Long-term follow-up of very old heart failure patients enrolled in a trial of exercise training

Little is known about how physical and psychological status changes with time in older heart failure patients. The authors followed up a cohort of 82 patients (mean age, 80.5 years) enrolled in a randomized controlled trial of exercise training in heart failure. Six-minute walk test, accelerometry, functional status, quality of life, anxiety, and depression were measured at baseline, 3 months, 6 months, and a mean of 19 months post-enrollment. There were no significant differences between the exercise and control groups at long-term follow-up. Six-minute walk distance declined by only 0.2 m/month in those attending final follow-up (vs 4.6 m/month in nonattenders; P=.03). Similar results were seen for other outcomes. Only a small proportion of the variance in change of any of the outcomes was explained by differences in baseline variables.     

Hypercoagulation and thrombophilia in nonalcoholic fatty liver disease: mechanisms, human evidence, therapeutic implications, and preventive implications

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of disorders with a high prevalence in the industrialized world. Despite the high prevalence, the etiology and fundamental pathophysiology for the disease process is poorly understood. There is now a growing fund of knowledge suggesting that the ongoing inflammatory state associated with NAFLD leads to a low-level activation of the coagulation system. Although the data supporting this activation of the coagulation system are significant, the link with end-organ disease, mainly cardiovascular disease, is less firm and mostly epidemiological. In this review, we will explore the evidence for and against a hypercoagulable or thrombophilic state in NAFLD. We will examine possible pathophysiologic explanations and mechanisms, human epidemiologic and population-based data, and the possible therapeutic and preventative implications for treatment of thrombophilia in patients with this disease process.     

Photodynamic Therapy Provides Local Control of Cholangiocarcinoma in Patients Awaiting Liver Transplantation

Many transplant centers use endoscopically directed brachytherapy to provide locoregional control in patients with otherwise incurable cholangiocarcinoma (CCA) who are awaiting liver transplantation (LT). The use of endoscopic retrograde cholangiopancreatography (ERCP)‐directed photodynamic therapy (PDT) as an alternative to brachytherapy for providing locoregional control in this patient population has not been studied. The aim of this study was to report on our initial experience using ERCP‐directed PDT to provide local control in patients with unresectable CCA who were awaiting LT. Patients with unresectable CCA who underwent protocol‐driven neoadjuvant chemoradiation and ERCP‐directed PDT with the intent of undergoing LT were reviewed. Four patients with confirmed or suspected CCA met the inclusion criteria for protocol LT. All four patients (100%) successfully underwent ERCP‐directed PDT. All patients had chemoradiation dose delays, and two patients had recurrent cholangitis despite PDT. None of these patients had progressive locoregional disease or distant metastasis following PDT. All four patients (100%) underwent LT. Intention‐to‐treat disease‐free survival was 75% at mean follow‐up of 28.1 months. In summary, ERCP‐directed PDT is a reasonably well tolerated and safe procedure that may have benefit by maintaining locoregional tumor control in patients with CCA who are awaiting LT.     

New 2-thioether-substituted apomorphines as potent and selective dopamine D₂ receptor agonists

A set of novel apomorphine derivatives were synthesized with diversely functionalized side chains in the proximity of position 2 of the aporphine skeleton. Amino and/or carboxylic functions were introduced to this region of the backbone to test their pharmacological effects. During the synthesis of 2-(S-3-mercaptopropionic acid)-derivative a heteroring-fused congener was also isolated. The structural elucidation confirmed that the formation of this product was in accordance with our previous observations on the reaction of thebaine (2) with thiosalycilic acid. All the novel apomorphine congeners 4a-g were neuropharmacologically characterized to discover their dopaminergic profiles. Two derivatives were identified as D₂ full agonists equipotent with apomorphine (1) having significantly increased D₂/D₁ selectivity ratios.     

Operative treatment of ulnar collateral ligament insufficiency of the elbow in female athletes

BACKGROUND: As women become more involved in athletic activity, injuries specific to this population also increase. No data exist regarding operative treatment of female patients with elbow instability secondary to ulnar collateral ligament insufficiency. HYPOTHESIS: Women with symptomatically unstable elbows who failed nonoperative treatment will improve after surgical intervention. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Nineteen women were retrospectively evaluated using the Andrews and Carson Elbow Outcome Score. Patients were included if they underwent repair or reconstruction of the ulnar collateral ligament for symptomatic instability that precluded them from participation in their desired sport or activities, despite nonoperative treatment. RESULTS: The mean age was 22.0 years (range, 15.1-37.2 years). The mean follow-up was 38.8 months (range, 12.4-68.6 months). Of the 19 patients, 14 were softball players, gymnasts, and tennis players. Only 1 was a pitcher. Eighteen women underwent repair by one of the following procedures: plication (n = 6), repair to bone using anchors (n = 11), or drill holes (n = 1). One patient underwent a palmaris graft reconstruction. The mean overall preoperative outcome score of 120 improved to 191 postoperatively (P < .0001). Seventeen of 18 athletes were able to return to their sport at a mean of 2.5 months postoperatively. One patient did not participate in athletics. CONCLUSION: This study demonstrated excellent overall results in 16 and good results in 3 female patients after medial elbow repair or reconstruction. Women appear to be able to consistently return to a high level of function after repair or reconstruction for medial elbow instability.