The role of poroelastic diffusion in the transient wetting behavior of hydrogels

Wetting and water absorption of hydrogels is often encountered in many applications. We seek to understand how wetting behavior can be affected by the time-dependent swelling of hydrogels. We measured the advancing contact angles of water droplets on hydrogels of varying thicknesses where thicker gels absorbed water more slowly. We also observed that, above a threshold advancing speed, water droplets would collapse into a lower contact angle state on the surface. We hypothesized that this collapse threshold speed is a result of competition between the poroelastic diffusion of water into the gel and the advance of the spreading droplet, the thickness of the surface, and the diffusion of water into the gel. Taking the ratio of the diffusion and advancing timescales results in a Peclet number with gel thickness as a characteristic length scale. Our results show that above a Peclet number of around 40, droplets will collapse on the surface across all gel thicknesses, confirming our hypothesis. This work provides simple insight to understand a complex time-dependent wetting phenomenon for a widely used hydrogel.

Relating Retinal Vascular Oxygen Saturation and Microvasculature Morphology at Progressive Stages of Diabetic Retinopathy

Purpose

Diabetic retinopathy (DR) is a common cause of vision loss in working age adults and presents changes in retinal vessel oxygenation and morphology. The purpose of this study was to test the hypothesis that there is an association of retinal vessel oxygen saturation with vessel density (VD) and tortuosity in DR.

Methods

Ninety-five subjects were classified in the following groups: nondiabetic control (N = 25), no DR (N = 28), mild nonproliferative DR (NPDR; N = 21), moderate to severe NPDR (N = 14), or treated proliferative DR (PDR; N = 7). Retinal oximetry was performed to measure arterial and venous oxygen saturation (SO_2A and SO_2V) and calculate oxygen extraction fraction (OEF). Optical coherence tomography angiography (OCTA) was performed for measurements of VD and vessel tortuosity index (VTI).

Results

There were statistically significant differences in SO_2A and SO_2V among groups (P< 0.004). SO_2A and SO_2V were higher in the PDR group compared to the control group and SO_2V was also higher in the moderate to severe NPDR group. VD differed significantly among groups (P = 0.003), whereas VTI was not significantly different (P = 0.22). Compared to the control group, VD was lower in moderate to severe NPDR and PDR groups. VD was also lower in the PDR group than that in the no DR group (P = 0.03). There was a significant correlation of VTI with SO_2V (r = 0.32, P = 0.002) and OEF (r = −0.35, P = 0.001).

Conclusions

Retinal vessel morphology, oxygenation, and tissue oxygen extraction were associated with each other in a cohort of subjects with and without DR.

Translational Relevance

The findings of this study have the potential to improve clinical management of DR by providing better understanding of human disease pathophysiology and propelling future studies to identify multiple image-based biomarkers for improved disease diagnosis and monitoring.

Seronegative autoimmune enteropathy with duodenal sparing and colonic clues in an adult female

Autoimmune enteropathy (AIE) is a rare immune disorder of the gut seldom found in adults and characterized by uncontrollable diarrhea resulting in malabsorption. While AIE is known to be pan-enteric, virtually all cases have presented with altered duodenal histology following known patterns with or without macroscopic change. We describe a unique case of seronegative AIE lacking typical duodenal manifestations in a 43-year-old female. To our knowledge, this is the first report of AIE lacking usual duodenal histologic changes, which resulted in missed diagnosis for years. Ultimately, crypt epithelial apoptosis, mononuclear inflammation of the lamina propria, and goblet cell loss of intestinal mucosa besides the duodenum clinched the diagnosis of AIE. Colonic histologic abnormalities consistent with AIE in the setting of diarrhea with malnutrition despite duodenal sparing should prompt suspicion for AIE given the pan-enteric nature of this disease.

Hypoalbuminemia and Bandemia Predict Failure of Infliximab Rescue Therapy in Acute Severe Ulcerative Colitis

BACKGROUND AND AIMS

Infliximab rescue therapy is effective in patients with corticosteroid refractory acute severe ulcerative colitis, but predictors of response remain poorly understood. We aimed to identify predictors of colectomy in this high-risk patient population.

METHODS

Patients hospitalized with acute severe ulcerative colitis who received infliximab after failing intravenous corticosteroid therapy between July 2012 and June 2017 were retrospectively identified. Stepwise regression with backward elimination was used to identify predictors of colectomy at 90 days and 1 year. Ninety-day and 1-year colectomy rates were compared between the patients who received 5 mg/kg and 10 mg/kg IFX rescue dose.

RESULTS

Sixty-three patients met the eligibility criteria. Twenty-nine patients received 5 mg/kg, and 34 received 10 mg/kg infliximab dose. Serum albumin on admission (OR 0.10; p = 0.04) and band neutrophil percentage at the time of infliximab administration (OR 1.21; p = 0.02) were independent predictors of 90-day colectomy. A combination of serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy. Unadjusted 90-day and 1-year colectomy rates were similar in the 5 mg/kg and 10 mg/kg infliximab groups. After adjusting for confounding factors, 10 mg/kg infliximab dose was potentially protective for 90-day (OR 0.07; p = 0.06) but not for 1-year colectomy (OR 0.19; p = 0.16).

CONCLUSIONS

Bandemia and low serum albumin are independent predictors of failure of infliximab rescue therapy in acute severe ulcerative colitis. Serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy.

A recommended "minimum data set" framework for SD-OCT retinal image acquisition and analysis from the Atlas of Retinal Imaging in Alzheimer's Study (ARIAS)

INTRODUCTION

We propose a minimum data set framework for the acquisition and analysis of retinal images for the development of retinal Alzheimer's disease (AD) biomarkers. Our goal is to describe methodology that will increase concordance across laboratories, so that the broader research community is able to cross-validate findings in parallel, accumulate large databases with normative data across the cognitive aging spectrum, and progress the application of this technology from the discovery stage to the validation stage in the search for sensitive and specific retinal biomarkers in AD.

