The impact of psychiatric diagnoses on two-year outcomes in patients with ventricular assist devices

Background

A multi-specialty approach is required during patient selection for left ventricular assist device (LVAD) implantation. In addition to a comprehensive medical evaluation, patients undergo an extensive psychiatric work up to ensure their candidacy when pursuing durable support devices. We aim to analyze the impact of psychiatric illnesses on 2-year outcomes after VAD implantation.

Methods

This study was a single center, retrospective analysis of 263 patients who underwent durable LVAD implantation between 2015 and 2017. All patients were evaluated by a single specialist during their work up for LVAD implantation. Patients who had a pre-existing diagnosis defined by criteria outlined in Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were assigned to the History of Psychiatric Diagnosis group. Statistical analysis was performed using Chi-Square and Student's t-tests, wherein p<0.05 was considered statistically significant.

Results

Of the 263 patients, 68 patients were found to have a history of psychiatric illness compared to 195 who had no previous diagnosis. Of those with a psychiatric history, 30.8% had Depression, 1.5% had Bipolar disorder, 22.1% had Anxiety, 1.5% had PTSD, and 16.2% had more than one diagnosis. 19.5% of patients with no history went on to be transplanted compared to 22.1% of patients with a psychiatric history (p=0.65). No significant difference was found between length of stay, days to readmission, 30-day survival, and 2-year survival. Patients without a psychiatric history were found to have fewer number of readmissions over 2 years (p<0.01) (See Table). No significant difference was seen in complications including driveline infections, bacteremia, cerebrovascular accidents, pump thromboses, pump hemolysis, or major bleeding events (See Table).

Conclusion

Psychosocial characteristics play a significant role in determining a patient's candidacy for LVAD implantation. Although patients with a history of psychiatric illness were found to have a greater number of readmissions, this did not correlate to poorer outcomes or increased morbidity and mortality over 2 years. This study highlights the importance of taking a multi-faceted approach when determining patient eligibility for mechanical support devices. Future studies with larger population models should be conducted.

Funding Acknowledgement

Type of funding sources: None.

Mortality and long-term outcomes of palliative inotropes in ischemic and non-ischemic cardiomyopathy

Background

Palliative inotropes are frequently utilized for symptom management in patients with end stage heart failure who are unable to undergo durable advanced heart failure therapies. With the advent of improved medical management and early intervention, palliative inotropes may allow for improved patient outcomes than seen previously. In this study, we aim to investigate the survival and outcomes of palliative inotrope therapy and its impacts on ischemic versus non-ischemic cardiomyopathy.

Methods

We retrospectively analyzed 220 patients with American Heart Association Stage D heart failure who were discharged with palliative inotrope therapy after January 1, 2010. Patients who underwent mechanical circulatory support (MCS) or those who underwent heart transplant were excluded. Those with a history of coronary artery disease, myocardial infarction, history of percutaneous intervention, or coronary artery bypass grafting were assigned to ischemic cardiomyopathy (ICM), while patients without these findings were assigned to non-ischemic cardiomyopathy (NICM). Statistical analysis was completed using Chi-Square and Student's t-tests, wherein p<0.05 was considered statistically significant.

Results

Of the 220 patients, 87 had NICM as opposed to 133 with ICM. Mean age was found to be higher among patients with ICM (70 [62–79]) compared to NICM (65 [55–72], p-value <0.01). No significant difference was seen in total days on inotrope therapy (p=0.6). While more patients in both groups were placed on milrinone as opposed to dobutamine, there was no difference between patients with ischemic and NICM (p=0.66 and 0.51 respectively). Although a greater number of patients with NICM had been lost to follow up, admitted to hospice, or expired at 2 years (p<0.01), survival at 3 months, 1 year, and 2 years showed no difference between both groups. No difference was seen in number of hospitalizations or clinic visits in one year. Both groups had similar complication rates with intravenous-access related PICC line infections and new arrhythmias. (See Table).

Conclusion

Despite more frequent use of durable mechanical support devices, many patients who are deemed unsuitable for invasive measures are treated with palliative inotrope therapy. We have found that there is no significant difference in survival, complications, and outcomes of patients on palliative inotropes among ischemic and NICM. These findings show the versatility of palliative inotrope therapy in end stage heart failure. Further studies with larger populations need to be evaluated.

Funding Acknowledgement

Type of funding sources: None.

