Inflammation in heart failure: pathophysiology and therapeutic strategies

A role for inflammation in the development and progression of heart failure (HF) has been proposed for decades. Multiple studies have demonstrated the potential involvement of several groups of cytokines and chemokines in acute and chronic HF, though targeting these pathways in early therapeutic trials have produced mixed results. These studies served to highlight the complexity and nuances of how pro-inflammatory pathways contribute to the pathogenesis of HF. More recent investigations have highlighted how inflammation may play distinct roles based on HF syndrome phenotypes, findings that may guide the development of novel therapies. In this review, we propose a contemporary update on the role of inflammation mediated by the innate and adaptive immune systems with HF, highlighting differences that exist across the ejection fraction spectrum. This will specifically be looked at through the lens of established and novel biomarkers of inflammation. Subsequently, we review how improvements in inflammatory pathways may mediate clinical benefits of existing guideline-directed medical therapies for HF, as well as future therapies in the pipeline targeting HF and inflammation.

Outcomes of untreated subclinical antibody-mediated rejection after heart transplantation

Subclinical antibody-mediated rejection (AMR) is represented by histopathological and/or immunopathological manifestations in the absence of significant cardiac allograft dysfunction. Treatment remains uncertain as there is a lack of data on asymptomatic heart transplant (HT) recipients (HTR) with a positive cardiac biopsy. We sought to determine the impact of untreated subclinical biopsy-proven AMR, regardless of circulating donor-specific antigen (DSA) expression, when diagnosed on surveillance biopsies in the first year after HT. This retrospective case control study evaluated 260 HTR between May 2004 and February 2021. These comprised 231 controls and 29 patients with untreated subclinical AMR. The mortality event rate was higher in controls (2.63 events per 100 person-years) compared to the scAMR Group (1.71 events per 100 person-years), a difference that did not reach statistical significance (hazard ratio 0.66, CI: 0.18-2.36). The combined event rate of cardiac allograft vasculopathy (CAV), graft dysfunction, or mortality was higher in the subclinical AMR group (5.60 events per 100 person-years) than in controls (3.89 events per 100 person-years) but did not reach statistical significance (hazard ratio 1.63, CI: 0.07-40.09). Our results suggest that subclinical AMR diagnosed in the first year after HT on surveillance biopsy is not associated with decreased survival. This may sway the management of subclinical AMR towards a more conservative approach in transplant-capable institutions that currently prioritize treatment, though prospective, randomized studies of such a management strategy are required.

Contemporary Left Ventricular Assist Device Therapy as a Bridge or Alternative to Transplantation

Left ventricular assist devices (LVADs), which were introduced as a bridge to heart transplantation, are now an established alternative to heart transplantation (HT) for patients with advanced heart failure. These devices have undergone significant technological advancements over the years, and contemporary LVADs prolong life substantially in patients dependent on inotropic therapy or in those with severe ambulatory advanced heart failure with a median survival that exceeds 5 y, and most patients benefit from a doubling in functional capacity, even among those intended as destination therapy because of ineligibility for transplantation. Other intended goals for LVAD implantation consist of (1) bridge to remission or recovery and (2) bridge to transplant or candidacy for transplant. In the former situation, few selected patients underwent LVAD implantation, facilitating myocardial remission to recovery that allowed explantation. Among those bridged to transplantation, survival in the intended goal was excellent, with 80% success at 5 y (with a 50% rate of transplantation). In this review, we provide a brief historical background on the evolution of LVADs and discuss outcomes with contemporary pumps, immunological and infection-related impact of such devices, impact of bridging in HT, and use of devices for facilitating myocardial recovery and remission. Furthermore, we discuss implications of HT allocation policies, with a specific focus within the United States, and outline future perspectives and novel device in development.

