Y-shaped stenting of brachiocephalic vein in a symptomatic hemodialysis patient

Stenosis or obstruction of neck great veins represent a frequent and severe complication in hemodialysis patients. Endovascular treatment with percutaneous transluminal angioplasty and/or stenting of these veins is the gold standard to restore patency. However, the jugular vein is frequently overstented in these cases and this might lead to persistent symptomatology of those patients also losing an access for future catheter placement. Herein, we present the 6-months performance of a Y-shaped stenting of the brachiocephalic and internal jugular vein leading to complete resolution of the symptoms, and maintenance of the jugular vein access.

The Multi-temporal and Multi-dimensional Global Urban Centre Database to Delineate and Analyse World Cities

Monitoring sustainable urban development requires comparable geospatial information on cities across several thematic domains. Here we present the first global database combining such information with city extents. The Global Human Settlement Urban Centre Database (GHS-UCDB) is produced by geospatial data integration to characterise more than 10,000 urban centres worldwide. The database is multi-dimensional and multi-temporal, containing 28 variables across five domains and having multitemporal attributes for one or more epochs when the UC are delineated (1975-1990-2000-2015). Delineation of urban centres for the year 2015 is performed via a logic of grid cell population density, population size, and grid cell contiguity defined by the Degree of Urbanisation method. Each of the urban centres has 160 attributes, including a validation assessment. The novel aspects of this database concern the thematic richness and temporal depth of the variables (across geography, socio-economic, environmental, disaster risk reduction, and sustainable development domains) and the type of geo-information provided (location and extent), featuring an overall consistency that allows comparative analyses across locations and time.

Cardiac valve calcification in patients on maintenance dialysis. The role of malnutrition-inflammation syndrome, adiposity andcomponents of sarcopenia. A cross-sectional study

BACKGROUND & AIMS

Cardiac valve calcification (CVC) is a predictor of cardiovascular disease and all-cause mortality in end stage kidney disease (ESKD) patients. Several risk factors are related to CVC in patients with ESKD including traditional ones as well as inflammation, bone mineral disease and malnutrition. Adiposity is associated with dyslipidemia and proinflammatory activity which could predispose for CVC. Sarcopenia or dynapenia is a state common in patients with ESKD. This study aimed to investigate the relationship of adiposity, sarcopenia and malnutrition-inflammation markers with CVC in patients on maintenance hemodialysis.

METHODS

CVC in aortic (AVC), mitral valves (MVC) and systolic and diastolic dysfunction (DD) were assessed by using two-dimensional echocardiography. Nutritional, adiposity and anthropometric assessments were made using several indices respectively. Creatinine index and muscle strength measurements were also performed. Biochemical parameters such as total proteins, albumin, calcium, phosphate, plasma lipoproteins, C-Reactive Protein and parathyroid hormone were also measured.

RESULTS

Adiposity, nutritional, and sarcopenia parameters did not show any difference between patients with or without CVC. Age ≥ 65 years [PR: 1.47 p = 0.012], DD [PR: 2.31, p = 0.005], high CRP/albumin ratio [PR: 1.46, p = 0.01], mid arm circumference (MAC) < 26 cm [PR: 1.37, p = 0.03] were associated with increased prevalence of AVC, while DD [PR: 1.97 p = 0.02], high CRP/albumin ratio [PR: 1.56, p = 0.02], and MAC < 26 cm [PR: 1.52, p = 0.01], showed positive correlation with MVC. Age ≥ 65 years [PR: 1.33, p = 0.028], DD [PR: 1.72, p = 0.01], high CRP/albumin ratio [PR: 1.53, p = 0.003], and MAC < 26 cm [PR: 1.4, p = 0.006], related to greater prevalence of calcification at any valve.

CONCLUSIONS

Ageing, diastolic dysfunction, MAC and increased CRP/albumin ratio were powerful predictors of CVC in patients on hemodialysis.

ATR-mediated DNA damage responses underlie aberrant B cell activity in systemic lupus erythematosus

B cells orchestrate autoimmune responses in patients with systemic lupus erythematosus (SLE), but broad-based B cell-directed therapies show only modest efficacy while blunting humoral immune responses to vaccines and inducing immunosuppression. Development of more effective therapies targeting pathogenic clones is a currently unmet need. Here, we demonstrate enhanced activation of the ATR/Chk1 pathway of the DNA damage response (DDR) in B cells of patients with active SLE disease. Treatment of B cells with type I IFN, a key driver of immunity in SLE, induced expression of ATR via binding of interferon regulatory factor 1 to its gene promoter. Pharmacologic targeting of ATR in B cells, via a specific inhibitor (VE-822), attenuated their immunogenic profile, including proinflammatory cytokine secretion, plasmablast formation, and antibody production. Together, these findings identify the ATR-mediated DDR axis as the orchestrator of the type I IFN-mediated B cell responses in SLE and as a potential novel therapeutic target.

