Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy

OBJECTIVES: Activation of the neuroendocrine axis in congestive heart failure is of prognostic significance, and neurohumoral blocking therapy prolongs survival. The hypothesis that surgical reduction of left ventricular size and function decreases neuroendocrine activation is less established. We evaluated the neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy. METHODS: Norepinephrine, plasma renin activity, and angiotensin II were measured in 10 patients before and 12 months after left ventricular reconstruction. In an additional 5 patients, brain natriuretric peptide was measured before and 3 months postoperatively. Three-dimensional cardiovascular imaging was used to assess ejection fraction and left ventricular end-diastolic volume index. RESULTS: Concurrent with improvements of New York Heart Association functional class (2.9 +/- 0.5 preoperatively vs 2.0 +/- 0.4 postoperatively, P <.001), ejection fraction (23.9% +/- 6.6% vs 36.2% +/- 6.2%, P <.01), and left ventricular end-diastolic volume index (140.8 +/- 33.8 mL/m(2) vs 90.6 +/- 18.3 mL/m(2), P <.01), considerable reductions were observed for median plasma profiles of norepinephrine (562.0 pg/mL vs 319.0 pg/mL, P <.05), plasma renin activity (5.75 microg/L/h vs 3.45 microg/L/h, P <.05), angiotensin II (41.0 ng/mL vs 23.0 ng/mL, P =.051), and brain natriuretric peptide (771.0 pg/mL vs 266.0 pg/mL, P <.05). The more plasma renin activity or angiotensin II decreased after left ventricular reconstruction, the higher was the increase in ejection fraction (R = -.745, P <.05 [plasma renin activity]; R = -.808, P <.05 [angiotensin II]). CONCLUSIONS: Surgical improvements of ejection fraction and left ventricular end-diastolic volume index by left ventricular reconstruction were accompanied by improvement of both the neuroendocrine activity and the functional status in patients with congestive heart failure. Whether this favorable neurohormonal response is predictive of an improved survival requires further evaluation.     

Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post Dural Puncture Headache in Parturients after Inadvertent Dural Puncture

Background: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch.

Methods: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch.

Results: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group.     

Imaging findings in hippocampal sclerosis: correlation with pathology

We evaluated the ability of preoperative radiologic imaging to detect hippocampal sclerosis in 31 patients who underwent surgery for intractable epilepsy. Hippocampal sclerosis is commonly associated with surgically treatable temporal lobe epilepsy. It is pathologically described as neuronal cell loss with associated gliosis in the hippocampus. While previous reports have correlated imaging results with clinical or qualitative histologic findings, this study used quantitative pathologic criteria (neuronal cell density) to diagnosis hippocampal sclerosis. We focused our study on the 11 patients with cryptogenic temporal lobe epilepsy. Of these, nine had hippocampal sclerosis by pathologic criteria. MR findings included unilateral hippocampal atrophy, an increased signal in the hippocampus on long TR scans, and atrophy in the adjacent white matter and temporal lobe. Hippocampal atrophy was most frequently seen in the red nucleus plane on coronal scans, corresponding to the body of the hippocampus. We also compared hippocampal size on MR with neuronal density in surgical specimens of the 11 patients with cryptogenic temporal lobe epilepsy. A statistically significant correlation was found between MR size and neuronal density in CA3 and CA4 of the cornu ammonis and the granular cell layer of the hippocampus. Since temporal lobectomy eliminated seizures in seven of nine patients with hippocampal sclerosis, preoperative diagnosis by MR has important therapeutic consequences.     

Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review

PURPOSE: To determine the number of patients who received a diagnosis of breast cancer after having an area of clinical concern at presentation and combined negative mammographic and ultrasonographic (US) findings. MATERIALS AND METHODS: During a 4-year period, 829 patients with a palpable abnormality at presentation and combined negative mammographic and US findings were identified. The number of women who went on to receive a diagnosis of breast cancer was determined retrospectively. The authors searched the breast imaging database and the pathology database, sent a contact letter to the referring physicians, and linked their data to the State Cancer Registry. They also analyzed the breast parenchymal density among all patients who had more than 2 years of follow-up. RESULTS: Of the 829 women, 374 had follow-up information. Two-hundred thirty-three patients had negative imaging findings with more than 2 years of follow-up. The other 141 women were presumed to be cancer free, as they were not identified by the State Cancer Registry. Six (2.6%) of the 233 women had a diagnosis of breast cancer in the area of the palpable abnormality. The six cancers were diagnosed among the 156 women who had radiographically dense breast tissue (Breast Imaging Reporting and Data System category 3 or 4). Among the 77 women with predominantly fatty tissues, no cancers were diagnosed. CONCLUSION: A negative mammographic and US finding of a palpable abnormality does not exclude breast cancer, but the likelihood of breast cancer is low, approximately 2.6%-2.7%. It may be higher if the breast tissues are dense and lower if they are predominantly fatty.     