Cancer Screening in Solid Organ Transplant Recipients: A Focus on Screening Liver, Lung, and Kidney Recipients for Cancers Related to the Transplanted Organ

Over the last few decades, the life expectancy of solid organ transplant recipients (SOTRs) has improved significantly. With SOTRs living longer, more recipients are dying from cancer. There is a reported 2- to 3-fold increased risk of cancer-specific mortality in SOTRs compared with the general population. Cancer in an SOTR can be de novo, recurrent, or donor-derived. Cancer screening in this population is crucial, as early detection and treatment may improve outcomes. In the absence of randomized controlled trials dedicated to SOTRs, clinicians rely on clinical practice guidelines from regional and national transplant societies; however, these may vary considerably across jurisdictions and transplanted organ. At present, no widely accepted consensus exists for cancer screening protocols in SOTRs, particularly with regard to screening for malignancy related to transplanted organ. Some SOTRs may be at higher risk of malignancies within the allograft. This is particularly the case in lung and liver recipients, though less common in kidney recipients who are at increased risk of developing renal cell cancer in their native kidneys. This increased risk has not been uniformly incorporated into screening recommendations for SOTRs. In this review, we summarize the cancer screening recommendations for SOTRs from various transplant organizations based on transplanted organ. This review also discusses the complexity and controversies surrounding screening of cancer in the allograft and future avenues to improve cancer detection in this context. More studies specific to SOTRs are required to form generalizable and evidence-based cancer screening guidelines, particularly with respect to cancer screening in the allograft.

Cardiorenal protection with SGLT2 inhibitors in patients with diabetes mellitus: from biomarkers to clinical outcomes in heart failure and diabetic kidney disease

Type 2 diabetes (T2D) is one of the most common causes of chronic kidney disease (CKD) and cardiovascular (CV) disease. Until recently, glycemic and BP control were the cornerstones for preventing progression of CKD and CV disease associated with T2D. However, there has been a paradigm shift in treatment since the publication of the first clinical trial demonstrating benefits of sodium glucose cotransporter 2 (SGLT2) inhibitors in 2015. SGLT2 inhibitors have been shown to reduce the risk of major adverse CV events and progression of kidney disease in the setting of T2D. However, the elucidation of mechanisms of underlying these clinical benefits is the subject of ongoing investigation. Experimental studies have shown that SGLT2 inhibitors have diverse pleiotropic effects such as modulation of neurohormones such as the renin-angiotensin-aldosterone system, increasing hematocrit, altering energy substrate use, and attenuating systemic inflammation and oxidative stress, all of which have been implicated in the CV and kidney protective effects of SGLT2 inhibitors. In this review, we highlight biomarkers linked with diabetic kidney disease and heart failure and discuss how SGLT2 inhibitor-associated changes potentially mediate the cardiorenal protection observed with these therapies.

Making a case for the combined use of SGLT2 inhibitors and GLP1 receptor agonists for cardiorenal protection

Sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) were initially approved to improve glycemic control in the treatment of type 2 diabetes. Clinical trials have also demonstrated beneficial effects with regards to cardiovascular and renal parameters. Beyond improving glycemic control, these therapies promote weight loss and lower blood pressure when used individually, and in an additive manner when used together. Accordingly, taking advantage of complementary mechanisms of action with the combined use of these two classes of agents to further improve cardiorenal outcomes is conceptually appealing, but has yet to be explored in detail in clinical trials. In this review, we discuss proposed mechanisms for renal protection, clinical benefits, and adverse events associated with the individual and combined use of SGLT2 inhibitors and GLP-1RA. The management of type 2 diabetes has significantly changed over the last few years, moving away from solely glycemic control towards the concurrent management of associated comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors and GLP-1RA in patients with type 2 diabetes.

A Rare Case of Coronary Artery Dilatation and Giant Pseudoaneurysm

Coronary artery fistula are anomalous connections with coronary vessels or cardiac chambers, potentially resulting in coronary dilatation and pseudoaneurysm formation. We present the case of a 68-year-old woman referred to our institution for a voluminous coronary pseudoaneurysm secondary to coronary artery fistula presenting as a nearly completely obstructive left atrial mass. (Level of Difficulty: Intermediate.).

