Peripartum dilatative cardiomyopathy. Case report with literature review]

Peripartum cardiomyopathy (PPCM) is a rare form of heart failure affecting women in the last month of pregnancy or the first six months post-partum. The etiology of PPCM remains poorly understood although some risk factors were described. Diagnosis is often difficult and is always necessary to exclude other prior heart disease and other cause of left ventricular dysfunction in pregnancy. Medical therapy for PPCM is similar to that for other forms of congestive heart failure; prognosis is better than in idiopathic cardiomyopathy but many authors observed that women who have had one episode of PPCM are likely to have recurrences in subsequent pregnancies. The present report describes the case of a woman presenting with severe cardiac failure immediately after cesarean section for twin pregnancy. The patient is a 35-year-old nulliparous white woman, with history of anorexia, subsequent amenorrhea, sterility and pregnancy induced with Gn-Rh. The diagnosis of PPCM was difficult for the presence of preeclampsia and acute pulmonary edema occurred four hours after delivery. The successful outcome was possible with an intensive treatment (mechanical ventilation, Swan-Ganz catheter). The whole resolution of the heart failure, six months post-partum, was demonstrated by ultrasonography.     

Nitric oxide-dependent human acrosomal loss induced by PPCM (SAMMA) and by nitric oxide donors occurs by independent pathways: basis for synthesis of an improved contraceptive microbicide

PPCM (previously designated sulfuric acid-modified mandelic acid [SAMMA]) is a contraceptive microbicide in preclinical development. Its contraceptive activity is attributable in part to its ability to promote premature acrosomal loss. Prior studies showed that PPCM-induced human acrosomal loss (PAL) is Ca(2+)-dependent. This study was carried out to determine transduction elements downstream from Ca(2+) entry. PAL is inhibited by inhibitors selective for endothelial-type nitric oxide synthase. PAL is completely inhibited by 0.1 microM ODQ (soluble guanylate cyclase inhibitor). PAL is inhibited by protein kinase G inhibitors with selectivity for the type II isotype. Several inhibitors of the nitric oxide/cyclic guanosine monophosphate (cGMP)/protein kinase G pathway induce Ca(2+)-dependent acrosomal loss when added alone. These responses are inhibited by nifedipine, a blocker of Ca(v1.x) voltage-dependent channels. Acrosomal loss induced by the nitric oxide donor SNAP (SNAL) does not require added Ca(2+). Sperm production of nitric oxide is increased by PPCM, an effect inhibited by nitro-L-arginine (nitric oxide synthase inhibitor). Although inhibited by ODQ, SNAL and acrosomal loss induced by other nitric oxide donors are unaffected by KT5823 (protein kinase G inhibitor). Unlike PAL, SNAL is partially inhibited by KT5720 (protein kinase A inhibitor) and genistein (protein tyrosine kinase inhibitor). Acrosomal loss response to PPCM and SNAP added in combination suggests that these agents act by independent mechanisms. A PPCM derivative was synthesized, in which a nitric oxide donor was esterified to PPCM (NOSPPA-23). NOSPPA-23 induces acrosomal loss with or without added Ca(2+). The ED(50) of NOSPPA-23 (4.8 nM) in the presence of Ca(2+) is 35-fold less than that of PPCM. These findings suggest the following: 1) elements responsible for PAL include endothelial nitric oxide synthase, soluble guanylate cyclase, and type II protein kinase G; 2) the resting state of the nitric oxide/cGMP/protein kinase G pathway is a determinant of acrosomal status; 3) PPCM and nitric oxide donors induce acrosomal loss via nitric oxide, but through independent pathways; and 4) covalent attachment of a nitric oxide donor to PPCM provides synergistic efficacy as a stimulus of acrosomal loss. Further studies with this novel prototype as an improved contraceptive microbicide are warranted.     

Congestive heart failure in postpartum: a case of peripartum cardiomyopathy

We report the case of an acute respiratory failure in a 36-year-old woman who presented a peripartum cardiomyopathy (PPCM). PPCM is a dilated cardiomyopathy with impaired systolic function that occurs between the last month of pregnancy and the five months following delivery. It is a rare disorder of unknown origin associated with high mortality (50%). Echocardiography confirms the diagnosis by showing a left ventricular dilatation and a decreased ejection fraction. Up to date, the treatment remains symptomatic.     

Peripartale Kardiomyopathie

Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.     

