Septal myectomy after previous septal artery ablation in hypertrophic cardiomyopathy

OBJECTIVE: To review our institution's experience with patients who failed to benefit from septal artery ablation, which necessitated subsequent septal myectomy, and to examine reasons for ablation failure and outcome of myectomy after ablation. PARTICIPANTS AND METHODS: Of 550 patients who underwent septal myectomy at Mayo Clinic Rochester between January 1, 1999, and December 31, 2006, 16 (3%) had had a total of 22 previous septal artery ablations. This subset of 16 patients was analyzed and compared with a reference group of 120 patients whose septal artery ablations were performed at our institution during this period. Angiograms obtained during septal ablation were available for 13 (81%) of 16 patients in this series and were reviewed by 2 interventional cardiologists (R.A.N. and S.R.O.). These cardiologists also reviewed preoperative and postoperative echocardiography data, hospital course, and follow-up data to compile a list of characteristics that could have contributed to failed ablation. RESULTS: The median age of the patients at operation was 65 years (interquartile range [IQR], 52-72 years), and interval between ablation and myectomy was 409 days (IQR, 162-568 days). Angiograms revealed 2 failed procedures secondary to technical error. One patient had a relatively large first septal perforator with a large resting gradient. In 10 patients no septal perforators supplying the proximal septum were identified. Postoperatively, mitral regurgitation decreased from 3.00 to 1.00 (P less than .001), and left ventricular outflow tract gradient decreased from 75 mm Hg to 0 mm Hg (IQR, 0-29 mm Hg; P less than .001). Two patients died after surgery: 1 patient developed multiple-organ system failure on postoperative day 7, and 1 patient developed arrhythmia on postoperative day 21. Patients with previous septal artery ablation were older (P=.04), were more likely to have preoperative permanent pacemakers or implantable cardioverter-defibrillators (P=.05), were more likely to require postoperative pacemaker placement (P less than .001), and had higher operative mortality (P less than .001) than control patients. Fourteen patients survived the early recovery phase; 9 were followed up at a median of 1.88 years (IQR, 306 days to 3.3 years). All patients' symptoms improved. Median gradient of the left ventricular outflow tract was 13 mm Hg (IQR, 0-15 mm Hg) at follow-up with mild to moderate (1.6) mitral regurgitation. CONCLUSION: Septal myectomy performed after failed ablation improves gradient and provides excellent relief of symptoms but is associated with a higher incidence of morbidity and mortality.     

Antiphospholipid syndrome and perioperative hemostatic management of cardiac valvular surgery

Hemostatic aspects of antiphospholipid syndrome (APS) present unique challenges to clinicians and laboratory personnel alike, particularly in the perioperative period. These challenges are especially evident in patients requiring cardiac valve replacement surgery. However, the literature outlining the optimal approach in such patients is limited. We present the case of a 25-year-old woman with severe aortic regurgitation as a result of APS with particular reference to the precautions necessary during perioperative care. Particularly important are the prevention of thrombotic or hemorrhagic complications, management of associated thrombocytopenia, and laboratory methods of perioperative anticoagulation monitoring in the setting of prolonged clotting times.     

Anterior segment parameters associated with extramuscular manifestations in polymyositis and dermatomyositis

AIM: To evaluate the efficacy and safety of high-dose ultrasound cyclo-plasty (UCP) for the treatment of refractory glaucoma in Chinese patients. METHODS: In this 6-month retrospective study, 37 eyes of 37 patients suffering from severe glaucoma with uncontrolled intraocular pressure (IOP) of ≥21 mm Hg underwent 8-s ultrasonic cyclocoagulation with ten active piezoelectric elements. A complete ophthalmic examination was performed before and at 1d, 1, 3, 6mo after UCP. Therapeutic success was defined as IOP reduction from baseline ≥20% and IOP > 5 mm Hg without adding new glaucoma medication compare to baseline at the 6-month follow-up visit. In addition to mean IOP at each follow-up visit, medications used and complications were also detected and compared to baseline. RESULTS: After UCP procedure, the mean IOP was significantly reduced (P<0.01) from the preoperative 44.1±11.9 mm Hg to postoperative 26.7±11.8 mm Hg at 3mo, and 30.4±14.5 mm Hg at 6mo. The overall mean IOP reductions achieved at 3 and 6mo were 39% and 31%. Sixty-one percent of patients responded well to UCP treatment with a mean IOP reduction of 48% at 3mo and 42% at 6mo. Ocular pain in most of patients were alleviated. No serious intraoperative or postoperative complications occurred. CONCLUSION: High-dose UCP treatment is an effective and safe procedure to reduce IOP in Chinese patients with severe glaucoma.     