Creatinine index as a predictive marker of sarcopenia in patients under hemodialysis

PURPOSE

Sarcopenia is a clinical condition that comprises declined skeletal muscle (SM) mass and SM strength, and is a risk factor for physical disability, impaired quality of life, and advanced morbidity and mortality in patients on hemodialysis (HD). The existing difficulty in evaluating SM mass and consequently of sarcopenia, with affordable and practical methods in clinical practice, is well established. The purpose of this study is to examine the creatinine index (CrI), a surrogate of SM mass, as a potential predictive marker of sarcopenia.

METHODS

In this cross-sectional study, we included 130 patients on HD with a mean age of 66.17 ± 12.47 years. SM mass and SM strength were evaluated with CrI and hand grip strength, respectively. Anthropometric, adiposity, nutritional, and biochemical assessments were also performed. Partial correlation and multivariate regression analyses were applied to investigate the association between CrI and SM strength.

RESULTS

Correlation analysis showed that mid-arm circumference, calf circumference, Geriatric nutritional index, and albumin-to-total protein ratio were positively associated with SM strength. Multivariate model indicated that CrI (β = 2.05, p < 0.001) and dialysis duration (β =- 0.53, p = 0.001) were independently related to SM strength. The significant positive correlation between CrI and SM strength remained unaffected even after adjusting for potential confounders.

CONCLUSIONS

Creatinine Index was significantly associated with SM strength highlighting its value as a new emerging practical in clinical setting sarcopenia predictive marker in HD patients.

MO907ASSOCIATION OF ADIPOSITY AND SARCOPENIA WITH CARDIAC VALVE CALCIFICATION IN PATIENTS ON MAINTENANCE HEMODIALYSIS. A CROSS-SECTIONAL STUDY

Background and Aims

Cardiac valve calcification (CVC) is a common disorder in patients with end stage kidney disease (ESKD) and is a predictor of cardiovascular disease and all-cause mortality. Several risk factors are related to CVC in patients with ESKD which include higher age, dyslipidemia, hypertension and diabetes as well as inflammation, bone mineral disease and malnutrition. Moreover, visceral adiposity is associated with disturbed lipid metabolism and proinflammatory activity which could predispose for CVC. Furthermore, sarcopenia and dynapenia is a state common in patients with ESKD. Thus, the aim of this cross-sectional study is to investigate the relationship of adiposity, components of sarcopenia and malnutrition with cardiac valves calcification in patients on chronic hemodialysis.

Method

Adult patients that were on maintenance hemodialysis were eligible for entering the study. Recruitment took place from March 2019 to September 2020. Exclusion criteria included, patients with less than 6 months on hemodialysis, patients with cancer, inflammatory bowel disease, severe infection, cardiac valve disease prior to dialysis initiation, history of parathyroidectomy and intravenous albumin administration 3 months prior to nutritional assessment. Calcification of heart valves and systolic and diastolic function was assessed by using two-dimensional echocardiography. Nutritional assessment was made using the Geriatric Nutritional Risk Index. Conicity Index, Waist to Height Ratio, the Visceral Adiposity Index, the Lipid Accumulation Product, the Height to Waist Phenotype were also calculated. Waist, calf and mid arm circumference measurement was performed in the end of a midweek dialysis session. Muscle strength was based on a measurement of hand grip strength using a hydraulic hand dynamometer in the non-fistula hand prior to dialysis session. Dynapenia was considered for values &lt; 16 kg in females and &lt; 27kg in males. Serum biochemistry parameters such as total protein, albumin, calcium, phosphate, total cholesterol, triglycerides, HDL, LDL, CRP and iPTH were also measured.

Results

Overall, 130 patients were included in the study with a mean age of 66±12.47 years (68.5% males) and an average dialysis duration of 4.37±4.95 years. No cardiac valve calcification was found in 34.6%, while both aortic and mitral valve calcification was found in 41.5% of patients. Calcification only of the aortic (AVC) or mitral (MVC) valve was found in 14.6% and 9.2% respectively. Compared to non AVC group, AVC group had significantly higher age, higher prevalence of diastolic dysfunction, CRP values and CRP/albumin ratio and lower albumin to total proteins ratio. Patients with MVC showed significantly higher prevalence of diastolic dysfunction, higher levels of iPTH, CRP/albumin ratio and lower albumin to total proteins ratio. Adiposity, nutritional, anthropometric indices and sarcopenia parameters such as creatinine index, muscle power and physical performance status did not show any difference between all CVC groups. Increased age [OR (95%CI):1.06 (1.00-1.12) p=0.05], diastolic dysfunction [OR (95%CI): 3.07 (1.05-8.92); p=0.04], CRP/albumin ratio were associated with increased risk of AVC, whereas the CRP/albumin ratio appeared as the most powerful risk factor for mitral and for any CVC [OR (95%CI): 3.41 (1.40-8.28); p=0.007, OR (95%CI): 7.98 (2.62-24.98) p&lt;0.001, respectively]. ROC analysis indicated that increased values of CRP/albumin ratio are strong positive predictors of AVC [AUC, 95%CI 0.66 (0.56-0.75) p=0.002], MVC [AUC, 95%CI 0.642 (0.545-0.74) p=0.005] and calcification of any valve [AUC, 95%CI 0.71 (0.615-0.806) p&lt;0.001].

