Tetralogy of Fallot with Cor Triatriatum Dexter in an Adult Patient: A Case Report

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect with only approximately 3% of uncorrected patients surviving past age 40. In this case report, we present a 48‐year‐old mentally retarded man suffering from congenital spastic quadriplegia who was diagnosed with a unique combination of symptomatic TOF and cor triatriatum dexter (CTD). Reduced preload because of CTD with spastic quadriplegia that prevented physical exertion is believed to have facilitated this patient's unusually long survival.     

YC-1, a novel activator of platelet guanylate cyclase

YC-1 [3-(5'-hydroxymethyl-2'-furyl)-1-benzylindazole] inhibited the aggregation of and ATP release from washed rabbit platelets induced by arachidonic acid (AA), collagen, U46619, platelet-activating factor (PAF), and thrombin in a concentration-dependent manner. YC-1 also disaggregated the clumped platelets caused by these inducers. The thromboxane B2 formation caused by collagen, PAF, and thrombin was inhibited by concentrations of YC-1 that did not affect formation of thromboxane B2 and prostaglandin D2 caused by AA. YC-1 suppressed the increase of intracellular Ca2+ concentration and generation of inositol 1,4,5-trisphosphate caused by these five aggregation inducers. Both the cAMP and cGMP contents of platelets were increased by YC-1 in a concentration- and time-dependent manner. Like sodium nitroprusside, YC- 1 potentiated formation of cAMP caused by prostaglandin E1 but not that by 3-isobutyl-1-methylxanthine. Adenylate cyclase and cAMP phosphodiesterase activities were not altered by YC-1. Activity of cGMP phosphodiesterase was unaffected by YC-1. Activities of guanylate cyclase in platelet homogenate and cytosolic fraction were activated by YC-1, whereas particulate guanylate cyclase activity was unaffected. The antiplatelet effect of sodium nitroprusside but not that of YC-1 was blocked by hemoglobin and potentiated by superoxide dismutase. After intraperitoneal administration for 30 minutes, YC-1 prolonged the tail bleeding time of conscious mice. These data indicate that YC-1 is a direct soluble guanylate cyclase activator in rabbit platelets. It may also possess antithrombotic potential in vivo.     

Neuropsychological testing of cognitive impairment in euthymic bipolar disorder: an individual patient data meta‐analysis

Objective

An association between bipolar disorder and cognitive impairment has repeatedly been described, even for euthymic patients. Findings are inconsistent both across primary studies and previous meta‐analyses. This study reanalysed 31 primary data sets as a single large sample (N = 2876) to provide a more definitive view.

Method

Individual patient and control data were obtained from original authors for 11 measures from four common neuropsychological tests: California or Rey Verbal Learning Task (VLT), Trail Making Test (TMT), Digit Span and/or Wisconsin Card Sorting Task.

Results

Impairments were found for all 11 test‐measures in the bipolar group after controlling for age, IQ and gender (Ps ≤ 0.001, E.S. = 0.26–0.63). Residual mood symptoms confound this result but cannot account for the effect sizes found. Impairments also seem unrelated to drug treatment. Some test‐measures were weakly correlated with illness severity measures suggesting that some impairments may track illness progression.

Conclusion

This reanalysis supports VLT, Digit Span and TMT as robust measures of cognitive impairments in bipolar disorder patients. The heterogeneity of some test results explains previous differences in meta‐analyses. Better controlling for confounds suggests deficits may be smaller than previously reported but should be tracked longitudinally across illness progression and treatment.     

Attention,awareness, and the right temporoparietal junction

The attention schema theory posits a specific relationship between subjective awareness and attention, in which awareness is the control model that the brain uses to aid in the endogenous control of attention. In previous experiments, we developed a behavioral paradigm in human subjects to manipulate awareness and attention. The paradigm involved a visual cue that could be used to guide attention to a target stimulus. In task 1, subjects were aware of the cue, but not aware that it provided information about the target. The cue measurably drew exogenous attention to itself. In addition, implicitly, the subjects’ endogenous attention mechanism used the cue to help shift attention to the target. In task 2, subjects were no longer aware of the cue. The cue still measurably drew exogenous attention to itself, yet without awareness of the cue, the subjects’ endogenous control mechanism was no longer able to use the cue to control attention. Thus, the control of attention depended on awareness. Here, we tested the two tasks while scanning brain activity in human volunteers. We predicted that the right temporoparietal junction (TPJ) would be active in relation to the process in which awareness helps control attention. This prediction was confirmed. The right TPJ was active in relation to the effect of the cue on attention in task 1; it was not measurably active in task 2. The difference was significant. In our interpretation, the right TPJ is involved in an interaction in which awareness permits the control of attention.     

