Acute heart failure syndromes: Potential strategies to improve post-discharge outcomes

Hospitalization for acute heart failure syndromes (AHFS) is a significant negative predictor of prognosis. Although patients' presenting symptoms generally improve throughout hospitalization in response to therapy, post-discharge event rates, defined as rehospitalization and/or mortality, remain unacceptably high. In the past decade, many lifesaving therapies for heart failure, such as beta-blockers, aldosterone antagonists, and cardiac resynchronization therapy (CRT), have been defined. Hospitalization presents a unique opportunity to implement these and other lifesaving therapies. However, these opportunities are often missed, perhaps because the traditional focus of hospitalization has been on symptom relief, not improvement of post-discharge outcomes. Although many therapies are now available, each needs to be tailored to each patient based on a proper assessment (eg, revascularization for those with severe coronary artery disease, CRT for those with wide QRS). Thorough cardiac assessment combined with tailored implementation may improve post-discharge outcomes. New strategies are needed to improve uptake of current best-evidence therapies to decrease the morbidity and mortality of AHFS.     

Brain Gray and White Matter Volume Loss Accelerates with Aging in Chronic Alcoholics: A Quantitative MRI Study

Magnetic resonance imaging (MRI) was used to study in vivo the brains of 49 patients with chronic alcoholism, 3 to 4 weeks post-withdrawal, and 43 normal healthy controls, all right-handed male veterans between the ages of 23 and 70 years. MRI scans were analyzed using a semi-automated procedure, which allowed the subcortical regions to be segmented into cerebrospinal fluid (CSF) and brain tissue and the cortical regions to be segmented into CSF, gray matter, and white matter. An age regression model was used to examine the effects of alcohol on brain structure, over and above that expected from the normal aging process. The alcoholics exhibited decreased tissue and increased CSF after correcting for aging. In the cortex, there was significant loss of both gray matter and white matter volume. In this sample of alcoholics, no particular cortical region was preferentially affected or spared. Furthermore, brain tissue volume loss increased with advanced age in the alcoholics. In this group of alcoholics there was no relationship between length of illness and age, i.e., the younger alcoholics had as heavy alcohol use histories as did the older alcoholics. Thus, the increased brain tissue loss with advanced age is interpreted as evidence for age-related increase in brain vulnerability to chronic alcohol abuse.     

Intramyocardial Injection of DNA Encoding Vascular Endothelial Growth Factor in a Myocardial Infarction Model

In a previous study, we observed that one injection of 500g of DNA for the plasmid encoding for vascular endothelial growth factor (ph VEGF₁₆₅) into one site in a rat myocardial infarction model resulted in neovascularization confined to angiomatous structures that did not contribute to regional myocardial blood flow. The purpose of the present study was to determine whether a lower dose (125g DNA), which is the same as that being used in some clinical trials, injected into four separate sites could enhance collateral flow and vascularity to the ischemic bed without inducing angiomas. Rats received injections of 125g DNA of the plasmid encoding phVEGF₁₆₅ or control DNA at four separate sites within the anterior free wall of the left ventricle (LV) supplied by the left coronary artery. The left coronary artery was ligated and hearts analyzed at 4 weeks. In vitro studies confirmed that the phVEGF₁₆₅ used was capable of producing VEGF polypeptide in mammalian cells. The infarct size (percentage of endocardial circumference that infarcted) was similar in controls (42±6%) and treated hearts (39±7%); the LV cavity area did not differ between groups. The number of vascular structures per high-power field within the infarct scar was 10.50±0.68 in controls and 10.00±0.85 in phVEGF₁₆₅-treated rats. Relative regional myocardial blood flow determined by radioactive microspheres and expressed as a ratio of radioactive counts within the scar divided by radioactive counts in the noninfarcted ventricular septum was similar in control (0.74±0.25) and treated hearts (0.88±0.30) (p=not significant). No angiomatous structures were observed. Injections of 125g of DNA of phVEGF₁₆₅ into myocardium to become ischemic had no effect on infarct size or LV cavity size. Unlike higher doses of 500g of DNA, it did not cause gross angiomatous structures; however, it failed to improve neovascularization or regional myocardial blood flow in this rodent model of acute myocardial infarction.     

The association between serum uric acid and asymptomatic intracranial arterial stenosis in middle-aged Koreans

Background and aims

Intracranial arterial stenosis (ICAS) is one of the most common causes of stroke, especially in Asians. Hyperuricemia has been associated with an increased risk of comorbidities such as metabolic syndrome or cardiovascular diseases. However, there are few studies focusing on the association between serum uric acid (SUA) levels and asymptomatic ICAS. The aim of this study was to explore the association between SUA and the prevalence of ICAS in middle-aged Korean health screening examinees.

The clinical impact of expert pathological review on lymphoma management: a regional experience

The All Wales Lymphoma Panel (AWLP) was established in January 1998 to provide a central expert pathological review service for district general hospital pathologists. A discordance rate of 20% between the submitted and reviewed diagnosis has previously been identified. It has not been known whether this change in diagnosis affects clinical management. Ninety-nine patients whose diagnosis was changed as a result of central pathological review are presented. Between January 1998 and August 2000, 125 of 745 (17%) specimens submitted for AWLP review had a consequent change in pathological diagnosis. Of these 125 specimens, 99 (79%) complete case notes were recovered. In all 99 cases, a hypothetical management plan was generated using collected data, clinical protocols and the submitted pathological diagnosis. These plans were compared with the actual management patients received based on the reviewed diagnosis proffered by the AWLP. Forty-six of 99 (46%) cases had a change in management as a result of central pathological review. Overall, management was changed in 8% of cases referred for central pathological review. In conclusion, expert central pathological review has a direct effect on patient management.     

