Predictive value of two-dimensional echocardiographic and hemodynamic measurements on admission with acute myocardial infarction

To identify high-risk patients with acute myocardial infarction, we compared admission values of two-dimensional echocardiography and hemodynamic monitoring. Left ventricular wall motion score (WMS), left ventricular stroke work index (LVSWI), and pulmonary capillary pressure (PCP) were obtained in 77 patients without clinical signs of heart failure. Progression into Killip grade 3 or 4 was found in 16 of 77 patients (21%) within 32 +/- 6 hours (mean +/- 1 standard deviation) after admission. Mean WMS, LVSWI, and PCP in those patients who developed severe pump failure were significantly different from those who did not: 13.4 +/- 4.9 versus 7.3 +/- 4, 30 +/- 4 versus 46 +/- 11 gm/m2, and 21 +/- 8 versus 12 +/- 6 mm Hg, respectively. Sensitivity of WMS of greater than 7 and LVSWI of less than 35 gm/m2 in predicting Killip grade 3 or 4 was 88% and 94%, specificity was 57% and 87%, positive predictive value was 35% and 65%, and negative predictive value was 95% and 98%. Sensitivity of PCP was low (50%). Early identification of patients developing myocardial rupture or reinfarction was limited by both methods. We conclude that echocardiographic examination on admission in patients with acute myocardial infarction provides an alternative approach for early identification of low-risk patients.     

Metabotropic glutamate receptors are associated with non-synaptic appendages of unipolar brush cells in rat cerebellar cortex and cochlear nuclear complex

Unipolar brush cells (UBCs) are a class of small neurons that are densely concentrated in the granular layers of the vestibulocerebellar cortex and dorsal cochlear nucleus. The UBCs form giant synapses with individual mossy fibre rosettes on the dendrioles which make up their brush formations and are provided with numerous, unusual non-synaptic appendages. In accord with the glutamatergic nature of mossy fibres, our previous post-embedding immunocytochemical studies indicated that various ionotropic glutamate receptor subunits are localized at the post-synaptic densities of the giant synapses, whereas the non-synaptic appendages are immunonegative. On the contrary, the metabotropic glutamate receptors mGluR1 and mGluR2/3 are situated at the non-synaptic appendages and are lacking at the post-synaptic densities. Other authors, however, have shown that antibodies to these metabotropic receptors stain both appendages and post-synaptic densities. In the present study, we have re-evaluated the distribution of metabotropic glutamate receptors in the UBCs of the cerebellum and the cochlear nuclear complex by light and electron microscopic pre-embedding immunocytochemistry with subtype-specific antibodies. We confirm that UBCs dendritic brushes are densely immunostained by antibody to mGluR1 particularly in the cerebellum and that antibody to mGluR2/3 labels at least a percentage of the UBC brushes in both the cerebellum and cochlear nuclei. At the ultrastructural level, it appears that mGluR1 and mGluR2/3 immunoreactivities are not associated with the post-synaptic densities of the giant mossy fibre–UBC synapses, but instead are concentrated on the non-synaptic appendages of the cerebellar UBCs. The non-synaptic appendages, therefore, may be an important avenue for regulating the excitability of UBCs and mediating glutamate effects on their still unknown intracellular signal transduction cascades. We also show that the pre-synaptic densities of UBC dendrodendritic junctions are mGluR2/3 positive. As previously demonstrated, antibodies to mGluR1 and mGluR2/3 label subsets of Golgi cells. Antibody to mGluR5 does not stain UBCs in the cerebellum and cochlear nucleus and reveals the somatodendritic compartment of Golgi cells situated in the core of the cerebellar granular layer, whilst cochlear nucleus Golgi cells are mGluR5 negative.     

Cerebellar choline acetyltransferase positive mossy fibres and their granule and unipolar brush cell targets: a model for central cholinergic nicotinic neurotransmission