Anaesthetic management and non-invasive monitoring for Caesarean section in a patient with cardiomyopathy

This paper describes the anaesthetic management of a 29-year-old woman for an elective repeat Caesarean section. A diagnosis of peripartum cardiomyopathy (PPCM) had been made after her first delivery by Caesarean section three years earlier. Although the patient was currently asymptomatic, recent echocardiography demonstrated persistent left ventricular dilatation. The choice of haemodynamic monitors and the clinical significance of PPCM in this situation are discussed.     

Myocardiopathie du péripartum : incidence,physiopathologie, manifestations cliniques,prise en charge thérapeutique et pronostic

Introduction

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology.

Methods

We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches.

Results

Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function.

Conclusion

PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.     

Suspected case of peripartum cardiomyopathy during perioperative period--a case report

A 31-year-old primigravida was admitted for control of twin gestation and delivery. At 36-week gestation, an emergent cesarean section was performed under combined spinal-epidural anesthesia because of progression of PIH. Anesthetic course was uneventful until the operation was finished. An hour later, systolic blood pressure started to decline to reach about 70 mmHg and Sp(O2) about 80%. Pleural effusion was observed in the chest X-ray on post-operative day 1. Echocardiography showed akinesis of the antero-septal wall with ejection fraction (EF) of 47%. Peripartum cardiomyopathy (PPCM) was strongly suspected. HELLP syndrome and DIC were also combined with PPCM, so intensive care was given to her from the 1st POD. Symptoms of heart failure were alleviated by furosemide and carperitide by the 12th POD. The EF increased to 58% on the 11th POD.     

Prevalence and predictors of right ventricular diastolic dysfunction in peripartum cardiomyopathy

Background

This study aimed to assess the prevalence of right ventricular diastolic dysfunction (RVDD) and its potential predictors in peripartum cardiomyopathy (PPCM) patients.

Methods

This was a cross-sectional study carried out in Nigeria. RVDD was defined and graded using Doppler filling and myocardial tissue Doppler velocities obtained at tricuspid annular level.

Results

Forty-three subjects with PPCM and mean age of 26.6 ± 7.0 years were recruited over 6 months. RVDD was found in 30 (69.8 %) subjects, of whom 16 (53.3 %) had grade I, 12 (40.0 %) had grade II and 2 (6.7 %) had grade III severity. RV systolic dysfunction (RVSD), defined as RV fractional area change <35 %, was found in 88.4 %, while combined RVSD and RVDD was found in 58.1 % of patients. Subjects with RVDD had significantly higher tricuspid E/e′ ratio (5.1 ± 2.8 versus 3.5 ± 1.0, p = 0.012) and prevalence of pulmonary hypertension (76.7 versus 46.2 %; p < 0.05), and lower serum selenium concentration (55.6 ± 12.1 versus 72.5 ± 12.0 µg/L, p = 0.001) than those with preserved RV diastolic function. Regression analyses showed serum selenium [odds ratio (OR) = 1.14; 95 % confidence interval (CI) = 1.0–1.3; p = 0.049] and combined RVSD and pulmonary hypertension (OR = 79.2; CI = 3.9–1593.7; p = 0.004) as the only predictors of RVDD, and serum selenium <70 µg/L increased the odds of RVDD by 6.67-fold (CI = 1.18–37.78; p = 0.032).

Conclusions

Both RVDD and RVSD were common in PPCM patients. Selenium deficiency and combined RVSD and pulmonary hypertension seemed to be the only determinants of RVDD in this small cohort, a finding that needs verification in a larger sample of patients.

     

Two cases of postpartum cardiomyopathy initially misdiagnosed for pulmonary embolism

PURPOSE: To underline the crucial role of urgent echocardiography in the differential diagnosis of acute respiratory and/or circulatory failure in the postpartum period. CLINICAL FEATURES: A 24-yr-old woman was admitted to the intensive care unit (ICU) with a preliminary diagnosis of pulmonary embolism (PE) one week after Cesarean section. Neither computerized tomography nor Doppler sonography showed any signs of deep venous thrombosis or PE. In the ICU she required intubation and ventilatory support for acute respiratory and circulatory failure. Bedside echocardiography revealed features of left ventricular failure. A diagnosis of postpartum cardiomyopathy (PPCM) was made, appropriate treatment instituted and the patient soon improved. A 29-yr-old, previously healthy primipara presented at the Maternity Clinic on the fourth postpartum day complaining of increasing dyspnea and fatigue. Within eight hours she required intubation, ventilatory support and subsequent defibrillation due to cardiac arrest. She was transferred to the ICU with a preliminary diagnosis of PE. She developed pulmonary edema followed by cardiac arrest with successful resuscitation. Bedside echocardiography revealed a left ventricular ejection fraction below 30% with an increased systolic diameter of the left ventricle, restrictive diastolic abnormalities and no signs of pulmonary hypertension. Peripartum cardiomyopathy was diagnosed and supportive treatment for heart failure was instituted. CONCLUSION: It is possible to misdiagnose postpartum cardiomyopathy for PE. An error in diagnosis is life-threatening for the patient. Echocardiography is a valuable tool in the differential diagnosis. As a noninvasive procedure, it should be performed at the bedside as soon as possible to institute proper treatment and to avoid potentially fatal errors.     