Heart Failure With Midrange Ejection Fraction-What Is It, If Anything?

The patient cohort with left ventricular ejection fractions (LVEFs) of 41%-49%, which has been defined as heart failure with midrange ejection fraction (HFmrEF), represent a significant proportion of the heart failure (HF) population. Despite the clear cutoffs established by different society guidelines, confusion remains regarding the exact significance of midrange LVEF within the HF syndrome. Patients with LVEF 41%-49% represent a heterogeneous group of patients sharing pathophysiologic mechanisms, biomarker profiles, comorbidities, and clinical characteristics with patients with preserved and reduced LVEF. In this clinical review, we discuss the underlying pathophysiologic mechanisms that culminate in the clinical syndrome of HF and contribute to the disparities observed between HFpEF, HFrEF, and HFmrEF. We highlight differences and similarities in clinical characteristics and imaging features between HFpEF and HFrEF in an effort to disentangle the heterogeneous group of patients with midrange LVEF, but ultimately we conclude that LVEF should be seen as simply one important element of a continuum throughout the HF syndrome, and that although is useful, it is an oversimplification, because HF syndrome is more of a continuum. The underlying pathophysiology, etiology, and comorbidities of patients presenting with HF is becoming ever more important as the limitations of a classification solely based on LVEF are being better recognised, and as patient-specific personalisation of care is becoming ever more important.

Statin Use and Risk of Vascular Events Among Cancer Patients After Radiotherapy to the Thorax, Head, and Neck

Background

This study aimed to explore whether statins reduce radiation‐induced vascular complications in cancer patients postradiotherapy to the thorax, head, and neck.

Methods and Results

We conducted a retrospective cohort study within a provincial linked database of 5718 cardiac patients with thorax and head or neck cancer having undergone radiotherapy between 2000 and 2011. One thousand five hundred fifty‐two patients were identified as nonstatin users and 4166 as statin users. The primary outcome of interest was the composite of cerebrovascular (transient ischemic attack, and fatal or nonfatal stroke) or cardiovascular events (fatal or nonfatal myocardial infarction). Time‐dependent Cox proportional hazard analyses were performed. The crude event rate was 10.31% for nonusers and 9.03% for statin users (hazard ratio of 0.92 [95% CI 0.76–1.10, P=0.3451]), over a mean time to event/censoring of 534±687 days for nonusers and 594±706 days for the statin users. After adjusting for age, sex, prior history of stroke/transient ischemic attack or myocardial infarction, diabetes mellitus, dyslipidemia, atrial fibrillation, chronic kidney disease, heart failure, and hypertension, statin use postradiotherapy was associated with a nonsignificant 15% relative risk reduction, but a strong trend toward reducing the primary outcome (hazard ratio=0.85 95% CI 0.69–1.04, P=0.0811). The use of statins was associated with a significant reduction of 32% for the outcome of stroke alone (hazard ratio=0.68, 95% CI 0.48–0.98, P=0.0368).

Conclusions

Statin use post radiation therapy was associated with a significant reduction in stroke, with a trend toward significantly reducing cardiovascular and cerebrovascular events.

Bacteria associated with yellow lupine grown on a metal-contaminated soil: in vitro screening and in vivo evaluation for their potential to enhance Cd phytoextraction

