Coronary vasculopathy due to moyamoya disease.

Moyamoya disease is a rare disorder associated with progressive intracranial arterial stenosis with fragile, small collateralization that gives an angiographic appearance of a puff of smoker or, in Japanese, "moya-moya". We report a case of coronary artery ostial occlusive disease as an extracranial manifestation of Moyamoya. In the case, we demonstrate that thigh risk features of cardiac positron emission tomography (PET) that ultimately lead to the diagnosis of coronary artery occlusion.

Left ventricular assist device infection on 18F-flourodeoxyglucose positron emission tomography.

The rising prevalence of heart failure with limited transplant availability has resulted in increased use of continuous left ventricular assist device (LVAD) support. LVAD driveline remains exposed to environment which predisposes it to high rates of infection. We describe a case of a persistent driveline infection in a patient for which 18F-FDG PET/CT was utilized to diagnose deep-seated infection.

Pain management for liver transplant recipients.

PURPOSE OF REVIEW: Liver transplant recipients pose several pain management challenges. Altered hepatic drug metabolism and clearance in end-stage liver disease patients complicates the use of certain medications, while existing coagulopathy and thrombocytopenia can limit the use of regional anesthetic techniques. Largely due to a high prevalence of substance use disorders, these patients have increased vulnerability to opioid misuse in the perioperative period, which can make acute postoperative pain difficult to control and potentiates prolonged and painful recovery, increasing the risk of developing chronic postsurgical pain. We present current evidence-based literature that reviews optimal pain management strategies for this challenging patient demographic. RECENT FINDINGS: Multiple studies have shown that thoracic epidurals provide superior pain control in open hepatic resections. Recent data suggests thoracic epidurals may be safely considered in select liver transplant recipients with normal preoperative coagulation status; however, this evidence is limited, and further studies are needed. When the risks of coagulopathy prohibit epidural placement, truncal blocks such as transversus abdominis plane blocks or quadratus lumborum blocks and abdominal wound catheters can serve as alternative regional modalities. Specialized teams should manage pain using a multimodal approach. SUMMARY: Thoracic epidural analgesia may be an option for liver transplant recipients with normal coagulation profiles prior to surgery; however, additional studies are warranted. Other regional techniques are also available. Emphasis should be placed on optimizing multimodal pain medication management. Nonpharmacological interventions should also be considered.

Outcomes of atrial fibrillation ablation in patients with or without silent pulmonary veins from prior ablation procedure.

INTRODUCTION: Pulmonary venous (PV) electrical recovery underlies most arrhythmia recurrences after atrial fibrillation (AF) ablation. Little is known about procedural profiles and outcomes of patients with electrically silent PVs upon redo ablation for AF. METHODS: In a prospectively maintained registry, we enrolled 838 consecutive patients (2013-2016) undergoing redo ablation procedures. Ablation procedures targeted the PVs, the PV antra, and non-PV sites at operators' discretion. Procedural profiles and clinical outcomes were assessed. The primary outcome was freedom from AF after a 3-month blanking period. The secondary outcome was improvement in quality of life. RESULTS: Most patients undergoing redo AF ablation (n = 684, 82%) had PV reconnection while the remaining 154 (18%) had electrically silent PVs. Patients with recurrent AF and electrically silent PVs were older (66 vs. 64 years, p = .02), had more prior ablation procedures (median 2 IQR 1-3 vs 1 IQR 1-2 p = .001), were more likely to have non-paroxysmal AF (62% vs. 49%, p = .004) and atrial flutter (48% vs. 29%, p = .001) and had significantly larger left atrial volumes (89 vs. 81 ml, p = .003). Patients with silent PVs underwent a more extensive non-PV ablation strategies with antral extension of prior ablation sets in addition to ablation of the roof, appendage, inferior to the right PVs, peri-mitral flutter lines, cavotricuspid isthmus lines and ablation in the coronary sinus. Upon one year of follow-up, patients with electrically silent PVs were less likely to remain free from recurrent atrial arrhythmias (64% vs. 76%, p = .008). Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. CONCLUSION: Rhythm control with extensive ablation allowed maintenance of sinus rhythm in about two thirds of patients with silent PVs during redo AF ablation procedures. Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. This remains a challenging group of patients, highlighting the need to better understand non-PV mediated AF.