青年期直肠癌的诊治特点

目的总结青年期直肠癌的诊治特点。方法就目前国内、外对青年期直肠癌的研究进展的文献进行综述,并对青年期直肠癌患者及其他年龄段直肠癌患者的临床资料进行对比,总结青年期直肠癌的诊治特点。结果青年期直肠癌患者(≤40岁)的发病与饮食、生活习惯和遗传因素都有一定的关系;相对于中老年患者来讲其分期更晚,低分化比例较高,淋巴结转移较早;青年期直肠癌常易误诊,预后差,目前公认以手术治疗为佳,并辅以新辅助治疗。结论青年期直肠癌在流行病学、病理学、治疗、预后等方面有其特殊性,但其手术治疗方面还需要进一步进行研究。     

Optimal adjuvant therapy for very young breast cancer patients

Approximately one in forty women diagnosed with early breast cancer is very young (<35 years) and this age group has a worse prognosis. The inferior prognosis in very young women appears to have two aspects. Very young women present more frequently with tumors with adverse histo-pathologic features. However, even when the histo-pathologic features appear favorable (ie. endocrine responsive tumors), analyses suggest that very young women with hormone receptor positive tumors are a sub-group at particular risk for adverse outcomes, compared to older premenopausal women with similar tumors. Chemotherapy induced amenorrhea has been shown to be associated with better outcomes and very young women are less likely to develop amenorrhea. Trials to determine the optimal adjuvant hormonal therapy for very young women are important. After breast conserving surgery, very young women are at increased risk for local recurrence and require particular attention to adequacy of surgical excision, including DCIS. Younger women undergoing breast conservation benefit from a boost dose of radiation. The option of genetic counseling should be provided to women diagnosed at a very young age. When considering adjuvant systemic treatments, fertility and contraception may be important considerations for this age group. Pregnancy after a diagnosis of adequately treated early breast cancer does not appear to be associated with an increased risk for relapse. Very young women are at higher risk for psycho-social distress and non-compliance with adjuvant systemic therapy. Young women should be informed that lifestyle factors after diagnosis may reduce the risk of recurrence.     

BREAST CANCER IN YOUNG WOMEN

Background : It is believed that cancer of the breast is more difficult to diagnose in young women and it has long been disputed whether breast cancer occurring in women aged 40 years is more aggressive than that occurring later in life. A number of reports in the literature suggest that the disease is of similar aggressiveness in the young patients and older age groups, while other reports suggest that it is more aggressive and carries a higher mortality in young women. Methods : To address these aspects of breast cancer we have undertaken a review of the cases treated at The Strathfield Breast Centre between 1989 and 1996 and compared the disease in the young and old groups with particular reference to the modes of diagnosis, the pathological staging and types of tumour and the outcomes of treatment. Results : The accuracy of ultrasound and fine needle aspiration biopsy were similar in both groups, but the false negative rate of mammography in the young patients was 15% or 50% greater than that which was observed in the older patients. The incidence of histopathological type, bilaterality, size of lesion and receptor positivity were the same in both groups. In the young group, 40% had Grade 3 tumours compared with 27% in the older group. Nineteen per cent of young patients had 4 or more lymph nodes involved while only 10% of the older patients had similar lymph node involvement. Overall 5-year survival was 79% in the older patients compared with 90% in the young patients. Conclusions : The spectrum of disease is similar in both the young and older patient and the prognosis is no worse for the young group but mammography is less effective in the diagnosis of the young patient.     

Squamous cell carcinoma of the tongue in young adults: increasing incidence and factors that predict treatment outcomes.