METHODS

The proposed minimum data set framework is based on the Atlas of Retinal Imaging Study (ARIAS), an ongoing, longitudinal, multi-site observational cohort study. However, the ARIAS protocol has been edited and refined with the expertise of all co-authors, representing 16 institutions, and research groups from three countries, as a first step to address a pressing need identified by experts in neuroscience, neurology, optometry, and ophthalmology at the Retinal Imaging in Alzheimer's Disease (RIAD) conference, convened by the Alzheimer's Association and held in Washington, DC, in May 2019.

RESULTS

Our framework delineates specific imaging protocols and methods of analysis for imaging structural changes in retinal neuronal layers, with optional add-on procedures of fundus autofluorescence to examine beta-amyloid accumulation and optical coherence tomography angiography to examine AD-related changes in the retinal vasculature.

DISCUSSION

This minimum data set represents a first step toward the standardization of retinal imaging data acquisition and analysis in cognitive aging and AD. A standardized approach is essential to move from discovery to validation, and to examine which retinal AD biomarkers may be more sensitive and specific for the different stages of the disease severity spectrum. This approach has worked for other biomarkers in the AD field, such as magnetic resonance imaging; amyloid positron emission tomography; and, more recently, blood proteomics. Potential context of use for retinal AD biomarkers is discussed.

Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps

Background and study aims  Standard endoscopic mucosal resection (EMR) of ileocecal valve (ICV) polyps is challenging. Cap-assisted endoscopic mucosal resection (C-EMR) can be performed when polyps are not easily amenable to standard EMR. Current literature is limited regarding its efficacy and safety for ICV polyps. The objectives of this study were to assess the efficacy and safety of C-EMR for ICV polyps. Patients and methods  A retrospective review was conducted from September 2008 to November 2018 at a tertiary care center. Patients included in the study underwent C-EMR for ICV polyps by a single gastroenterologist (LHJ). Polyps were successfully eradicated if they were removed en-bloc as confirmed by pathology, or had a negative biopsy on follow-up colonoscopy. Outcomes of the procedures were evaluated, including complete adenoma clearance and adverse events. Results  Twenty-one ICV polyps were removed with C-EMR. Median polyp size was 15 mm (range, 5-45). The rate of complete adenoma clearance was 100 %. Procedure-related complications occurred in five patients (24 %): delayed GI bleeding (4.8 %) and deep mucosal resection/visible vessel (14.3 %). Three patients had subsequent surveillance colonoscopies at 8, 56, and 67 months, respectively. The third patient was found to have a 6-mm flat polyp at the edge of the previous polypectomy site. This was treated with C-EMR and repeat colonoscopy 6 months later did not show residual. Conclusion  C-EMR is highly effective in treating ICV polyps with a low complication rate. It is our suggested method in approaching ICV polyps that are difficult to remove via standard freehand snare EMR technique.

Modes and timing of death in 66 252 patients with non-ST-segment elevation acute coronary syndromes enrolled in 14 TIMI trials

Aims

Although presenting features and early sequelae of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) are well described, less is known about longer-term risks and modes of death. The purpose of this study was to characterize modes of death following NSTE-ACS in clinical trial populations.

Methods and results

We evaluated 66 252 patients with NSTE-ACS enrolled in 14 Thrombolysis in Myocardial Infarction (TIMI) trials, examining baseline characteristics and modes and timing of death. Of the 66 252 patients followed for a median of 372 (interquartile range 218-521) days, 3147 (4.8%) died by the time of last follow-up. Of the 2606 patients (82.8%) with known modes of death, 75.1% were related to a cardiovascular (CV) event, 3.0% were related to a bleeding event (including intracranial haemorrhage), and 21.8% were related to a non-CV/non-bleeding event. The most common modes of CV death were sudden death (SD) and recurrent myocardial infarction (MI) (36.4% and 23.4%, respectively, of CV deaths). The proportion of CV deaths related to recurrent MI was higher in the first 30 days than it was after 30 days following NSTE-ACS (30.6% vs. 18.7%), whereas the proportion of SD was lower in the first 30 days than after 30 days (21.6% vs. 46.2%).

Conclusion

Sudden death represents the largest proportion of CV deaths after 30 days among patients enrolled in CV clinical trials with NSTE-ACS. Further investigations aimed at defining the epidemiology of SD and developing specific therapies and management approaches to reduce SD following NSTE-ACS may be critical to reducing late mortality.

Ocular Determinants of Peripapillary Vessel Density in Healthy African Americans: The African American Eye Disease Study

Purpose

The African American (AA) population has unique ocular anatomic characteristics and a disproportionately high incidence of glaucoma, which is associated with lower peripapillary vessel density (VD). This study aimed to identify ocular determinants of peripapillary VD in healthy AAs.

Methods

This was a cross-sectional, population-based study of 1029 AAs, ages 40 and older. Participants underwent examination to obtain axial length (AL), IOP, central corneal thickness (CCT), mean retinal nerve fiber layer (RNFL) thickness, visual field mean deviation (MD), and 6 × 6-mm optical coherence tomography angiography scans of the optic nerve. Participants with glaucoma, vision-threatening diabetic retinopathy, or other relevant ocular disease were excluded. Prototype software was used to quantify VD. A multivariable regression model, controlling for age and signal strength, identified the ocular variables that predicted peripapillary VD. The contribution of each variable was assessed with the magnitude of standardized regression coefficients (SRC).

Results

Based on univariate regressions, AL, RNFL thickness, and MD had significant associations with peripapillary VD (all P < 0.001). In the final multivariate model, lower mean RNFL thickness (β = 0.0022, P < 0.001, SRC = 0.542) and longer AL (β = -0.0055, P < 0.001, SRC = -0.118) were associated with lower peripapillary VD, controlling for age and signal strength, with model R2 of 0.69.

Conclusions

Thinner RNFL and longer AL were the most influential ocular determinants of lower peripapillary perfusion in healthy AA eyes. Additional research is needed to clarify whether longer AL increases risk of glaucoma by affecting capillary perfusion.