髋保护器的临床应用

目的:总结并分析髋部骨折的原因和生理机制,探讨髋保护器在适合人群中应用的意义。方法:应用计算机检索Pubmed 1989-01/2004-08关于髋保护器的文章。检索词为“髋部骨折,髋保护器(请翻译为英文)”并限制文章的语言种类为English。同时利用计算机检索中国期刊全文数据库1989-01/2004-08的相关文章,限定文章语言种类为中文,检索词“髋部骨折,髋保护器”。对检索到资料进行初审,纳入标准:①髋部骨折的原因、生理机制、护理措施。②髋保护器的作用、适应性及使用效果的评价。排除标准:相同性的文献资料。结果:髋保护器在临床上应用的时间只有短短几年,是简单有效、依从性较好,非药物干预的一种低廉的护理干预措施。适用于身体虚弱、老年患者、骨质疏松患者和有髋部骨折趋势的患者。因此,髋保护器不仅能预防跌倒后引起的髋部骨折,使髋部骨折降低15%～25%,而且能提高患者自身防跌倒自信,提高运动能力,使患者获得较好的生活质量。结论:有针对性的使用髋部保护器,不仅能预防跌倒后引起的髋部骨折,而且提高患者自身防跌倒自信。     

Marginal Gaps between 2 Calcium Silicate and Glass Ionomer Cements and Apical Root Dentin

Introduction

The outcome of periapical surgery has been directly improved with the introduction of novel material formulations. The aim of the study was to compare the retrograde obturation quality of the following materials: calcium silicate (Biodentine; Septodont, Saint-Maur-des-Fosses, France), mineral trioxide aggregate (MTA+; Cerkamed Company, Stalowa Wola, Poland), and glass ionomer cement (Fuji IX; GC Corporation, Tokyo, Japan).

静脉注射同种异体骨髓间充质干细胞对血管性痴呆大鼠海马区脑组织形态及微管相关蛋白2表达的影响

目的:骨髓间充质干细胞移植进入脑组织后,能否影响脑组织的形态及微管相关蛋白2的表达从而改善痴呆状态下的认知功能?观察静脉注射同种异体骨髓间充质干细胞后,血管性痴呆模型大鼠脑海马CA1区脑组织形态及微管相关蛋白2的变化。方法:实验于2004-08/2005-05在解放军第二军医大学完成。①实验动物:健康雄性SD大鼠60只,随机数字表法分为细胞移植组、模型对照组、假手术组,20只/组。②实验方法:另取20只大鼠用于体外分离、培养扩增骨髓间充质干细胞,传至第2代时加入BrdU进行标记,制备单细胞悬液,调整细胞浓度为3×109L-1。细胞移植组、模型对照组采用双侧颈总动脉结扎法建立血管性痴呆动物模型,假手术组仅暴露双侧颈总动脉但不结扎。造模后4周,细胞移植组尾静脉注射骨髓间充质干细胞悬液1mL,模型对照组注射等量磷酸盐缓冲液,假手术组不进行尾静脉注射。③实验评估:细胞移植后4周,苏木精-伊红染色检测各组大鼠脑海马CA1区脑组织形态变化,免疫荧光染色观察经BrdU标记的骨髓间充质干细胞示踪情况,免疫组织化学染色检测脑海马CA1区微管相关蛋白2的表达。结果:细胞移植组5只大鼠死亡,模型对照组3只大鼠死亡,假手术组均进入结果分析。①脑海马CA1区锥体细胞形态变化:细胞移植组和模型对照组CA1区锥体细胞较假手术组排列稀疏、紊乱,细胞肿胀、脱失,核固缩,但细胞移植组细胞排列较模型对照组规则,且细胞肿胀、脱失及核固缩较模型对照组减轻。②脑海马内骨髓间充质干细胞的示踪:细胞移植后4周,大鼠脑海马内可见被绿色荧光标记的骨髓间充质干细胞。③脑海马CA1区微管相关蛋白2的表达:与假手术组比较,细胞移植组及模型对照组脑海马CA1区锥体细胞层微管相关蛋白2阳性产物的吸光度值均明显降低(P<0.05);细胞移植组明显高于模型对照组(P<0.05)。结论:静脉注射骨髓间充质干细胞能够使血管性痴呆大鼠脑海马CA1区神经元损伤及脱失减轻,并使微管相关蛋白2表达增加。     

Results of extracorporeal life support implementation in routine clinical practice: single center experience

Aim

To describe our experience in the clinical application of extracorporeal life support (ECLS) and analyze whether ECLS leads to acceptable clinical outcomes in patients with cardiac failure.

Methods

Data from clinical database of University Hospital Center Zagreb, Croatia, on 75 patients undergoing ECLS support from 2009 to 2014 due to cardiac failure were retrospectively analyzed. Outcomes were defined as procedural and clinical outcomes. ECLS as a primary procedure and ECLS as a postcardiotomy procedure due to inability to wean from cardiopulmonary bypass were analyzed.