Utility of isoproterenol to provoke outflow tract gradients in patients with hypertrophic cardiomyopathy

It is important to identify patients with hypertrophic cardiomyopathy (HC) who have labile left ventricular outflow tract (LVOT) obstruction for consideration of ventricular septal reduction therapy. Although Doppler echocardiography has become the diagnostic modality to assess LVOT obstruction, it may not identify all patients with labile obstruction. This study assessed the diagnostic value of cardiac catheterization using isoproterenol challenge in 25 patients with HC in whom an LVOT obstruction (gradient >or=50 mm Hg) was clinically suspected, but not diagnosed using Doppler echocardiography. These patients underwent cardiac catheterization using a transseptal approach with isoproterenol challenge. During isoproterenol infusion, the gradient increased to >or=50 mm Hg in 14 patients and remained <50 mm Hg in 11 patients. Ten patients subsequently underwent surgical myectomy, 6 patients underwent alcohol septal ablation, and 9 patients were managed medically. Median follow-up was 26 months. Of patients who had a provoked gradient >50 mm Hg during isoproterenol infusion, 8 patients who underwent septal myectomy and 5 of 6 patients who underwent alcohol septal ablation had sustained alleviation of symptoms at follow-up. In conclusion, cardiac catheterization with isoproterenol challenge may identify patients with HC who may benefit from septal reduction therapy for whom the initial noninvasive evaluation does not show severe obstruction.     

Characterization of MGMT and EGFR protein expression in glioblastoma and association with survival

Journal of Neuro-Oncology - Understanding the molecular landscape of glioblastoma (GBM) is increasingly important in the age of targeted therapy. O-6-Methylguanine-DNA methyltransferase (MGMT)...     

Claudin-4 differentiates biliary tract cancers from hepatocellular carcinomas.

The recently identified claudins are dominant components of tight junctions, responsible for cell adhesion, polarity and paracellular permeability. Certain claudins have been shown to have relevance in tumor development, with some of them, especially claudin-4, even suggested as future therapeutic target. The aim of the present study was to analyze the expression of claudin-4 in the biliary tree, biliary tract cancers and hepatocellular carcinomas. A total of 107 cases were studied: 53 biliary tract cancers, 50 hepatocellular carcinomas, 10 normal liver and 10 normal extrahepatic biliary duct samples. Immunohistochemical analysis was performed on conventional specimens and on tissue microarrays as well. Claudin-4 was further investigated by Western blot analysis and real-time RT-PCR. Intense membranous immunolabeling was found for claudin-4 in all biliary tract cancers unrelated to the primary site of origin, namely intrahepatic, extrahepatic or gallbladder cancers. Normal biliary epithelium showed weak positivity for claudin-4. In contrast, normal hepatocytes and tumor cells of hepatocellular carcinomas did not express claudin-4. The results of Western immunoblot analysis and real-time RT-PCR were in correlation with the immunohistochemical findings. Cytokeratins, as CK7 (92%) and CK19 (83%) were mostly positive in biliary tract cancers, however, one-third of hepatocellular carcinomas also expressed CK7 (34%). HSA antibody (HepPar1) reacted with the majority of hepatocellular carcinomas (86%), while being positive in a low percentage of the biliary tract cancers (8%). In conclusion, this is the first report of a significantly increased claudin-4 expression in biliary tract cancers, which represents a novel feature of tumors of biliary tract origin. Claudin-4 expression seems to be a useful marker in differentiating biliary tract cancers from hepatocellular carcinomas and could well become a potential diagnostic tool.     