The Expanding Role of Anti-IL-12 and/or Anti-IL-23 Antibodies in the Treatment of Inflammatory Bowel Disease

The interleukin (IL)-12/IL-23 pathway is one of many proposed mechanistic pathways of intestinal inflammation. Earlier studies introduced IL-12 as a major cytokine in the pathogenesis of inflammatory bowel disease. However, the discovery of IL-23 drew attention toward this new cytokine. Overwhelming data indicated that antibodies against IL-12p40 rendered their anti-inflammatory effect primarily via inhibition of IL-23. This is because IL-12 and IL-23 have the subunit p40 in common. These cytokines have become an attractive target of treatment in patients with inflammatory bowel disease. Targeting IL-12 selectively was not found to be an efficacious treatment. Coblockade of IL-12 and IL-23 via targeting of p40, however, was found to be effective. More recently, selective IL-23 blockade has been extensively studied with promising preliminary results. To date, there are several ongoing randomized clinical trials investigating the safety and efficacy profiles of selective IL-23 inhibitors. Overall, the classes of anti-IL-12/IL-23 inhibitors and selective IL-23 inhibitors seem to be effective alternatives in patients who are nonresponders to anti-tumor necrosis factor-α agents, especially in a subgroup of secondary nonresponders. In addition, the immunogenicity and adverse event rates associated with antibodies against IL-12 and/or IL-23 seem to be very low. Considering all of this, these agents will be an important part of the treatment algorithm for patients with inflammatory bowel disease going forward.

Fecal Microbiota Transplantation in Inflammatory Bowel Disease: A Primer for Internists

Inflammatory bowel disease consists of disorders characterized by chronic idiopathic bowel inflammation. The concept of host-gut-microbiome interaction in the pathogenesis of various complex immune-mediated chronic diseases, including inflammatory bowel disease, has recently generated immense interest. Mounting evidence confirms alteration of intestinal microflora in patients with inflammatory bowel disease. Thus, restoration of normal gut microbiota has become a focus of basic and clinical research in recent years. Fecal microbiota transplantation is being explored as one such therapeutic strategy and has shown encouraging results in the management of patients with inflammatory bowel disease.

Double balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in Roux-en-Y gastric bypass anatomy: expert vs. novice experience

BACKGROUND AND STUDY AIMS

 Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (DBE-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients is a technically challenging procedure. We aimed to determine the success rate of DBE-ERCP performed by a novice to the procedure in post-RYGB after training with an expert.

PATIENTS AND METHODS

 Medical records for 103 consecutive post-RYGB patients who underwent DBE-ERCP in a tertiary center were retrospectively reviewed. The procedures were performed by Operator A (18 years of high-volume ERCP practice before acquiring DBE skill in 2004), and operator B ( < 2 years' experience in DBE and ERCP). ERCP success rate and time in patients with an intact papilla were compared between Operator A's first and last sets of cases in equal number to the cases performed by Operator B.

RESULTS

 A total of 129 DBE-ERCPs were performed (Operator A: 109; Operator B: 20) over an 80-month time span. Among patients with an intact papilla, DBE-ERCP success rates for Operator A's first (87.5 %) and last (92.9 %) 20 cases were similar to that of Operator B (92.9 %) ( P  = 1.00 for both). Mean of DBE-ERCP time for the last 20 cases of Operator A was (100 minutes; 95 % confidence interval: 81,123) less than that for operator B (176 minutes; 95 % confidence interval: 138,224) ( P  = 0.01). Overall adverse events rates were 11 % and 5 % for Operators A and B, respectively ( P  = 0.69): pancreatitis (n = 10), cholangitis (n = 1), and perforation (n = 2); all were mild and treated conservatively.

CONCLUSIONS

 Despite the intrinsic technical difficulty, DBE-ERCP can be successfully and safely performed in post-RYGB patients by an endoscopist proficient in both conventional DBE and ERCP. Ideally, this endoscopist should observe several cases of DBE-ERCP performed by an expert to learn the techniques.

Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas

BACKGROUND AND AIMS

Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA.

METHODS

The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up.

RESULTS

Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15 mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P = .02).

CONCLUSION

C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.

Sire breed and sex effects on the fatty acid composition and content of heart, kidney, liver, adipose and muscle tissues of purebred and first-cross prime lambs

The present study investigated sire breed and sex effects on the fatty acid (FA) composition and content of subcutaneous adipose, Longissimus lumborum muscle, kidney, heart and liver tissues in prime lambs. Tissue samples were taken from 40 Merino ewe and wether lambs sired by Black Suffolk, Dorset, Merino and White Suffolk rams. FA proportion (% total FA) showed significant variations. The highest relative concentrations of total saturated fatty acid (SFA) were in adipose tissue, concentrations of monounsaturated fatty acids (MUFA) were highest in muscle and concentrations of two nutritionally important omega-3 long-chain (≥C20) polyunsaturated FA (LC-PUFA), namely, eicosapentaenoic (EPA, 20:5n-3) and docosahexaenoic (DHA, 22:6n-3) acids, were highest in kidney tissue (10.4% total FA), as were those of total PUFA in heart tissue. Sire breed variations in kidney for 18:3n-3, 22:6n-3, 16:0, 16:1n-7c and total omega-6 PUFA, and in muscle for 17:0, 18:3n-3 and 18:1n-7 were evident. Adipose tissue concentrations of 16:1n-9c, 17 : 0 and 16 : 0 in the heart and liver were affected by sire breed. The effect of sex on most major individual FA and totals of SFA, MUFA, omega-3 and omega-6 PUFA were, for the most part, negligible. These results suggest that consumption of lamb heart, liver and kidney can prove beneficial because of their high total PUFA composition and, in particular, concentration (mg/100 g) of key health-benefitting n-3 LC-PUFA. The fact that there were significant sire-breed variations implies that the manipulation of FA composition and content of lamb products and their associated nutritional and sensory qualities will need a deliberate breeding management that matches product goals with available sire breeds.

