Chylopericardial tamponade masquerading as hemopericardium: an uncommon complication of cardiac surgery

Chylopericardial tamponade occurs very rarely after heart surgery. It may be the result of lymphatic duct interruption during mammary artery harvest, division of a large thymic remnant, or thrombosis of the subclavian or internal jugular vein by an indwelling central line. Although relatively straightforward when the pericardial aspirate has the usual milky appearance, the correct diagnosis can easily be overlooked particularly early after surgery when the patient is still fasting. We present a case report that illustrates the importance of sending all aspirates for chemical analysis irrespective of their color to arrive at the correct diagnosis and institute the appropriate medical management of this rare condition.     

Optimization of dose and image quality of paediatric cardiac catheterization procedure

The purpose of this study is to quantify the quality of the available imaging modes for various iodine-based contrast agent concentration in paediatric cardiology. The figure of merit (FOM) was defined as the squared signal to noise ratio divided by a patient dose related parameter. An in house constructed phantom simulated a series of vessel segments with iodine concentrations from 10% or 30 mg/cc to 16% or 48 mg/cc of iodine in a blood plasma solution, all within the dimensional constraints of a paediatric patient. The phantom also used test inserts of tin (Sn). Measurements of Entrance Surface Air Kerma (ESAK) and exit dose rate were performed along with calculations of the signal-to-noise ratio (SNR) of all the objects. A first result showed that it was favourable to employ low dose fluoroscopy mode and lower frame rate modes in cine acquisition if dynamic information is not critical. Normal fluoroscopy dose mode provided a considerably higher dose level (in comparison to low dose mode) with only a slight improvement in SNR. Higher frame rate cine modes should be used however when the clinical situation dictates so. This work also found that tin should not be intended as iodine replacement material for research purposes due to the mismatching SNR, particularly on small vessel sizes.     

Evaluation of a ventricular septal defect in an orangutan: a case report

A 15-year-old male Sumatran orangutan (Pongo pymaeus abeli) with a history of an interventricular septal defect was evaluated with cardiac catheterization and two-dimensional echocardiography. Results demonstrated that by Homo sapiens standards the right heart pressures were normal. The oxygen saturations were consistent with a small ventricular septal defect. Echocardiography demonstrated a slight enlargement of the right ventricle.     

Mechanically induced electrical storm as a complication of cardiac resynchronization therapy: A case report

BackgroundCardiac resynchronization therapy (CRT) has been shown to improve both the functional status and mortality of heart failure patients with left bundle branch block. Multiple recent studies suggest several mechanisms for proarrhythmia associated with CRT device.Case summaryA 51-year-old male with symptomatic non-ischemic cardiomyopathy and no previous history of ventricular arrhythmias underwent placement of a biventricular cardioverter-defibrillator. The patient developed sustained monomorphic ventricular tachycardia (VT) soon after implantation. The VT recurred despite reprogramming to right ventricular only pacing. The electrical storm resolved only after a subsequent discharge from the defibrillator caused inadvertent dislodgement of the coronary sinus lead. No recurrent VT occurred throughout 10-years follow up after urgent coronary sinus lead revision.DiscussionWe describe the first reported case of mechanically induced electrical storm due to the physical presence of the CS lead in a patient with a new CRT-D device. It is important to recognize mechanical proarrhythmia as a potential mechanism of electrical storm, as it may be intractable to device reprogramming. Urgent coronary sinus lead revision should be considered. Further studies on this mechanism of proarrhythmia are needed.     

Colovaginal anastomosis: an unusual complication of stapler use in restorative procedure after Hartmann operation

Background

To support decisions about surgical treatment of elderly patients with cancer, population-based estimates of postoperative mortality (POM) rates are required.

Methods

Electronic records from the Rotterdam Cancer Registry were retrieved for octogenarians and nonagenarians who underwent resection in the period 1987–2000. POM was defined as death within 30 days of resection and both elective and emergency operations were included.

Results

In a series of 5.390 operated patients aged 80 years and older, POM rates were 0.5% for breast cancer, 1.7% for endometrial cancer and 4.2% for renal cancer. For patients with colorectal cancer, POM increased from 8% for the age group 80–84 to 13% for those 85–89 to 20% in nonagenarians. For stomach cancer, the respective figures were 11%, 20% and 44%.

Conclusion

These results show that resections can be performed at acceptable risk in selected elderly patients with cancer.     

