Postoperative ST-segment elevation: was vasospasm caused by anaphylaxis or by its treatment with epinephrine?

BACKGROUND: Anaphylaxis must be recognized and treated promptly to avoid significant morbidity and mortality. In this clinical setting, electrocardiographic changes can be multifactorial. OBJECTIVE: To discuss vasospasm as a cause of myocardial ischemia and its possible triggering by anaphylaxis itself or by the administration of epinephrine. METHODS: We describe a patient with multiple previous allergies who received intravenous epinephrine to treat suspected anaphylaxis. She immediately developed crushing chest pain with ST-segment elevations in the inferior leads. Throughout the discussion, we address differential diagnoses, physiologic features, and treatment. RESULTS: Her symptoms and electrocardiographic changes were consistent with vasospasm, which resolved after treatment with sublingual nitroglycerin. However, the reaction was sufficient to cause an elevation in the troponin T level and, therefore, myocardial damage on the cellular level. CONCLUSIONS: Cardiovascular complications, including electrocardiographic changes, may be induced by anaphylactic mediators or by medications used for its treatment.     

Laparoscopic assisted cholecystostomy

Laparoscopic assisted cholecystostomy (LAC) is a safe method for external biliary drainage in jaundiced patients with distal common bile duct obstruction. It consists of the retrieval of the fundus of the gallbladder through the trocar, thus through abdominal wall followed by suture to the skin. This technique could be an option for surgeons who manage a patients with jaundice by distal common bile duct obstruction.     

GRK2 as a therapeutic target for heart failure

Introduction: G protein-coupled receptor (GPCR) kinase-2 (GRK2) is a regulator of GPCRs, in particular β-adrenergic receptors (ARs), and as demonstrated by decades of investigation, it has a pivotal role in the development and progression of cardiovascular disease, like heart failure (HF). Indeed elevated levels and activity of this kinase are able to promote the dysfunction of both cardiac and adrenal α- and β-ARs and to dysregulate other protective signaling pathway, such as sphingosine 1-phospate and insulin. Moreover, recent discoveries suggest that GRK2 can signal independently from GPCRs, in a ‘non-canonical’ manner, via interaction with non-GPCR molecule or via its mitochondrial localization.

Areas covered: Based on this premise, GRK2 inhibition or its genetic deletion has been tested in several disparate animal models of cardiovascular disease, showing to protect the heart from adverse remodeling and dysfunction.

Expert opinion: HF is one of the leading cause of death worldwide with enormous health care costs. For this reason, the identification of new therapeutic targets like GRK2 and strategies such as its inhibition represents a new hope in the fight against HF development and progression. Herein, we will update the readers about the ‘state-of-art’ of GRK2 inhibition as a potent therapeutic strategy in HF.     

Expression of the genes GAD67 and Distal-less-4 in the forebrain of Xenopus laevis confirms a common pattern in tetrapods

We investigated whether gamma-amino butyric acidergic (GABAergic) cell populations correlate positionally with specific Dlx-expressing histogenetic territories in an anamniote tetrapod, the frog Xenopus laevis. To that end, we cloned a fragment of Xenopus GAD67 gene (xGAD67, expressed in GABAergic neurons) and compared its expression with that of Distal-less-4 gene (xDll-4, ortholog of mouse Dlx2) in the forebrain at late larval and adult stages. In Xenopus, GABAergic neurons were densely concentrated in xDll-4-positive territories, such as the telencephalic subpallium, part of the hypothalamus, and ventral thalamus, where nearly all neurons expressed both genes. In contrast, the pallium of Xenopus generally contained dispersed neurons expressing xGAD67 or xDll-4, which may represent local circuit neurons. As in amniotes, these pallial interneurons may have been produced in the subpallium and migrated tangentially into the pallium during development. In Xenopus, the ventral division of the classic lateral pallium contained extremely few GABAergic cells and showed only low signal of the pallial gene Emx1, suggesting that it may represent the amphibian ventral pallium, homologous to that of amniotes. At caudal forebrain levels, a number of GABAergic neurons was observed in several areas (dorsal thalamus, pretectum), but no correlation to xDll-4 was observed there. The location of GABAergic neurons in the forebrain and their relation to the developmental regulatory genes Dll and Dlx were very similar in Xenopus and in amniotes. The close correlation in the expression of both genes in rostral forebrain regions supported the notion that Dll/Dlx are among the genes involved in the acquisition of the GABAergic phenotype.     