Conclusion

Adiposity, nutritional, anthropometric indices and sarcopenia did not show to correlate with CVC in patients with ESKD on hemodialysis. Factors, such as diastolic dysfunction and notably increased CRP/albumin ratio were strong predictors of CVC.

Hospital Resources May Be an Important Aspect of Mortality Rate among Critically Ill Patients with COVID-19: The Paradigm of Greece

For critically ill patients with coronavirus disease 2019 (COVID-19) who require intensive care unit (ICU) admission, extremely high mortality rates (even 97%) have been reported. We hypothesized that overburdened hospital resources by the extent of the pandemic rather than the disease per se might play an important role on unfavorable prognosis. We sought to determine the outcome of such patients admitted to the general ICUs of a hospital with sufficient resources. We performed a prospective observational study of adult patients with COVID-19 consecutively admitted to COVID—designated ICUs at Evangelismos Hospital, Athens, Greece. Among 50 patients, ICU and hospital mortality was 32% (16/50). Median PaO₂/FiO₂ was 121 mmHg (interquartile range (IQR), 86–171 mmHg) and most patients had moderate or severe acute respiratory distress syndrome (ARDS). Hospital resources may be an important aspect of mortality rates, since severely ill COVID-19 patients with moderate and severe ARDS may have understandable mortality, provided that they are admitted to general ICUs without limitations on hospital resources.

Convolutional neural networks for global human settlements mapping from Sentinel-2 satellite imagery

Spatially consistent and up-to-date maps of human settlements are crucial for addressing policies related to urbanization and sustainability, especially in the era of an increasingly urbanized world. The availability of open and free Sentinel-2 data of the Copernicus Earth Observation program offers a new opportunity for wall-to-wall mapping of human settlements at a global scale. This paper presents a deep-learning-based framework for a fully automated extraction of built-up areas at a spatial resolution of 10 m from a global composite of Sentinel-2 imagery. A multi-neuro modeling methodology building on a simple Convolution Neural Networks architecture for pixel-wise image classification of built-up areas is developed. The core features of the proposed model are the image patch of size 5 × 5 pixels adequate for describing built-up areas from Sentinel-2 imagery and the lightweight topology with a total number of 1,448,578 trainable parameters and 4 2D convolutional layers and 2 flattened layers. The deployment of the model on the global Sentinel-2 image composite provides the most detailed and complete map reporting about built-up areas for reference year 2018. The validation of the results with an independent reference dataset of building footprints covering 277 sites across the world establishes the reliability of the built-up layer produced by the proposed framework and the model robustness. The results of this study contribute to cutting-edge research in the field of automated built-up areas mapping from remote sensing data and establish a new reference layer for the analysis of the spatial distribution of human settlements across the rural–urban continuum.

A global cloud free pixel- based image composite from Sentinel-2 data

Large-scale land cover classification from satellite imagery is still a challenge due to the big volume of data to be processed, to persistent cloud-cover in cloud-prone areas as well as seasonal artefacts that affect spatial homogeneity. Sentinel-2 times series from Copernicus Earth Observation program offer a great potential for fine scale land cover mapping thanks to high spatial and temporal resolutions, with a decametric resolution and five-day repeat time. However, the selection of best available scenes, their download together with the requirements in terms of storage and computing resources pose restrictions for large-scale land cover mapping. The dataset presented in this paper corresponds to global cloud-free pixel based composite created from the Sentinel-2 data archive (Level L1C) available in Google Earth Engine for the period January 2017- December 2018. The methodology used for generating the image composite is described and the metadata associated with the 10 m resolution dataset is presented. The data with a total volume of 15 TB is stored on the Big Data platform of the Joint Research Centre. It can be downloaded per UTM grid zone, loaded into GIS clients and displayed easily thanks to pre-computed overviews.