Results

ECLS was used in 75 adult patients, and in 24 (32%) of those procedural success was noted. ECLS was implemented as a primary procedure in 36 patients and as a postcardiotomy procedure in 39 patients. Nine out of 39 (23.08%) patients had postcardiotomy ECLS after heart transplantation. Bleeding complications occurred in 30 (40%) patients, both in primary (11/36 patients) and postcardiotomy group (19/39 patients). ECLS was established by peripheral approach in 46 patients and by central cannulation in 27 patients. In 2 patients, combined cannulation was performed, with an inflow cannula placed into the right atrium and an outflow cannula placed into the femoral artery. Eleven patients treated with peripheral approach had ischemic complications.

Conclusion

ECLS is a useful tool in the treatment of patients with refractory cardiac failure and its results are encouraging in patients who otherwise have an unfavorable prognosis. The idea of extracorporeal life support (ECLS) became a reality with the introduction of the heart-lung machine by Gibbon in 1954 (1). However, only in 1971 the first successful extracorporeal membrane oxygenation treatment was described (2). Since then continuous technological improvements have led to the growing interest in this type of treatment (3).ECLS may significantly improve the level of patient care in patients with acute and chronic heart failure. It is an advanced form of treatment and the patient management is carried out by a multidisciplinary team of cardiac surgeons, anesthesiologists, and cardiologists.There are two main groups of indications for ECLS: those not related and those related to cardiac surgery. Primary ECLS procedures are not related to cardiac surgery but to acute cardiorespiratory failure arising from underlying cardiac disease. Postcardiotomy ECLS procedures may be considered as a secondary procedure and are directly related to cardiac surgery procedures. These procedures are indicated after cardiac surgery procedures when patients cannot be weaned from cardiopulmonary bypass or when there is low cardiac output syndrome in the early postoperative phase. Postcardiotomy cardiogenic shock occurs in up to 6% of cardiac operations (4-6), with only 25% of those patients surviving to hospital discharge (4). Therefore, postcardiotomy cardiogenic shock is one of the most difficult and resource-consuming conditions, as it is associated with particularly high mortality rates. Since the risk profiles of patients scheduled for cardiac surgery procedures are continuously worsening, one may expect an increase in the number of patients requiring ECLS peri-operatively. Although these patients have only 25% of survival to hospital discharge (4), one should be aware that they would have nearly 100% mortality if they were not placed on ECLS. Although early ECLS results for postcardiotomy cardiogenic shock were found to be poor (5,7), they have been improved by continuous technological advances (5,8-10). Primary ECLS procedures may also play a significant role in cardiac surgery patients. In general, ECLS restores body perfusion and allows different treatment modalities. This may help optimize a patient’s clinical condition while waiting for a heart transplant. If a patient is not considered a suitable candidate for a heart transplant, ECLS may provide a bridge to long-term mechanical circulatory support. However, if ECLS is intended to bridge a patient to recovery (for instance in patients with acute myocarditis), then ECLS support may be considered as a treatment per se.ECLS may be used as either; 1) bridge to recovery, 2) bridge to transplant, 3) bridge to decision, or 4) bridge to intermediate or long term support. “Bridging concept” is important because a lack of exit strategy (eg, reason for bridging) may actually suggest a possible contraindication for ECLS.ECLS may play a significant role in patients with acute cardiogenic shock prior to scheduled cardiac surgery procedures such as intermediate to long term mechanical circulatory support, heart transplant, or other cardiosurgical procedures depending on the preexisting condition.Preoperative patient optimization using ECLS improves the outcomes of the level 1 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) patients receiving a permanent ventricular assist device (11). This “bridge-to-bridge” concept consisted of preoperative stabilization of level 1 INTERMACS patients using ECLS a few days prior to ventricular assist device implantation. ECLS significantly improved renal, hepatic, and pulmonary functions (11).In addition to this, preoperative ECLS support may significantly improve outcomes in patients presenting with acute myocardial infarction (AMI) complicated with ventricular septal defect (VSD) and cardiogenic shock (12). Preoperative ECLS provided hemodynamic support, ensured end-organ perfusion, helped the myocardium to recover and allow scar tissue to be formed by reducing sheer forces, thus leading to more favorable outcomes (12).For both primary and postcardiotomy indications, our team generally prefers combined support to the heart and lungs (ECLS) rather than isolated mechanical circulatory support to the failing heart. ECLS can be implanted bedside, providing support to both the heart and the lungs simultaneously. Nowadays ECLS is available in many centers that do not perform ventricular assist device implantation. In such centers, patients should be preoperatively stabilized and transferred on support to tertiary care centers for further treatment. To facilitate this process, it would be necessary to establish an ECLS network with ECLS centers cooperating with tertiary centers that perform long term mechanical circulatory support, heart transplant, as well as complex surgical corrections. In this article, we describe our experience in the clinical application of extracorporeal life support (ECLS) and aim to analyze whether ECLS leads to acceptable clinical outcomes in patients with cardiac failure.