Circulating platelet‐derived extracellular vesicles correlate with night‐time blood pressure and vascular organ damage and may represent an integrative biomarker of vascular health

Elevated office blood pressure (BP) has previously been associated with increased levels of circulating extracellular vesicles (EVs). The present study aimed to assess the relationship between levels of platelet derived EVs, ambulatory BP parameters, and pulse wave velocity as a marker of macrovascular organ damage. A total of 96 participants were included in the study. Platelet‐derived extracellular vesicles (pEVs) were evaluated by flow cytometry (CD41+/Annexin v+). BP evaluation included unobserved automated office BP and ambulatory BP monitoring. Carotid‐femoral pulse wave velocity (PWV) was measured as a marker of macrovascular damage. pEVs correlated with nocturnal systolic BP (r = 0.31; p = .003) and nocturnal dipping (r = ‐0.29; p = .01) in univariable analysis. Multivariable regression models confirmed robustness of the association of EVs and nocturnal blood pressure (p = .02). In contrast, systolic office, 24h‐ and daytime‐BP did not show significant associations with pEVs. No correlations were found with diastolic BP. Circulating pEVs correlated with pulse wave velocity (r = 0.25; p = .02). When comparing different hypertensive phenotypes, higher levels of EVs and PWV were evident in patients with sustained hypertension compared to patients with white coat HTN and healthy persons. Circulating platelet derived EVs were associated with nocturnal BP, dipping, and PWV. Given that average nocturnal BP is the strongest predictor of CV events, platelet derived EVs may serve as an integrative marker of vascular health, a proposition that requires testing in prospective clinical trials.     

Experiences From the Patient Perspective on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitatively Driven Mixed Method Analysis

IntroductionWhen neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective.ObjectivesThe aim of this study was to qualitatively and quantitatively map the FBSS patients’ experiences with SCS and the effects of SCS on low back pain caused by FBSS.Materials and MethodsA qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire.ResultsSeven themes regarding patients’ experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. “Acceptance” and “coping” emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients’ expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life.ConclusionMultiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.     

Influence of a strict glucose protocol on serum potassium and glucose concentrations and their association with mortality in intensive care patients

IntroductionTight glucose control therapy (TGC) has been implemented to control hyperglycemia in ICU patients. TGC may also influence serum potassium concentrations. We therefore investigated the influence of TGC on both serum glucose and serum potassium concentrations and associated mortality.MethodWe performed a retrospective analysis including all patients admitted to the ICU of a tertiary hospital for 24 hours or more and with at least three serum glucose and serum potassium concentrations between 1999–2001 (conventional period), 2002–2006 (implementation period) or 2007–2009 (TGC period). Segmented regression analysis was used to estimate changes in outcomes that occurred after the intervention controlling for pre-intervention trends. Means and standard deviations (SDs) of serum glucose and serum potassium concentrations, and rate of severe hypoglycemia (≤2.2 mmol/L) and hypokalemia (≤3 mmol/L), were compared between the TGC and conventional period.ResultsAlthough mean serum glucose concentrations dropped 2.1 mmol/L (95 % CI =−1.8 to −2.3 mmol/L, p<0.002), mean serum potassium concentrations did not change (absolute increase 0.02 mmol/L; 95 % CI = −0.06 to 0.09 mmol/L, p=0.64). The rate of severe hypoglycemia increased with 5.9 % (95 % CI=−3.0 to −8.9, p<0.002), but the rate of hypokalemia remained equal (absolute reduction 4.8 %; 95 % CI = −11.1 % to 1.5 %, p=0.13). The SD of serum glucose concentrations within a patient did not change, while the SD of serum potassium concentrations even decreased 0.04 mmol/L (95 % CI = −0.01 to −0.07, p=0.01). ICU mortality decreased but this decrease was not significant (absolute difference −3.63 %; 95 % CI = −9.33 to 2.09, p=0.20).Mean serum glucose concentrations, mean serum potassium concentrations and SDs of both serum glucose and serum potassium concentrations were all independently associated with ICU mortality. Highest mortality rates were seen at both the lowest and highest mean values (U/J-shaped association) and mortality rates increased with increasing variability (SDs) for both serum glucose and serum potassium concentrations.ConclusionOur study shows that a TGC was not associated with an increased risk of serum potassium related events. Low and high mean values and high variability of both serum glucose and serum potassium concentrations are predictors for high ICU mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0959-9) contains supplementary material, which is available to authorized users.     

Factors underlying clinicians’ judgements of patient insight and confidence in using clinical judgement in psycho-legal settings

This study investigates the factors that clinicians use to make clinical judgements of insight and their confidence in using clinical judgement across three clinical and forensic assessment domains. The 12 participating clinicians rated 30 DVD vignettes of psychiatric patients with a psychotic disorder. Qualitative analyses revealed eight themes that align closely with the dimensions of insight reported in the literature. However, it is unclear how clinicians weigh each dimension. The clinicians were more confident in making a judgement on insight for treatment planning than for involuntary treatment or fitness to stand trial evaluations. They wanted more information when making a judgement in the forensic domains, recognising the greater consequences for the patients and the greater level of scrutiny of their judgements in legal settings compared to clinical settings. The data obtained suggest that both clinical and forensic assessment of insight would benefit from empirically derived structured professional judgement (SPJ) tools.     

Correction to: Cerebral aneurysm in a giant perivascular space

Neuroradiology - The above article was published online with incorrect spelling of author name. The published online paper states “Frederik Meijer”, whereas it should be...     

Expanding the differential of cutaneous epithelioid tumors: A case of dedifferentiated liposarcoma with epithelioid features involving the skin,with review of the literature

Liposarcomas are categorized into four distinct histopathological subtypes: atypical lipomatous tumors (ALT)/well-differentiated liposarcoma (WDL), dedifferentiated, myxoid, and pleomorphic. Dedifferentiated liposarcomas account for approximately 18% of all liposarcomas, characteristically arising in the deep soft tissue. They are reported to have lower rates of metastasis compared to other pleomorphic sarcomas.^1–3 The classic histopathologic appearance is ALT/WDL admixed or juxtaposed with a predominantly nonlipogenic sarcoma. Epithelioid features are rare, appearing in as few as 3% of tumors, and have not previously been reported in a superficial location. Herein, we present a 57-year-old male with intradermal and subcutaneous metastasis of his known deep dedifferentiated liposarcoma with epithelioid features. By H&E the tumor featured cords and sheets of crowded, plump, epithelioid cells with thick nuclear membranes and prominent nucleoli, which raised a broad differential including carcinoma and melanoma. By immunohistochemistry the tumor was diffusely positive for MDM2 and CDK4, on the other hand stains for Sox10, Melan A, MITF, CKAE1/3, desmin, and S100 protein were negative. This case serves as an opportunity to raise awareness of this rare morphological subtype, which can involve the skin and mimic epithelial and melanocytic malignancies. It can be a potential diagnostic pitfall, especially if metastases are the first presentation.