Role of Cardiac Computed Tomography in Planning Transcatheter Mitral Valve Replacement (TMVR).

PURPOSE OF REVIEW: Transcatheter mitral valve replacement (TMVR) is an evolving and rapidly expanding field within structural interventions, offering renewed treatment options for patients with high-risk mitral valve disease. We aim to highlight and illustrate the importance of cardiac CT in the planning of TMVR. RECENT FINDINGS: As TMVR has evolved, so has the specific nuances of cardiac CT planning, we now understand the importance of accurate annular sizing and valve simulation to predict complications such as neo-LVOT obstruction and paravalvular leak (PVL). More so than any other modality, cardiac CT remains instrumental in accurately planning TVMR from feasibility, device sizing, access, and fluoroscopic angles. Cardiac CT remains the key modality in TMVR evaluation, often the first step in determining patient eligibility through comprehensive procedural planning as well as informing potential outcomes and prognosis. In this review, we discuss the critical role of cardiac computed tomography (CT) and the specific considerations involved in TMVR.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit.

BACKGROUND: Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. OBJECTIVES: In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. METHODS: We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. RESULTS: In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (ß1 .8.26, 95% CI 4.09-12.43; p < 0.01). CONCLUSION: A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Consumption of energy drinks is associated with depression, anxiety, and stress in young adult males: Evidence from a longitudinal cohort study.

BACKGROUND: Energy drinks (EDs) claim to boost mental performance, however, few studies have examined the prospective effects of EDs on mental health. This study examined longitudinal associations between ED use and mental health symptoms in young adults aged 20 years over a 2-year period. METHODS: Data were drawn from Gen2 (Generation 2) of the Raine Study, a prospective population-based study in Western Australia. Self-report questionnaires assessed ED consumption and mental health symptoms (Depression Anxiety Stress Scale [DASS]-21) when Gen2 participants were 20 and 22 years old. Changes in ED use and DASS-21 scores over time were analyzed and results presented for the whole sample and by sex. RESULTS: For the whole sample (n = 429), participants who changed from being a non-ED user to an ED user had an average increase in stress scores of 2.30 (95% confidence interval [CI] = 0.04, 4.55) across the 2-year follow-up. Males, but not females who changed from being a non-ED user to an ED user had an average increase in depression, anxiety, and stress scores of 6.09 (95% CI = 3.36, 8.81), 3.76 (95% CI = 1.82, 5.70), and 3.22 (95% CI = 0.47, 5.97), respectively. CONCLUSION: ED consumption may be a possible marker for mental health symptoms in young male adults. Practicing clinicians could consider screening for ED use in routine assessments of mental health, particularly for young males presenting with depression, anxiety, and stress symptoms.

Medical findings in 1,026 consecutive adult inpatient-residential eating disordered patients.

OBJECTIVE: Eating disorders are associated with multiple medical complications. We report contemporary medical data, for newly admitted adult inpatient and residential level of care patients. METHOD: Medical records of a transdiagnostic sample of 1,026 patients, with eating disorders, were retrospectively reviewed for the presence of a broad array of medical complications at time of admission. The prevalence of physiologically relevant medical complications was assessed across major eating disorder categories. RESULTS: Of the patients, 93.6% were female, and they had an average age of 28.1 (SD = 10.1, range 17-69). The average admission body mass index was 16.1 (SD = 2.3). The prevalence of abnormal laboratory values varied by eating disorder subtype. In patients with anorexia nervosa-restricting subtype, 51.4% had low prealbumin, 36.1% were leukopenic, 34.3% had osteoporosis, 30.0% vitamin D deficiency, 16.8% metabolic alkalosis, 16.0% had hyponatremia, 14.2% hypokalemia, and 7.1% hypoglycemia. These patients had normal average QTc intervals. In patients with anorexia nervosa-binge purging subtype, 42.4% had hypokalemia, 33.3% metabolic alkalosis, osteoporosis in 21.1%, and they had longer QTc intervals (433.9 ms, p < .001). Only 6.0% of patients with anorexia nervosa had hypophosphatemia. Patients with bulimia nervosa demonstrated hypokalemia in 26.2%, and metabolic alkalosis in 23.4%; the QTc interval was longer than in AN-R patients (437.9 ms, p < .001), but still in the normal range. DISCUSSION: Numerous medical complications are associated with severe eating disorders. As the severity increases, the number of complications increase and are related to the presence or absence of purging behaviors.