Design and characterization of microstrip based E-field sensor for GSM and UMTS frequency bands

An Electric (E-) field sensor based on coplanar waveguide-fed microstrip antenna to measure E-field strength for dual-band operation at 914 MHz and 2.1 GHz is proposed, designed, and characterized. The parametric optimization of the design has been performed to obtain resonance at global system for mobile communication and universal mobile telecommunication system frequency band. Low return loss (-17 dB and -19 dB), appropriate gain (0.50 dB and 1.55 dB), and isotropic behaviour (directivity ∼ 1 dB), respectively, at 914 MHz and 2.1 GHz, are obtained for probing application. Antenna factor (AF) is used as an important parameter to characterize the performance of the E-field sensor. The AF measurement is explained in detail and results are reported. Finally, using the designed E-field sensor, the E-field strength measurements are carried out in a transverse electromagnetic cell. The key sources of uncertainties in the measurement are identified, evaluated, and incorporated into the final results. The measurement results are compared with theoretical values, which are found in good agreement. For comparative validation, the results are evaluated with reference to an already calibrated commercially available isotropic probe.

Development of a real-time PCR for Escherichia coli based on gadE, an acid response regulatory gene

Increasingly, molecular methods have become important in identification and confirmation of bacteria at the species level. Rapid molecular methods provide sensitivity and specificity while reducing cost and resources. The primary goal of this study was to develop a real-time PCR assay for identification of Escherichia coli from an agar plate. GadE (gadE) directly regulates the glutamate-dependent acid response system (GDAR) in E. coli and is responsible for survival of at pH 2. Based on gene sequence data, a real-time PCR assay targeting gadE was developed for this purpose. Seventy bacterial isolates recovered from ground beef enrichments and 714 isolates from caecal contents were identified biochemically and tested with the real-time PCR assay developed in this study. The PCR assay and the biochemical identification had 100% agreement on the tested isolates. The gadE real-time PCR assay was demonstrated in this study to be an inexpensive, reliable method for confirming E. coli colonies within 1.5 h from an agar plate, thereby saving on final identification time.

Control of life, death, and differentiation in cultured midgut cells of the lepidopteran, Heliothis virescens

Differentiated cells in the insect midgut depend on stem cells for renewal. We have immunologically identified Integrin beta1, a promotor of cell-cell adhesion that also induces signals mediating proliferation, differentiation, and apoptosis on the surfaces of cultured Heliothis virescens midgut cells; clusters of immunostained integrin beta1-like material, indicative of activated integrin, were detected on aggregating midgut columnar cells. Growth factor-like peptides (midgut differentiation factors 1 and 2 [MDF1 and MDF2]), isolated from conditioned medium containing Manduca sexta midgut cells, may be representative of endogenous midgut signaling molecules. Exposing the cultured midgut cells to Bacillus thuringiensis (Bt) toxin caused large numbers of mature differentiated cells to die, but the massive cell death simultaneously induced a 150-200% increase in the numbers of midgut stem and differentiating cells. However, after the toxin was washed out, the proportions of cell types returned to near-control levels within 2 d, indicating endogenous control of cell-population dynamics. MDF1 was detected immunologically in larger numbers of Bt-treated columnar cells than controls, confirming its role in inducing the differentiation of rapidly produced stem cells. However, other insect midgut factors regulating increased proliferation, differentiation, as well as inhibition of proliferation and adjustment of the ratio of cell types, remain to be discovered.

Apoptosis in cultured midgut cells from heliothis virescens larvae exposed to various conditions

We exposed midgut cells from primary cultures of Heliothis virescens larvae to cell-free previously used medium, the Vaughn X and HyQ SFtrade mark media used for serum-free culture of insect cell lines which do not support H. virescens midgut cells, and to toxin from Bacillus thuringiensis. A statistically significant increase in the percent of dying cells was counted in cell populations in Vaughn X medium. Use of the TUNEL method to detect apoptosis indicated a low rate (7.2%) of apoptosis in control cultures grown in Heliothis medium, an increase to approximately 20% in previously used and HyQ SFtrade mark media, and to approximately 45% of cells remaining after exposure to and initial destruction by B. thuringiensis toxin. Apoptotic nuclei were predominant (approximately 6%) in mature columnar cells in control cultures. Approximately 1% of goblet, stem, and differentiating cells were apoptotic. However, apoptosis rose to 12% in stem and differentiating cells exposed to used and unsuitable medium. B. thuringiensis exposure to toxin for 2-3 days resulted in visible membrane damage and necrosis, causing the death of 84% of the cells as measured by both the TUNEL and Annexin methods. Some of the columnar cells and stem and differentiating cells that remained also contained apoptotic nuclei. Stem and differentiating cells normally replace dying mature cells in the midgut. Thus, exposure of cultures of H. virescens midgut cells to adverse environments such as unsuitable or poisonous media appeared to induce down-regulation of the cell populations by apoptosis.

