The Gene and Protein Expression of the Main Components of the Lipolytic System in Human Myocardium and Heart Perivascular Adipose Tissue. Effect of Coronary Atherosclerosis.

The aim of our study was to examine the regulation of triacylglycerols (TG) metabolism in myocardium and heart perivascular adipose tissue in coronary atherosclerosis. Adipose triglyceride lipase (ATGL) is the major TG-hydrolase. The enzyme is activated by a protein called comparative gene identification 58 (CGI-58) and inhibited by a protein called G0/G1 switch protein 2 (G0S2). Samples of the right atrial appendage and perivascular adipose tissue were obtained from two groups of patients: 1-with multivessel coronary artery disease qualified for coronary artery bypass grafting (CAD), 2-patients with no atherosclerosis qualified for a valve replacement (NCAD). The mRNA and protein analysis of ATGL, HSL, CGI-58, G0S2, FABP4, FAT/CD36, LPL, ß-HAD, CS, COX4/1, FAS, SREBP-1c, GPAT1, COX-2, 15-LO, and NFκß were determined by using real-time PCR and Western Blot. The level of lipids (i.e., TG, diacylglycerol (DG), and FFA) was examined by GLC. We demonstrated that in myocardium coronary atherosclerosis increases only the transcript level of G0S2 and FABP4. Most importantly, ATGL, ß-HAD, and COX4/1 protein expression was reduced and it was accompanied by over double the elevation in TG content in the CAD group. The fatty acid synthesis and their cellular uptake were stable in the myocardium of patients with CAD. Additionally, the expression of proteins contributing to inflammation was increased in the myocardium of patients with coronary stenosis. Finally, in the perivascular adipose tissue, the mRNA of G0S2 was elevated, whereas the protein content of FABP-4 was increased and for COX4/1 diminished. These data suggest that a reduction in ATGL protein expression leads to myocardial steatosis in patients with CAD.

Value of APACHE II, SOFA and CardShock scoring as predictive tools for cardiogenic shock: A single-centre pilot study.

AIMS: The aim of this study was to determine the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and CardShock scoring systems in predicting the risk of in-hospital, 30 day and 3 year mortality in patients with cardiogenic shock (CS). METHODS: This was a single-centre observational study conducted between May 2016 and December 2017. Data from consecutive patients with CS admitted to the intensive cardiac care unit (ICCU) were included in the analysis. RESULTS: The study group comprised 63 patients with CS {median age 71.0 [interquartile range (IQR), 59-82]; 42 men}: 32 patients with ischaemic and 31 with non-ischaemic aetiology. The median APACHE II, SOFA and CardShock scores were 13 (IQR, 9.9-19.0) points, 8.0 (IQR, 6.0-10.0) points and 3.0 (IQR, 2.0-5.0) points, respectively. The in-hospital, 30 day and 3 year mortality rates were 39.7%, 41.3% and 77.8%, respectively. APACHE II and SOFA scores were significantly higher in the group of patients who died at 30 days (P = 0.043 and P = 0.045, respectively). The CardShock score was higher in patients with CS who died in hospital (P = 0.007) and within 30 days (P = 0.004). No score was statistically significant for 3 year mortality. Area under the curve (AUC) analysis showed that the CardShock score had the highest value in predicting in-hospital and 30 day mortality relative to APACHE II and SOFA, with a cut-off score of 5 points [AUC: 0.70; 95% confidence interval (CI): 0.59-0.81; P = 0.001] and 4 points (AUC: 0.71; 95% CI: 0.60-0.82; P < 0.001), respectively. The Bayesian Weibull model demonstrated the utility of all scales in estimating short-term risk in patients with CS, with the impact of APACHE II and SOFA on patient life expectancy decreasing to a non-significant level at approximately 32 days and CardShock at 33 days. The forest plots derived from the Bayesian logistic regression analysis show significant estimated coefficients with 94% highest density interval (HDI) for in-hospital and 30 day mortality. The use of invasive or non-invasive ventilation, a higher heart rate and a less negative fluid balance showed an unfavourable prognosis. Survival was associated with being in the pre-CS class, with a higher glomerular filtration rate and a higher platelet count. CONCLUSIONS: APACHE II and SOFA could be used for the risk stratification of patients with CS admitted to the ICCU. CardShock proved to be a more appropriate tool for assessing short-term prognosis in patients with CS of all aetiologies, suggesting that there is potential for its promotion for use in daily clinical practice.