Glomerular expression pattern of long non-coding RNAs in the type 2 diabetes mellitus BTBR mouse model

The prevalence of type 2 diabetes mellitus (T2DM) and by association diabetic nephropathy (DN) will continuously increase in the next decades. Nevertheless, the underlying molecular mechanisms are largely unknown and studies on the role of new actors like long non-coding RNAs (lncRNAs) barely exist. In the present study, the inherently insulin-resistant mouse strain "black and tan, brachyuric" (BTBR) served as T2DM model. While wild-type mice do not exhibit pathological changes, leptin-deficient diabetic animals develop a severe T2DM accompanied by a DN, which closely resembles the human phenotype. We analyzed the glomerular expression of lncRNAs from wild-type and diabetic BTBR mice (four, eight, 16, and 24 weeks) applying the "GeneChip Mouse Whole Transcriptome 1.0 ST" array. This microarray covered more lncRNA gene loci than any other array before. Over the observed time, our data revealed differential expression patterns of 1746 lncRNAs, which markedly differed from mRNAs. We identified protein-coding and non-coding genes, that were not only co-located but also co-expressed, indicating a potentially cis-acting function of these lncRNAs. In vitro-experiments strongly suggested a cell-specific expression of these lncRNA-mRNA-pairs. Additionally, protein-coding genes, being associated with significantly regulated lncRNAs, were enriched in various biological processes and pathways, that were strongly linked to diabetes.

Antibodies to inositol 1,4,5-triphosphate receptor 1 in patients with cerebellar disease

OBJECTIVE

To describe newly identified autoantibodies associated with cerebellar disorders.

DESIGN/METHODS

We first screened the sera of 15 patients with cerebellar ataxia, without any known associated autoantibodies, with immunocytochemistry on mouse brain. After characterization and validation of a newly identified antibody, 85 additional patients with suspected autoimmune cerebellar disease were screened using a cell-based assay.

RESULTS

Immunoglobulin G from one of the first 15 patients demonstrated a distinct staining pattern on Purkinje neurons. This autoantibody, as characterized further by immunoprecipitation and mass spectrometry, was binding inositol 1,4,5-triphosphate receptor 1 (IP3R1), an intracellular channel that mediates the release of Ca²⁺ from intracellular stores. Anti-IP3R1 specificity was then validated with a cell-based assay. On this basis, screening of 85 other patients with cerebellar disease revealed 2 additional IP3R1-positive patients. All 3 patients presented with cerebellar ataxia; the first was eventually diagnosed with primary progressive multiple sclerosis, the second had a homozygous CAG insertion at the gene TBP, and the third was thought to have a neurodegenerative disease.

CONCLUSIONS

We independently identified an autoantibody against IP3R1, a protein highly expressed in Purkinje neurons, confirming an earlier report. Because a mouse knockout model for IP3R1 exhibits ataxia and epilepsy, this autoantibody may have a functional role. The heterogeneity of the antibody-positive patients suggests that this antibody may either have a direct involvement in disease pathogenesis or it is a surrogate marker secondary to cerebellar injury. Anti-IP3R1 antibodies should be further explored in various ataxic and epileptic syndromes as they may denote a marker of response to immunotherapies.

Simultaneous "traumatic Gerbode" and aortic rupture due to blunt chest trauma

The Gerbode defect is characterized by a perimembranous ventricular septal defect between the left ventricle and the right atrium. This intracardiac shunt is a congenital defect but may be iatrogenic after valve surgery or atrioventricular node ablation, may be the result of endocarditis or may be traumatic. It is really rarely encountered as sequelae of non-penetrating heart trauma, and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications, and their diagnostic approach is not always feasible. We hereby present a case of a young man with the left ventricle to the right atrium communication after blunt thoracic trauma due to a car accident and concomitant rupture of the thoracic aorta. We present also the case and the ways of treatment according to the international bibliography.

Nephrin, a transmembrane protein, is involved in pancreatic beta-cell survival signaling

Nephrin, a cell surface signaling receptor, regulates podocyte function in health and disease. We study the role of nephrin in β-cell survival signaling. We report that in mouse islet β-cells and the mouse pancreatic beta-cell line (βTC-6 cells) nephrin is associated and partly co-localized with PI3-kinase. Incubation of cells with functional anti-nephrin antibodies induced nephrin clustering at the plasma membrane, nephrin phosphorylation and recruitment of PI3-kinase to nephrin thus resulting in increased PI3K-dependent Akt phosphorylation and augmented phosphorylation/inhibition of pro-apoptotic Bad and FoxO. Nephrin silencing abolished Akt activation and increased susceptibility of cells to apoptosis. High glucose impaired nephrin signaling, increased nephrin internalization and up-regulated PKCα expression. Interestingly, a marked decrease in nephrin expression and phosphorylated Akt was observed in pancreatic islets of db/db lepr-/- diabetic mice. Our findings revealed that nephrin is involved in β-cell survival and suggest that glucose-induced changes in nephrin signaling may contribute to gradual pancreatic β-cell loss in type 2 diabetes.

