Rationale and design of the FELICITAR registry (Frailty Evaluation After List Inclusion,Characteristics and Influence on Transplantation and Results)

Frailty reflects a state of decreased physiological reserve and vulnerability to stressors. Its prevalence among patients with cardiovascular disease is as high as 60%. Frailty is associated with a poor prognosis for patients with heart failure, increasingly frequent hospitalization, and death. The recent published listing criteria for heart transplantation of the International Society for Heart and Lung Transplantation recommend assessing frailty (class IIb recommendation, level of evidence C). However, this recommendation is not based on prospective studies, and frailty scores have only been validated in patients age > 65 years. The aim of the FELICITAR registry (Frailty Evaluation After List Inclusion, Characteristics and Influence on Transplantation and Results) is to assess the impact of frailty on prognosis before and after heart transplantation. A series of 100 patients from 3 Spanish centers will be included as soon as they are added to the national heart transplantation waiting list. Frailty will be evaluated again every 3 months until heart transplantation and at 3, 6, and 12 months thereafter. Depression, cognitive assessment, and quality of life also will be analyzed. The 2 primary endpoints are all‐cause mortality and prevalence of frailty assessed using the Fried frailty index. Results from this study may show that frailty is frequent in patients with advanced heart failure listed for heart transplantation and is associated with a poor prognosis both before and after surgery. The findings may contribute to a better understanding of the characteristics of the optimal candidate for heart transplantation.     

Infective endocarditis due to Streptococcus bovis in a series of nonaddict patients: clinical and morphological characteristics of 20 cases and review of the literature

BACKGROUND AND OBJECTIVES: Controversy frequently exists about the actual frequency of Streptococcus bovis infective endocarditis (IE), its incidence of malignancy and its outcome. Consequently, the characteristics of S bovis IE were examined in an unselected population of nondrug-addicted patients. The literature was also reviewed. METHODS: Nondrug-addicted patients with S bovis IE were retrospectively reviewed. Clinically definite IE was diagnosed according to the Duke classification criteria at the single reference hospital for a defined population in northwestern Spain over a 13-year period. The clinical features, need for surgery and mortality rate of these patients were compared with those of other nondrug-addicted patients with IE examined during the same time period. RESULTS: Between 1987 and 1999, S bovis IE was diagnosed in 20 consecutive patients. This pathogen was responsible for 16.8% of the cases of definite IE in nondrug-addicted patients. Underlying conditions and embolic septic events were common. The aortic valve was the most common site of IE. Simultaneous involvement of two cardiac valves and moderate to severe regurgitation were more common in patients with S bovis IE. Colonic neoplasms were observed in 77% of patients. However, in-hospital mortality rate, need for in-hospital surgery and surgery during follow-up did not differ between patients with S bovis IE and the other nondrug-addicted patients with IE. CONCLUSIONS: In unselected patients, the rate of mortality due to S bovis IE is similar to that observed in IE due to other microorganisms. However, colonoscopic evaluation during admission and follow-up is required.     

Rheumatic manifestations of infective endocarditis in non-addicts. A 12-year study

Infective endocarditis (IE) is due to a microbial infection of the heart valves or of the endocardium in close proximity to either congenital or acquired cardiac defects. This infection is associated with a high risk of complications. Rheumatic manifestations are known to be frequent complications of IE. Controversy, however, frequently exists about the actual incidence of these complications. This may be due to the small number of series describing the frequency and type of rheumatic manifestations, the absence of uniform criteria used for the diagnosis of IE, and the fact that some studies on rheumatic manifestations in IE have been described from tertiary referral centers, which implicates associated problems of referral bias and uncertainty of denominator population. To investigate further the incidence, clinical spectrum, and outcome of patients with IE and rheumatic manifestations, we examined the features of patients diagnosed with clinically definite IE according to the Duke classification criteria at the single reference hospital for a defined population in northwestern Spain during a 12-year period. Between 1987 and 1998, 100 consecutive patients had 110 episodes of clinically definite IE. Rheumatic manifestations were observed in 46 of the 110 episodes (41.8%). As in other western countries, they occurred more commonly in men aged in their 50s. The most frequent valve involved was the aortic (43.5%) followed by the mitral valve (30.4%). Myalgia was a frequent symptom. Peripheral arthritis, generally as monoarthritis, was clinically evident in 15 cases (13.6%), and sacroiliitis in 1 patient. Low back pain was described in 14 cases (12.7%). Septic discitis was observed in 2 cases, and biopsy-proved cutaneous leukocytoclastic vasculitis was found in 4 cases. Other conditions such as trochanteric bursitis and polymyalgia were observed in 2 and 1 case, respectively. Apart from a significantly higher frequency of hematuria and a trend to lower serum complement levels in patients with rheumatic complications, no differences in clinical features, laboratory tests, or microbiologic blood culture results were found between cases with IE with or without rheumatic manifestations. Also, although patients with rheumatic manifestations had more embolic complications, the inhospital mortality rate in patients with rheumatic manifestations was not significantly different from that of the rest of the patients. The present study supports the claim that rheumatic complications are frequent in patients with clinically definite IE from southern Europe. The presence of musculoskeletal or vasculitic manifestations may be of some help, as warning signs, for the recognition of patients with severe disease who require rapid diagnosis and therapy.     