Does item overlap render measured relationships between pain and challenging behaviour trivial? Results from a multicentre cross‐sectional study in 13 German nursing homes

Several studies suggest that pain is a trigger for challenging behaviour in older adults with cognitive impairment. However, such measured relationships might be confounded due to item overlap as instruments share similar or identical items. The purpose of this study was to examine whether the frequently observed association between pain and challenging behaviour might be traced back to item overlap. This multicentre cross‐sectional study was conducted in 13 nursing homes and examined pain (measure: Pain Assessment in Advanced Dementia Scale) and challenging behaviour (measure: Cohen‐Mansfield Agitation Inventory) in 150 residents with severe cognitive impairment. The extent of item overlap was determined by juxtaposition of both measures’ original items. As expected, comparison between these instruments revealed an extensive item overlap. The statistical relationship between the two phenomena can be traced back mainly to the contribution of the overlapping items, which renders the frequently stated relationship between pain and challenging behaviour trivial. The status quo of measuring such associations must be contested: constructs’ discrimination and instruments’ discrimination have to be discussed critically as item overlap may lead to biased conclusions and assumptions in research as well as to inadequate care measures in nursing practice.     

The effect of selegiline on total scavenger capacity and liver fat content: a preliminary study in an animal model

Selegiline is a selective irreversible inhibitor of the B-type of monoamine oxidase (MAO-B). The spectrum of its pharmacological activity is wide, possesses antioxidant, antiapoptotic and neuroprotective properties and, additionally, we found it is effective on the total scavenger capacity (TSC), and the regulation of fat content in rat liver kept on lipid-rich diet. Our aim was to clarify whether the oral treatment with selegiline is protective on oxidative damage of Sprague?CDawley adult rats in vivo. Four groups of rats (five animals in a group) were examined: (1) lipid-rich diet, (2) normal rat food, (3) lipid-rich diet?+?selegiline and (4) normal rat food?+?selegiline. Selegiline solution (2.5???g/ml) was supplied with the drinking water, which was freely available for the animals. Regarding the drinking habit of the rats (20?C30?ml/day), the daily dose was roughly equal with that used in the human therapy (5?C10?mg/day). TSC was determined both at the beginning (0?day) and at the end of the study (28?days), when the blood samples were taken for chemiluminometric assay. Fat content of the liver was determined in the freshly frozen tissue by Sudan staining. TSC was increased in both the selegiline-treated groups. Selegiline treatment prevented the increase of liver fat in the group fed with lipid-rich diet. Our results led us to the conclusion that prolonged selegiline administration can raise the antioxidant capacity of the animals and prevents the accumulation of fat in their livers.     

Exercise Dependence in Amateur Competitors and Non-Competitor Recreational Exercisers

Research has demonstrated that exercising has health promoting effects. However, if habitual sporting activities become uncontrollable, detrimental health consequences can occur among a minority of individuals. Furthermore, such obligatory exercise can cause serious decline in school/work productivity, as well as financial problems, relationship problems, and poor psychological and physical wellbeing. The aim of the present study was to compare characteristics related to exercise dependence (ED) between recreational exercisers and amateur competitors. A total of 1439 participants (41.4 % male; mean age = 32 years) completed a battery of measures including the Exercise Dependence Scale (EDS), SCOFF, Well-Being Questionnaire, and Rosenberg’s Self-Esteem Scale. Results showed that 6.5 % of participants identified themselves as amateur competitive exercisers. Amateur competitors exercised significantly more (6.4 h) than non-competitor recreational exercisers (4.6 h). Amateur competitors also scored significantly higher on the EDS. Significant effects were found between competing and self-esteem concerning ED. Results showed that both features had a strong effect on ED. The study highlights the connection between ED symptoms and lower self-esteem and/or lower levels of subjective wellbeing. These influential factors are worth considering when planning preventive interventions addressing ED for both amateur competitors and non-competitive recreational athletes as well as when promoting sport as a healthy activity.