Levosimendan: A retrospective single-center case series

Purpose

The purpose of this study is to describe the effect of levosimendan (without loading dose) on hemodynamics, inotropes/vasopressors, and mortality in acute heart failure (AHF).

Materials and Methods

Patients who received levosimendan for AHF were analyzed. Levosimendan dose, hemodynamic data, inotrope/vasopressor requirements, and fluid balance before commencement, at conclusion of, and 24 hours after levosimendan were collected. Mortality is also reported.

Results

Eighty-seven patients were analyzed. The mean levosimendan dose (without loading) was 0.096 μg/kg per minute (± 0.014), and mean duration, 26 (± 7.2) hours. There was no change in heart rate (start, post, and 24 hours post) (92 [± 19], 92 [± 26], and 92 [± 15]) or mean arterial pressure (69 [± 10], 72 [± 8], and 72 [± 10] mm Hg, respectively). There was a significant reduction in median dobutamine from 7.27 to 0 μg/kg per minute and noradrenaline from 0.20 to 0.1 μg/kg per minute before and 24 hours after. There was a significant increase in both mean cardiac index from 2.38 ± 0.0.72 to 2.98 ± 0.0.77 L/min per square meter and in markers of perfusion: base excess from − 2.77 to 0.39 mmol/L, and lactate from 2.1 to 1.4 mmol/L before and 24 hours after infusion. Survival was 53%.

Conclusions

Levosimendan, without a loading dose, improved cardiac index and perfusion while allowing a reduction in inotropic/vasopressor requirements in patients with AHF.     

Family-Driven Youth-Guided Practices in Residential Treatment: Findings from a National Survey of Residential Treatment Facilities

Family-driven, youth-guided practices have shaped the development of community-based mental health services for children and youth; however, the extent to which residential treatment providers have adopted these practices is unclear. This study reports the findings from a survey of 293 residential treatment providers conducted to examine the adoption of family-driven, youth-guided care. Residential treatment providers reported several practices consistent with family-driven, youth-guided care, including strength-based individualized treatment planning, collaboration with community-based providers to develop treatment plans, and the provision of various forms of support to families. Thirty percent of providers reported that the youth or family member was the primary decision maker in the development of treatment plans, 20.9% included youth or family members in program oversight, and 88.0% reported that staff had not heard of family-driven, youth-guided principles or required further training to implement them.     

ABH and Lewis antigen and antibody expression after bone marrow transplantation

We have tested 10 bone marrow transplant donors and recipients for ABH and Lewis antigens and ABH antibodies. Two group A2 recipients stably engrafted with group O marrow produced anti-A1. Small quantities of recipient-type ABH substance were found on the posttransplant erythrocytes in cases where the recipient was a secretor but not in a single nonsecretor recipient. Lewis antigens were always of recipient type. The incidence of graft-versus-host disease and graft rejection were similar in 41 patients who received ABO-mismatched and 61 patients who received ABO-matched grafts.     

Effect of tobacco and alcohol consumption on the Langerhans cell population of human lingual epithelium determined using a monoclonal antibody against HLADR

Tobacco and alcohol consumption are known predisposing factors to the development of oral cancer, though the mechanism by which they act is unclear. The density of Langerhans cells (LC) has been shown to decrease in the uterine cervix of smokers, possibly indicating reduced immune surveillance and increased risk of malignant change. This study examined biopsies of normal human lateral border of tongue taken from 41 necropsies whose histories of tobacco and alcohol consumption were known. LC were identified in fixed, wax-embedded sections using a monoclonal antibody to HLADR and an immunoperoxidase technique. The mean density of LC in smokers of the equivalent of 11 or more cigarettes daily was significantly higher than moderate and non-smokers when counts were expressed per mm epithelial surface and basement membrane length. There were no significant differences in LC numbers in relation to alcohol consumption, age or sex, but there was a significant interaction between tobacco and alcohol. The results suggest that either human oral LC respond to external toxins, or that physical changes in the epithelial barrier induced by such toxins necessitate the presence of more LC to maintain the integrity of the epithelium.     