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.     

A method for going from 2D laparoscope to 3D acquisition of surface landmarks by a novel computer vision approach

Purpose

This paper presents a method to use the Smart Trocars—our new surgical instrument recognition system—or any accurate localization system of surgical instrument for acquiring intraoperative surface data. Complex laparoscopic surgeries need a proper guidance system which requires registering the preoperative data from a CT or MRI scan to the intraoperative patient state. The Smart Trocar can be used to localize the instruments when it comes to contact with the soft tissue surface.

Method

Two successive views through the laparoscope at different angles with the 3D localization of a fixed tool at one single location using the Smart Trocars can point out visible features during the surgery and acquire their location in 3D to provide a depth map in the region of interest. In other words, our method transforms a standard laparoscope system into a system with three-dimensional registration capability.

Result

This method was initially tested on a simulation for uncertainty assessment and then on a rigid model for verification with an accuracy within 2 mm distance. In addition, an in vivo experiment on pig model was also conducted to investigate how the method might be used during a physiologic respiratory cycle.

Conclusion

This method can be applied in a large number of surgical applications as a guidance system on its own or in conjunction with other navigation techniques. Our work encourages further testing with realistic surgical applications in the near future.

     

Medicinal signaling cells niche in stromal vascular fraction from lipoaspirate and microfragmented counterpart

AimTo expand our previous findings by increasing the number of patients in a study characterizing medicinal signaling cells (MSC) of stromal vascular fraction from lipoaspirate (SVF-LA) and from microfragmented lipoaspirate (SVF-MLA) applied for the treatment of osteoarthritis (OA).MethodsTwenty OA patients, including 8 new patients, acquiring autologous microfragmented adipose tissue were enrolled. In-parallel immunophenotyping of SVF-LA and SVF-MLA was performed. The samples were incubated in a DuraClone SC prototype tube targeting the CD31, CD34, CD45, CD73, CD90, CD105, and CD146 surface markers, stained with the DRAQ7 cell nuclear dye and Live/Dead Yellow Fixable Stain, and analyzed by flow cytometry.ResultsThe population phenotypes in SVF-LA and SVF-MLA samples included CD31⁺CD34⁺CD73^±CD90^±CD105^±CD146^± endothelial progenitors (EP), CD31⁺CD34^-CD73^±CD90^±CD105^-CD146^± mature endothelial cells, CD31^-CD34^-CD73^±CD90⁺CD105^-CD146⁺ pericytes, CD31^-CD34⁺CD73^±CD90⁺CD105^-CD146⁺ transitional pericytes, and CD31^-CD34⁺CD73^highCD90⁺CD105^-CD146^- supra-adventitial-adipose stromal cells. Compared with the autologous SVF-LA samples, the prevailing cell type in SVF-MLA were EP, which outnumbered leukocytes and supra-adventitial-adipose stromal cells (SA-ASC). The ratio of progenitor cells in SVF-MLA samples differed between female and male patients, showing a higher EP-pericyte and pericyte-SA-ASC ratio in men.ConclusionOur results, hallmarked by EP-enriched anti-inflammatory features and indicating a possible sex-specific impact, contribute to defining the cellular composition of the clinically applied MSC serving as a regenerative cell therapy in OA.