OBJECTIVE: This study was designed to determine whether the incidence of squamous cell carcinoma of the oral tongue (SCCOT) in young adults has changed during the past 25 years and to determine prognostic factors for young adult patients (aged < 40 years) with SCCOT. METHODS AND PATIENTS: A retrospective review of young adults with SCCOT who sought treatment at the M. D. Anderson Cancer Center between 1973 and 1995 was undertaken. RESULTS: The percentage of young adult SCCOT patients at M. D. Anderson increased from 4% in 1971 to 18% in 1993. T stage, N stage, perineural invasion, and lymphatic invasion were all associated with decreased survival. Patients who received a neck dissection as part of their primary treatment had a better chance of survival than patients who did not. CONCLUSIONS: The incidence of SCCOT in the young adult population is increasing in the United States. Appropriate surgical management for young adults with SCCOT includes resection of the primary tumor along with a selective node dissection.     

Stem fracture after hemiresurfacing for femoral head osteonecrosis

The ideal treatment of the young patient with a large necrotic segment in the femoral head remains controversial. Hemiresurfacing is a reasonable option in the young patient with a large osteonecrotic lesion that has collapsed. Complications reported after hemiresurfacing include implant loosening, femoral neck fracture, acetabular wear, and persistent pain. We present a case of stem fracture after hemiresurfacing in a young patient with femoral head osteonecrosis.     

Gastric cancer in young patients

Background: Delayed diagnosis, a high rate of histologically undifferentiated types of tumors, and rapid disease progression are frequently cited as the main reasons for the poor prognosis of gastric cancer in young patients. An improved prognosis has been anticipated for young gastric cancer patients because of recent improvements in digestive tract diagnostic techniques. This retrospective study was designed to determine whether these trends have had an impact on young Japanese patients with gastric cancer, and to further elucidate differences in clinicopathologic features between elderly and young patients.Methods: From 1984 to 1995, 1654 patients with gastric cancer were admitted to our hospital. Of these, 86 patients (5.2%) were less than 40 years of age (young group). The clinicopathologic features of this young group were reviewed retrospectively, using hospital records, and compared with those of older patients (n = 499 [29.4%], 60 to 69 years of age).Results: The young group contained significantly higher percentages of female patients, epigastric pain symptoms, depressed superficial type lesions, mucosal invasion, and poorly differentiated histology; percentages of hepatic metastasis and venous invasion were lower. Survival rates for all patients and for the resected cases were significantly better in the young group (p = 0.035 and 0.017 respectively). The percentage of early stage stomach cancers for the group less than 40 years of age was 49.0% in 1984–89, but had risen to 60.9% by 1990–95.Conclusions: Early diagnosis has improved the prognosis of young gastric cancer patients. Furthermore, these data show a recent shift in stage distribution; additional prognostic improvement is anticipated for young patients with early gastric cancer.     

Health outcomes and costs for injured young people hospitalised with and without chronic health conditions

BackgroundThe prevalence of chronic health conditions such as diabetes among young people is increasing. Limited information is known about the impact of these conditions on young people who have been traumatically injured. Injury is the global leading cause of death and disability in young people. The aim of this study is to compare health outcomes for injured young people with and without chronic health conditions.MethodA retrospective examination of injury in young people aged ≤25 years with and without a chronic health condition using linked hospitalisation and mortality records during 1 January 2010 to 30 June 2014 in New South Wales, Australia. Health outcomes, including hospital length of stay (LOS), 28-day unplanned hospital readmission, hospital treatment costs, and 30-day and 12-month mortality were examined. A 1:1 matched design was used to determine excess mean hospital LOS and cost for young people with a chronic health conditions versus no health condition.ResultsThere were 184,819 injury-related hospitalisations of young people; 13.8% had a chronic health condition. Compared to young people who did not have a chronic health condition, those with one were found to have double the mean hospital cost, higher unplanned hospital readmission, and a higher rate of mortality. Injured young people had a three times higher likelihood of having a prolonged LOS if they had a chronic health condition (Adjusted odds ratio: 3.89; 95% CI: 3.69–4.11). Renal conditions, anaemia, coagulation defects, hypertension, and mental health conditions had the highest excess LOS and anaemia, hypertension, coagulation defects and renal conditions had the highest excess mean cost for matched injured individuals with and without the health condition.ConclusionsHealth outcomes following injury are worse for young people with a chronic health condition. The increasing prevalence of young people with a chronic health condition has implications for treatment, resource use, provision of support services, and survival following traumatic injury.     