The biochemistry of the action of chymopapain in relief of sciatica

A study has been made of the mechanism of action of intradiscal injections of preparations of chymopapain in the treatment of sciatica. Such preparations were found to contain at least four distinct proteins, but enzymatically active chymopapain was the component mainly responsible for releasing glycosaminoglycan from cartilaginous tissue. Previous suggestions that an electrostatic interaction between chymopapain and glycosaminoglycan is important to the action of injected enzyme were not supported by the finding that both positively and negatively charged forms of chymopapain efficiently released glycosaminoglycan from cartilaginous tissue. In contrast, cysteine alone did not cause release of glycosaminoglycan. Chymopapain was found to be inhibited efficiently by the protein inhibitors, cystatin C and low molecular weight kininogen in vitro, and the possible relevance of this finding to the efficacy and safety of chemonucleolysis is discussed.     

Computed Tomography Screens Stable Patients at Risk for Penetrating Cardiac Injury

Objective: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable pitients with penetrating chest injuries.
Methods: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center.
Results: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18–100%). 96.6% (95% CI 88–100%). and 96.7% (95% CI 89–100%), respectively.
Conclusion: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors advocate the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.     

The artificial urinary sphincter in the female: Indications for use, surgical approach and results

Female urinary incontinence is a common problem. Among the many treatment options a few patients may be suitable candidates for the artificial urinary sphincter (AUS). The indications for placement of an AUS are much more common in males: however, we review the indications, technique and potential complications of the AUS in the female population. Although few indications exist for the placement of an AUS in women, if proper patient selection is made, with strict adherence to proper surgical technique, it can be a suitable treatment option for those suffering from sphincteric incontinence.     

Use of inferior vena cava filters in the Medicare population

To examine the use of inferior vena cava (IVC) filters, we performed a population-based study using a 5% random sample of the United States Medicare population (1.25 million persons). Filter placement and its timing relative to diagnosis of venous thromboembolism (VTE) were determined using both hospital and physician Medicare billing codes after detailed review of large samples of complete individual claims records. Comorbid conditions and mortality were also noted. From July 1986 through June 1989, a total of 806 patients in the sample population received IVC filters. Mortality rates after filter placement were high: 16% during initial hospitalization, 32% within 6 months of filter placement, and 48% after 2 years. However, only 3 (1%) of 423 patients who underwent filter placement without the diagnosis of pulmonary embolism (PE) suffered PE within 1 year of filter placement. Use of IVC filters increased significantly over the study period (p <0.001).Rates of filter placement among the nine census divisions of the United States differed significantly (p<0.001).An East-West trend was notable with the highest rate (37 filters/100,000 enrollees/yr) in New England, as compared with 14 filters/100,000 enrollees/yr in the Pacific Division. No explanation for these regional-differences was evident after patient demographics and comorbidity were examined. Vena cava filters prevent PE for at least 1 year after placement. The frequency of IVC filter use in elderly patients is increasing and varies substantially by region. Although reasons for these trends are unclear, these findings suggest the need for uniform practice guidelines for IVC filter placement.Supported in part by the National Institutes of Aging, grant R0 1 AG 07-146, and by a training grant from the National Library of Medicine (NIH 5 T15 LM07044) to Dr. Birkmeyer.     

Purified human oral mucosal Langerhans cells function as accessory cells in vitro.

Oral mucosal Langerhans cells (OMLC) may have an important role in the induction of immune responses to oral pathogens. In this study, anti-HLA-DR antibody-coated immunomagnetic beads were used to purify OMLC from suspensions of normal human buccal epithelium and the capacity of the purified cells to function as accessory cells (AC) was investigated. Electron microscopy was used to show that the purified cells possessed all recognized ultrastructural features previously described in epidermal Langerhans cells. Using T lymphocyte proliferation assays in hanging drop microcultures, it was found that purified OMLC could function as AC for responses to concanavalin A by autologous T cells. Purification of OMLC from small biopsies of oral mucosa has enabled us to show that OMLC, like epidermal Langerhans cells, can function as AC in vitro.