Felbamate increases [3H]glycine binding in rat brain and sections of human postmortem brain

The anticonvulsant compound felbamate (2-phenyl-1,3-propanediol dicarbamate; FBM) appears to inhibit the function of the N-methyl-D-aspartate (NMDA) receptor complex through an interaction with the strychnine-insensitive glycine recognition site. Since we have demonstrated previously that FBM inhibits the binding of [3H]5, 7-dichlorokynurenic acid (DCKA), a competitive antagonist at the glycine site, we assessed the ability of FBM to modulate the binding of an agonist, [3H]glycine, to rat forebrain membranes and human brain sections. In contrast to its ability to inhibit [3H]5,7-DCKA binding, FBM increased [3H]glycine binding (20 nM; EC50 = 485 microM; Emax = 211% of control; nH = 1.8). FBM, but not carbamazepine, phenytoin, valproic acid or phenobarbital, also increased [3H]glycine binding (50 nM; EC50 = 142 microM; Emax = 157% of control; nH = 1.6) in human cortex sections. Autoradiographic analysis of human brain slices demonstrated that FBM produced the largest increases in [3H]glycine binding in the cortex, hippocampus and the parahippocampal gyrus. Because various ions can influence the binding of glycine-site ligands, we assessed their effects on FBM-modulation of [3H]glycine binding. FBM-enhanced [3H]glycine binding was attenuated by Zn++ and not inhibited by Mg++ in human brain. These results suggest that FBM increases [3H]glycine binding in a manner sensitive to ions which modulate the NMDA receptor. These data support the hypothesis that FBM produces anticonvulsant and neuroprotective effects by inhibiting NMDA receptor function, likely through an allosteric modulation of the glycine site.

Localization of dopamine receptors and associated mRNA in transplants of human fetal striatal tissue in rodents with experimental Huntington's disease

Huntington's Disease (HD) is characterized by deficits in motor and cognitive functions. This neurodegenerative disease shows an extensive loss of medium-sized spiny projection neurons (GABAergic) within the neostriatum. With the loss of these neurons, there is a concomitant loss of associated receptors, such as those for GABA, glutamate, and dopamine. In the present study, we have addressed the question of whether dopamine receptors are re-established in the lesioned rodent striatum following the transplantation of human striatal cells. Human striatal cell suspension or saline (transplant controls) was injected into the striatum of rats previously lesioned with quinolinic acid (QA). Three nine months following transplantation, the animals were sacrificed and the brains were processed for receptor autoradiography and in situ hybridization of dopamine D1 and D2 receptor subtypes. Our results demonstrate that animals transplanted with human striatal cells show a significant increase in D1 receptors following transplantation when compared to the lesion area in control animals, while D1 receptor mRNA remains unchanged. In contrast to D1 receptor binding, D2 receptor levels are not increased in the lesioned and transplanted area of the striatum when compared to controls; however, D2 receptor mRNA levels are significantly increased. These results demonstrate that at the times the animals were examined, D1 and D2 receptors were differentially regulated. Our results further indicate that human striatal primordium will survive following transplantation and will express D1 receptors and D2 receptor mRNA that are depleted in the QA lesioned rodent striatum. This study compliments and extends previous findings on human striatal cell transplantation in rodent models of HD.

The temporal evolution of striatal dopamine receptor binding and mRNA expression following hypoxia-ischemia in the neonatal rat

Neonatal hypoxic-ischemic (HI) brain injury in the rat alters dopamine receptors. To determine whether such changes are permanent, dopamine receptors and corresponding mRNA were examined at various time points after neonatal HI using receptor autoradiography and in situ hybridization. Rat pups underwent ligation of the left common carotid artery followed by hypoxic exposure (8.5% O2 for 3 h). Controls underwent sham surgery alone. Animals surviving for 2-80 days following HI were studied. Striatal D1 receptors (labeled by [3H]SCH23390) were reduced as early as 2 days following HI, remained depressed for 21 days, but recovered to control levels by young adulthood (3 months of age). D2 receptors (labeled by [125I] iodosulpride) did not decline until 10 days after HI, and remained uniformly depressed throughout the caudate-putamen thereafter. Changes in D1 receptor mRNA transcripts closely paralleled alterations in receptors: early reductions in D1 mRNA signal recovered by young adulthood. D2 mRNA exhibited a unique temporal profile with an early decrease (2 days following HI), and prompt, persistent recovery. Dopamine receptors and transcripts are differentially affected by HI injury early in development. Whereas D1 receptor expression recovers from neonatal HI injury, D2 receptors remain permanently affected despite the presence of normal levels of D2 receptor transcripts. A persistent, post-transcriptional effect of HI on D2 receptor expression is suggested.