闽南地区青年与老年大肠癌临床病理对比分析

【摘要】〓目的〓探讨福建闽南地区青老年大肠癌的临床特点和病理特征。方法〓回顾性分析闽南地区132例青年大肠癌和893例老年大肠癌的临床特点及病理特征方面的差异。结果〓两组患者临床表现均以便血、粘液血便为主要表现,发病部位均以直肠癌为主。青年组的粘液腺癌和印戒细胞癌比例、晚期病例比例均高于老年组,5年生存率低于老年组。结论〓闽南地区青年大肠癌和老年大肠癌有不同的临床特点,早期诊断和治疗是提高青年和老年大肠癌预后的关键,应重视青年大肠癌的诊断。     

青年人胃癌

作者分析了１９７６年～１９９１年间６７５例胃癌病例的临床病理情况及随访结果，将其中年龄≤３５岁的青年组胃癌５１例与年龄＞３５岁的６２４例中老年组相比较。分析结果：（１）青年组胃癌发病男、女之比为１∶１．２，比值随年龄而增加，至５０～５９岁达高峰为２．８∶１。（２）青年组胃癌组织学分化较差者占８８．２％，明显高于中老年组（Ｐ＜０．０１）。（３）青年组胃癌分期多数偏晚，Ⅲ、Ⅳ期占７２．５％（Ｐ＞０．１）。作者认为：青年组与中老年组在手术切除率及术后生存率方面差异均无显著意义，大多数青年患者诊断较晚，争取早期发现是改善预后的主要措施。     

Physicochemical properties of the aging and diabetic sand rat intervertebral disc.

Hydration, fixed charge density, (FCD) and hydration under various osmotic pressures were compared in young, old, and young diabetic sand rats. This rat is a desert animal that may develop diabetes when fed a regular diet; it is also known to have radiographic and histologic evidence of intervertebral disc (IVD) disease. Forty-five rats and 180 IVD were used in this study; they were divided into three equal groups: young healthy, old healthy, and young diabetics. IVD, cancellous bone, and muscle were sampled from distal lumbar spines. The young diabetic rats (YD) were considerably heavier than the age-matched controls, had higher insulin and glucose levels, and all YD had cataracts. The discs of the young diabetic animals demonstrated decreased hydration, FCD and ability to resist compression under osmotic pressures as compared with the young and healthy discs and were more similar to the discs from old rats. The IVD is the most affected musculoskeletal connective tissue in sand rats with aging and diabetes. The aged and diabetic discs in the sand rat demonstrated changes similar to human changes with regard to lower hydration, FCD, and ability to resist osmotic pressure. Therefore, the sand rat may be a suitable animal model for studying the pathogenesis of disc degeneration.     

Rats with a Glucocorticoid‐Induced Catabolic State Show Symptoms of Oxidative Stress and Spleen Atrophy: The Effects of Age and Recovery

In this study we wanted to determine whether changes in antioxidant profile could follow the catabolic effects of glucocorticoids. We also wanted to compare resistance to glucocorticoid overload in young and old rats. To address these questions, whole body catabolism was induced by the administration of dexamethasone (Dex) at either 2 mg/kg bodyweight/day to young (6 weeks old) or 0.5 mg/kg bodyweight/day to old (94 weeks old) rats. Bodyweight loss of pair‐fed rats not given Dex was only 2% in the young rats and 8% in the old rats, whereas in Dex‐treated rats the decrease in bodyweight was 22% in the young rats and 13% in the old rats after 5 days of treatment. Spleen weight decreased by 65% in the young rats and by 52% in the old rats. Additionally, in the young rats there was a 46% reduction in glutathione (GSH) in erythrocytes as well as a 36% reduction in GSH/tissue wet weight in the soleus muscle. The corresponding figures for the old rats were 35 and 26%, respectively. Taken together, these results suggest that Dex directly and/or indirectly impaired the antioxidant reactions. This was further confirmed by a significant (50%) decline in Cu–Zn superoxide dismutase (SOD‐1) activity in erythrocytes isolated from the young rats treated with Dex but not the old rats as they showed a significant elevation in SOD‐1 activity (by 101%). Thiobarbituric acid reactant substances were significantly higher in both young and old rats. Activity of blood plasma creatine kinase increased by 73% in the young rats and by 307% in the old rats treated with Dex. Although both the young and the old rats could recover from oxidative stress, the old rats in contrast to the young rats remained catabolic until the end of the experiment. In conclusion, we suggest that old rats are more vulnerable to the catabolic action of Dex, whereas young rats are more susceptible to the oxidative stress induced by Dex.