Mechanical circulatory support. An expert opinion of the Association of Intensive Cardiac Care and the Association of Cardiovascular Interventions of the Polish Cardiac Society.

Mechanical circulatory support (MCS) methods are used in patients with both acute and chronic heart failure, who have exhausted other options for pharmacological or surgical treatments. The purpose of their use is to support, partially or completely, the failed ventricles and ensure adequate organ perfusion, which allows patients to restore full cardiovascular capacity, prolonging their life and effectively improving its quality. The three most popular devices include an intra-aortic balloon pump (IABP), percutaneous assist devices (including Impella, TandemHeart), and venoarterial extracorporeal membrane oxygenation (VA-ECMO). A multidisciplinary approach with the special participation of the Heart Team is required to determine the proper MCS strategy, the choice of the supporting method, and the time of its use. The studies published so far do not allow us to determine which MCS method is the safest and the most effective. Thus, the site experience and accessibility of the method seem to matter most today. MCS finds particular application in patients with acute coronary syndromes complicated by refractory cardiogenic shock, as well as in patients with acute heart failure of the high potential for reversibility. It can also serve as a backup for percutaneous coronary interventions of high risk (complex and high-risk indicated percutaneous coronary intervention [PCI], complex and high-risk indicated PCI [CHIP]). The use of appropriate supportive drugs, precise hemodynamic and echocardiographic monitoring, as well as optimal non-invasive or mechanical ventilation, are extremely important in the management of a patient with MCS. The most serious complications of MCS include bleeding, thromboembolic events, as well as infections, and hemolysis.

Insulin-like growth factor-binding protein 7 (IGFBP 7) as a new biomarker in coronary heart disease.

PURPOSE: The role of insulin-like growth factor-binding protein-7 (IGFBP-7) in atherosclerosis is still not well-known. The objective of this study was to find out the following: 1) whether IGFBP-7 may act as a biomarker of coronary artery disease (CAD) occurrence and extent; 2) whether IGFBP-7 is potentially related to the classical and new markers of cardiovascular risk (carotid intima-media thickness - cIMT); 3) whether IGFBP-7 may be a marker of mortality in the group of patients with myocardial infarction (MI). MATERIALS/METHODS: The study group consisted of 212 patients with MI and 75 patients with stable CAD, the control group included 100 healthy volunteers. IGFBP-7 serum concentration was measured. RESULTS: IGFBP-7 value was considerably higher in the study group (MI and CAD patients - 35.1 ng/ml (P = 0.000001) and 32.7ng/ml (P = 0.0001), respectively), than in the controls - 25.2ng/ml. No statistically significant differences between IGFBP-7 concentrations in the MI and CAD group were found. No relationship between IGFBP-7 and the coronary lesions advancement in the study group was observed. No changes in IGFBP-7 concentration in the MI patients during hospitalization were observed. In the group of MI patients who died during follow-up, a considerably higher cIMT values were found whereas no statistically significant difference was observed in relation to IGFBP-7 (34.6 vs. 35.2 ng/ml). CONCLUSIONS: IGFBP-7 is a good biomarker of CAD occurrence but not of its advancement. We demonstrated the existence of the relation between higher IGFBP-7 concentration and the selected classical risk factors of cardiovascular events as well as cIMT values. IGFBP-7 cannot serve as a marker of acute ischemia. Also, IGFBP-7 was not confirmed as a predictor of mortality in the MI patients.

Vorapaxar for reduction of thrombotic cardiovascular events in myocardial infarction and peripheral artery disease.

