Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy: series of six patients and review of literature

BACKGROUND:

Although an autoimmune mechanism has been postulated for myocarditis and acute-onset inflammatory dilated cardiomyopathy (DCM), immunomodulatory treatment strategies are still under investigation.

METHODS AND RESULTS:

The clinical data of six patients with acute inflammatory DCM referred for evaluation for possible heart transplantation were reviewed. All patients were admitted with acute congestive heart failure and severely impaired left ventricular (LV) function and were treated with high-dose (2 g/kg) intravenous immunoglobulin (IVIG). The diagnosis of acute inflammatory DCM was based on recent onset of congestive heart failure (New York Heart Association functional class III or IV) with severely depressed LV ejection fraction ([LVEF] 30% or lower) occurring shortly after viral-like illness. All patients had inflammation on endomyocardial biopsy or elevated cardiac enzymes, as well as a normal coronary angiogram. All patients were in New York Heart Association class I or II at the time of hospital discharge. The mean LVEF improved from 21.7±7.5% at baseline to 50.3±8.6% at discharge (P=0.005). Four patients had complete recovery (LVEF 50% or higher) and two patients had partial LV recovery. Patients were followed for a median 13.2 months (range two to 24 months) and had a mean LVEF of 53±6% (P not significant versus LVEF at discharge).

CONCLUSIONS:

Therapy with intravenous high-dose IVIG may be a potentially useful treatment in selected patients if given early in the course of acute fulminant inflammatory DCM. A randomized, prospective trial is warranted to prove the real benefit of IVIG in this patient population.     

Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study

BACKGROUND:

Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from ‘wet’ to ‘dry’ to a ‘goal-directed’ approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss.

OBJECTIVE:

The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration.

METHODS:

Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%.

RESULTS:

There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m² versus 3.0±0.5 L/min/m²; P=0.02) and SVI (51.4±2.4 mL/m² versus 43.3±2.3 mL/m²; P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01).

DISCUSSION:

Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less ‘rescue’ fluid administration during the perioperative period.     

Effect of Intravenous Administration of Liposomal Prostaglandin E1 on Microcirculation in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Intervention

Background:

Several studies have demonstrated that primary percutaneous coronary intervention (PCI) can result in reperfusion injury. This study aims to investigate the effectiveness of liposomal prostaglandin E1 (Lipo-PGE1, Alprostadil, Beijing Tide Pharmaceutical Co., Ltd.) for enhancing microcirculation in reperfusion injury. In addition, this study determined the optimal administration method for acute ST elevation myocardial infarction (STEMI) patients undergoing primary PCI.

Methods:

Totally, 68 patients with STEMI were randomly assigned to two groups: intravenous administration of Lipo-PGE1 (Group A), and no Lipo-PGE1 administration (Group B). The corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC) and myocardial blush grade (MBG) were calculated. Patients were followed up for 6 months. Major adverse cardiac events (MACE) were also measured.

Results:

There was no significant difference in the baseline characteristics between the two groups. The cTFC parameter in Group A was significantly lower than Group B (18.06 ± 2.06 vs. 25.31 ± 2.59, P < 0.01). The ratio of final MBG grade-3 was significantly higher (P < 0.05) in Group A (87.9%) relative to Group B (65.7%). There was no significant difference between the two groups in final TIMI-3 flow and no-reflow. Patients were followed up for 6 months, and the occurrence of MACE in Group A was significantly lower than that in Group B (6.1% vs. 25.9% respectively, P < 0.05).

Conclusions:

Myocardial microcirculation of reperfusion injury in patients with STEMI, after primary PCI, can be improved by administering Lipo-PGE1.     

Paradoxical response to intravenous immunoglobulin in a case of Parvovirus B19-associated chronic fatigue syndrome

We describe a case of chronic fatigue syndrome (CFS) associated to Parvovirus B19 infection where administration of intravenous immunoglobulins (IVIG), previously reported as effective, induced a paradoxical clinical response and increased viral replication. The indication of IVIG administration in the treatment of Parvovirus B19-associated CFS should be carefully reconsidered.     

Diagnosis and classification of Kawasaki disease

Kawasaki disease is an acute systemic vasculitis of unknown etiology. Diagnosis is based on clinical criteria that include fever, exanthema, conjunctivitis, changes in the extremities, erythema of oral mucosa and lips and cervical lymphadenopathy. However, these criteria have low sensitivity and specificity and therefore, other clinical and laboratory features may be helpful in establishing the diagnosis, especially for cases of atypical or incomplete Kawasaki disease. Prognosis depends on the extent of cardiac involvement; coronary aneurysms develop in 20–25% of untreated patients and these may lead to myocardial infarction and sudden death. Treatment with high-dose intravenous immunoglobulin is effective in reducing the risk of coronary aneurysms in most cases and is the treatment of choice for initial Kawasaki disease.     

舒心病房护理流程优化的探究和分析

目的：对静脉输液流程优化在舒心病房中的应用效果进行分析。方法建立流程管理组,并采取优化措施,对护理人员进行培训,监督反馈优化后流程执行情况。结果在药液核对分配时间、肝素封管时间以及换液时间方面,优化前后有明显差异(P<0.05)。流程优化以后,病房整体满意度为93.75%(75/80)、输液满意度为96.25%(77/80)。结论在对舒心病房输液流程进行优化以后,加强输液环节质量,使患者满意度得以提高,缩短患者等待时间。     

姜黄素预处理对急性缺血再灌注模型大鼠肝脏的保护作用

目的：建立姜黄素预处理的大鼠急性肝脏缺血再灌注模型,初步探讨姜黄素对急性缺血再灌注后大鼠肝脏的保护作用。方法：10只SD大鼠随机分为假手术组（n=3）、溶剂对照组（n=3）和实验组（n=4）。实验组和溶剂对照组大鼠在进行急性肝脏缺血再灌注前分别腹腔注射姜黄素和1%羧甲基纤维素钠（CMC）进行预处理。假手术组大鼠不进行急性肝脏缺血再灌注。采用超高效液相色谱-质谱（UPLC-MS）联用法分析各组大鼠血清中姜黄素水平,胆管导管术和荧光分析法检测各组大鼠胆汁流量,丙二醛（MDA）试剂盒检测各组大鼠肝脏组织中MDA水平。结果：腹腔注射200mg·kg^-1姜黄素1h后大鼠血清中姜黄素水平达到（0.17±0.05）mg·L^-1,并在注射3h后降到检测线以下。实验组大鼠肝脏组织中MDA水平为（9.18±1.78）mmol·g^-1,低于溶剂对照组（527.54mmol·g^-1±237.38mmol·g^-1）和假手术组（162.73mmol·g^-1±90.50 mmol·g^-1）。实验组大鼠在缺血再灌注后胆汁流量恢复到基线的40%左右,与溶剂对照组比较差异无统计学意义（P>0.05）,假手术组大鼠胆汁流量则保持在基线水平。结论：姜黄素腹腔注射给药后能迅速进入大鼠血液循环,并在体内较快代谢,其水平在给药3h后降到检测线以下。姜黄素预处理能有效降低缺血再灌注后肝脏组织中MDA水平,对肝脏起到保护作用,但对恢复胆汁流量的效果不明显。