In order to stimulate selection for plant-associated bacteria with the potential to improve Cd phytoextraction, yellow lupine plants were grown on a metal-contaminated field soil. It was hypothesised that growing these plants on this contaminated soil, which is a source of bacteria possessing different traits to cope with Cd, could enhance colonisation of lupine with potential plant-associated bacteria that could then be inoculated in Cd-exposed plants to reduce Cd phytotoxicity and enhance Cd uptake. All cultivable bacteria from rhizosphere, root and stem were isolated and genotypically and phenotypically characterised. Many of the rhizobacteria and root endophytes produce siderophores, organic acids, indole-3-acetic acid (IAA) and aminocyclopropane-1-carboxylate (ACC) deaminase, as well as being resistant to Cd and Zn. Most of the stem endophytes could produce organic acids (73.8%) and IAA (74.3%), however, only a minor fraction (up to 0.7%) were Cd or Zn resistant or could produce siderophores or ACC deaminase. A siderophore- and ACC deaminase-producing, highly Cd-resistant Rhizobium sp. from the rhizosphere, a siderophore-, organic acid-, IAA- and ACC deaminase-producing highly Cd-resistant Pseudomonas sp. colonising the roots, a highly Cd- and Zn-resistant organic acid and IAA-producing Clavibacter sp. present in the stem, and a consortium composed of these three strains were inoculated into non-exposed and Cd-exposed yellow lupine plants. Although all selected strains possessed promising in vitro characteristics to improve Cd phytoextraction, inoculation of none of the strains (i) reduced Cd phytotoxicity nor (ii) strongly affected plant Cd uptake. This work highlights that in vitro characterisation of bacteria is not sufficient to predict the in vivo behaviour of bacteria in interaction with their host plants.

The performance of foreign medical graduates on the National Board of Medical Examiners (NBME) standardized patient examination prototype: a collaborative study of the NBME and the Educational Commission for Foreign Medical Graduates (ECFMG)

OBJECTIVES

The purpose of the study was to explore foreign medical graduates' (FMGs) performance on a clinical skills (SPX) examination. The National Board of Medical Examiners (NBME) is in the process of developing an SPX for potential use in the United States Medical Licensing Examination (USMLE). The Educational Commission for Foreign Medical Graduates (ECFMG) is developing the Clinical Skills Assessment (CSA) as an additional requirement for FMGs who wish to be certified by ECFMG.

DESIGN

Thirty-three FMGs and 151 United States medical students (USMSs) took the SPX during the winter of 1996 as part of the ongoing pilot studies conducted by the NBME. Four clinical skill areas were assessed: history-taking, physical examination, communication and interpersonal skills. The examination used in this research consisted of 12 cases. The examination utilizes standardized patients (SPs) who are trained to document examinee behaviours and evaluate the communication component of the test. The SPs were also trained to evaluate the English proficiency of the candidates. Candidates were also administered the Test of Spoken English developed by the Educational Testing Services (ETS).

SETTING

The examination was conducted in one medical school which served as an SPX centre for NBME pilot studies.

SUBJECTS

Thirty-three foreign medical students and 151 US medical students.

RESULTS

The indications were that the majority of candidates in both groups felt the examination was moderately fair but 78% of FMGs felt moderately pressed for time, vs. 80% of the USMSs who did not feel pressed for time. Reliabilities obtained for the various SPX components were somewhat higher for the FMGs reflecting the heterogeneity of this group.

CONCLUSIONS

The NBME-ECFMG collaborative study yielded important information regarding the NBME SPX prototype as a performance measure for FMGs.

Changes in Canadian women's mammography rates since the implementation of mass screening programs

OBJECTIVES

This study reports on Canadian mammography rates between 1990, when mass screening programs were launched, and 1994/95.

METHODS

Mammography rates from 2 national surveys were compared according to the presence of a provincial screening program.

RESULTS

Mammography rates among women aged 50 to 69 years (the targeted group) increased significantly, by 16%; increases were twice as high in provinces with screening programs. Among women in their 40s (nontargeted group), the changes were insignificant and independent of screening program status.

CONCLUSIONS

Screening programs appear to have influenced the mammography rates of targeted women aged 50 to 69 years.

Assessing clinical competence of medical students in women's health care: use of the objective structured clinical examination

OBJECTIVE

To assess clinical competency of third-year medical students completing a problem-oriented, primary care emphasis clerkship in obstetrics and gynecology using an objective structured clinical examination, and to determine the feasibility of implementing the objective structured clinical examination in the curriculum.