Epidemiology of heart failure with preserved ejection fraction.

The prevalence of heart failure (HF) and its subtype, HF with preserved ejection fraction (HFpEF), is on the rise due to aging of the population. HFpEF is convergence of several pathophysiological processes, which are not yet clearly identified. HFpEF is usually seen in association with systemic diseases, such as diabetes, hypertension, atrial fibrillation, sleep apnea, renal and pulmonary disease. The proportion of HF patients with HFpEF varies by patient demographics, study settings (cohort vs. clinical trial, outpatient clinics vs. hospitalised patients) and cut points used to define preserved function. There is an expanding body of literature about prevalence and prognostic significance of both cardiovascular and non-cardiovascular comorbidities in HFpEF patients. Current therapeutic approaches are targeted towards alleviating the symptoms, treating the associated comorbid conditions, and reducing recurrent hospital admissions. There is lack of evidence-based therapies that show a reduction in the mortality amongst HFpEF patients; however, an improvement in exercise tolerance and quality of life is seen with few interventions. In this review, we highlight the epidemiology and current treatment options for HFpEF.

A Look Forward and a Look Back: The Growing Role of ERAS Protocols in Orthopedic Surgery.

The success of enhanced recovery after surgery (ERAS) protocols in improving patient outcomes and reducing costs in general surgery are widely recognized. ERAS guidelines have now been developed in orthopedics with the following recommendations. Preoperatively, patients should be medically optimized with a focus on smoking cessation, education, and anxiety reduction. Intraoperatively, using multimodal and regional therapies like neuraxial anesthesia and peripheral nerve blocks facilitates same-day discharge. Postoperatively, early nutrition with appropriate thromboprophylaxis and early mobilization are essential. As the evidence of their improvement in patient outcomes and satisfaction continues, these pathways will prove invaluable in optimizing patient care in orthopedics.

Phytochemical and pharmacological characteristics of phalsa (Grewia asiatica L.): A comprehensive review.

Phalsa is a tropical and subtropical fruit that is high in nutritional value and is primarily cultivated for its fruit. As, Phalsa fruit contain high number of vitamins (A and C), minerals (calcium, phosphorus, and iron), and fibre while being low in calories and fat. The fruit and seed of Phalsa contain 18 amino acids, the majority of which are aspartic acid, glutamic acid, and leucine. Based on in vivo and in vitro studies phalsa plant possess high antioxidant, anti-inflammatory, anticancer, antimicrobial, antidiabetic properties. However, antioxidant properties are found in the form of vitamin C, total phenolic, anthocyanin, flavonoid, and tannin. The phalsa plant's fruits and leaves have substantial anticancer action against cancer cell lines. Because of the presence of a broad range of physiologically active chemicals, investigations on phalsa plants revealed that some plant parts have radioprotective qualities. The anti-glycosidase and anti-amylase activity of aqueous fresh fruit extract was shown to be substantial. The phalsa plant contains an abundance of biologically active chemicals, allowing it to control microorganisms through a variety of processes. Phalsa methanolic leaf extract was revealed to have antimalarial and antiemetic effects. The hot and cold polysaccharide fractions extracted from the phalsa plant have potent hepatoprotective and therapeutic properties. Therefore, this review is based on the nutritional, bioactive, phytochemicals, and potential pharmacological uses of phalsa. The potential health benefits and economic potential of the phalsa berry's phytochemicals are promising areas for further study.

