Extrinsic Esophageal Compression by Cervical Osteophytes in Diffuse Idiopathic Skeletal Hyperostosis: A Contraindication to Transesophageal Echocardiography?

Contraindications to transesophageal echocardiography (TEE) include various esophageal pathologies, but compression of the esophagus by vertebral osteophytes is not listed in the current American Society of Echocardiography guidelines. We report a case of diffuse idiopathic skeletal hyperostosis (DISH) in an 81‐year‐old man who had incidentally been found to have extrinsic esophageal compression by cervical osteophytes prior to a proposed TEE. The incidence of esophageal perforation in patients with DISH and vertebral osteophytes is not well documented. We believe these patients are at increased risk of esophageal perforation during TEE, and thus, TEE may be relatively contraindicated in patients with DISH.     

Is Transesophageal Echocardiography Necessary before D.C. Cardioversion in Patients with a Normal Transthoracic Echocardiogram?

PURPOSE: Transesophageal echocardiography has emerged as an accepted approach before D.C. cardioversion for atrial fibrillation. The frequency of atrial thrombi detected on transesophageal echocardiography has varied from 7% to 23%. Many patients undergoing transesophageal echocardiography have had a previous transthoracic echocardiogram. Though transthoracic echocardiography has a low yield for the detection of intracardiac thrombi, it is highly accurate in diagnosing a structurally abnormal heart. The purpose of this study was to assess the frequency of thrombi detected by transesophageal echocardiography in patients with an entirely normal transthoracic echocardiogram and hence the advocacy of a selective approach in performing transesophageal echocardiography in patients undergoing D.C. cardioversion for atrial fibrillation. METHODS: 112 consecutive patients with atrial fibrillation who had undergone transesophageal echocardiography before D.C. cardioversion were evaluated. They all had a transthoracic echocardiogram within the 2 months preceding their transesophageal echocardiogram. Based on their transthoracic echocardiographic study, they were divided into two groups: Group 1 consisted of patients with a normal transthoracic echocardiogram and Group 2, those with an abnormal study. RESULTS: Thrombi or spontaneous echo contrast were found in 14 of 112 patients (16%). All however were detected in Group 2 patients. There was no patient with a normal transthoracic echocardiogram who had thrombus on his/her transesophageal echocardiogram. CONCLUSIONS: Our results suggest that a selective approach may be exercised in the use of transesophageal echocardiography prior to D.C. cardioversion for atrial fibrillation. Patients with an entirely "normal" transthoracic echocardiogram may proceed directly to cardioversion without a precardioversion transesophageal echocardiogram.     

Has Transesophageal Echocardiography Changed the Approach to Patients with Suspected or Known Infective Endocarditis?

Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis.     

Multiple Source Biosimilar Insulin,What’s a Provider to Do?

In the United States the FDA designates generic products that are bioequivalent as AB substitutable (FDA rating signifying the approved application contains adequate scientific evidence establishing through in vivo and/or in vitro studies the bioequivalence of the product to a selected reference product) and are expected to produce the same therapeutic results as the innovator product. In the case of biological proteins that are similar to already approved innovator biologicals, such as recombinant human insulin, the insulin molecule and accompanying secondary and tertiary structures will differ between manufacturing sources. Even subtle differences between innovator (branded) and alternative “biosimilar” products may produce different therapeutic endpoints. Substitution of a branded insulin with a biosimilar insulin product may result in more, less, or equal therapeutic response making in difficult for the practitioner to assess glycemic control between patient follow-up visits. Significant therapeutic difference is possible, which could result in mild to severe hypoglycemia reaction or hyperglycemia induced tissue damage. Slight molecular changes along with different accompanying proteins, protein fragments, and other naturally occurring contaminants theoretically increase odds of insulin resistance or allergic reaction. Current review of medication product and device quality relies on manufacturer self-oversight and individual reporting of product adverse events after use. While this is usually sufficient for oral medications and many medical devices, critical use products such as sterile products, biosimilar insulin, insulin delivery devices, self-monitoring blood glucose monitoring systems, and test strips require much more vigorous oversight to prevent individual and/or large scale catastrophe. Health care providers should advocate for their patient to have access to affordable, consistent, quality-assured products to effectively and safely manage their medical issues. A potential commonsense solution would be to utilize existing nonprofit organizations with access to pharmacy/laboratory services that have vested interest in ensuring product quality throughout the supply pipeline. The old adage “an ounce of prevention is worth a pound of cure” holds even more true in today’s medical environment.     