Heritability of motor control and motor learning

The aim of this study was to elucidate the relative contribution of genes and environment on individual differences in motor control and acquisition of a force control task, in view of recent association studies showing that several candidate polymorphisms may have an effect on them. Forty‐four healthy female twins performed brisk isometric abductions with their right thumb. Force was recorded by a transducer and fed back to the subject on a computer screen. The task was to place the tracing of the peak force in a force window defined between 30% and 40% of the subject's maximum force, as determined beforehand. The initial level of proficiency was defined as the number of attempts reaching the force window criterion within the first 100 trials. The difference between the number of successful trials within the last and the first 100 trials was taken as a measure of motor learning. For motor control, defined by the initial level of proficiency, the intrapair differences in monozygotic (MZ) and dizygotic (DZ) twins were 6.8 ± 7.8 and 13.8 ± 8.4, and the intrapair correlations 0.77 and 0.39, respectively. Heritability was estimated at 0.68. Likewise for motor learning intrapair differences in the increment of the number of successful trials in MZ and DZ twins were 5.4 ± 5.2 and 12.8 ± 7, and the intrapair correlations 0.58 and 0.19. Heritability reached 0.70. The present findings suggest that heredity accounts for a major part of existing differences in motor control and motor learning, but uncertainty remains which gene polymorphisms may be responsible.

Individual differences in motor control and learning are attributed to a great extent to genetic predisposition. However, uncertainty remains which gene polymorphism may be responsible.

Transgelin Up-Regulation in Obstructive Nephropathy

Fibrosis is a complex and multifactorial process, affecting the structure and compromising the function of several organs. Among those, renal fibrosis is an important pathological change, eventually leading to renal failure. Proteomic analysis of the renal parenchyma in the well-established rat model of unilateral ureteral obstruction (UUO model) suggested that transgelin was up-regulated during the development of fibrosis. Transgelin up-regulation was confirmed both at the protein and at the mRNA level. It was observed that at early stages of fibrosis transgelin was mainly expressed in the interstitial compartment and, more specifically, in cells surrounding the glomeruli. Subsequently, it was confirmed that transgelin expressing cells were activated fibroblasts, based on their extensive co-expression of α-SMA and their complete lack of co-distribution with markers of other cell types (endothelial, epithelial and cells of the immune system). These periglomerular fibroblasts exhibited staining for transgelin mainly cytoplasmic but occasionally nuclear as well. In addition, transgelin expression in periglomerular fibroblasts was absent in renal fibrosis developed in a hypertensive model, compared to the UUO model. Promoter analysis indicated that there are several conserved motifs for transcription factor binding. Among those, Kruppel-like factor 6 was found to be up-regulated in transgelin positive periglomerular activated fibroblasts, suggesting a possible involvement in the mechanism of transgelin up-regulation. These data strongly suggest that transgelin is up-regulated in the obstructive nephropathy and could be used as a novel marker for renal fibrosis in the future.

Paclitaxel-ifosfamide-carboplatin combination chemotherapy regimen in advanced uterine and adnexal malignant mixed Mullerian tumours

Background:

Malignant mixed Mullerian tumours (MMMTs) of the uterus and adnexa represent aggressive gynaecologic malignancies with a high rate of loco-regional and distant failure. For that reason, we evaluated the paclitaxel–ifosfamide–carboplatin (TICb) combination in patients with advanced MMMTs.

Methods:

Female patients with advanced MMMTs, WHO-PS 0–2, no prior chemotherapy for systemic disease, unimpaired haemopoietic and organ function were eligible. Chemotherapy was administered at the following doses; paclitaxel: 175 mg m^–2 on day 1, ifosfamide: 2.0g m^–2 day^–1 – days 1 and 2, and carboplatin at a target area under the curve 5 on day 2, with prophylactic G-CSF from day 3.

Results:

Forty patients of a median age 61 (45–72) years, performance status 0–2 with advanced MMMTs of the uterus (n=34), tubes (n=2) or ovary (n=4) have entered and all were evaluable for response and toxicity. Responses were as follows: 27 out of 40 (67.5%) evaluable patients responded, with 11 complete responses and 16 partial responses, while 10 had stable disease, and 3 developed progressive disease. The median response duration was 9 months (range, 4–40 months), median progression-free survival 13 months (range, 3–42 months), while median overall survival 18 months (range, 4–48 months). Grade 3/4 neutropenia was recorded in 22 out of 40 (55%) – with 13 developing grade 4 (⩽7 days) and 7 out of 40 (17.5%) of patients at least one episode of febrile neutropenia.

Conclusion:

In this study, it appears that the TICb combination, yielded important activity with manageable toxicity in females with advanced MMMTs warranting further randomised comparison with current standard regimens.

