Systemic bevacizumab as salvage therapy for persistent severe bleeding and anemia in heyde syndrome following aortic valve replacement

Journal of Thrombosis and Thrombolysis - Heyde syndrome is characterized by the co-occurrence of aortic stenosis and bleeding gastrointestinal angiodysplasias, often with acquired von Willebrand...     

Bronchiectasis and chronic asthma: how common in pediatrics?

Asthma represents one of the most common chronic medical conditions affecting children. Although complications of asthma are rare, they deserve consideration when treating children with asthma. The aim of this study was report our experience with an 11-year-old boy with asthma that was complicated by bronchiectasis and to review our hospital's 10-year experience with bronchiectasis. We observed clinical and laboratory findings in a young boy with chronic asthma who developed bronchiectasis, reviewed medical records of 53 children with bronchiectasis followed at a university children's hospital to identify etiologies of bronchiectasis, and reviewed articles in the medical literature. Complications of asthma along with their diagnosis, pathogenesis, and treatment options are outlined in the discussion section. We describe the case of an 11-year-old boy with chronic asthma who did not respond to conventional asthma management and was found to have bronchiectasis. A detailed workup undertaken to identify the cause was negative for usual etiologies of bronchiectasis. In this patient, bronchiectasis was felt to be secondary to a long-standing history of asthma. Aggressive treatment of bronchiectasis led to significant improvement of asthma. Among 53 patients admitted for bronchiectasis, only 3 cases (5.6%) of asthma were identified. Cystic fibrosis (50.9%) and infection (13.2%) were the most common etiologies identified in our hospital's experience. No clear etiology was identified in 1.8% of patients. Although rare, bronchiectasis does occur in patients with chronic asthma. It is important that complications be recognized and treated for optimal management of asthma.     

Expression of heat shock proteins 70 and 47 in tissues following short-pulse laser irradiation: Assessment of thermal damage and healing

In order to develop effective laser-based therapeutics, the extent of laser-induced damage must be quantified for given laser parameters. Therefore, we want to determine the spatiotemporal expression patterns of heat shock proteins, both to understand the roles of heat shock proteins in laser-induced tissue damage and repair and to develop heat shock proteins as tools to illustrate the extent of laser-induced damage and wound healing following irradiation. We exposed anesthetized mice to the focused beam of a short-pulse Nd:YAG laser (1064 nm; 200 ns pulsewidth) for 15 s, while measuring temperature distribution in the skin using an infrared thermal camera. Following irradiation, we examined expression of HSP47 and HSP70 over time (0–24 h) as indicators of the heat shock response and recovery from damage in the laser-irradiated region. Expression patterns of HSP70 and HSP47 as detected by immunohistochemistry and confocal microscopy delineate the extent of damage and the process of healing in tissue. Both HSP70 and HSP47 were expressed in dermis and epidermis following laser irradiation, and the spatial and temporal changes in HSP expression patterns define the laser-induced thermal damage zone and the process of healing in tissues. HSP70 may define biochemically the thermal damage zone in which cells are targeted for destruction, and HSP47 may illustrate the process of recovery from thermally induced damage. Studying the effects of different laser parameters on the expression of HSPs will allow development of effective laser therapies that provide accurate and precise tissue ablation and may promote rapid wound healing following laser-based surgery.     

Inter‐Institutional Pathology Consultation: The Importance of Breast Pathology Subspecialization in a Setting of Tertiary Cancer Center

Inter‐institutional pathology consultation (IPC) has shown to be significant in patient care. The purpose of the study was to evaluate the impact of IPC for breast biopsies in our institution. A total of 502 consecutive consult cases of breast core needle biopsies were reviewed. The original pathology reports from the referring institutions and our reports were compared for all cases. All cases were reviewed by specialized breast pathologists. Discordance was divided into minor and major based on the impact on patient care. We reviewed the subsequent excisional biopsy for all discordant cases. Discordance was seen in 104 (20.7%) cases; 40 (8%) had a major discordance and 64 (13%) had a minor discordance. Subsequent surgical excision was available for 25 (62.5%) cases with major discordance and for 13 (20.3%) with minor discordance. Our interpretation changed management in 15 (3%) patients, while 25 (5%) had a potential of management change. The cases with major discordance could be subcategorized into five groups, malignant 5 (12.5%), premalignant 16 (40%), biomarkers 10 (25%), fibroepithelial lesions 6 (15%), and others 3 (7.5%). Our findings support the value of IPC review in decreasing the likelihood of diagnostic errors that may lead to significant impact on patient care. It is necessary that outside pathology material in the referral settings been reviewed by a specialized breast pathologist.     