METHODS

Sixteen groups of third-year medical students were evaluated prospectively on their exit performances with a six-station objective structured clinical examination designed to test clinical competency in basic primary care obstetrics-gynecology. Consistency of scores across stations, differences in performance for separate groups, and relationship of objective structured clinical examination scores compared with other indicators of medical proficiency, such as written examinations and faculty evaluations, were assessed.

RESULTS

One hundred ninety-eight students were evaluated over 25 months. Test reliability across stations revealed alpha values ranging between .50 and .56. Correlations between performance on the objective structured clinical examination and the written test (r = .10) were low, demonstrating that the objective structured clinical examination clearly tests a separate domain of student capability. Cost of the objective structured clinical examination was $81.66 per student.

CONCLUSION

The objective structured clinical examination is a reliable and valid test of the clinical competence of medical students in the primary health care of women. It provides information that is not obtained by more traditional assessment modalities at a reasonable cost.

Implementing breast cancer screening guidelines: results of the Ontario Health Status Survey

INTRODUCTION

The Ontario Health Status Survey (OHS) was undertaken by the Ontario Ministry of Health in 1990 to provide data on factors related to health and health service use in a province of 10 million inhabitants. OHS analyses for this report focused on patterns of breast screening behaviors in relation to physician contact and various sociodemographic and psychological variables.

METHODS

The OHS was a probability sample survey using a multistage stratified cluster design to gather household-level data. SUDAAN was used to obtain population estimates for study variables. Data analyses were restricted to women 40 years of age and older.

RESULTS

Although over 85% of respondents reported contact with their physicians in the previous 12 months, most women did not adhere to recommended breast screening guidelines. Educational achievement, income adequacy, and smoking status were important factors explaining differences in screening behaviors.

CONCLUSIONS

Physicians should not overlook opportunities to recommend mammography screening, where appropriate, and include breast examinations as part of regular physical exams. The involvement of educationally or economically disadvantaged women in the design of appropriate recruitment strategies for breast cancer screening would be informative.

Respiratory infections and the autumn increase in asthma morbidity

Unexplained autumn increases in hospital admissions for asthma have been reported in many countries, including the United States, Canada, England and Wales. To investigate the role of infection, the association was tested between hospital admissions for asthma and respiratory infections among preschool children in Metropolitan Toronto, Canada during the period 1981 to 1989. The seasonal pattern in overall hospital utilization was assessed by admissions for nonrespiratory diseases. Time series analysis was used to remove potentially confounding temporal trends and the influence of correlated errors. A fourfold increase in asthma admissions occurred between July and October unaccompanied by similar increases in nonrespiratory admissions. Admissions began increasing during the third week of August, peaked during the third week in September, and slowly decreased during November and December. After adjusting for serial correlation, trends, climate, ambient air pollution and aeroallergens, the seasonal pattern of respiratory infection explained 14% of the variance in asthma admissions. Based on seasonal patterns, respiratory infection is the major identifiable risk factor for the large autumnal increase in asthma admissions.

Validation of a food habits questionnaire: poor performance in male manual laborers

OBJECT

To examine the reliability and validity of a food habits questionnaire developed by Kristal et al in male manual laborers.

DESIGN

A cross-sectional baseline survey.

SETTING

The community of Ottawa-Carleton, Canada.

SUBJECTS

All people working in non-office-based positions for two local governments were invited to a heart-health screening clinic. Male subjects (n = 362) who met risk factor eligibility criteria were interviewed and entered into the study.

MAIN OUTCOME MEASURES

The food habits questionnaire developed by Kristal et al was the main focus of analysis. Additional outcomes included a food frequency questionnaire and risk factors for cardiovascular disease.

STATISTICAL ANALYSES

Reliability was assessed using Cronbach's alpha and Pearson correlation coefficients; confirmatory factor analysis was also done. Validity assessment included partial correlations.