Lung sonography and recruitment in patients with early acute respiratory distress syndrome: a pilot study

INTRODUCTION

Bedside lung sonography is a useful imaging tool to assess lung aeration in critically ill patients. The purpose of this study was to evaluate the role of lung sonography in estimating the nonaerated area changes in the dependent lung regions during a positive end-expiratory pressure (PEEP) trial of patients with early acute respiratory distress syndrome (ARDS).

METHODS

Ten patients (mean ± standard deviation (SD): age 64 ± 7 years, Acute Physiology and Chronic Health Evaluation II (APACHE II) score 21 ± 4) with early ARDS on mechanical ventilation were included in the study. Transthoracic sonography was performed in all patients to depict the nonaerated area in the dependent lung regions at different PEEP settings of 5, 10 and 15 cm H2O. Lung sonographic assessment of the nonaerated lung area and arterial blood gas analysis were performed simultaneously at the end of each period. A control group of five early ARDS patients matched for APACHE II score was also included in the study.

RESULTS

The nonaerated areas in the dependent lung regions were significantly reduced during PEEP increases from 5 to 10 to 15 cm H2O (27 ± 31 cm2 to 20 ± 24 cm2 to 11 ± 12 cm2, respectively; P < 0.01). These changes were associated with a significant increase in arterial oxygen partial pressure (74 ± 15 mmHg to 90 ± 19 mmHg to 102 ± 26 mmHg; P < 0.001, respectively). No significant changes were observed in the nonaerated areas in the dependent lung regions in the control group.

CONCLUSIONS

In this study, we show that transthoracic lung sonography can detect the nonaerated lung area changes during a PEEP trial of patients with early ARDS. Thus, transthoracic lung sonography might be considered as a useful clinical tool in the management of ARDS patients.

Plasticity in human motor cortex is in part genetically determined

Brain plasticity refers to changes in the organization of the brain as a result of different environmental stimuli. The aim of this study was to assess the genetic variation of brain plasticity, by comparing intrapair differences between monozygotic (MZ) and dizygotic (DZ) twins. Plasticity was examined by a paired associative stimulation (PAS) in 32 healthy female twins (9 MZ and 7 DZ pairs, aged 22.6±2.7 and 23.8±3.6 years, respectively). Stimulation consisted of low frequency repetitive application of single afferent electric stimuli, delivered to the right median nerve, paired with a single pulse transcranial magnetic stimulation (TMS) for activation of the abductor pollicis brevis muscle (APB). Corticospinal excitability was monitored for 30 min following the intervention. PAS induced an increase in the amplitudes of the motor evoked potentials (MEP) in the resting APB, compared to baseline. Intrapair differences, after baseline normalization, in the MEP amplitudes measured at 25-30 min post-intervention, were almost double for DZ (1.25) in comparison to MZ (0.64) twins (P =0.036). The heritability estimate for brain plasticity was found to be 0.68. This finding implicates that genetic factors may contribute significantly to interindividual variability in plasticity paradigms. Genetic factors may be important in adaptive brain reorganization involved in motor learning and rehabilitation from brain injury.

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

INTRODUCTION

Both experimental and clinical data give convincing evidence to acute cardiac dysfunction as the origin or a cofactor of weaning failure in patients with chronic obstructive pulmonary disease. Therefore, treatment targeting the cardiovascular system might help the heart to tolerate more effectively the critical period of weaning. This study aims to assess the hemodynamic, respiratory and clinical effects of nitroglycerin infusion in difficult-to-wean patients with severe chronic obstructive pulmonary disease.

METHODS

Twelve difficult-to-wean (failed ≥ 3 consecutive trials) chronic obstructive pulmonary disease patients, who presented systemic arterial hypertension (systolic blood pressure ≥ 140 mmHg) during weaning failure and had systemic and pulmonary artery catheters in place, participated in this prospective, interventional, non-randomized clinical trial. Patients were studied in two consecutive days, i.e., the first day without (Control day) and the second day with (Study day) nitroglycerin continuous intravenous infusion starting at the beginning of the spontaneous breathing trial, and titrated to maintain normal systolic blood pressure. Hemodynamic, oxygenation and respiratory measurements were performed on mechanical ventilation, and during a 2-hour T-piece spontaneous breathing trial. Primary endpoint was hemodynamic and respiratory effects of nitroglycerin infusion. Secondary endpoint was spontaneous breathing trial and extubation outcome.

RESULTS

Compared to mechanical ventilation, mean systemic arterial pressure, rate-pressure product, mean pulmonary arterial pressure, and pulmonary artery occlusion pressure increased [from (mean ± SD) 94 ± 14, 13708 ± 3166, 29.9 ± 4.8, and 14.8 ± 3.8 to 109 ± 20 mmHg, 19856 ± 4877 mmHg b/min, 41.6 ± 5.8 mmHg, and 23.4 ± 7.4 mmHg, respectively], and mixed venous oxygen saturation decreased (from 75.7 ± 3.5 to 69.3 ± 7.5%) during failing trials on Control day, whereas they did not change on Study day. Venous admixture increased throughout the trial on both Control day and Study day, but this increase was lower on Study day. Whereas weaning failed in all patients on Control day, nitroglycerin administration on Study day enabled a successful spontaneous breathing trial and extubation in 92% and 88% of patients, respectively.