Carbonic anhydrase-mimicking metal-organic frameworks built from amino acid and cadmium ions.

Built from L-histidine amino acid ligand and cadmium ions, two new 3D chiral metal-organic frameworks, [α-Cd(HIS)] (1) and [ß-Cd(HIS)] (2), which contain metal-histidine bonds mimicking the structure features of carbonic anhydrase, demonstrate interesting properties of catalyzing the hydrolysis of p-nitrophenylacetate (p-NPA) to para-nitrophenol (p-NP).

Unmet needs and future directions in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a highly treatable monogenetic disorder affecting nearly 0.2% of the population. The high burden of this disease demands suitable measures for early diagnosis and preventing as well as tackling misdiagnosis. While conventionally available therapies have been efficacious in reducing symptoms, they have not been able to change the natural history of the disease. The landscape of medical treatment is rapidly changing with advent of novel pharmacotherapies such as cardiac myosin inhibitors. Ongoing investigations in gene editing have demonstrated benefits in correcting underlying genetic mutations and this is where the future of treatment lies. Contemporary procedural techniques as alternatives to available septal reduction therapies independent of coronary vascular anatomy are also emerging. This review details the recent developments, unmet needs and future directions in diagnosis, medical and invasive treatment of HCM.

Modern tools in cardiac imaging to assess myocardial inflammation and infection.

Myocardial forms of infection and inflammation are highly heterogeneous in clinical course and presentation but associated with diagnostic and treatment uncertainty, high morbidity, mortality, and financial burden. Historically, these pathologies were diagnosed invasively with biopsy, surgical pathology, or explanted hearts. However, in the current era, the diagnosis has been aided by a variety of non-invasive imaging tools in the appropriate clinical presentation. This review provides a comprehensive understanding of the available imaging modalities for guiding the diagnosis, treatment, and prognosis of cardiac infection and inflammation.

Valsartan Protects in High Fat Diet During Ischemic Reperfusion Injury.

AIM: The study investigates the effect of Valsartan, an Angiotensin II type 1 receptor blocker (ARB), on the blunted neuroprotective response of ischemic post-conditioning (iPoCo) in rats subjected to High Fat Diet (HFD). BACKGROUND: The neuroprotective response of iPoCo is blunted in conditions of vascular endothelial dysfunction (ED) associated with hypercholesterolemia, diabetes, hypertension, etc. Objectives: The study was undertaken to investigate the effect of Valsartan, an ARB, on the blunted neuroprotective response of iPoCo in rats subjected to HFD. METHODS: Wistar rats were subjected to HFD for 56 days. The cerebral ischemic injury was induced by bilateral common carotid artery occlusion (BCCAO) for 12 min followed by reperfusion of 24 hrs. iPoCo was induced by three preceding cycles of ischemia and reperfusion lasting 1 min each given immediately after BCCAO at the onset of prolonged reperfusion. The extent of the injury was assessed in terms of memory impairment using the Morris Water Maze test (MWM), sensorimotor disturbance using the neurological severity score (NSS), and cerebral infarct size using triphenyl tetrazolium chloride staining. Series of biochemical estimations including brain thiobarbituric acid reactive species (TBARS); reduced glutathione (GSH); myeloperoxidase (MPO); tumor necrosis factor-α (TNF-α); Nrf-2 and serum cholesterol, serum nitrite levels were performed. RESULTS: BCCAO produced significant cerebral injury indicated by increased cerebral infarct size, memory impairment, increased NSS, and various biochemical alterations (increased cholesterol, TBARS, MPO, TNF-α, Nrf-2, and decreased nitrite and GSH levels). Significant neutrophil infiltration was also observed. iPoCo attenuated BCCAO-induced injury with respect to the above parameters in normal rats. The protective response of iPoCo was lost in HFD-treated rats. Treatment of Valsartan attenuated cerebral injury, potentiated the neuroprotective response of iPoCo in normal rats, and also restored the blunted neuroprotective effect of iPoCo in HFD-treated rats along with enhanced Nrf-2 levels. CONCLUSION: Valsartan exerted a neuroprotective effect by virtue of its multiple actions with a crucial role of Nrf2 activation.