Left Atrial Appendage Remodeling After Lariat Left Atrial Appendage Ligation

Background—

Left atrial appendage (LAA) ligation with the Lariat device is being used for stroke prevention in atrial fibrillation. Residual leaks into the LAA are commonly reported after the procedure. Little is known about the anatomic LAA remodeling after Lariat ligation.

Methods and Results—

In an exploratory study, we evaluated LAA 3-dimensional geometry via computed tomographic scan in 31 consecutive patients before Lariat closure and after a minimum of 30 days post procedure. Thirteen patients were classified as unfavorable cases based on anatomic criteria. Our population had an average age of 70±12 years, a mean CHADS2 (congestive heart failure, hypertension, age>75, diabetes mellitus, history of stroke) score of 3.2±1.2, a mean CHADS2VASC (CHADS2 in addition to female sex, ages 65–75, as well as double impact of age >75, vascular disease) of 4.2±1.5, and a mean HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding predisposition/history, labile international normalized ratio, elderly, drugs/alcohol) bleeding score of 4.0±1.1. Successful suture deployment was achieved in all cases, but 3 patients had intraprocedural residual flow into the LAA (leak). On follow-up, 10 patients (32%) had recanalized residual LAA cavities, which were morphologically similar to the original LAA, albeit significantly smaller in volume (22.5±13.3% of the original volume). Recanalization was not associated with age, sex, comorbid conditions, stroke or bleeding risk scores, follow-up interval, baseline LAA volume, or morphology. Unfavorable cases had anatomic outcomes comparable with those of the anatomically favorable population. No patients have exhibited thromboembolism after 842±338 days post ligation.

Conclusions—

Incomplete LAA ligation after Lariat is common. However, the remodeled LAA cavity is dramatically reduced. Diminished cavity size and tightening of the LAA orifice may play a role in the reduction of thrombus formation.

Liver metastasis from hepatoid adenocarcinoma of the esophagus mimicking hepatocellular carcinoma

Alpha-fetoprotein (AFP)-producing adenocarcinoma, histologically mimicking hepatocellular carcinoma (HCC), is a distinct entity known as hepatoid adenocarcinoma (HAC). Reported cases of HAC arising from the esophagus are extremely rare. Due to common liver metastasis and elevated AFP levels in patients with esophageal HAC, differentiation of HAC with liver metastasis from HCC could be challenging. We describe a case of esophageal HAC that presented with a liver mass showing hepatoid features and elevated serum AFP levels. Initial presentation was suspicious for HCC. Upon further diagnostic work-up, the patient was diagnosed with esophageal HAC with liver metastasis. The distinction between these two entities is particularly important because HAC is more aggressive, and its therapeutic options are very limited.

Diagnosis of primary squamous cell carcinoma of the pancreas using endoscopic ultrasound-guided core needle biopsy

Primary squamous cell carcinoma (SCC) of the pancreas is a particularly rare entity. Diagnosis of this tumor is tentatively made after ruling out metastatic SCC from another primary site and adenosquamous carcinoma (ASC) of the pancreas. Here we discuss the case of a 76-year-old woman who was found to have a solitary pancreatic lesion and multiple hepatic lesions. Results of computed tomography-guided biopsy of the liver lesions were consistent with a metastatic carcinoma displaying squamous differentiation; therefore, an endoscopic ultrasound (EUS)-guided core-needle biopsy (CNB) of the pancreatic mass was performed. Meticulous histopathological examination of the pancreatic specimen at multiple levels revealed moderately well-differentiated SCC with no glandular component. An extensive metastatic work-up did not reveal an extra-pancreatic origin for this SCC; hence, a diagnosis of primary SCC of the pancreas was established. To our knowledge, this is the first report of the diagnosis of a primary SCC of the pancreas using EUS-guided CNB. We believe that CNB has a diagnostic yield equivalent to that of fine-needle aspiration for recognizing pancreatic adenocarcinoma; however, when cytological examinations reveal atypical squamous epithelial cells suggestive of malignancy, CNB may provide a better tissue specimen, from which to determine the presence of a glandular component. Such an assessment will differentiate pancreatic SCC from ASC.

Spleen size in cirrhosis of different etiologies

OBJECTIVES

The purpose of this study was to evaluate the impact of cirrhosis etiology on spleen size as measured by sonography and computed tomography (CT).

METHODS

The spleen images of 139 patients with cirrhosis secondary to alcohol abuse, hepatitis C, or nonalcoholic steatohepatitis were reviewed retrospectively. The maximum diagonal spleen length on a single sonogram and maximum spleen diameter on axial, coronal, or sagittal CT, whichever was largest, was compared among the etiologic groups.

RESULTS

In 127 patients who underwent sonography, the mean spleen size ± SD on sonography in the alcohol group (13.1 ± 2.5 cm) was significantly smaller than in the hepatitis C (15.0 ± 3.4 cm) and nonalcoholic steatohepatitis (15.2 ± 3.0 cm) groups (95% confidence intervals of the mean difference, 0.6 to 3.3 and 0.8 to 3.4 cm, respectively). In 87 patients who underwent CT, the mean spleen size on CT in the alcohol group (14.0 ± 2.7 cm) was smaller than in the hepatitis C (15.9 ± 3.4 cm) and nonalcoholic steatohepatitis (15.5 ± 3.6 cm) groups, but the difference was not statistically significant. The spleen sizes on both sonography and CT in 79 patients were strongly correlated (r = 0.88; P < .0001).

CONCLUSIONS

Spleen size in patients with cirrhosis varies by the etiology of the disease. Therefore, to apply spleen size as a diagnostic or prognostic criterion in this context, it is important to recognize that cutoff values derived from spleen size in one etiologic group may not produce the same results when extrapolated to another etiologic group.

Can endoscopic ultrasound distinguish between mediastinal benign lymph nodes and those involved by sarcoidosis, lymphoma, or metastasis?

