Ketamine for Bipolar Depression: A Systematic Review

BackgroundKetamine appears to have a therapeutic role in certain mental disorders, most notably unipolar major depressive disorder. However, its efficacy in bipolar depression is less clear. This study aimed to assess the efficacy and tolerability of ketamine for bipolar depression.MethodsWe conducted a systematic review of experimental studies using ketamine for the treatment of bipolar depression. We searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Central Register for relevant studies published since each database’s inception. We synthesized evidence regarding efficacy (improvement in depression rating scores) and tolerability (adverse events, dissociation, dropouts) across studies.ResultsWe identified 6 studies, with 135 participants (53% female; 44.7 years; standard deviation, 11.7 years). All studies used 0.5 mg/kg of add-on intravenous racemic ketamine, with the number of doses ranging from 1 to 6; all participants continued a mood-stabilizing agent. The overall proportion achieving a response (defined as those having a reduction in their baseline depression severity of at least 50%) was 61% for those receiving ketamine and 5% for those receiving a placebo. The overall response rates varied from 52% to 80% across studies. Ketamine was reasonably well tolerated; however, 2 participants (1 receiving ketamine and 1 receiving placebo) developed manic symptoms. Some participants developed significant dissociative symptoms at the 40-minute mark following ketamine infusion in 2 trials.ConclusionsThere is some preliminary evidence supporting use of intravenous racemic ketamine to treat adults with bipolar depression. There is a need for additional studies exploring longer-term outcomes and alterative formulations of ketamine.     

Late outcome after repair of mitral valve rupture during balloon atrial septostomy in a neonate

Balloon atrial septostomy is ordinarily a safe palliative procedure for cyanotic congenital heart disease; however, if echocardiographic guidance is unavailable and fluoroscopy is used, distortions in the cardiac anatomy can invalidate the usual landmarks. Herein, we report iatrogenic mitral papillary muscle rupture during balloon atrial septostomy in a 4-day-old male neonate with total anomalous connection of the pulmonary veins. The anomalous connection and severe mitral regurgitation were emergently corrected, and the patient grew and developed normally. At age 24 years, he had only mild residual mitral regurgitation and was in New York Heart Association functional class I.In addition to describing the surgical treatment and positive late outcome of a rare complication, we highlight the importance of accurately evaluating balloon catheter location during atrial septostomy, especially in patients with a small left atrium.     

Racial Disparities in Clinical Characteristics and Outcomes of Women Undergoing Percutaneous Coronary Intervention

Background/purposeWomen are underrepresented in cardiovascular clinical studies. Black women have a higher ischemic heart disease mortality risk than their white counterparts. However, there exist limited outcome data comparing black women and white women after percutaneous coronary intervention (PCI). The aim of this retrospective analysis was to evaluate for racial disparities in 1-year major adverse cardiovascular events (MACE) in women undergoing PCI.Methods/materialsWithin our PCI database, we identified 4776 female patients who underwent PCI between 2003 and 2016. Of those, 1916 were black and 2860 were white. Endpoints included MACE, death, myocardial infarction, target vessel revascularization (TVR) and stent thrombosis (ST) at 30 days and 1 year. A proportional Cox hazard model analysis was performed to assess outcomes after adjustment for confounding factors.ResultsBlack women presented at a younger age and had a significantly higher prevalence of risk factors. Periprocedural and in-hospital outcomes were similar in the 2 groups. At 30 days and 1 year, the rates of myocardial infarction, TVR and ST were significantly higher in black women. After adjustment for baseline differences, only ST appears to be more likely to occur in black women than in white women.ConclusionsIn this large cohort of women with coronary artery disease undergoing PCI, we observed racial disparities primarily in baseline characteristics indicative of need for interventions to achieve early diagnosis and better prevention in black women. Future directions should include efforts to identify and better characterize the factors underlying and contributing to cardiovascular outcomes in women after PCI.SummaryIn this real-world analysis from a large cohort of women with coronary artery disease undergoing percutaneous coronary intervention at a US tertiary-care center, racial disparities were observed, especially in baseline characteristics, indicating late presentation.     

Aortic root surgery does not increase the operative risk of acute type A aortic dissection

Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 (P = NS). By multivariate analysis, preoperative shock (P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias (P = 0.002, OR = 4.62), and packed red blood cell transfusion (P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.     