Summary A subset of cerebellar mossy fibres is rich in choline acetyltransferase, the rate-limiting enzyme for the synthesis of acetylcholine. These choline acetyltransferase-positive mossy fibres are concentrated in the vestibulocerebellum and originate predominantly from the medial vestibular nucleus. The granular layer of the vestibulocerebellum is also enriched in unipolar brush cells, an unusual type of small neuron that form giant synapses with mossy fibres. In this immunocytochemical light and electron microscopic study, we explored whether choline acetyltransferase-positive mossy fibres innervate unipolar brush cells of the rat cerebellum. We utilized monoclonal antibodies to rat choline acetyltransferase of proven specificity, and immunoperoxidase procedures with 3,3-diaminobenzidine tetrahydrochloride as the chromogen. A high density of choline acetyltransferase-positive fibres occurred in the nodulus and ventral uvula, where they showed an uneven, zonal distribution. Immunostained mossy fibre rosettes contained high densities of round synaptic vesicles and mitochondria. They formed asymmetric synaptic junctions with dendritic profiles of both granule cells and unipolar brush cells. The synaptic contacts between choline acetyltransferase-immunoreactive mossy fibres and unipolar brush cells were very extensive, and did not differ from synapses of choline acetyltransferase-negative mossy fibres with unipolar brush cells. Analysis of a total area of 1.25 mm² of the nodulus from three rats revealed that 14.2% of choline acetyltransferase-immunoreactive mossy fibre rosettes formed synapses with unipolar brush cells profiles. Choline acetyltransferase-positive rosettes accounted for 21.7% of the rosettes forming synapses with unipolar brush cells. Thus, the present data demonstrate that unipolar brush cells are innervated by a heterogeneous population of mossy fibres, and that some unipolar brush cells receive cholinergic synaptic input from the medial vestibular nucleus. The ultrastructure of these synapses is compatible with the possibility that choline acetyltransferase-positive mossy fibres co-release acetylcholine and glutamate. As the granular layer of the vestibulocer-ebellum contains nicotinic binding sites, the choline acetyltransferase-positive mossy fibres may be a model for studying nicotinic neurotransmission in the CNS.25th Anniversary IssueTo whom correspondence should be addressed.     

Heart Failure Telemonitoring in Japan and Sweden: A Cross-Sectional Survey

Background

Telemonitoring of heart failure (HF) patients is increasingly discussed at conferences and addressed in research. However, little is known about actual use in specific countries.

Objective

We aimed to (1) describe the use of non-invasive HF telemonitoring, (2) clarify expectations of telemonitoring among cardiologists and nurses, and (3) describe barriers to the implementation of telemonitoring in Japan and Sweden.

Methods

This study used a cross-sectional survey of non-invasive HF telemonitoring. A total of 378 Japanese (120 cardiologists, 258 nurses) and 120 Swedish (39 cardiologists, 81 nurses) health care professionals from 165 Japanese and 61 Swedish hospitals/clinics nationwide participated in the study (210 in Japan and 98 in Sweden were approached). Data were collected between November 2013 and May 2014 with a questionnaire that was adapted from a previous Dutch study on telemonitoring.

Results

The mean age of the cardiologists and nurses was 47 years and 41 years, respectively. Experience at the current position caring for HF patients was 19 years among the physicians and 15 years among the nurses. In total, 7 Japanese (4.2%) and none of the Swedish health care institutions used telemonitoring. One fourth (24.0%, 118/498) of the health care professionals were familiar with the technology (in Japan: 21.6%, 82/378; in Sweden: 30.0%, 36/120). The highest expectations of telemonitoring (rated on a scale from 0-10) were reduced hospitalizations (8.3 in Japan and 7.5 in Sweden), increased patient self-care (7.8 and 7.4), and offering high-quality care (7.8 and 7.0). The major goal for introducing telemonitoring was to monitor physical condition and recognize signs of worsening HF in Japan (94.1%, 352/374) and Sweden (88.7%, 102/115). The following reasons were also high in Sweden: to monitor effects of treatment and adjust it remotely (86.9%, 100/115) and to do remote drug titration (79.1%, 91/115). Just under a quarter of Japanese (22.4%, 85/378) and over a third of Swedish (38.1%, 45/118) health care professionals thought that telemonitoring was a good way to follow up stable HF patients. Three domains of barriers were identified by content analysis: organizational barriers “how are we going to do it?” (categories include structure and resource), health care professionals themselves “what do we need to know and do” (reservation), and barriers related to patients “not everybody would benefit” (internal and external shortcomings).

Conclusions

Telemonitoring for HF patients has not been implemented in Japan or Sweden. However, health care professionals have expectations of telemonitoring to reduce patients’ hospitalizations and increase patient self-care. There are still a wide range of barriers to the implementation of HF telemonitoring.     

Epidemiology,pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus‐driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high‐quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in‐hospital management.     

Learning Self-care After Left Ventricular Assist Device Implantation

The number of heart failure (HF) patients living with a left ventricular assist device (LVAD) as destination therapy is increasing. Successful long-term LVAD support includes a high degree of self-care by the patient and their caregiver, and also requires long-term support from a multidisciplinary team. All three components of self-care deserve special attention once an HF patient receives an LVAD, including activities regarding self-care maintenance (activities related both to the device and lifestyle), self-care monitoring (e.g., monitoring for complications or distress), and self-care management (e.g., handling alarms or coping with living with the device). For patients to perform optimal self-care once they are discharged, they need optimal education that focuses on knowledge and skills through a collaborative, adult learning approach.