Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis

The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords "PAIVS/CPS", Ebstein's anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice.

Antiarrhythmic Drug Dosing in Children-Review of the Literature

Antiarrhythmic drugs represent a mainstay of pediatric arrhythmia treatment. However, official guidelines and consensus documents on this topic remain scarce. There are rather uniform recommendations for some medications (including adenosine, amiodarone, and esmolol), while there are only very broad dosage recommendations for others (such as sotalol or digoxin). To prevent potential uncertainties and even mistakes with regard to dosing, we summarized the published dosage recommendations for antiarrhythmic drugs in children. Because of the wide variations in availability, regulatory approval, and experience, we encourage centers to develop their own specific protocols for pediatric antiarrhythmic drug therapy.

Only Subclinical Alterations in the Haemostatic System of People with Diabetes after COVID-19 Vaccination

People with diabetes have an increased risk of experiencing adverse COVID-19 outcomes. COVID-19 vaccination is, therefore, highly recommended. However, people with diabetes have an inherently elevated risk of thrombotic events and the impact of the vaccination on the coagulation system in this patient population remains to be elucidated. The aim of this study was to investigate the impact of COVID-19 vaccination on the haemostatic system in people with type 1 or type 2 diabetes. We evaluated the effects of COVID-19 vaccination (BioNTech Pfizer, Moderna, AstraZeneca) on standard coagulation parameters, whole blood coagulation (Thrombelastometry), platelet function (impedance aggregation), and thrombin generation (calibrated automated thrombography) in people with type 1 diabetes mellitus (n = 41) and type 2 diabetes mellitus (n = 37). Blood sampling points were prior to vaccination and two weeks after the respective vaccination. Thrombelastometry measurements indicated moderately increased clot formation post-vaccination in people with type 1, as well as with type 2, diabetes: "Clot formation times" were significantly shorter, and both "maximum clot firmness" and "alpha angles" were significantly higher, as compared to the respective pre-vaccination values. Therefore, TEM parameters were not altered after vaccination in patients receiving ASA. Moreover, platelet aggregation was enhanced in people with type 1 diabetes, and plasma levels of D-Dimer were increased in people with type 2 diabetes, following COVID-19 vaccination. All other standard coagulation parameters, as well as thrombin generation, were not affected by the vaccination. The coagulation responses of people with diabetes to COVID-19 vaccination were only subclinical and comparable to those observed in healthy individuals. Our findings suggest that people with diabetes do not face an increased activation of the coagulation post-vaccination.

[Treatment for chronic back pain? : Active multimodal, interdisciplinary pain therapy vs. physiotherapy-physical therapy for chronic back pain]

BACKGROUND

In industrialized countries, chronic back pain is referred to as the "number one common disease".

OBJECTIVES

Are there any indications of different outcomes of chronic back pain patients when treated with a multimodal, interdisciplinary pain therapy (MMSTh) compared to physiotherapy-physical therapy?

MATERIALS AND METHODS

Entrance and final examination by means of survey, questionnaires and physical tests in the intervention and control group, evaluation and comparison of the results.

RESULTS

The intervention group showed very significant improvements in all tests. In contrast, the control group achieved only partial improvements in physical parameters and quality of life. This resulted in clear group differences in favor of the MMSTh. In terms of patient satisfaction, the control group showed a better result than the intervention group.

CONCLUSIONS

Treatment with MMSTh is superior to standard physiotherapy-physical. Due to the extensive, proven positive effect on many pain-causing and pain-preserving factors, multimodal pain centers should be used more frequently in chronic back pain patients.

Istaroxime, a potential anticancer drug in prostate cancer, exerts beneficial functional effects in healthy and diseased human myocardium

The current gold standard for prostate cancer treatment is androgen deprivation therapy and antiandrogenic agents. However, adverse cardiovascular events including heart failure can limit therapeutic use. Istaroxime, which combines Na⁺-K⁺-ATPase (NKA) inhibition with sarco/endoplasmic reticulum Ca²⁺-ATPase 2a (SERCA2a) stimulation, has recently shown promising anti-neoplastic effects in prostate cancer (PC) models and may also improve cardiac function. Considering the promising anticancer effects of istaroxime, we aimed to assess its functional effects on human myocardium.

[Pain measurement in cognitively impaired patients with the Doloshort scale]

BACKGROUND

Until recently the measurement of pain in cognitively impaired patients represented a neglected field in the diagnostics and treatment of pain. Investigations indicate a prevalence of pain in nursing home residents of between 45 % and 80 %.

MATERIAL AND METHODS

This study investigated the reliability of the German translation of the Doloshort scale and compared it with the visual analog scale (VS). The aim of this study was to determine the practical applicability of this scale in the clinical routine and to calculate the intrarater reliability (retest) and interrater reliability.

RESULTS

The interrater and intrarater reliability of the Doloshort scale was between 0.949 and 0.970. There was a highly significant correlation between the values of the Doloshort scale and the VAS.

CONCLUSION

The Doloshort scale is a well suited measurement instrument for the evaluation of pain in cognitively impaired patients. Because of the short form only simple instructions are necessary and it has a high acceptance with users.

Campylobacter jejuni infection associated with myopericarditis in adolescents: report of two cases

Two cases of myopericarditis associated with Campylobacter jejuni infection in male adolescents are presented. C. jejuni is the most common cause of bacterial gastroenteritis worldwide; however, cardiac complications are rare, even in adults. To our knowledge, these are the first reported cases of campylobacter-related myopericarditis in adolescents.