Mitral Annular Calcification Related Infective Endocarditis: A Contemporary Systematic Review.

Mitral annular calcification (MAC) is a chronic degenerative process often found incidentally on imaging. MAC is associated with elevated risk of atherosclerosis and stroke. The association between MAC and the risk of infective endocarditis (IE) is less well known. Therefore, we conducted this systematic review in order to understand the diagnosis, clinical outcomes, and management of IE associated with MAC. We conducted a systematic review of published data regarding MAC related IE in various databases until November 20, 2019. Case series and cohort studies were included. A total of 8 studies with a cohort of 113 patients were included. Mean age was 69 years with equal gender distribution (50% female). Hypertension (55.8%) was the most common comorbidity seen in this patient population. IE was diagnosed by either antemortem trans esophageal echocardiographic examination (76%) or post-mortem autopsy (24%). Staphylococcus aureus (47%) was the most common pathogen identified. MAC was adjudicated to be moderate-to-severe in 100% of identified cases, with 77.9% of cases presenting with distinct vegetation's. Twenty-six percent of patients (n = 29) underwent surgery. MAC may be associated with development of IE. Echocardiography is the most common non-invasive technique for diagnosis. Due to the difficulties associated with antemortem diagnosis, diagnosis is occasionally made on post-mortem examination. Neurologic complications are frequently encountered, and reported mortality is high in MAC associated IE.

Endless Journey of Adenosine Signaling in Cardioprotective Mechanism of Conditioning Techniques: Clinical Evidences.

Myocardial ischemic injury is a primary cause of death among various cardiovascular disorders. The condition occurs due to interrupted blood supply and vital nutrients (necessary for normal cellular activities and viability) to the myocardium, eventually leading to damage. Restoration of blood supply to ischemic tissue is noted to cause even more lethal reperfusion injury. Various strategies, including some conditioning techniques like preconditioning & postconditioning have been developed to check detrimental effects of reperfusion injury. Many endogenous substances have been proposed to act as initiator, mediators and end effectors of these conditioning techniques. Substances like adenosine, bradykinin, acetylcholine, angiotensin, norepinephrine, opioids, etc., have been reported to mediate cardioprotective activity. Among these agents, adenosine has been widely studied and suggested to have the most pronounced cardioprotective effects. The current review article highlights the role of adenosine signaling in the cardioprotective mechanism of conditioning techniques. The article also provides an insight into various clinical studies that substantiate the applicability of adenosine as a cardioprotective agent in myocardial-reperfusion injury.

Endocarditis after Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) use is gaining momentum as the mainstay for the treatment of aortic stenosis compared to surgical aortic valve replacement (SAVR). Unfortunately, TAVR-related infective endocarditis (TAVR-IE) is expected to be detected more and more as a result of the ever-expanding indications in younger patients. Given the overall poor prognosis of TAVR-IE, it is imperative that clinicians familiarize themselves with common presentations, major risk factors, diagnostic pitfalls, therapeutic approaches, and the prevention of TAVR-IE. Herein, we review all of the above in detail with the most updated available literature.

A Look Forward and a Look Back: The Growing Role of ERAS Protocols in Orthopedic Surgery.

The success of enhanced recovery after surgery (ERAS) protocols in improving patient outcomes and reducing costs in general surgery are widely recognized. ERAS guidelines have now been developed in orthopedics with the following recommendations. Preoperatively, patients should be medically optimized with a focus on smoking cessation, education, and anxiety reduction. Intraoperatively, using multimodal and regional therapies like neuraxial anesthesia and peripheral nerve blocks facilitates same-day discharge. Postoperatively, early nutrition with appropriate thromboprophylaxis and early mobilization are essential. As the evidence of their improvement in patient outcomes and satisfaction continues, these pathways will prove invaluable in optimizing patient care in orthopedics.