Barrett's Esophagus: Where Do We Stand?

Barrett''s esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.     

Glycemic Control and Cardiovascular Disease: What’s a Doctor to Do?

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in individuals with diabetes mellitus. Moreover, rates of CVD mortality are two to four times higher in diabetes than in those without diabetes. It was conventional thinking that achieving near-normoglycemia would help reduce CVD risk and overall mortality in type 2 diabetes mellitus. Several recent large trials attempted to answer this question using a randomized control trial design with a conventional therapy and an intensive control arm. Surprisingly, these trials did not demonstrate neither mortality nor a CVD advantage with intensive glycemic control. Moreover, some studies (e.g., the ACCORD [Action to Control Cardiovascular Risk in Diabetes] study) showed increased mortality in the intensive control arm. In this review, our goal is to summarize the findings of the major trials in this field and to explore the potential reasons for why these trials had largely negative results. We conclude with some lessons that may be applied to the clinical management of patients with diabetes.     

Does Rapid Volume Loading During Transesophageal Echocardiography Differentiate Constrictive Pericarditis from Restrictive Cardiomyopathy?

BACKGROUND: Respiratory variation of the pulmonary venous (PV) peak flow velocities can be used to distinguish constrictive pericarditis (constriction) from restrictive cardiomyopathy (restriction). Rapid volume expansion has been used successfully to enhance diastolic pressure equalization in occult constriction. The effect of volume on the respiratory variation in constriction has not been studied previously. This study assessed the utility of volume in enhancing the PV respiratory variation of constriction to further separate it from restriction. METHODS: The study population consisted of 15 patients referred to the echocardiography laboratory for further evaluation of clinically suspected diastolic dysfunction. Pulsed-Doppler transesophageal echocardiography (TEE) of the left or right upper pulmonary vein and mitral inflow was performed with respiratory monitoring before and after infusion of 1 liter of normal saline over 5 to 10 minutes. The classification of patients as constriction (n = 8) or restriction (n = 7) was confirmed independently by cardiac catheterization or surgery. Peak velocities of the PV systolic and diastolic waves and the mitral inflow E were measured during inspiration and expiration. A mean of 3-6 respiratory cycles was obtained for each value before and after volume loading. The percent change from expiration to inspiration (%E) was calculated using the formula %E = expiration - inspiration / expiration. RESULTS: At baseline, patients with constrictive pericarditis can be separated reliably from those with restrictive cardiomyopathy based on a higher systolic/diastolic ratio and greater respiratory variation of their PV diastolic flow velocity. There were no complications in any patient due to volume expansion. Although the change from baseline to volume expansion was not statistically significant in either constriction or restriction, the %E of the PV diastolic wave became significantly higher in constriction than in restriction (P < 0.05). CONCLUSIONS: Rapid volume expansion is relatively safe during TEE and can be used for further separation of constrictive pericarditis from restrictive cardiomyopathy by significantly enhancing the respiratory variation of the PV diastolic flow velocity in constrictive pericarditis.     

Do mitochondrial DNA haplogroups play a role in susceptibility to tuberculosis?

BACKGROUND AND OBJECTIVES: Mitochondrial DNA has a unique role in ATP production and subsequent mitochondrial reactive oxygen species (ROS) production in eukaryotic cells and there is a potential role for ROS and oxygen burst against Mycobacterium tuberculosis, an intracellular pathogen. This study aimed to determine whether the frequency of different mitochondrial haplogroups was significantly different in patients with tuberculosis (TB) compared with a normal population. METHODS: Mitochondrial DNA haplogroups M, N, J and K were studied by PCR-restriction fragment length polymorphism and sequencing. Cases were 54 patients with confirmed smear positive pulmonary TB. Controls were 256 healthy persons. RESULTS: There were no statistically significant differences between those with TB and the control group. CONCLUSIONS: There was no statistically significant association between mtDNA haplogroups and the presence of TB infection.