Increased shear stress- and ristocetin-induced binding of von Willebrand factor to platelets in cord compared with adult plasma

Multiple indications do exist that the extensive neonatal platelet adhesion and aggregation, and the shorter closure time of neonatal compared with adult whole blood in the platelet function analyzer 100 are attributable to the physiological high plasma concentrations and high concentrations of unusually large von Willebrand factor (vWf) multimers in neonates. However, to date the direct experimental evidence is lacking. Therefore, we compared in the present study the ability of neonatal vWf to bind to platelets to that of adult vWf. Platelet-poor plasma of neonatal or adult origin, containing antibody-stained vWf, was incubated with neonatal or adult platelet suspension. Subsequently, vWf-platelet interaction was induced by exposing the mixture to shear stress by means of a cone/plate measuring system or by incubating the mixture with ristocetin. Finally, samples were analyzed in a FACScan flow cytometer. Detected fluorescence intensities directly correlate with the amount of vWf attached to the platelet surface. We found that significantly higher amounts of neonatal vWf were attached to platelets in the presence of shear stress or ristocetin. This efficient neonatal vWf-platelet interaction is an effect intrinsic to the neonatal vWf, and not to the neonatal platelet: the amount of neonatal vWf attached to neonatal platelets was not different from the amount of neonatal vWf attached to adult platelets. Furthermore, decreasing the vWf content in cord plasma to adult level resulted in significantly suppressed vWf-platelet attachment in the presence of ristocetin, indicating that the high neonatal vWf level contributes to the efficient vWf-platelet binding in neonates.

Higher concentrations of heparin and hirudin are required to inhibit thrombin generation in tissue factor-activated cord plasma than in adult plasma

Neonatal plasma clots slower than adult plasma, and only 30-50% of peak adult thrombin activity can be produced in neonatal plasma when high amounts of tissue factor (TF) are added to trigger clotting, as used in standard clotting assays. Plasma activation by addition of low amounts of TF probably better reflects conditions in vivo. Under these conditions, cord plasma clots faster than adult plasma. In the present study, we show that after activation with low amounts of TF, higher amounts of the anticoagulants heparin and hirudin are required in cord plasma for effective inhibition of thrombin generation compared with adult plasma. After strong activation with high amounts of TF (30 microM), the thrombin potential was significantly more suppressed in cord plasma compared with adult plasma in the presence of 0.4 IE/mL heparin (-92 versus -75%; p < 0.01) and in the presence of 2 IE/mL hirudin (-18 versus -8%; p < 0.01). In contrast, after weak activation with low amounts of TF (30 pM), the thrombin potential was significantly more suppressed in adult plasma compared with neonatal plasma in the presence of 0.025 IE/mL heparin (-93 versus -8%; p < 0.01) and in the presence of 2 IE/mL hirudin (-89 versus -48%; p < 0.01). Our results show that in neonates, effects of anticoagulants very much depend on the type of activation used to initiate clotting, and doses of anticoagulants should not be derived from studies done in adults, because potentially higher doses of anticoagulants may be required.

A laboratory method for parallel determination of platelet aggregation and thrombin generation

Optimal use of combinations of antiaggregating and antithrombotic drugs in vivo requires improved methods for testing of possible synergistic drug effects. Therefore, we developed an in vitro model that allows parallel evaluation of the influence of drugs on the time course of platelet aggregation inhibition and on thrombin generation inhibition. Platelet rich plasma samples were incubated with different amounts of antiaggregating and/or antithrombotic agents and the effects on thrombin generation, lag phase until the onset of platelet aggregation, and on inhibition of platelet aggregation were detected. Plasma activation was performed by addition of high (29 nM final concentration, "high coagulant challenge") or low (5 pM final concentration, "low coagulant challenge") amounts of tissue factor. Thus, platelet activation is initiated in our model by endogenously generated thrombin and not by exogenously added agonists, as usual in conventional evaluation of platelet aggregation. The combination of glycoprotein IIb/IIIa inhibitors (eptifibatide or abciximab) and anticoagulants (unfractionated heparin, low molecular weight heparin, or recombinant hirudin) used in this study exhibited an additive effect on prolongation of the lag phase until the onset of platelet aggregation. Under high but not under low coagulant challenge the combination of eptifibatide and anticoagulants had a synergistic inhibitory effect on platelet aggregation. Combination of abciximab and anticoagulants had no additive inhibitory effects on platelet aggregation under both high and low coagulant challenge. Under low coagulant challenge combination of eptifibatide but not abciximab with low molecular weight heparin significantly reduced the thrombin generation. We suggest that our laboratory method might be useful for pre-clinical testing of in vitro effects of glycoprotein IIb/IIIa inhibitors and anticoagulants.

Shorter PFA-100 closure times in neonates than in adults: role of red cells, white cells, platelets and von Willebrand factor

In neonates, despite poor platelet function in various in vitro tests, closure times (CTs) in PFA-100 measurements are shorter than in adults. Neonates have a higher polymeric von Willebrand factor (vWF). They also have a higher haematocrit and higher white blood cell count than adults. which may interfere with the evaluation of platelet and vWF function by means of the PFA-100 in neonates. To assess the role of different blood constituents on neonatal CTs, red blood cell, platelet and white blood cell counts in cord blood were modified. These modifications did not provide any evidence that the difference in number between adult and neonatal blood cells was responsible for shorter neonatal CTs. In further experiments, platelets and/or vWF were inhibited by means of abciximab and anti-vWF antibody, and mixing experiments with neonatal platelet-rich and platelet-poor plasma were performed. The results showed that short cord blood PFA-100 CTs were caused by a constituent of neonatal platelet-poor plasma, probably the neonatal high multimeric vWF.

CONCLUSION

This study demonstrates that CTs in neonates are dependent on the same components, platelets and vWF, as in adults, making it likely that the PFA-100 can be used in neonates in the same way as in adults to investigate platelet and vWF function.