New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study

There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child–Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.     

Mid-trimester thoracoamniotic shunting for the treatment of fetal primary pleural effusions in a twin pregnancy. a case report

Thoracoamniotic shunting has been described as having a beneficial role in the antenatal management of primary pleural effusions in singleton pregnancies. We report a case of a twin pregnancy in which progressive pleural effusions and hydrops were diagnosed in one of the fetuses at 16 weeks of gestation. An initial evaluation ruled out underlying genetic and anatomic abnormalities in both twins. At 19 weeks gestation, the first procedure of bilateral thoracoamniotic shunting was performed in the affected fetus, subsequent to which the lungs re-expanded and the hydrops resolved. Three additional shunt replacements and one therapeutic amniocentesis were required on follow-up. At 35 weeks, labor was induced. The first fetus (healthy) was delivered vaginally and the second fetus (affected) was delivered by cesarean section. Both neonates are healthy at one year follow-up.     

Multisite time-series studies versus cohort studies: methods, findings, and policy implications

Time-series and cohort studies of air pollution on human health have advanced greatly our understanding of the effects of air pollution on health since the earliest studies. Availability of large national databases and progress in computational tools and statistical methods have made possible the estimation of national average pollution effects and the exploration of potential sources of heterogeneity in the effects of air pollution across countries or regions. Interpretation of the findings needs to account for several challenges, including confounding and the resolution of seemingly conflicting results from time-series and cohort studies. This article presents an overview of the time-series and cohort studies' approaches for estimating the relative risk of mortality from particulate air pollution and discusses the statistical issues and challenges inherent in each of these studies. We also discuss policy relevant summaries in air pollution epidemiology, approaches for estimating the impact of particulate matter on mortality from time-series and cohort studies, and research opportunities under the National Medicare Cohort Study (NMCS).