Central projections of photoreceptor axons originating from ectopic eyes in Drosophila

Ectopic expression of the retinal determination gene eyeless (ey) induces the formation of supernumerary eyes on antennae, legs, wings, and halteres. These ectopic eyes form ommatidia that contain photoreceptors and accessory cells and respond to light. Here, we demonstrate that ectopic eyes on antennae and legs extend axonal projections to the central nervous system. Furthermore, electroretinograms and morphological evidence indicate that the photoreceptor axons of at least the antennal ectopic eyes can form completely constituted ectopic synapses with foreign postsynaptic elements and suggest that transmission at these sites may be functional. However, the ectopic axons do not connect to their correct optic lobe targets and do not project deeply into the neuropile, but rather form synapses at superficial positions in the neuropils. By means of confocal and electron microscopy we show that these ectopic synapses resemble normal synapses, albeit with some distinct morphological differences. Our data strongly suggest that the developmental programs controlling photoreceptor synaptogenesis and visual map formation depend to a considerable extent on presynaptic and thus photoreceptor-autonomous steps. Our data also suggest that photoreceptor axon projections and the establishment of the highly stereotypical neural circuitry in the optic lobe, the normal target neuropil, may depend on target-specific cues that appear to be absent from the antennal lobe and thoracic ganglion.     

Hyperglycemia alters perception of rectal distention and blunts the rectoanal inhibitory reflex in healthy volunteers

Acute hyperglycemia has been shown to alter gastrointestinal motility. The effects of hyperglycemia on rectal afferent neural and anal sphincter function were studied. Perception of rectal balloon distention, pressure-volume relationships, volumes necessary to induce reflex internal anal sphincter relaxation, resting anal sphincter pressure, and maximal anal sphincter squeeze pressure were measured under basal, hyperglycemic clamp, and euglycemic, hyperinsulinemic clamp conditions in 9 healthy volunteers. Hyperglycemic clamping (258 ± 14 mg/dL) significantly blunted threshold perception and the urge to defecate in response to rectal distention without altering perception of maximally tolerated distention. In contrast, euglycemic, hyperinsulinemic clamping had no effect on perception of rectal distention. Rectal pressure-volume relationships after hyperglycemic clamping were unchanged compared with basal conditions. Hyperglycemic clamping caused a significant increase in the distention necessary to induce the rectoanal inhibitory reflex. This effect was not observed under euglycemic, hyperinsulinemic clamp conditions. Hyperglycemia did not significantly affect resting internal anal sphincter pressure or maximal external anal sphincter squeeze pressure. Acute hyperglycemia but not secondary hyperinsulinemia reduces sensation of rectal distention and blunts the onset of the rectoanal inhibitory reflex, suggesting effects both on visceral afferents projecting to the cortex and intrinsic afferents mediating local reflex activity.     

Severe acute respiratory syndrome (SARS)

The severe acute respiratory syndrome (SARS) is a highly infectious respiratory disease, to the best of our knowledge caused by a hitherto unknown corona virus. The virus has spread from South East Asia to many countries of the world. Three case reports of patients from the Prince of Wales Hospital of The Chinese University of Hong Kong demonstrate typical clinical courses. Fever, cough, in most cases non-productive, myalgia, chills, and rigor are the leading symptoms. Leucopenia and thrombocytopenia are the most prominent laboratory parameters, increased values for lactatedehydrogenase (LDH) reflect a more severe clinical course. Advanced age and coexisting conditions seem to influence the prognosis unfavourably. The chest roentgenogram may be normal initially but at a later stage progressive consolidations in the majority of peripheral parts of the lung are observed, which cannot be differentiated from pneumonias of other origin. Even young patients can enter a stage of respiratory compromise rather fast. A therapy against the cause of the disease is not known. Empirical therapy with ribavirin in combination with high dose corticosteroids have proved successful. The disease may progress into respiratory failure comparable with an acute respiratory distress syndrome (ARDS). Mortality is around five to ten per cent. Stringent hygiene and quarantine measures are mandatory to prevent the further spread of this threatening disease.     

A case of colon obstruction developed during the recovery period of acute pancreatitis]

Complications of acute pancreatitis usually occur in pancreas and its contiguous organs. The prevalence of colonic invasion is rare, however, the consequence is fatal, with mortality above 50%. The initial symptoms and onset times are variable and major affected sites are transverse colon and splenic flexure. The spread of inflammatory exudates into the colon is the main mechanism of colonic invasion. If the colonic stenosis develops, it is necessary to manage it surgically. We report a case who arrived at the hospital with watery diarrhea and abdominal distension in the recovery period of acute alcoholic pancreatitis and was diagnosed as a colonic obstruction in the splenic flexure. The patient underwent loop ileostomy instead of the resection of the lesion because of severe adhesion around the splenic flexure. The patient died due to sepsis 5 days after the operation.