PURPOSE: The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, dosage and administration, cost, and place in therapy of vorapaxar in the secondary prevention of atherosclerotic events are reviewed. SUMMARY: Vorapaxar is a highly selective, reversible antagonist of protease-activated receptor-1 expressed on platelets. Vorapaxar competitively inhibits thrombin from activating the receptor, thereby decreasing platelet aggregation. Vorapaxar is rapidly absorbed and distributed, with peak plasma levels being reached within 60-90 minutes. Vorapaxar's effective half-life is three to four days and its terminal elimination half-life is eight days. Vorapaxar sulfate 2.5 mg (equivalent to 2.08 mg of vorapaxar) orally daily without a loading dose was clinically effective for the secondary prevention of ischemic events in patients with a history of myocardial infarction (MI) or with peripheral arterial disease (PAD) without a history of stroke. Phase II and III trials of vorapaxar given with aspirin or a thienopyridine or both demonstrated a reduction in the primary endpoint of cardiovascular death, MI, and stroke in patients with a history of MI or coronary artery disease and PAD. Patients with a history of stroke were found to have an increased rate of intracranial hemorrhage (ICH), which led to a boxed warning placed on vorapaxar's labeling to warn of the increased risk for bleeding in patients with a history of stroke. CONCLUSION: Vorapaxar is a novel antiplatelet agent that has demonstrated efficacy in reducing atherosclerotic events in patients with a history of MI or PAD without a history of stroke, transient ischemic attack, or ICH when taken in combination with aspirin and clopidogrel.

Impact of a combined pharmacist and social worker program to reduce hospital readmissions.

BACKGROUND: The Patient Protection and Affordable Care Act (2010) directed the Centers for Medicare and Medicaid Services to implement a hospital readmissions reduction program that reduces payments to hospitals for excess readmissions that began in October 2012. As such, hospitals across the country have been trying to identify and implement successful strategies for reducing hospitalizations. OBJECTIVE: To evaluate the impact of a combined pharmacist and social worker program on reducing 30-day, all-cause readmission rates to the same hospital. METHODS: Our study design was a retrospective, cross-sectional study that included 100 inpatients discharged from a large academic medical center. Fifty patients were enrolled in the combined pharmacist and social worker program, and 50 received usual care; all were deemed high risk for readmission due to clinical or social factors. In the program group, a pharmacist performed a thorough medication history and review of discharge medications and, in some cases, communicated with the patient after discharge. The program group was also followed by a social worker team in the hospital and after discharge; as necessary, psychosocial interventions were performed. RESULTS: The 2 patient cohorts had similar demographic and clinical characteristics. Ten percent of patients enrolled in the combined pharmacist and social worker program were readmitted to the hospital for any reason within 30 days of discharge, compared with 30% of patients in the usual care group (P = 0.012). CONCLUSION: The combined pharmacist and social worker program demonstrated a significant reduction in 30-day, all-cause readmission rates to the same hospital.

Estudio clínico epidemiológico de leishmaniasis cutánea en población pediátrica / Clinic-epidemiological study of cutaneous leishmaniasis in pediatric population

Se estudio una población de 47 pacientes con diagnóstico de leishmaniasis que acudían al Servicio de Consulta Externa del Departamento de Enfermedades Transmisibles y Dermatológicas del Hospital General Base Cayetano Heredia, siendo registrados en fichas clínicas de control especialmente diseñadas para dichos pacientes. Se consideraron para el estudio todos los paciente pediátricos (hasta 14 años inclusive), que fueron evaluados en el servicio desde octubre de 1983 hasta diciembre de 1986, siendo la procedencia variada. Los pacientes fueron admitidos al programa de leishmaniasi, siendo seguidos por consultorio externo en forma regular. La mayoría de pacientes fueron menores de 3 años, y acudieron con un tiempo de enfermedad menor a 6 meses, lo que hace suponer que los resultados del presente estudio son aplicables a lo que sucede realmente en el trabajo de campo. Los tamaños de lesiones encontrados son mayores a lo habitualmente reportado, lo que parece significar un comportamiento de la leishmania braziliensis peruaviana similar a la leishmania brazilienzis en lo referente a la agresividad: este podría indicar que ambas son subespecies pertenecientes al mismo complejo. El porcentaje de seguimiento logrado es bastante satisfactorio, sobretodo si tomamos en cuenta que se trata de población hospitalaria con seguimiento ambulatorio. El porcentaje de recaídas (3 por ciento) es sorprendentemente alto, a pesar de que los tratamiento son aplicados en la mayoría de los casos en forma regular y supervivida por el personal del servicio, y a pesar de que en muchos casos, se aplicaron hasta tres cursos completos.Esto tal vez indique la necesidad de revisar los esquemas y criterios de retratamiento, ya que como se trata de una población pediátrica, estos toleran mejor dosis más altas