Arthroscopic intervention in early hip disease

Advancement in diagnostic and therapeutic applications for hip arthroscopy have dispelled previous myths about early hip disease. Arthroscopic findings have established the following facts: Acetabular labral tears do occur; acetabular chondral lesions do exist; tears are most frequently anterior and often associated with sudden twisting or pivoting motions; and labral tears often occur in association with articular cartilage lesions of the adjacent acetabulum or femoral head, and if present for years, contribute to the progression of delamination process of the chondral cartilage. Magnetic resonance arthrography represents an improvement over conventional magnetic resonance imaging, it does have limitations when compared with direct observation. Although indications for hip arthroscopy are constantly expanding, the most common indications include: labral tears, loose bodies, chondral flap lesions of the acetabular or femoral head, synovial chondromatosis, foreign body removal, and crystalline hip arthropathy (gout, pseudogout, and others). Contraindications include conditions that limit the potential for hip distraction such as joint ankylosis, dense heterotopic bone formation, considerable protrusio, or morbid obesity. Complication rates have been reported between 0.5 and 5%, most often related to distraction and include sciatic or femoral nerve palsy, avascular necrosis, and compartment syndrome. Transient peroneal or pudendal nerve effects and chondral scuffing have been associated with difficult or prolonged distraction. Meticulous consideration to patient positioning, distraction time and portal placement are essential. Judicious patient selection and diagnostic expertise are critical to successful outcomes. Candidates for hip arthroscopy should include only those patients with mechanical symptoms (catching, locking, or buckling) that have failed to respond to conservative therapy. The extent of articular cartilage involvement has the most direct relationship to surgical outcomes. Improvements in technique and instrumentation have made hip arthroscopy an efficacious way to diagnose and treat a variety of intra-articular problems.     

Reactivation during encoding supports the later discrimination of similar episodic memories

Episodic memory is characterized by remembering events as unique combinations of features. Even when some features of events overlap, we are later often able to discriminate among them. Here we ask whether hippocampally mediated reactivation of an earlier event when a similar one occurs supports subsequent memory that two similar but not identical events occurred (mnemonic discrimination). In two experiments, participants viewed objects (Experiment 1) or scenes (Experiment 2) during functional MRI (fMRI). After scanning, participants had to remember whether repeated items had been identical or similar. In Experiment 2, representational similarity between the 1st and 2nd presentation predicted participants' ability to remember that the presentations were different, suggesting that the first item was reactivated while viewing the second. A similar but weaker result was found in Experiment 1 that did not survive correction for multiple comparisons. Furthermore, both experiments yielded evidence that the hippocampus was involved in reactivation; hippocampal pattern similarity (and, in Experiment 2, hippocampal activity during the 2nd presentation) correlated with pattern similarity in several regions of visual cortex. These results provide the first fMRI evidence that hippocampally mediated reactivation contributes to the later memory that two similar, but different events occurred. © 2016 Wiley Periodicals, Inc.     

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.     

Initial survival data of kidney transplant patients with pre-transplant monoclonal gammopathy

Soltero L, Carbajal H, Xu J, McCarthy J, Suki WN, Gaber AO, Adrogué HE. Initial survival data of kidney transplant patients with pre‐transplant monoclonal gammopathy.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01539.x.
© 2011 John Wiley & Sons A/S. Abstract: Background: Monoclonal gammopathy of undetermined significance (MGUS) is the presence of a serum monoclonal protein at a concentration of <3 g/dL without evidence of lymphoproliferative disease or organ damage. The prevalence of MGUS in kidney transplantation (KT) candidates is unknown. The present is a retrospective report of patients who underwent evaluation for a KT and were found to have MGUS at our center. Methods: All transplant candidates found to have MGUS between the years 2000 and 2007 were included. Variables were collected. Patients with MGUS that received a KT were compared with patients with MGUS that were not transplanted. Results: Of a total of 1215 KT candidates, 34 were found to have MGUS during the KT evaluation. Nine patients with MGUS were transplanted. Myeloma or lymphoproliferative disease was not observed. Following transplantation, the MGUS group had a lower survival than the non‐transplanted group. However, survival from the time of MGUS diagnosis was not different between the transplanted and non‐transplanted MGUS groups. Conclusions: In this group, transplantation did not confer a survival benefit. It is our hope that these initial data will serve as a platform for future studies. We suggest MGUS screening in all patients older than 50 yr of age undergoing evaluation for transplantation.     

Does the quality,accuracy, and readability of information about lateral epicondylitis on the internet vary with the search term used?

Background

Concern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis.

Methods

We used three different search terms (“tennis elbow,” “lateral epicondylitis,” and “elbow pain”) in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website’s readability using the Flesch–Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons.

Results

The mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms “tennis elbow” and “lateral epicondylitis” compared to “elbow pain” (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information.

Conclusions

Reliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.