CONCLUSIONS

In this clinical setting, nitroglycerin infusion can expedite the weaning by restoring weaning-induced cardiovascular compromise.

Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized study

Introduction

Critically ill patients are characterized by increased loss of muscle mass, partially attributed to sepsis and multiple organ failure, as well as immobilization. Recent studies have shown that electrical muscle stimulation (EMS) may be an alternative to active exercise in chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) patients with myopathy. The aim of our study was to investigate the EMS effects on muscle mass preservation of critically ill patients with the use of ultrasonography (US).

Methods

Forty-nine critically ill patients (age: 59 ± 21 years) with an APACHE II admission score ≥13 were randomly assigned after stratification upon admission to receive daily EMS sessions of both lower extremities (EMS-group) or to the control group (control group). Muscle mass was evaluated with US, by measuring the cross sectional diameter (CSD) of the vastus intermedius and the rectus femoris of the quadriceps muscle.

Results

Twenty-six patients were finally evaluated. Right rectus femoris and right vastus intermedius CSD decreased in both groups (EMS group: from 1.42 ± 0.48 to 1.31 ± 0.45 cm, P = 0.001 control group: from 1.59 ± 0.53 to 1.37 ± 0.5 cm, P = 0.002; EMS group: from 0.91 ± 0.39 to 0.81 ± 0.38 cm, P = 0.001 control group: from 1.40 ± 0.64 to 1.11 ± 0.56 cm, P = 0.004, respectively). However, the CSD of the right rectus femoris decreased significantly less in the EMS group (-0.11 ± 0.06 cm, -8 ± 3.9%) as compared to the control group (-0.21 ± 0.10 cm, -13.9 ± 6.4%; P < 0.05) and the CSD of the right vastus intermedius decreased significantly less in the EMS group (-0.10 ± 0.05 cm, -12.5 ± 7.4%) as compared to the control group (-0.29 ± 0.28 cm, -21.5 ± 15.3%; P < 0.05).

Conclusions

EMS is well tolerated and seems to preserve the muscle mass of critically ill patients. The potential use of EMS as a preventive and rehabilitation tool in ICU patients with polyneuromyopathy needs to be further investigated.

Trial Registration

clinicaltrials.gov: NCT00882830

Paclitaxel (T), ifosfamide (I), and carboplatin (Cb) (TICb) combination chemotherapy in advanced uterine and adnexal malignant mixed mullerian tumors (MMMTs)

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Background: Malignant mixed mullerian tumors (MMMTs) of the uterus and adnexa represent aggressive gynecologic malignancies with a high rate of locoregional and distant failure. For that reason we evaluated the TICb combination in patients with advanced MMMTs. Methods: Patients with advanced MMMTs [stages III-IV and relapses after surgery (Sx)±RT], WHO-PS 0–2, no prior chemotherapy, unimpaired hematopoietic/organ function were eligible. Chemotherapy was administered as follows; T: 175 mg/m2 d1, I: 2.0 g/m2/d-d1+2, and Cb at a target AUC = 5 (according to creatinine clearance based on Calvert's formula) on d2 after I. G-CSF was administered from day 3–7. Results: Thirty-two patients with MMMTs of the uterus (n = 28), tubes (n = 2), or ovary (n = 2) have entered so far and all are evaluable for response and toxicity: median age = 61 (45–72), PS = 1 (0–1), stages; III = 18 (56%), IV = 14 (44%), histologies were; with homologous sarcoma component: 21, with heterologous component: 11. Prior treatment for locoregional disease included Sx: 23, Sx+RT: 9. Disease sites at diagnosis included: pelvic disease 12; pelvic/paraortic lymph nodes 14; peritoneal implants 16; liver 4; lung nodules 9; bone metastases 1; malignant pleural effusion 4. Responses were as follows: 21/32 (66%) evaluable patients responded, with 9 complete responses (CR) and 12 partial responses (PR), while 8 had stable disease (SD), and 3 developed progressive disease (PD). The median response duration was 8 mo (4–28), median time-to-progression (TTP) 12.5mo (4–26), while median overall survival (OS) has not been reached yet since most patients receive second-line therapy. Grade (Gr) 3/4 toxicities included: neutropenia 18/32 (56%)-with 11 developing Gr4 (≤7 days) and 19% of patients at least one episode of febrile neutropenia managed successfully by broad spectrum antibiotics, thrombocytopenia Gr3: 5/32 (16%) and Gr4 3/32 (9%), no Gr3 neuropathy, Gr1 CNS toxicity in 1, no renal toxicity, 15 Gr2 myalgias, and 4 Gr3 vomiting. Conclusions: In the present study, it appears that the TICb combination, yielded important activity with acceptable toxicity in females with advanced MMMTs.