Mesenchymal stromal/stem cells (MSC) are well known for their capability of differentiating into mesenchymal cell types. Caplan has recently suggested that they are renamed into medicinal signaling cells with the same acronym (1). The name ought to be adapted as our knowledge of the biological concept has expanded: during tissue regeneration, MSC perform their function via signaling rather by than differentiating – as they do under cell culture conditions (2-4). MSC comprise a heterogeneous population of stromal and stem cells with additional immunosuppressive and trophic properties, which upon injury or inflammation modulate the local environment by secreting numerous anti-apoptotic, anti-scaring, angiogenic, and mitotic factors (1,5). This paradigm for tissue regeneration has been brought up by the studies of MSC in osteoarthritis (OA), the most common joint disorder (6). MSC from adipose tissue are now widely investigated as a novel therapeutic method in the treatment of OA (7).Although 20 years have passed since the first characterization of the multipotent MSC from adult adipose tissue, ie lipoaspirate (3), a complete characterization of this heterogeneous cell type remains elusive. This tremendous discovery opened up unprecedented possibilities in clinical application, however, undefined cellular heterogeneity and non-standardized protocols represent the main obstacle to the MSC usage in regenerative medicine. Together with other cell types, MSC are found in the stromal vascular fraction (SVF), which is obtained from adipose tissue upon collagenase treatment. Besides being a fruitful source of MSC, adipose tissue seems to potentiate the MSC-mediated tissue regeneration if it previously undergoes microfragmentation. The secretome of microfragmented adipose tissue more abundantly harbors cytokines and angiogenic factors, accompanied by immunomodulation, angiogenesis, and tissue reparation benefits (8). In this new light of paracrine activity of microfragmented adipose tissue, the Lipogems® device brings innovative technology for processing autologous adipose tissue, producing small intact clusters of perivascular microfragments with a high therapeutic potential (9,10). In a prospective non-randomized study, an intra-articular injection of such a product led to a successful outcome, as revealed by an increased glycosaminoglycan content in the hyaline cartilage of the knee joint (11,12). Several studies of knee OA treatment demonstrated the efficacy of adipose MSC in tissue repair, and even a low-dose MSC application yielded significant functional improvement with pain relief (13-15).Although clinical implementation of microfragmented adipose tissue has brought an impressive step forward in orthopedics, standardization of clinical application requires a better understanding of MSC heterogeneity and the cellular subset characterization. The flow cytometry analysis of human lipoaspirate has shown that a heterogeneous SVF mixture contains endothelial progenitor (EP) cells (CD31⁺CD34⁺CD146⁺), endothelial mature (EM) cells (CD31⁺CD34^-CD146^±), pericytes (CD31^-CD34^-CD146⁺), supra-adventitial-adipose stromal cells (SA-ASC) (CD31^-CD34⁺CD146^-), and transitional pericytes (TP) (CD31^-CD34⁺CD146⁺), with differential expression of the CD73, CD90, and CD105 mesenchymal markers (16,17). The aim of this study was to expand the number of patients from our previous immunophenotyping analysis of SVF from lipoaspirate (SVF-LA) or microfragmented lipoaspirate (SVF-MLA) by means of polychromatic flow cytometry (18). Since SVF-MLA is used therapeutically in OA patients, the results contribute to the biological understanding of the cartilage regeneration.     

Relapse of obsessive–compulsive disorder after cerebral venous sinus thrombosis: a case report

Obsessive–compulsive disorder (OCD) is characterized by repetitive, persistent and unwanted thoughts and ritualistic, repetitive behaviors. The pathophysiology of OCD involves many distinct cortical and subcortical regions and it has been reported that OCD may occur as a consequence of traumatic brain injury, infections and tumors as well as cerebrovascular insult such as cerebral venous sinus thrombosis (CVST). We here describe the case of a 36-year-old woman who developed OCD at the age of 13 with almost complete remission of the symptoms after a 1 year-long treatment. Interestingly, after suffering CVST at the superior sagittal sinus at the age of 33, she experienced a relapse of OCD. The patient was successfully treated with Sertraline and Clomipramine. Previous studies revealed cases of OCD following different cerebrovascular accidents, i.e. predominantly arterial stroke. However, the present case is the first to describe OCD after venous thrombosis. Based on our clinical experience, the most effective treatment of OCD after CVST represents the combination of the selective serotonin reuptake inhibitor Sertraline and the tricyclic antidepressant Clomipramine.     

Reconstruction by revascularization of a hand subtotally amputated at the middle section

Authors describe the successful revascularization operation of the subtotally amputated hand of a 21 years old man. The patient was controlled after 2 years. He was satisfied with the function of the restored hand and worked in his original job.