3-Keto-5-aminohexanoate cleavage enzyme: a common fold for an uncommon Claisen-type condensation

The exponential increase in genome sequencing output has led to the accumulation of thousands of predicted genes lacking a proper functional annotation. Among this mass of hypothetical proteins, enzymes catalyzing new reactions or using novel ways to catalyze already known reactions might still wait to be identified. Here, we provide a structural and biochemical characterization of the 3-keto-5-aminohexanoate cleavage enzyme (Kce), an enzymatic activity long known as being involved in the anaerobic fermentation of lysine but whose catalytic mechanism has remained elusive so far. Although the enzyme shows the ubiquitous triose phosphate isomerase (TIM) barrel fold and a Zn(2+) cation reminiscent of metal-dependent class II aldolases, our results based on a combination of x-ray snapshots and molecular modeling point to an unprecedented mechanism that proceeds through deprotonation of the 3-keto-5-aminohexanoate substrate, nucleophilic addition onto an incoming acetyl-CoA, intramolecular transfer of the CoA moiety, and final retro-Claisen reaction leading to acetoacetate and 3-aminobutyryl-CoA. This model also accounts for earlier observations showing the origin of carbon atoms in the products, as well as the absence of detection of any covalent acyl-enzyme intermediate. Kce is the first representative of a large family of prokaryotic hypothetical proteins, currently annotated as the "domain of unknown function" DUF849.     

Predictors of cardiac rehabilitation referral,enrolment and completion after acute myocardial infarction: an exploratory study

BackgroundDespite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to assess which patient-related characteristics can predict dropout.MethodsIn a retrospective cohort study, we selected patients who had been hospitalised with an AMI in our centre in 2015 or 2016. Patients were selected pseudonymously based on reimbursement codes in the electronic health record. We extracted baseline characteristics and data on CR referral, enrolment and completion for each patient. Multivariable logistic regression was used to assess which characteristics predicted referral and dropout.ResultsThe 666 patients included were predominantly male (66%), with a mean age of 69.0 years. Of the 640 eligible patients, 201 (31%) were not referred for CR. Enrolment after referral was 94%. Nonreferral was independently associated with older age, female sex, traveling distance, non-ST-elevation myocardial infarction (NSTEMI; as compared with STEMI), no coronary revascularisation and prior manifestations of coronary artery disease. Of the 414 enrolled patients, 24% did not complete their CR programmes (i.e. dropped out). Older age and worse exercise capacity at baseline were independently associated with dropout. The ability of the multiple regression models to predict nonreferral and noncompletion was good to fair, with an area under the receiver operating characteristic curves of 0.86 and 0.71, respectively.ConclusionThe main reason for not participating in or not completing CR after AMI was nonreferral. To optimise CR utilisation, improvement of referral rates should be prioritised.     

益生菌治疗中国儿童手足口病疗效Meta分析

目的 系统评价补充益生菌对中国儿童手足口病的疗效。 方法 电脑检索资料库,包括知网、万方、维普、PubMed、Medline、The Cochrane Library。检索时间为建库至2020年3月,搜集有关益生菌辅助治疗儿童手足口病疗效的随机对照试验,由两位研究者独立筛选文献,提取数据并进行质量评价。运用RevMan 5.3软件作数据分析。 结果 共纳入12项临床研究,计943例患儿。Meta分析结果显示,补充益生菌可缩短患儿皮疹消退时间[MD=-1.20 d,95%CI(-1.63～-0.77),P结论 现有证据表明,益生菌作为手足口病的辅助治疗方法,可减轻患儿临床症状,缩短病程且不增加副反应发生率。     

Anodal stimulation: an underrecognized cause of nonresponders to cardiac resynchronization therapy

Objective

The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients.

Background

Approximately 30-40% of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode).

Methods

Patients enrolled in our center''s CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson''s method and CRT responder was defined as 15% or greater reduction in LVESV.

Results

Of the 102 patients, 46 (45.1%) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5%) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 ± 0.6%, increase in EF 5.0 ± 1.4%) compared to 46% responders for those without anodal stimulation, (change in LVESV 18.7 ± 25.6%, EF 7.6 ±10.9%). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48%) of those without anodal stimulation.

Conclusion

Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.     

