Heme oxygenases in pregnancy II: HO-2 is downregulated in human pathologic pregnancies

PROBLEM: We previously reported a diminished expression of the heme-degrading enzymes heme oxygenases (HO)-1 and HO-2 in decidua and placenta from mice undergoing Th1-mediated abortion, strongly indicating the protective effect of HO in murine pregnancy maintenance. Here we investigated whether the expression of HO-1 and HO-2 is also reduced at the feto-maternal interface of pathologic human pregnancies. METHOD OF STUDY: Immunohistochemistry was used to detect HOs expression in placental and decidual first-trimester tissue from patients with: spontaneous abortion (n = 14), choriocarcinoma (n = 14), hydatidiform mole (H-mole) (n = 12), compared with normally progressing pregnancies (n = 15). Further, we investigated early third-trimester decidual and placental tissue from patients with pre-eclampsia (n = 13) compared with fetal growth retardation (n = 14) as age-matched controls. RESULTS: In first trimester tissue, we observed a significant reduction of HO-2 expression in invasive trophoblast cells, endothelial cells, and syncytiotrophoblasts in samples from patients with spontaneous abortion compared with normal pregnancy. H-mole samples showed a diminished expression of HO-2 in invasive trophoblast cells and endothelial cells in comparison with NP, whereas choriocarcinoma samples showed no significant differences compared with the control. In third trimester tissue, HO-2 was also reduced in syncytiotrophoblasts and invasive trophoblast cells from pre-eclampsia compared with samples from fetal growth retardation. HO-1 expression was diminished in all pathologies investigated; however, the differences did not reach levels of significance. CONCLUSIONS: Our data indicate that HOs play a crucial role in pregnancy and low expression of HO-2, as observed in pathologic pregnancies, may lead to enhanced levels of free heme at the feto-maternal interface, with subsequent upregulation of adhesion molecules, allowing enhanced inflammatory cells migration to the feto-maternal interface.     

Reply to: ‘Liposuction-assisted brachioplasty in breast cancer-related lymphedema: Impact on volume reduction and quality of life’

BackgroundNecrotizing fasciitis (NF) is a rapid infectious process involving the fascia and subcutaneous tissue. Current standards of care rely on surgical debridement, resulting in large defects, with limited reconstructive options. Wound management has evolved over the last decade, including use of bilayer wound matrices (BWM). The authors sought to assess the use of collagen-GAG bilayer wound matrices on STSG take for NF wounds.MethodsA qualitative clinical evaluation (2016–2018) was performed to analyze the efficacy of BWM to aide in STSG take. Primary outcomes were 180-day bilayer matrix success, defined by progressing to split-thickness skin graft (STSG) and STSG take, determined by clinical evaluation. Wounds without a diagnosis of NF or reconstruction with BWM were excluded.ResultsTen patients with 11 NF wounds were identified. Average BMI was 32 kg/m². Comorbidities included hypertension (70%), diabetes (40%), and peripheral vascular disease (40%). Average wound size was 542cm² (range: 49cm² -1050cm²) and average wound age was 19 days at BWM placement. Matrices were applied to the lower extremity (64%), upper extremity (27%), and perineum (9%). One-hundred percent (n = 11) of wounds were deemed successful by receiving a STSG. Average time to STSG was 44 days (21d –108d). Complications consisted of delayed healing (n = 1, 8%) and partial necrosis (n = 1). No instances of infection or STSG graft loss occurred.ConclusionComplex defects caused by soft tissue necrotizing infections remain a reconstructive challenge. We highlight the benefit of a BWM as a treatment modality for reconstruction by priming the wound bed for a definitive STSG.     

A dedicated cardioversion unit for the treatment of atrial fibrillation

Background

Atrial fibrillation (AF) is the most frequent arrhythmia seen in man. Many patients are admitted to the hospital to undergo transesophageal echocardiography (TEE) for thrombus exclusion and subsequent electrical cardioversion (ECV) under deep sedation to restore sinus rhythm. The present study investigated prospectively how workflow optimization can contribute to reducing time and costs in AF patients scheduled for ECV in an outpatient setting.

Methods

A cardioversion unit (CU) was established and equipped to perform all ECV-associated procedures. Between November?2007 and January?2009, ECV was performed in 115?patients in an outpatient setting. Three different settings were tested for ECV: (1) usual care (n?=?19): preparation/follow-up in the outpatient clinic, blood testing in the central hospital laboratory (CHL), TEE in the echocardiography laboratory, and ECV in the intensive care unit; (2) optimized process?1 (n?=?41): preparation/follow-up, TEE?+?ECV during one sedation in the CU, blood testing in the CHL; (3) optimized process?2 (n?=?55): preparation/follow-up, TEE?+?ECV and point of care (POC) blood testing in the CU. All procedure-related costs were listed and classified according to material, human resources, and infrastructure.

Results

From setting?1 to 3, there was a significant decrease in procedural time from 480?±?105?min to 205?±?85?min (p?Conclusion Establishing a CU for AF enables a more than 50% reduction in procedural time and costs. A combination of TEE and ECV in one sedation and POC testing in the CU were the major contributors to this time and cost reduction.     