BACKGROUND

Lymph nodes (LNs) echofeatures on endoscopic ultrasound (EUS) and concurrent fine needle aspiration (FNA) are alternatives to highly invasive approaches for etiologic diagnosis of mediastinal lymphadenopathy (MLAD).

AIMS

To evaluate the efficacy of LNs echofeatures and FNA via EUS to distinguish benign LNs from LNs involved by sarcoidosis, lymphoma, and metastasis in non-lung cancer patients.

METHODS

A retrospective review of patients who underwent EUS-FNA for MLAD was performed. Echofeatures of LNs including echogenicity, margins, shape, and LN size were recorded. Final diagnosis was made based on surgical sampling or clinical diagnosis with long-term follow-up. Only patients diagnosed as benign MLAD, sarcoidosis, lymphoma, and metastasis included. Diagnostic value of echofeatures and FNA was evaluated.

RESULTS

Included were 162 patients with final diagnosis of benign (68), sarcoidosis (33), lymphoma (20), and metastasis (41). The median LN along axis in the benign group [20.5 mm (6-76)] was significantly shorter than in the metastasis [28 mm (9-82)] and sarcoidosis [27 mm (17-50)] groups (p < 0.05). The median LN short axis in the benign group [11 mm (2-50)] was significantly shorter than in the metastasis [17 mm (5-44)] and lymphoma [16 mm (7-47)] groups (p < 0.05). No other echofeatures showed a discriminant value among the groups. When performing FNA, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 73.7, 100, 100, 72.2, and 84.4 %, respectively.

CONCLUSION

Although benign MLAD tend to be smaller than other etiologies, echofeatures of LNs are not reliable etiologic diagnostic approach to MLAD. Therefore, FNA is suggested when feasible. However, due to relatively low sensitivity, LNs with benign FNA results should be subjected to further work-up if they are clinically suspicious.

Prevalence and penetrance of ZFPM2 mutations and deletions causing congenital diaphragmatic hernia

Zinc finger protein, FOG2 family member 2 (ZFPM2) (previously named FOG2) gene defects result in the highly morbid congenital diaphragmatic hernia (CDH) in humans and animal models. In a cohort of 275 CDH patient exomes, we estimated the prevalence of damaging ZFPM2 mutations to be almost 5%. Genetic analysis of a multigenerational family identified a heritable intragenic ZFPM2 deletion with an estimated penetrance of 37.5%, which has important implications for genetic counseling. Similarly, a low penetrance ZFPM2 frameshift mutation was observed in a second multiplex family. Isolated CDH was the predominant phenotype observed in our ZFPM2 mutation patients. Findings from the patients described herein indicate that ZFPM2 point mutations or deletions are a recurring cause of CDH.

Review of side-effect profile of combination ezetimibe and statin therapy in randomized clinical trials

Effective treatment to achieve target lipid parameters in high-risk patients may require combination drug therapies. Concerns regarding risks associated with such combination therapies may limit their use. A systematic overview of randomized controlled trials to assess risks associated with combination statin and ezetimibe therapy was performed. Eighteen trials were identified, including 14,471 patients. Follow-up ranged from 6 to 48 weeks. Compared with statin monotherapy, combination therapy did not result in significant absolute increases in risks of myalgias (risk difference -0.033, 95% confidence interval [CI] -0.06 to -0.01), creatine kinase increases (risk difference 0.011, 95% CI -0.02 to 0.04), rhabdomyolysis (risk difference -0.003, 95% CI -0.01 to 0.004), transaminase increases (risk difference -0.003, 95% CI -0.01 to 0.005), gastrointestinal adverse events (risk difference 0.005, 95% CI -0.03 to 0.04), or discontinuations because of an adverse event (risk difference -0.005, 95% CI -0.03 to 0.02). In conclusion, based on available randomized trials, the addition of ezetimibe to statin therapy did not increase the risk of myalgias, creatine kinase increases, rhabdomyolysis, transaminase increases, gastrointestinal adverse events, or discontinuations because of an adverse event. Additional trials are necessary to ensure that results of clinical trials are consistent with routine clinical practice, particularly in older patients with more co-morbid conditions and patients on higher statin doses.

Fluid retention in cirrhosis: pathophysiology and management

Accumulation of fluid as ascites is the most common complication of cirrhosis. This is occurring in about 50% of patients within 10 years of the diagnosis of cirrhosis. It is a prognostic sign with 1-year and 5-year survival of 85% and 56%, respectively. The most acceptable theory for ascites formation is peripheral arterial vasodilation leading to underfilling of circulatory volume. This triggers the baroreceptor-mediated activation of renin-angiotensin-aldosterone system, sympathetic nervous system and nonosmotic release of vasopressin to restore circulatory integrity. The result is an avid sodium and water retention, identified as a preascitic state. This condition will evolve in overt fluid retention and ascites, as the liver disease progresses. Once ascites is present, most therapeutic modalities are directed on maintaining negative sodium balance, including salt restriction, bed rest and diuretics. Paracentesis and albumin infusion is applied to tense ascites. Transjugular intrahepatic portosystemic shunt is considered for refractory ascites. With worsening of liver disease, fluid retention is associated with other complications; such as spontaneous bacterial peritonitis. This is a primary infection of ascitic fluid caused by organisms originating from large intestinal normal flora. Diagnostic paracentesis and antibiotic therapy plus prophylactic regimen are mandatory. Hepatorenal syndrome is a state of functional renal failure in the setting of low cardiac output and impaired renal perfusion. Its management is based on drugs that restore normal renal blood flow through peripheral arterial and splanchnic vasoconstriction, renal vasodilation and/or plasma volume expansion. However, the definitive treatment is liver transplantation.