Clinical outcomes for a novel 6 degrees of freedom image guided localization method for frameless radiosurgery for intracranial brain metastases

Stereotactic radiosurgery (SRS) is an accepted method of treatment for intracranial brain metastases with sub-millimeter accuracy. Frameless radiosurgery (FRS) is becoming an alternative to framed SRS due to its less invasive requirements. The purpose of this study is to describe the clinical outcomes and local patterns of failure for a novel 6 degrees of freedom CT guided method of localization for FRS of intracranial brain metastases. 42 patients underwent linear accelerator-based FRS to 94 intracranial brain metastases between 01/2009 and 07/2011. 78 and 22 % of treated sites were intact metastases and resection cavities, respectively. 55 % of patients had undergone prior brain radiotherapy (45 % SRS, 26 % whole brain radiation therapy). The 1 year actuarial local recurrence rate was 18 %, with a median imaging follow-up period of 13.2 months. Single fraction equivalent dose was the most important predictor of local recurrence. The 1 year actuarial first distant brain recurrence and total intracranial recurrence rate was 58 and 69 %, respectively. The crude radiographic radiation necrosis rate was 3 %. Of the 10 local recurrence events, 8 (80 %) were in-field only, 1 (10 %) was marginal only, and 1 (10 %) was both. The preponderance of in-field only patterns of failure suggests that geographic miss is not a major contributor to local recurrence using this novel localization method for FRS. The 1 year local control rate is comparable to other similar published series of framed and frameless radiosurgery.     

Synthesis and antimicrobial activity of chalcone derivatives of indole nucleus

A series of previously unreported (2Z)-2-(1H-indol-1-yl)-3-(4-substituted phenyl)-1-phenylprop-2-en-1-one (5a–d) have been synthesized from easily accessible 2-(1H-indol-1-yl)-1-phenylethanone (3), which was obtained via a reaction of indole (1) with chloromethylphenyl ketone (2). The structures of the synthesized products have been elucidated using IR, ¹H NMR, and mass-spectroscopic data and elemental analyses. The final products were screened for their antimicrobial activity. Excellent results were obtained against both bacteria and fungi. In conclusion, we have developed a novel, convenient and simple method for the preparation of indole – chalcone hybrid compounds via the reaction of indole derivative with carbonyl compounds in the presence of a strong base. The rapid conversion, excellent yield, utilization of a base, and operational simplicity are great advantages of the proposed method.     

Larvicidal activity of Ocimum sanctum Linn. (Labiatae) against Aedes aegypti (L.) and Culex quinquefasciatus (Say)

The acetone, chloroform, ethyl acetate, hexane, and methanol leaf and flower extracts of Ocimum sanctum were studied against fourth instar larvae of Aedes aegypti and Culex quinquefasciatus. The highest larval mortality was found in leaf extract of O. sanctum against the larvae of A. aegypti and C. quinquefasciatus. The LC₅₀ values of O. sanctum against the larvae of A. aegypti were 425.94, 150.40, 350.78, 575.26, and 175.67 and against the larvae of C. quinquefasciatus were 592.60, 93.92, 212.36, 76.61, and 82.12 ppm, respectively.     

Endovascular repair of a ruptured descending thoracic aortic aneurysm in a patient with an ascending aortic aneurysm: hybrid open arch reconstruction with simultaneous thoracic stent-graft deployment within elephant trunk

Endovascular repair of the thoracic aorta is now widely practiced. The extension of this technique to emergent settings is in evolution. Pathology of the ascending and transverse aortic arch may preclude thoracic aortic stent grafting due to the lack of a proximal seal zone. Several hybrid open/endovascular approaches have been described. We recently encountered the difficult case of a contained rupture of a 6.8 cm descending thoracic aortic aneurysm in a 60-year-old patient with aneurysmal degeneration of the ascending and transverse aortic arch. This patient was treated with a hybrid approach of open ascending and transverse arch reconstruction along with simultaneous stent-graft repair of the descending thoracic aorta. The open repair established an excellent proximal landing zone by use of the "elephant trunk" technique. This technique also allowed direct suture fixation of the stent graft to the arch graft to prevent stent-graft migration. This hybrid surgical approach was successful and avoided the cumulative morbidity that a left thoracoabdominal approach would have added to the sternotomy. Further creative uses of these hybrid techniques will undoubtedly serve a larger role in the treatment of thoracic aortic pathology.     

Echocardiographic features of an unruptured mycotic aneurysm of the right aortic sinus of Valsalva.

This report describes a 25-year-old man with a pierced tongue in whom Streptococcus constellatus endocarditis of the aortic valve developed. Bacterial endocarditis in this patient was complicated by the development of a mycotic aneurysm of the right aortic sinus of Valsalva. Transthoracic and transesophageal echocardiographic studies were useful for the diagnosis of this rare lesion. Findings were confirmed at operation.