Collaboration between breast and reconstructive surgery in optimizing outcomes for women with breast cancer

Performing successful breast reconstruction after mastectomy requires communication and collaboration between the breast and reconstruction surgery teams. This allows for oncologic safety while providing esthetic and functional reconstruction. In this article, we discuss the numerous techniques we have adopted successfully into our breast reconstructive practice that were possible due to this collaboration including prophylactic lymphaticovenous bypass (LVB), tumor ultrasound‐guided incision (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve identification at time of mastectomy to allow for sensate reconstruction, and the prevention of chronic pain and strategic oncoplasty.     

Depression,psychological distress,and quality of life in patients with cardioverter defibrillator with or without cardiac resynchronization therapy

Congestive heart failure is frequent and leads to reduced exercise capacity, reduced quality of life (QoL), and depression in many patients. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) offer therapeutic options and may have an impact on QoL and depression. This study was performed to evaluate physical and mental health in patients undergoing ICD or combined CRT/ICD-implantation (CRT-D). Echocardiography, spiroergometry, and psychometric questionnaires [Beck Depression Inventory, General World Health Organization Five Well-being Index (WHO-5), Brief Symptom Inventory and 36-item Short Form (SF-36)] were obtained in 39 patients (ICD: 17, CRT-D: 22) at baseline and 6-month follow-up (FU) after device implantation. CRT-D patients had a higher NYHA class and broader left bundle branch block than ICD patients at baseline. At FU, ejection fraction (EF), peak oxygen uptake, and NYHA class improved significantly in CRT-D patients but remained unchanged in ICD patients. Patients with CRT-D implantation showed higher levels of depressive symptoms, psychological distress, and impairment in QoL at baseline and FU compared to ICD patients. These impairments remained mostly unchanged in all patients after 6 months. Overall, these findings imply that there is a need for careful assessment and treatment of psychological distress and depression in ICD and CRT-D patients in the course of device implantation as psychological burden seems to persist irrespective of physical improvement.     

Moderate physical exercise: a simplified approach for ventricular rate control in older patients with atrial fibrillation

Aims  This prospective pilot-study was performed to assess whether regular moderate physical activity elevates the parasympathetic tone to the atrio-ventricular node and decreases VR during permanent AF. Background  Adequate ventricular rate (VR) control in patients with permanent atrial fibrillation (AF) is not easy to accomplish. Methods  10 patients (mean age 59 ± 10 years) with permanent AF (duration: 10 ± 8 years) underwent moderate physical exercise adjusted to their individual physical capability (45 min walking/jogging twice a week). To analyze VR control physical exercise tests and Holter-ECG recordings were performed before and after 4 months. In addition, stepwise lactate tests and psycho-pathometric examinations were obtained. Results  After 4 months of training, there was a trend toward a decrease of mean VR in 24 h Holter-ECGs by 12% from 76 ± 20 to 67 ± 12 bpm (P = 0.05) while there was no significant decrease of the minimal VR (38 ± 8 vs. 36.3 ± 4.5 bpm, P = 0.54). At a lactate threshold of 2 mmol/l there was a trend towards an increase of the running speed from 105 ± 11 to 116 ± 12 m/min (P = 0.05). A significant VR decrease of 8% (range 5–10%) was observed at almost all exercise levels during exercise treadmill testing. Increases of exercise capacity and decreases of VR were accompanied by subjective improvements of health perception. Conclusion  Regular moderate physical activity decreases VR at rest and during exercise while increasing exercise capacity. Physical training should be taken into account for ventricular rate control during AF. The study was supported by the German Atrial Fibrillation Competence Network (AFCN) funded by the Fedral Ministry of Education and Research (FMBI). A. Blumberg and J. Plisiene contributed equally to this study.     

Dilatation of the pulmonary veins in atrial fibrillation: a transesophageal echocardiographic evaluation

Ectopic beats originating from sleeves of atrial tissue within the pulmonary veins (PVs) can induce and sustain paroxysmal atrial fibrillation (AF). Left atrial stretch and dilatation favors the development of atrial ectopy and AF. Similarly, PV dilatation, if present, might trigger PV ectopy in patients with AF. This study was designed to evaluate whether PV dilatation is present in patients with nonfocal AF and whether the PV diameter correlates to the left atrial diameter (LAD). The diameters of the right superior (RSPV) and left superior PV (LSPV) were measured at the ostium and at a depth of 1 cm in 170 patients (AF, n = 75; sinus rhythm [SR], n = 95) using transesophageal echocardiography. The LAD was determined by transthoracic echocardiography. The diameters of the PVs were significantly larger in patients with AF than in patients with SR (LSPV(ostium): AF 13.6 +/- 3.5 mm vs SR 10.6 +/- 2.7 mm, P < 0.001; LSVP(1cm): AF 12.5 +/- 2.9 mm vs SR 10.2 +/- 2.5 mm, P < 0.001; RSPV(ostium): AF 13.9 +/- 3.5 mm vs SR 11.7 +/- 2.9 mm, P < 0.001; RSVP(1cm): AF 12.8 +/- 2.8 mm vs SR 10.6 +/- 2.6 mm, P < 0.05). Similarly, LAD was larger in patients with AF (44.7 +/- 7.7 mm) as compared to patients with SR (38.8 +/- 6.8 mm, P < 0.001). Neither for the SR nor the AF group did the PV size correlate to the LAD. AF is associated with a significant enlargement of the RSPV, LSPV, and LAD. There is no correlation between LAD and PV diameters. This raises the question whether PV dilatation in patients with AF is a cause or a consequence of AF and whether it may contribute to the development and perpetuation of AF.