RESULTS

Low internal consistency was found for the five subscales of the questionnaire (alpha = .13 to .53). Confirmatory factor analysis did not reveal the postulated five-factor (subscale) structure. Correlation of the subscale scores with dietary fat intake was low (r = -.09 to -.23), and none of these associations were statistically significant after adjustment for age, body mass index, and education. An alternative scoring system that treated the questionnaire as a unidimensional behavioral checklist produced a higher internal consistency (alpha = .70) and significant correlation with dietary fat intake (r = -.27).

CONCLUSIONS

The psychometric properties and scoring of the food habits questionnaire need to be explored in additional populations before the questionnaire is adopted for general use.

The paraphilias: a multiplicity of deviant behaviours

The DSM-II and DSM-III both allow for multiple diagnoses. The DSM-III acknowledges that a patient may have multiple paraphilias but the true nature and extent of the multiplicity has only been documented recently. In order to study the degree of crossover between the various paraphiliac acts, a study of men who admitted to at least one paraphilia was conducted. A proportional index of multiple deviation was obtained. In addition, the mean number of admitted sexually deviant incidents per paraphilic category was computed as an estimate of the extent of deviant acts committed by this population. The results indicated that paraphiliacs tend to have multiple types of sexual aberrations as well as a high frequency of deviant acts per individual.

Potential for hepatic and renal dysfunction during influenza B infection, convalescence, and after induction of secondary viremia

Whether infection with influenza B virus alters hepatic function was examined in the ferret. Also, the possibility that viral-specific antibodies (Ab) could be produced well before their detection in serum was explored. During the febrile period of influenza, reductions in the serum potassium, anion gap, ammonia, albumin and CPK and elevations of the BUN, creatinine and the GGTP levels occurred. With convalescence, the electrolytes, BUN and creatinine normalized, FFA, SGPT and CPK levels rose and the serum GGTP rose even further. Hepatic fatty acid (FA) oxidation, ornithine transcarbamylase (OTC) and carnitine palmitoyltransferase (CPT) activities were minimally altered and liver ATP and total lipid content remained normal. Following experimental secondary viremia, serum FFA continued to rise, TG decreased and CPK remained elevated while SGPT and GGTP levels normalized. In the liver, FA oxidation and OTC rates remained unchanged but CPT activity was inhibited and the liver content of ATP was significantly reduced. Immune complex (IC) protein recovered from postmicrosomal supernatant fractions by polyethylene glycol precipitation was progressively increased in livers from convalescent and viremic animals. While the amount of IC protein recovered in the spleen also increases during convalescence, this is not the case after viremia when the IC formed seem to be processed largely by the liver. By SDS/PAGE, the major proteins identified in the IC were IgM and other viral proteins. However, the viral proteins could not be validated by immunoblot with Ab produced against purified influenza B hemagglutinin (HA) and neuraminidase (NA) most probably due to phagocytic alterations of glycoprotein immunodeterminants. These findings indicate that during influenza, convalescence and post viremia changes in the concentrations of several serum and liver components occur that reflect hepatic involvement. Also, antiviral Ab, largely IgM, appears to be produced early, complexes with Ag and can be found sequestered in both the liver and spleen at a time when Ab is not detectable in the serum.

[Corneal and lens deposits due to treatment by phenothiazine type neuroleptics]

The authors have studied the corneal and lens lesions which appeared following a prolonged treatment by phenothiazines. They examined 186 patients: 147 took phenothiazines of which 35 of them presented anterior segment alterations. It seems that all phenothiazines can be held responsible for the apparition of these lesions. At this point the authors evaluated the global dose of the various phenothiazines which were administered. The threshold at which the association of these lesions seem to appear, seems to be situated around 300 gr. The total quantity of phenothiazines which are absorbed seems to be a good measure of the risk of ocular toxicity. In the case of one patient they observed that his visual keenness was lowered due to the importance of his corneal and lens lesions.