No significant financial relationships to disclose.

End-inspiratory occlusion maneuver during transesophageal echocardiography for patent foramen ovale detection in intensive care unit patients

OBJECTIVE

Mechanically ventilated patients in the intensive care unit cannot cooperate to perform the Valsalva maneuver during echocardiography for detection of patent foramen ovale. We evaluated the effectiveness of the end-inspiratory occlusion maneuver to enhance detection of patent foramen ovale in this patient population.

DESIGN

Prospective interventional study.

SETTING

The 40-bed intensive care unit of a university hospital.

PATIENTS AND PARTICIPANTS

Twenty five sedated and mechanically ventilated intensive care unit patients referred by their attending physician for bedside transesophageal echocardiography and agitated saline contrast study for detection of patent foramen ovale.

INTERVENTION

Agitated saline contrast study with end-inspiratory occlusion maneuver.

MEASUREMENTS AND RESULTS

All patients underwent a complete transesophageal echocardiographic study without any complications. Reduction in right atrial cross-sectional area (from 15.80 +/- 6.08 cm2 to 12.40 +/- 4.63 cm2; p < 0.001) and interatrial septum deviation during the maneuver were recorded in all patients. Microbubbles imaged in the left atrium within three cardiac cycles after injection of agitated saline diagnosed patent foramen ovale in three patients. When end-inspiratory occlusion maneuver was added, patent foramen ovale was diagnosed in seven patients (McNemar chi2 = 9.33, p = 0.0023).

CONCLUSIONS

The end-inspiratory occlusion maneuver enhances the sensitivity of transesophageal echocardiography with agitated saline contrast study for diagnosing intermittent patent foramen ovale in critically ill mechanically ventilated patients.

Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage

We report the life-saving administration of thrombolysis during cardiopulmonary resuscitation in a patient with recent intracerebral haemorrhage. A 53-year-old male with intracerebral haemorrhage was admitted to the intensive care unit. On the 24th day of treatment he suffered cardiac arrest with pulseless electrical activity. Transoesophageal echocardiography was performed during ongoing cardiopulmonary resuscitation. Thrombi in the right heart cavities with excessive right ventricular dysfunction confirmed the diagnosis of fulminant pulmonary embolism. Permanent restoration of a spontaneous rhythm was feasible only after administration of systemic thrombolysis with recombinant tissue plasminogen activator. Neurological examination and a computed tomogram of the brain did not show rebleeding. We conclude that under extreme circumstances absolute contraindications to thrombolysis should be weighed against the potential benefit.

Primary Small Cell Bladder Carcinoma: A Case Report and Review of the Current Literature

Primary small cell bladder carcinoma is an extremely rare and highly aggressive tumor. Unfortunately, the optimal therapeutic strategy for the tumor is still unknown. Recently, a two-stage system for limited and extensive small cell bladder carcinoma has been suggested in analogy to the practiced staging and treatment of small cell lung carcinoma. We present a new case of small cell bladder carcinoma and discuss relevant current literature.

Precise Nucleosome Positioning and the TATA Box Dictate Requirements for the Histone H4 Tail and the Bromodomain Factor Bdf1

Acetylation of histone tails plays a key role in chromatin dynamics and is associated with the potential for gene expression. We show here that a 2-3 bp mispositioning of the nucleosome covering the TATA box at PHO5 induces a dependency on the acetylatable lysine residues of the histone H4 N-terminal region and on the TFIID-associated bromodomain factor Bdf1. This dependency arises either through fusion of the PHO5 promoter to a lacZ reporter or by mutation of the TATA box in the natural gene. The results suggest that promoters in which the TATA box is either absent or poorly accessible on the surface of a nucleosome may compensate by using Bdf1 bromodomains and acetylated H4 tails to anchor TFIID to the promoter during the initial stages of transcription activation. We propose that nucleosome positioning at the nucleotide level provides a subtle, but highly effective, mechanism for gene regulation.

Mediastinal mass with Dysphagia in an elderly patient

We report the use of endoscopic techniques for successful diagnosis in a case of atypical esophageal tuberculosis. Tuberculosis of the esophagus is an unusual presentation of this disease, having been estimated to occur in 0.15% of the people who die of tuberculosis. A few cases of possible primary tuberculous esophagitis have been described. This report describes a patient with dysphagia who appeared to have esophageal tuberculosis without HIV and in the absence of other signs of tuberculosis. The patient responded promptly to treatment with tuberculostatics.