Management of ST-elevation myocardial infarction: an update on pharmacoinvasive recanalization

The immediate goal of reperfusion in acute ST-elevation myocardial infarction (STEMI) is the prompt restoration of myocardial blood flow. Over the past 50 years, numerous advances have been made in achieving this goal by combining pharmacologic regimens with primary percutaneous coronary intervention (PCI) [i.e. pharmacoinvasive recanalizaton]. Fibrinolytics and glycoprotein (GP) IIb/IIIa inhibitors remain the most promising and widely used pharmacologic agents used to date. Early GP IIb/IIIa inhibition in patients undergoing PCI for STEMI results in early reperfusion and can result in improved clinical outcomes. Combination therapy with fibrinolytics and GP IIb/IIIa inhibitors is currently under investigation. The importance of time in the administration of these agents, especially in patients with expected delays to mechanical reperfusion, cannot be overemphasized. Benefits of revascularization are dependent on establishing reperfusion early enough to salvage the myocardium and preserve the left ventricular ejection fraction. As time passes, the effectiveness of treatments decline and patient outcomes are worse. This dependence upon time applies to both fibrinolytic therapy as well as primary PCI. In the current era, primary PCI is the preferred modality for treating patients with STEMI with a goal door-to-balloon time of <90 minutes. However, this modality is not available to all patients presenting with STEMI. Given the importance of time to reperfusion, a pharmacoinvasive approach may be ideal for this patient population. In this paper, we review the literature on pharmacoinvasive recanalization and discuss the optimal combination and timing of these agents. We have linked current American College of Cardiology/American Heart Association Clinical Practice Guidelines to clinical data available in the literature.

Rescue Angioplasty or Repeat Fibrinolysis After Failed Fibrinolytic Therapy for ST-Segment Myocardial Infarction

OBJECTIVES

We sought to best estimate the benefits and risks associated with rescue percutaneous coronary intervention (PCI) and repeat fibrinolytic therapy as compared with conservative management in patients with failed fibrinolytic therapy for ST-segment myocardial infarction (STEMI).

BACKGROUND

Fibrinolytic therapy is the most common treatment for STEMI; however, the best therapy in patients who fail to achieve reperfusion after fibrinolytic therapy remains uncertain.

METHODS

We performed a meta-analysis of randomized trials using a fixed-effects model. We included 8 trials enrolling 1,177 patients with follow-up duration ranging from hospital discharge to 6 months.

RESULTS

Rescue PCI was associated with no significant reduction in all-cause mortality (relative risk [RR] 0.69; 95% confidence interval [CI] 0.46 to 1.05), but was associated with significant risk reductions in heart failure (RR 0.73; 95% CI 0.54 to 1.00) and reinfarction (RR 0.58; 95% CI 0.35 to 0.97) when compared with conservative treatment. Rescue PCI was associated with an increased risk of stroke (RR 4.98; 95% CI 1.10 to 22.5) and minor bleeding (RR 4.58; 95% CI 2.46 to 8.55). Repeat fibrinolytic therapy was not associated with significant improvements in all-cause mortality (RR 0.68; 95% CI 0.41 to 1.14) or reinfarction (RR 1.79; 95% CI 0.92 to 3.48), but was associated with an increased risk for minor bleeding (RR 1.84; 95% CI 1.06 to 3.18).

CONCLUSIONS

Rescue PCI is associated with improved clinical outcomes for STEMI patients after failed fibrinolytic therapy, but these benefits must be interpreted in the context of potential risks. On the other hand, repeat fibrinolytic therapy is not associated with significant clinical improvement and may be associated with increased harm.

Risks Associated With Statin Therapy

Background— Although statins reduce the risk of cardiovascular events, concerns about adverse effects may deter physicians from prescribing these agents. We performed a systematic overview of randomized statin trials to quantify the risks of musculoskeletal, renal, and hepatic complications associated with therapy.

Methods and Results— Major statin trials were identified by electronic search of the MEDLINE database from 1966 to December 2005. We included English language reports of adults with documented hyperlipidemia; double-blind, random allocation of ≥100 patients to statin monotherapy versus placebo; and reports of myalgia, creatine kinase elevations, rhabdomyolysis, transaminase elevations, and discontinuation due to adverse events. Among 74 102 subjects enrolled in 35 trials (follow-up range, 1 to 65 months), statin therapy (excluding cerivastatin) did not result in significant absolute increases in risks of myalgias (risk difference/1000 patients [RD], 2.7; 95% CI, −3.2 to 8.7), creatine kinase elevations (RD, 0.2; 95% CI, −0.6 to 0.9), rhabdomyolysis (RD, 0.4; 95% CI, −0.1 to 0.9), or discontinuation due to any adverse event (RD, −0.5; 95% CI, −4.3 to 3.3). The absolute risk of transaminase elevations was significantly higher with statin therapy (RD, 4.2; 95% CI, 1.5 to 6.9).

Conclusions— On the basis of data available from published clinical trials, statin therapy is associated with a small excess risk of transaminase elevations, but not of myalgias, creatine kinase elevations, rhabdomyolysis, or withdrawal of therapy compared with placebo. Further study is necessary to determine whether the results from these published clinical trials are similar to what occurs in routine practice, particularly among patients who are older, have more severe comorbid conditions, or receive higher statin doses than most patients in these clinical trials.

Significance of QRS complex duration in patients with heart failure

Prolongation of QRS (> or =120 ms) occurs in 14% to 47% of heart failure (HF) patients. Left bundle branch block is far more common than right bundle branch block. Left-sided intraventricular conduction delay is associated with more advanced myocardial disease, worse left ventricular (LV) function, poorer prognosis, and a higher all-cause mortality rate compared with narrow QRS complex. It also predisposes heart failure patients to an increased risk of ventricular tachyarrhythmias, but the incidence of cardiac or sudden death remains unclear because of limited observations. A progressive increase in QRS duration worsens the prognosis. No electrocardiographic measure is specific enough to provide subgroup risk categorization for excluding or selecting HF patients for prophylactic implantable cardioverter-defibrillator (ICD) therapy. In ICD patients with HF, a wide underlying QRS complex more than doubles the cardiac mortality compared with a narrow QRS complex. There is a high incidence of an elevated defibrillation threshold at the time of ICD implantation in patients with QRS > or =200 ms. Mechanical LV dyssynchrony potentially treatable by ventricular resynchronization occurs in about 70% of HF patients with left-sided intraventricular conduction delay, a fact that would explain the lack of therapeutic response in about 30% of patients subjected to ventricular resynchronization according to standard criteria relying on QRS duration. The duration of the basal QRS complex does not reliably predict the clinical response to ventricular resynchronization, and QRS narrowing after cardiac resynchronization therapy does not correlate with hemodynamic and clinical improvement. Mechanical LV dyssynchrony is best shown by evolving echocardiographic techniques (predominantly tissue Doppler imaging) currently in the process of standardization.