Increased myosin orientation during muscle contraction: a measure of cardiac contractility

Myosin form birefringence has been studied in cryostat sections of left ventricular myocardium from the dog and human. The muscle in such sections has been shown to demonstrate the sliding filament phenomenon. The sarcomere length of canine myocardium agreed with that found in comparable electron micrographs. Unexpectedly, it was found that glycerol, normally used as an inert and optically ideal mountant, caused profound change in myosin birefringence. This apparently invalidates results obtained with this mountant. The absolute birefringence found in these sections, whether mounted in glycerol or in an ATP-calcium buffer, corresponded to values found by other workers with skeletal muscle and isolated myosin. However, the birefringent properties (optical path difference: o.p.d.) of well functioning muscle was found to be low, the o.p.d. increasing when exposed to ATP and calcium. Poorly functioning muscle could be distinguished from well functioning muscle on the basis of its higher 'in air' o.p.d. This difference correlated well with physiological assessments of myocardial function or with clinical assessments of cardiac failure. Evidence is presented indicating that changes in apparent birefringence, caused by ATP-calcium or by anoxia, are due to altered orientation of the myosin micelles and can be inhibited by agents that inhibit myosin ATPase activity.     

Mechanical advantages of the Neanderthal thumb in flexion: a test of an hypothesis

It has been proposed that the pollical phalangeal length proportions of the Neanderthals provided them with a greater mechanical advantage relative to recent humans for their pollical flexor muscles in power grips across the interphalangeal (IP) joint at the expense of the mechanical advantage of those pollical flexor muscles in precision grips at the finger tip. To test these related hypotheses, we compared the pollical load arm dimensions (phalanx lengths) to power arm dimensions (dorsopalmar articular heights) for the European and Near Eastern Neanderthals and for European and Amerindian samples of recent humans. It was found, initially, that the proximal articular height of the pollical distal phalanx is a poor predictor of the power arm at the IP articulation, even though the proximal articular height of the pollical proximal phalanx was an adequate indicator of the power arm size at the metacarpophalangeal (MCP) joint. In addition, differences in distal pollical ulnar deviation at the IP joint appeared to make little difference in the mechanical advantage comparisons. More importantly, the relative shortness of Neanderthal proximal pollical phalanges and the relative lengthening of their distal pollical phalanges was confirmed, and it was determined that, despite some minor differences in articular dimensions between Neanderthals and recent humans, these pollical phalangeal length contrasts translated into significant differences in mechanical advantages for the flexor muscles across the MCP and IP articulations.     

Usefulness of F2-isoprostanes in early prognostication after cardiac arrest: a topical review of the literature and meta-analysis of preclinical data

Abstract

Prognostication after cardiac arrest (CA) represents a challenging issue, and several biomarkers have been proposed in the attempt to predict outcome. Among these, F2-isoprostanes stand out as potential biomarkers for early prognostication, providing information on the magnitude of global oxidative injury after return of spontaneous circulation (ROSC). We performed a topical review searching PubMed and Scopus databases to identify studies evaluating the modifications of F2-isoprostanes in the early period after CA, and a meta-analysis of studies providing curves of F2-isoprostanes plasma levels seeking to describe the biomarker’s kinetics after CA. Evidence suggests that plasma levels of F2-isoprostanes increase in the early post-resuscitation period and seem well correlated with the burden of ischaemia-reperfusion injury. Our meta-analysis shows a possible increase as early as 5?minutes after ROSC, which persists at 2?hours and is attenuated at 4?hours. Clinical studies are warranted to evaluate the utility of this biomarker for prognostication purposes in CA survivors.     

Morphological and biochemical analysis of human cardiac valve allografts after an increment of the cryostorage temperature

Cryopreserved human cardiac valve allografts could suffer lethal damages if the temperature is elevated during cryostorage. This work describes the functional and morphological alterations suffered by human cardiac valve allografts after a gradual increment of the cryostorage temperature from −147 °C to −47 °C due to a technical failure. Three experimental groups of human pulmonary and aortic allografts were compared: fresh, cryopreserved (−147 °C) and cryopreserved with temperature changes from −147 °C up to −47 °C and back to −147 °C. Fibroblast functionality was studied to asses the degree of valvular damages. Collagen network was also analyzed with bright light field and polarized microscopy; an immunohistochemistry for procollagen I was performed and the MTT colorimetric assay was used to evaluate fibroblast mitochondrial enzymatic activity. Porcine heart grafts valves were used to set the MTT colorimetric assay.With bright light field microscopy, disorganized collagen network was seen together with interstitial edema in cryopreserved groups. Polarized microscopy showed that fresh allografts had abundant collagen type I and III, cryopreserved group had less amount of collagen type I and in allografts that suffered cryopreservation temperature elevation collagen type I synthesis could not been demonstrated. Procollagen I was present in fibroblast cytoplasm of fresh group, but it was diminished in cryopreserved group and was absent in the group that suffered temperature elevation.Temperature changes during the cryopreservation period of human cardiac valve allografts induced fibroblast activity reduction. When the cryopreservation temperature is elevated during cryostorage, fibroblasts lost their functionality and the allografts may be not suitable for transplant.     