Variants in Intron 4 of PD-1 Gene are Associated with the Susceptibility to SLE in an Iranian Population

Background: Programmed cell death protein 1 (PD-1) is a negative costimulatory molecule with immunomodulatory properties. Recently, PD-1 gene defects have attracted attention in the pathogenesis of SLE. Objective: Here, we assessed the association of PD-1 gene polymorphisms in intron 4 and haplotypes with the susceptibility to SLE. Method: Seventy-six SLE patients and 159 healthy controls were included. We screened the polymorphisms by amplifying the intron 4 of the PD-1 gene with the specific primers followed by sequencing. Results: Two distinct SNPs were identified (rs6705653 and rs41386439) within the intron 4 of the PD-1 gene. The AA genotype of +7499 (G/A) SNP was associated with the higher risk of SLE [OR=3.31, 95% CI (1.25-8.76), p-value=0.045], while A allele was identified as a risk allele [OR=1.75, 95% CI (1.10-2.76), p-value=0.015]. However, no significant association was observed between the allele and the genotype frequencies of +7209 (C/T) polymorphic region of the PD-1 gene and susceptibility to SLE. Haplotype analysis showed the significantly higher presence of H2 haplotype (AC; +7499/+7209) [OR=1.70, 95% CI (1.24-2.33), p-value=0.0012] in SLE patients. Conclusion: To the best of our knowledge, this is the first report of the significant association of PD-1 +7499 (G/A) SNP with the SLE susceptibility and the first detection of both polymorphic loci in a population from Iran. However, more investigations are necessary to confirm these findings.     

Long-stay patients in pediatric intensive care units: Five-years, 2-points,cross-sectional study

Objectives:To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources.Methods:This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included.Results:Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%).Conclusion:A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.     

Angiotensin converting enzyme inhibitors effect on arterial stiffness and wave reflections: a meta-analysis and meta-regression of randomised controlled trials

ObjectiveSeveral studies have assessed the effect of angiotensin converting enzyme inhibitors (ACEIs) on arterial stiffness and wave reflections as measured by pulse wave velocity (PWV) and augmentation index (AIx), respectively. We conducted a meta-analysis to investigate this effect in comparison to placebo and to other antihypertensive agents. Additionally, we investigated this effect when ACEIs are combined with other antihypertensive agents and in comparison to a combination of antihypertensive agents.MethodsMEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to May 2011 on randomised controlled trials (RCTs) which assessed the effect of ACEIs on arterial stiffness vs. placebo or no treatment and ACEIs vs. angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), β-blockers and diuretics. RCTs which assessed the effect of ACEIs combined with other antihypertensives or compared ACEIs with a combination of antihypertensives were also sought. Data from included RCTs were pooled with use of fixed and random effects meta-analysis of the weighted mean change differences between the comparator groups. Heterogeneity across studies was assessed with the I² statistic.ResultsIn 5 trials including 469 patients, treatment with ACEIs (n = 227) vs. placebo (n = 216) significantly reduced PWV (pooled mean change difference ?1.69, 95% C.I. ?2.05, ?1.33, p < 0.00001 with insignificant heterogeneity). In 9 trials which included 378 patients, treatment with ACEIs (n = 178) insignificantly reduced PWV when compared with other antihypertensives (ARBs, CCBs, β-blockers, diuretics and a combination of ACEI and ARB) (n = 220) (pooled mean change difference ?0.19, 95% C.I. ?0.59, 0.21, p = 0.36, I² = 0%). ACEI effect on AIx in comparison to placebo was assessed in 7 trials. Treatment with ACEIs significantly reduced AIx (pooled mean change difference ?3.79, 95% C.I. ?5.96, ?1.63, p = 0.0006) with significant heterogeneity. In 7 trials, treatment with ACEIs significantly reduced AIx when compared with other antihypertensives (pooled mean change difference ?1.84, 95% C.I. ?3, ?0.68, p = 0.002, I² = 32%, p for heterogeneity = 0.11). However, this effect was only significant when compared with β-blockers (pooled mean change difference ?1.6, 95% C.I. ?2.84, ?0.36, p = 0.01). Mean BP differences between baseline and end of treatment did not predict the treatment (ACEI) induced changes in PWV.ConclusionsACEIs reduce PWV and AIx which are markers of arterial stiffness and wave reflections in patients with different pathological conditions. However, due to the lack of high quality and properly powered RCTs, it is not clear whether ACEIs are superior to other antihypertensive agents in their effect on arterial stiffness. The ability of ACEIs to reduce arterial stiffness (PWV) seems to be independent of its ability to reduce BP.