Angiography and revascularization in patients with heart failure following fibrinolytic therapy for ST-elevation acute myocardial infarction

We evaluated the use of coronary angiography and clinical outcomes among patients who had heart failure and were enrolled in the Intravenous Novel Plasminogen Activator (NPA) for the Treatment of Infarcting Myocardium Early study, a large international trial of fibrinolytic therapy in ST-elevation myocardial infarction.

Severity of heart failure, treatments, and outcomes after fibrinolysis in patients with ST-elevation myocardial infarction

AIMS

To define the clinical characteristics, co-morbidities, treatment, and clinical outcomes of patients with varying degrees of heart failure (HF) complicating ST-elevation myocardial infarction (STEMI), and to identify patients at high risk for HF following fibrinolysis.

METHODS AND RESULTS

15,078 STEMI patients enrolled in a worldwide fibrinolytic trial (InTIME-II) were categorised into one of four hierarchical, mutually exclusive groups of HF: shock (n = 719, 5%); severe HF (n = 1082, 7%); mild HF (n = 1619, 11%); no HF (n = 11,658, 77%). In a multivariable model, anterior MI (OR 1.8, 95% CI [1.6; 1.9]), age > or = 65 (OR 1.8 [1.6; 2.0]), prior HF (OR 3.3 [2.6; 4.2]), and creatinine clearance < 60 mL/min (OR 1.8 [1.6; 2.1]) were the four most powerful correlates of HF. Although 30-day mortality was sixfold higher for patients with HF (18.9% vs. 3.1%, P < 0.0001), these patients were less likely to undergo angiography (30% vs. 40%, P < 0.0001) and revascularisation (19% vs. 25%, P , 0.0001), than patients without HF. Likewise, angiotensin-inhibitors and beta-blockers were not optimally utilised in patients with HF following MI.

CONCLUSIONS

During the index admission following fibrinolysis 23% of patients had HF. Despite a higher risk profile, patients with more severe HF were treated less aggressively than patients without HF.

The role of integrins in the modulation of neurotransmitter release from motor nerve terminals by stretch and hypertonicity

Integrins are found at most or all synapses and play a variety of roles. At frog neuromuscular junctions, mechanical tension on integrins due to muscle stretch or hypertonicity causes a powerful modulation of release efficacy. Understanding the mechanism(s) of integrin-mediated modulation will likely further our understanding of mechanisms of neurotransmitter release. The modulation of evoked release with stretch occurs with no detectable delay, does not adapt, and bypasses the Ca(2+) triggering step in vesicle fusion. It depends primarily on integrin bonds to native ligands and requires that one or more proteins in the link between integrins and vesicle fusion be dephosphorylated. Hypertonicity, studied in both frog and Drosophila terminals, causes a larger but slower phasic-tonic change in spontaneous release, which is also Ca(2+)-independent and mostly dependent on integrins, but not dependent on the phosphorylation state of molecules in its pathway of action. In Drosophila, the integrin-dependent component involves the cAMP/PKA pathway, and is absent in mutants lacking PKA. Both stretch and hypertonicity responses in frog terminals are enhanced by agents that elevate PKA levels, suggesting that, in frogs, the cAMP/PKA cascade primarily determines the size of the pool of vesicles available for release by the integrin-mediated mechanism and is not a direct intermediary in the modulation. Evoked release is affected little or even inhibited by hypertonicity. In Drosophila, the inhibition can be explained by a decrease in Ca(2+) influx. The effect of hypertonicity on evoked release in frogs may similarly be a balance between mechanisms that enhance spontaneous release and those that suppress I (Ca).

Aortic Perforation by Active‐Fixation Atrial Pacing Lead

This report describes perforation of the aorta related to the implantation of an active-fixation atrial pacing lead, a previously undocumented complication of pacemaker implantation. The complication was related to excessive tissue penetration by the screw at the tip of the lead or perforation of the lead body by the positioning stylet during manipulation whereupon the stylet traversed the atrial wall and aortic wall. Perforation of the aorta should be part of the differential diagnosis of cardiac tamponade after pacemaker implantation.

A case of pacemaker and pacemaker-like syndrome

This report describes the occurrence of both pacemaker syndrome and a pacemaker-like syndrome (so-called "pseudopacemaker syndrome") in a patient who exhibited an atrioventricular junctional rhythm probably on the basis of sick sinus syndrome. The clinical and hemodynamic manifestations of the two clinical situations were similar and associated with regular retrograde ventriculoatrial conduction. The abnormalities during the junctional rhythm were reproduced during ventricular pacing. Surprisingly, the occurrence of the pacemaker-like syndrome during junctional rhythm in patients with normal left ventricular function has rarely been described.

Plasma cell variant of Castleman's disease occurring concurrently with Hodgkin's disease in the neck

BACKGROUND

Castleman's disease, a benign lymphoproliferative disorder, may be seen as a self-limited, curable unifocal process, or highly aggressive multicentric disease frequently resulting in death despite aggressive management. Non-Hodgkin's lymphoma has been known to arise within the context of Castleman's disease, usually when multicentric. Hodgkin's lymphoma, however, can also arise within the context of Castleman's disease, but this is a rare process. We report a case of unifocal Castleman's disease (plasma cell variant) occurring concurrently with Hodgkin's disease in the neck of a young woman.