Correlation of molecular and functional effects of mutations in cardiac troponin T linked to familial hypertrophic cardiomyopathy: an integrative in silico/in vitro approach

Nearly 70% of all of the known cTnT mutations that cause familial hypertrophic cardiomyopathy fall within the TNT1 region that is critical to cTn-Tm binding. The high resolution structure of this domain has not been determined, and this lack of information has hindered structure-function analysis. In the current study, a coupled computational experimental approach was employed to correlate changes in cTnT dynamics to basic function using the regulated in vitro motility assay (R-IVM). An in silico approach to calculate forces in terms of a bending coordinate was used to precisely identify decreases in bending forces at residues 105 and 106 within the proposed cTnT "hinge" region. Significant functional changes were observed in multiple functional properties, including a decrease in the cooperativity of calcium activation, the calcium sensitivity of sliding speed, and maximum sliding speed. Correlation of the computational and experimental findings revealed an association between TNT1 flexibility and the cooperativity of thin filament calcium activation where an increase in flexibility led to a decrease in cooperativity. Further analysis of the primary sequence of the TNT1 region revealed a unique pattern of conserved charged TNT1 residues altered by the R92W and R92L mutations and may represent the underlying "structure" modulating this central functional domain. These data provide a framework for further integrated in silico/in vitro approaches that may be extended into a high-throughput predictive screen to overcome the current structural limitations in linking molecular phenotype to genotype in thin filament cardiomyopathies.     

Interaction of cardiac troponin with cardiotonic drugs: a structural perspective

Over the 40 years since its discovery, many studies have focused on understanding the role of troponin as a myofilament based molecular switch in regulating the Ca²⁺-dependent activation of striated muscle contraction. Recently, studies have explored the role of cardiac troponin as a target for cardiotonic agents. These drugs are clinically useful for treating heart failure, a condition in which the heart is no longer able to pump enough blood to other organs. These agents act via a mechanism that modulates the Ca²⁺-sensitivity of troponin; such a mode of action is therapeutically desirable because intracellular Ca²⁺ concentration is not perturbed, preserving the regulation of other Ca²⁺-based signaling pathways. This review describes molecular details of the interaction of cardiac troponin with a variety of cardiotonic drugs. We present recent structural work that has identified the docking sites of several cardiotonic drugs in the troponin C-troponin I interface and discuss their relevance in the design of troponin based drugs for the treatment of heart disease.     

Perceptual learning in an appetitive Pavlovian procedure: Analysis of the effectiveness of the common element

Non-reinforced preexposure to two stimuli often enhances discrimination between them. Analyses of this perceptual learning phenomenon have mainly focused on the role played by the distinctive stimulus features; this study examined the contribution of the non-distinctive common elements. A standard appetitive Pavlovian procedure was used. Rats received two different schedules of exposure - alternated or blocked - to two compound auditory stimuli, AX and BX. In Experiment 1 a generalization test to BX that followed conditioning to AX showed that animals responded less, and hence discriminated better, following alternated exposure, thus extending the generality of this perceptual learning effect to standard appetitive Pavlovian procedures. The degree to which the common element X was mediating this effect was explored in the next three experiments. Experiment 2 assessed the effectiveness of X following conditioning to AX. Experiment 3 explored X's effectiveness throughout extensive conditioning to X. Experiment 4 tested the ability of X to overshadow a novel stimulus Y. The results were consistent with the suggestion that alternated preexposure can reduce the relative effectiveness of the common element.     

Long-term prognosis of patients with cardiac syndrome X: a review

AimsFollow-up studies of patients with cardiac syndrome X (CSX) generally report good prognosis. However, some recent studies report an adverse outcome for women.ConclusionThe present review of recent archival literature demonstrates an overall major cardiac event rate of 1.5% per 5 years. Although this is an excellent prognosis for CSX patients, the quality of life is impaired because of the high recurrence rate of angina pectoris (55%).     

Air entrapment as a cause of early inappropriate shocks after subcutaneous defibrillator implant: A case series

Inappropriate shock (IAS) is the most frequent device-related complication among patients with subcutaneous implantable cardioverter-defibrillator (S-ICD). Air entrapment (AE) has been described as an underdiagnosed cause of early postimplant IAS. We report 6 consecutive cases of early IAS after S-ICD implant, in whom the electrogram analysis (EGM) and/or chest radiography (CXR) were consistent with AE.