.7 and 0.6% for urinary bladder and ureteric injuries. These figures compare well with other published series. CONCLUSION: Urinary tract injuries are an uncommon occurrence but when they occur they have serious implications in terms of morbidity and litigation. The prevalence of urinary bladder and ureteric injuries observed in our review is comparable to previous reported international series. Of concern is the fact that most of the ureteric injuries were diagnosed post operatively which means that further vigilance and preventive strategies need to be designed.     

Confirm Rx insertable cardiac monitor for primary atrial fibrillation detection in high-risk heart failure patients (Confirm-AF trial)

Background

Patients with heart failure (HF) represent a large population of patients who are at high risk for complications related to undiagnosed atrial fibrillation (AF). However, currently there are limited modalities available for early AF detection in this high-risk population. An implantable cardiac monitor (ICM) is inserted subcutaneously and can provide long-term arrhythmia information via remote monitoring.

Methods and Results

Confirm-AF is a prospective randomized, nonblinded, two arm, multicenter clinical trial to be performed in the United States, enrolling 477 patients with a history of HF hospitalization and left ventricular ejection fraction >35% from 30 medical sites. Patients will be randomized in a 2:1 fashion to undergo ICM implant with remote monitoring and symptom-triggered mobile app transmissions versus (vs.) Non-ICM management and follow-up. The primary objective of this trial is to compare the time to first detection of AF lasting > 5 min using an Abbott ICM compared to non-ICM monitoring in symptomatic HF patients. This article describes the design and analytic plan for the Confirm-AF trial.

Conclusions

The Confirm-AF trial seeks to accurately define the burden of AF in high-risk HF patients with LVEF > 35% using an Abbott ICM. A finding showing significantly higher incidence of AF along with improved clinical outcomes with ICM monitoring is expected to have substantial clinical implications and may change the method of monitoring high-risk HF patients.     

Cardiac and kidney benefits of empagliflozin in heart failure across the spectrum of kidney function: Insights from the EMPEROR-Preserved trial

Aim

In the EMPEROR-Preserved trial, empagliflozin improved clinical outcomes of patients with heart failure (HF) with preserved ejection fraction. In this pre-specified analysis, we aim to study the effect of empagliflozin on cardiovascular and kidney outcomes across the spectrum of kidney function.

Methods and results

Patients were categorized by the presence or absence of chronic kidney disease (CKD) at baseline (CKD defined by an estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m² or urine albumin to creatinine ratio >300 mg/g). The primary and key secondary outcomes were (i) a composite of cardiovascular death or first HF hospitalization (primary outcome); (ii) total number of HF hospitalization, (iii) eGFR slope; and a pre-specified exploratory composite kidney outcome including a sustained ≥40% decline in eGFR, chronic dialysis or renal transplant. The median follow-up was 26.2 months. A total of 5988 patients were randomized to empagliflozin or placebo, of whom 3198 (53.5%) had CKD. Irrespective of CKD status, empagliflozin reduced the primary outcome (with CKD: hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.69–0.94; without CKD: HR 0.75, 95% CI 0.60–0.95; interaction p = 0.67) and total (first and recurrent) hospitalizations for HF (with CKD: HR 0.68, 95% CI 0.54–0.86; without CKD: HR 0.89, 95% CI 0.66–1.21; interaction p = 0.17). Empagliflozin slowed the slope of eGFR decline by 1.43 (1.01–1.85) ml/min/1.73 m²/year in patients with CKD and 1.31 (0.88–1.74) ml/min/1.73 m²/year in patients without CKD (interaction p = 0.70). Empagliflozin did not reduce the pre-specified kidney outcome in patients with or without CKD (with CKD: HR 0.97, 95% CI 0.71–1.34; without CKD: HR 0.92, 95% CI 0.58–1.48; interaction p = 0.86) but slowed progression to macroalbuminuria and reduced the risk of acute kidney injury. The effect of empagliflozin on the primary composite outcome and the key secondary outcomes was consistent across five baseline eGFR categories (all interaction p >0.05). Empagliflozin was well tolerated independent of CKD status.

Conclusions

In EMPEROR-Preserved, empagliflozin had a beneficial effect on the key efficacy outcomes in patients with and without CKD. Overall, the benefit and safety of empagliflozin was consistent across a wide range of kidney function spectrum, down to a baseline eGFR of 20 ml/min/1.73 m².     

Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC

Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.     

D-Fenfluramine induces serotonin-mediated Fos expression in corticotropin-releasing factor and oxytocin neurons of the hypothalamus, and serotonin-independent Fos expression in enkephalin and neurotensin neurons of the amygdala

The neurotransmitters expressed by neurons activated by D-fenfluramine (5 mg/kg, i.p.) were identified in the hypothalamus, amygdala and bed nucleus of the stria terminalis. Induction of Fos immunoreactivity following D-fenfluramine injection was used as an index of neuronal activation. To test whether D-fenfluramine activated neurons by releasing serotonin from the serotonergic nerve terminals, rats were pretreated with fluoxetine (10 mg/kg, i.p.), a serotonin reuptake inhibitor that prevents the release of serotonin stimulated by D-fenfluramine, 12 h before D-fenfluramine injection. The approximate percentages of peptidergic neurons that contained Fos immunoreactivity after D-fenfluramine administration were 94% of corticotropin-releasing factor and 22% of oxytocin cells in the paraventricular nucleus of the hypothalamus, 6% of oxytocin cells in the supraoptic nucleus of the hypothalamus, 36% of enkephalin and 15% of neurotensin cells in the central amygdaloid nucleus, and 19% of enkephalin and 9% of neurotensin cells in the bed nucleus of the stria terminalis. Fluoxetine pretreatment blocked Fos expression in corticotropin-releasing factor- and oxytocin-expressing cells in the hypothalamus, but not in enkephalin-and neurotensin-expressing cells located in the bed nucleus of the stria terminalis and central amygdaloid nucleus. D-Fenfluramine did not induce Fos immunoreactivity in vasopressin-, thyrotropin-releasing hormone-, somatostatin- and tyrosine hydroxylase-containing cells in the hypothalamus, and corticotropin-releasing factor-expressing cells in the central amygdaloid nucleus and bed nucleus of the stria terminalis. These results show that D-fenfluramine stimulates corticotropin-releasing factor- and oxytocin-expressing cells in the hypothalamus via serotonin release. The enkephalin- and neurotensin-expressing cells in the amygdala are activated by D-fenfluramine via non-serotonergic mechanisms. Induction of Fos expression by D-fenfluramine in restricted populations of cells suggests a selective activation of neuronal circuitry that is likely to be involved in the appetite suppressant effects of D-fenfluramine.