METHODS

The presentation, workup, pathologic evaluation, and management of a young woman diagnosed with Castleman's disease occurring concurrently with Hodgkin's disease in the neck is presented and discussed.

RESULTS

A 32-year-old woman with a 5-year history of unifocal right cervicoparotid Castleman's disease (plasma cell variant) underwent right functional neck dissection and superficial parotidectomy for cosmetic and functional purposes. Pathologic and immunohistochemical analysis confirmed Hodgkin's lymphoma occurring in a background of the plasma cell variant of Castleman's disease. The patient subsequently underwent external beam radiation therapy as definitive management for her early-stage Hodgkin's lymphoma.

CONCLUSIONS

Castleman's disease can occur as an isolated regional process in the head and neck. Furthermore, lymphoma (and specifically Hodgkin's lymphoma) can develop within regionally isolated cervical Castleman's disease. Although complete surgical excision of unifocal Castleman's disease is curative, the management of lymphoma occurring within the context of the Castleman's disease warrants a standard lymphoma workup and management strategy.

Safety of repeated intravitreous injections of antibiotics and dexamethasone

PURPOSE

To determine the retinotoxicity of repeated intravitreous injections of vancomycin, ceftazidime, and dexamethasone in rabbit eyes.

METHODS

Twenty pigmented New Zealand rabbits were divided into two groups. In Group 1, the right eyes received repeated intravitreous injections with vancomycin 0.3 mg, ceftazidime 0.7 mg, and dexamethasone sodium phosphate 0.13 mg at three consecutive 48-hour intervals. Group 2 right eyes received three times higher dose of the same intravitreous drugs as used in Group 1, repeated at the same frequency. All left eyes served as control eyes. Retinotoxicity was monitored by slit-lamp biomicroscopy, indirect ophthalmoscopy, electroretinography, and light and electron microscopy.

RESULTS

No evidence of retinotoxicity was found in Group 1 eyes. Photopic A-waves were significantly elevated, and 30- and 50-Hz flicker fusion amplitudes were significantly depressed in Group 2 eyes. No changes were found by clinical or histopathologic examination in the retinas of either group.

CONCLUSIONS

Three repeated intravitreous injections at 48-hour intervals of a combination of vancomycin, ceftazidime, and dexamethasone in rabbit eyes at dosages that approximate drug concentrations recommended for human endophthalmitis were nontoxic. Similar injections at three times higher doses resulted in mild electroretinogram changes.

High dose intramuscular methylprednisolone in experimental Staphylococcus aureus endophthalmitis

We attempted to determine whether treatment using intramuscular methylprednisolone plus intravitreal vancomycin decreased ocular inflammation and preserved retinal function better in experimental Staphylococcus aureus (S. aureus) endophthalmitis than treatment with intravitreal vancomycin alone. Sixteen rabbits received intravitreal inoculations in both eyes with S. aureus and the rabbits were divided into two groups (group I and group II) of eight rabbits each. Group I rabbits were treated with one injection of intravitreal vancomycin in each eye at either 24, 36, 48 or 72 hours after bacterial inoculation followed by seven consecutive days of high dose intramuscular methylprednisolone (30 mg/kg per day). Group II rabbits were treated with only one intravitreal injection of vancomycin in each eye at equivalent time intervals as in Group I. Clinical evaluations of ocular inflammation were performed by slit-lamp biomicroscopy and indirect ophthalmoscopy. Electroretinography (ERG) was performed eight days after bacterial inoculation to assess retinal function in all eyes. The combination of intramuscular methylprednisolone and intravitreal vancomycin resulted in a degree of ocular inflammation equal to eyes treated with intravitreal vancomycin alone at all treatment intervals. ERG responses were not significantly different in either group. A single intravitreal injection of vancomycin plus daily intramuscular methylprednisolone for seven days were found neither to decrease ocular inflammation nor preserve retinal function better than a single intravitreal injection of vancomycin in our experimental model of S. aureus endophthalmitis.

Hemodynamic effects of exchange transfusions with liposome-encapsulated hemoglobin

The ability of liposome-encapsulated hemoglobin (LEH) to sustain life in rats at hematocrits 45% below lethal levels was demonstrated by virtually total exchange transfusions. All control animals (transfused with 7% albumin in Erilyte) died at a mean hematocrit of 5.35%, with corresponding oxygen-carrying capacity of 2.65 ml/100 ml. All LEH animals survived with a final RBC hematocrit of 2.96% and an oxygen-carrying capacity of 7.05 ml/100 ml. LEH animals maintained normal blood pressures and essentially normal cardiac output, while control animals failed to do so. Systemic vascular resistance of control animals at 78% exchange was reduced to 33% of baseline, while of LEH animals at 92% exchange, to 80% of baseline. In-vitro measurements were made of LEH and RBC suspension viscosity as a function of shear rate, suspension concentration, and lipid membrane composition. The viscous behavior of the LEH suspensions was non-Newtonian and nearly the same as suspensions of natural RBC prepared similarly, though LEH suspensions had slightly higher viscosity.

Measurements of viscosity of synthetic erythrocyte suspensions

Measurements were made of the viscosity of suspensions of synthetic erythrocytes composed of hemoglobin solutions encapsulated in liposomes, as a function of shear rate, temperature, suspension concentration, lipid membrane composition, and the viscosity of the suspending medium. It was found that the viscous behavior of the synthetic erythrocyte suspensions was non-Newtonian and nearly the same as that of suspensions of natural erythrocytes prepared similarly, with the major difference being that synthetic erythrocyte suspensions are somewhat more viscous. Suspensions of Fluosol FC-43 prepared similarly were found to be essentially Newtonian fluids, and substantially different and more viscous than either erythrocyte suspension. The higher viscosity of synthetic erythrocyte suspensions probably accounts for the ability of these suspensions to maintain normal systemic vascular resistance in transfusion experiments, in spite of the fact that synthetic erythrocytes are smaller than natural erythrocytes.