Enhanced uptake of ifosfamide into GH3 prolactinomas with hypercapnic hyperoxic gases monitored in vivo by (31)P MRS

Previously, ³¹P magnetic resonance spectroscopy (MRS) has been used to detect ifosfamide (IF) in vivo and to show that breathing carbogen (5% CO₂/95% O₂) enhances the uptake and increases the efficacy of IF in rat GH3 prolactinomas [Rodrigues LM, Maxwell RJ, McSheehy PMJ, Pinkerton CR, Robinson SP, Stubbs M, and Griffiths JR (1997). In vivo detection of ifosfamide by ³¹P MRS in rat tumours; increased uptake and cytotoxicity induced by carbogen breathing in GH3 prolactinomas. Br J Cancer 75, 62–68]. We now show that other hypercapnic and/or hyperoxic (5% CO₂ in air, 2.5% CO₂ in O₂) gas mixtures also increase the uptake of IF into tumors, measured by ³¹P MRS. All gases caused an increased uptake (C_max) of IF compared to air breathing, with carbogen inducing the largest increase (85% (P<.02) compared to 46% with 2.5% CO₂ in O₂ (P<.004) and 48% with 5% CO₂ in air (P<.004)). The T_max (time of maximum concentration in tumor posintravenous injection of IF) was significantly (P<.04) later in the cohort that breathed 5% CO₂ in air. The increased uptake of IF with carbogen breathing was selective to tumor tissue and there were no significant increases in any of the normal tissues studied, suggesting that any host tissue toxicity would be minimal. Carbogen breathing by patients causes breathlessness. There was no significant difference in IF uptake between breathing carbogen and 2.5% CO₂ in O₂ and, therefore, the ability of 2.5% CO₂ in O₂ to also increase IF uptake may be clinically useful as it causes less patient discomfort.     

Needle catheter jejunostomy versus "Witzel" tube jejunostomy for early postoperative enteral nutrition in surgical patients. Prospective randomized study

Malnutrition in surgical patients can be present since their admission into hospital or can appear in the postoperative period. Early postoperative enteral nutrition (EPEN) is recommended to these patients as often as possible. In cases where the patients are severely malnourished with major digestive surgical interventions which we estimate that will be unable to feed orally efficient minimum 7-10 days postoperatively, we recommend EPEN on jejunostomy. Prospective randomized evaluation of 37 patients (75.6% severely malnourished): 19 with needle catheter jejunostomy (NCJ), group A, respectively 18 with standard "Witzel" tube jejunostomy (STJ), group B. 22 patients presented malignant tumors and 15 serious benign problems. On 7 patients the jejunostomy was done at the reoperation. Postoperative major complications were observed on 54.05% of the patients (independent of the jejunostomy) and the postoperative mortality rate was of 13.33% on the patients that had jejunostomy and EPEN on their first operation, and 57.14 respectively on the patients where jejunostomy was done at the reoperation. The two groups were similar with respect to age, sex, length of EPEN and hospital stay, presence of malnutrition, complications and mortality. Postoperative complications were statistically more frequent in anemic patients (68.8%) respectively anemic and severely malnourished (76.47). Minor complication related to the jejunostomy occurred in 5.6% of the group A and 22.2% of the group B. NCJ was done rapidly the same as STJ (7 min vs. 15 min). In conclusion, EPEN on jejunostomy on surgically malnourished patients, who have suffered major superior digestive interventions is beneficial. Postoperative complications have been more frequent on anemic and severely malnourished. NCJ is easier to perform and safer.     

Expression patterns of developmental regulatory genes show comparable divisions in the telencephalon of Xenopus and mouse: insights into the evolution of the forebrain

In this study, we review data on the existence of comparable divisions and subdivisions in the telencephalon of different groups of tetrapods based on expression of some developmental regulatory genes, having a particular focus in the comparison of the anuran amphibian Xenopus and the mouse. The available data on Xenopus, mouse, chick and turtle indicate that apparently all tetrapod groups possess the same molecularly distinct divisions and subdivisions in the telencephalon. This basic organization was likely present in the telencephalon of stem tetrapods. Each division/subdivision is characterized by expression of a unique combination of developmental regulatory genes, and appears to represent a self-regulated and topologically constant histogenetic brain compartment that gives rise to specific groups of cells. This interpretation has an important consequence for searching homologies, since a basic condition for cell groups in different vertebrates to be considered homologous is that they originate in the same compartment. However, evolution may allow individual cell groups derived from comparable (field homologous) subdivisions to be either similar or dissimilar across the vertebrate groups, giving rise to several possible scenarios of evolution, which include both the evolutionary conservation of similar (homologous) cells or the production of novel cell groups. Finally, available data in the lamprey, a jawless fish, suggest that not all telencephalic subdivisions were present at the origin of vertebrates, raising important questions about their evolution.