Biological behaviour of moderate dysplasia--a prospective study

The present communication reports the biological behaviour of women with moderate dysplastic lesions of uterine cervix based on a long term prospective study. Two hundred and thirty nine women with moderate dysplasia by cervical cytology who satisfied the criteria for registration were longitudinally followed up at 3 +/- 1 monthly intervals along with age and parity matched controls for a period ranging from 4 to 132 months. The cumulative rate of progression from moderate dysplasia to malignancy (CIS) was observed to be 23.0% at the end of 72 months of follow up with mean transition interval of 24.2 months. Out of 239 cases, 142 women who had more than 24 months of follow up were considered for studying the biological behaviour of the lesion. It was observed that during a follow up of 132 months, 14(9.9%) and 15(10.6%) women progressed to carcinoma in-situ and severe dysplasia respectively. The persistence of lesion was observed in 21(14.8%) women while 11(7.3%) and 81(57.0%) regressed to mild dysplasia and normalcy respectively.

Age-related loss of cholinergic-muscarinic coupling to PLC: comparison with changes in brain regional PLC subtypes mRNA distribution

Activation of phospholipase C (PLC) coupled to phosphoinositide (PtdIns) hydrolysis occurs through one of the two pathways. One of the major pathways for the neurotransmitter signaling involves phosphoinositide (PtdIns) specific and G-protein dependent PLC-beta, which stimulates the formation of inositol triphosphate (IP3) and inositol tetraphosphate (IP4). Another pathway through the stimulation of calcium influx can directly activate all of the PLC isozymes. At least three isozymes of PLC have been characterized in the brain; PLC-A (alpha), PLC-I (beta) and PLC-II (gamma), which are shown to be localized differentially in brain regions. Muscarinic-cholinergic signals are mediated in large part through the hydrolysis of PtdIns by PLC. To investigate changes in muscarinic coupling to PLC during aging, we examined carbachol stimulated and calcium stimulated PtdIns hydrolysis in cerebral cortical membranes in young, middle aged and old rats. In order to determine whether PtdIns hydrolysis changes correspond to PLC isozyme expression in these animals, we examined three subtypes of PLC mRNA expression in brain sections of young and old rats using in situ hybridization technique. Our study indicated decreased carbachol-induced PLC activity in the cerebral cortex and, in contrast, increased PLC-beta mRNA in the frontal cortex and superficial cortical layer of aged rats. PLC-alpha mRNA was decreased in hippocampal regions of older rats. These studies suggest that during aging there is an uncoupling of muscarinic stimulated PtdIns hydrolysis, which is accompanied by an increased PLC-beta mRNA and decreased PLC-alpha mRNA that may represent compensatory changes in PLC expression.

Age does not alter Protein kinase C isozymes mRNA expression in rat brain

Calcium and phospholipid dependent Protein kinase C (PKC) may play a role in memory function and pathogenesis of many neurodegenerative disorders such as Alzheimer's disease (AD). Abnormal phosphorylation by PKC as well as reduced levels of PKC has been implicated in the neurodegeneration associated with AD and aging. Recently, many subtypes of PKC isozymes have been identified by molecular biology techniques which are expressed differentially in various regions of the brain. The reduction and alterations in the activities and distribution of these subtypes of PKC isozymes may be accountable for the decline of selective neurons during aging. In order to investigate the role of PKC isozymes during aging, we examined the distribution of PKC-alpha, beta, and gamma mRNA expressions between young (4 months) and old (25 months) rat brains using in situ hybridization histochemistry. Our studies showed that signals of three isoforms of PKC mRNA vary in cortical and hippocampal regions. However, no change was detected in any of the PKC isoforms mRNA expression in aged animals.

Time dependent changes in DA uptake sites, D1 and D2 receptor binding and mRNA after 6-OHDA lesions of the medial forebrain bundle in the rat brain

Quantitative receptor autoradiography and in situ hybridization techniques were used to examine the temporal pattern of changes in dopamine uptake sites, D1 and D2 receptors and their transcripts in the striata of animals lesioned with 6-hydroxydopamine. Animals were unilaterally lesioned in the medial forebrain bundle and the brains were analyzed at 1, 2, 4, 6, 8, and 16 weeks postlesion. Degeneration of the nigrostriatal pathway induced a significant loss of dopamine uptake sites in the ipsilateral caudate putamen of all lesioned animals. D1 receptor binding was significantly increased in the caudate putamen on the lesioned side from 1 week to 16 weeks postlesion, whereas the expression of D1 receptor mRNA did not show any change during this period. There was a significant upregulation of D2 receptor binding as well as D2 mRNA from 2 weeks to 8 weeks postlesion. However, at 16 weeks postlesion, D2 receptor binding continued to increase, whereas the mRNA appeared to compensate. These studies show that a different regulatory mechanism may exist between these two DA receptor subtypes. D1 receptor changes occur at the post-transcriptional or translational level, whereas D2 alterations occur by both transcriptional and translational processes. These studies also indicate that the postsynaptic supersensitivity observed in D1 receptors may not be accompanied by a corresponding increase in D1 receptor mRNA.