Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure.

BACKGROUND: About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy. METHODS: We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined. RESULTS: Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007). CONCLUSIONS: Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

Eczema Monkeypoxicum in a Female Patient With Atopic Dermatitis.

A female patient with atopic dermatitis who had recently received a tattoo presented with severe right ear pain and several vesiculopustular lesions. Over 1 week, she developed approximately 80 widely distributed lesions. Laboratory testing confirmed mpox (previously monkeypox) virus, and no further lesions developed after initiation of oral tecovirimat.

The impact of failed novel technology and technical errors on the revision burden in total hip arthroplasty: what percentage of revision hip arthroplasty was potentially avoidable?

BACKGROUND: Despite the high success rate of total hip arthroplasty (THA), new implant technologies continue to be developed. Although potentially useful, such novel developments may result in unintended consequences, leading to revision surgery, often prematurely. In several instances, new technology that appeared promising was later found to be inferior to existing technology and resulting in early revision surgery. Additionally, technical surgical errors may also lead to early revisions. Some have argued that revisions related to such phenomena are potentially avoidable. The present analysis investigates to what extent the contribution of "failed new technology" and "technical errors" contributes to the revision burden and to the need for premature revision arthroplasty. METHODS: We retrospectively analysed 432 revision THAs and categorised them as either "late revisions" based on survivorship of 10 years or "premature revisions". Among both cohorts, we determined what percentage of revisions were potentially avoidable and due to failed novel technologies and technical errors, and what percent were "unavoidable". RESULTS: Of the 432 revisions, 267 (62%) were considered premature and 38% were considered late. Of the premature revisions, 108 were considered potentially avoidable (81 failed novel technologies, 27 technical errors). CONCLUSIONS: Our data demonstrates that new technology and surgical techniques can result in premature failure of THA. Surgeons should take caution when incorporating new implant technology or surgical techniques into their practice.

Translational regulation in the brain by TDP-43 phase separation.

The in vivo physiological function of liquid-liquid phase separation (LLPS) that governs non-membrane-bound structures remains elusive. Among LLPS-prone proteins, TAR DNA-binding protein of 43 kD (TDP-43) is under intense investigation because of its close association with neurological disorders. Here, we generated mice expressing endogenous LLPS-deficient murine TDP-43. LLPS-deficient TDP-43 mice demonstrate impaired neuronal function and behavioral abnormalities specifically related to brain function. Brain neurons of these mice, however, did not show TDP-43 proteinopathy or neurodegeneration. Instead, the global rate of protein synthesis was found to be greatly enhanced by TDP-43 LLPS loss. Mechanistically, TDP-43 LLPS ablation increased its association with PABPC4, RPS6, RPL7, and other translational factors. The physical interactions between TDP-43 and translational factors relies on a motif, the deletion of which abolished the impact of LLPS-deficient TDP-43 on translation. Our findings show a specific physiological role for TDP-43 LLPS in the regulation of brain function and uncover an intriguing novel molecular mechanism of translational control by LLPS.

Immersive Virtual Reality for Pain Relief in Upper Limb Complex Regional Pain Syndrome: A Pilot Study.

Objective: This pilot study explored the effects of therapeutic immersive virtual reality (VR) on pain in upper limb complex regional pain syndrome (CRPS). While acute pain relief with VR has been studied in multiple populations, there is little data on the use of this modality in treating chronic pain, especially CRPS. Participants: Volunteer participants were recruited from outpatient rehabilitation services. Inclusion criteria required the diagnosis of CRPS in at least one upper limb and the ability to communicate in English to receive instructions from study personnel. A total of eight participants were recruited, with six fully completing the study. Interventions: An immersive virtual three-dimensional interactive kitchen environment was designed that allowed visualization of and object manipulation with virtual hands. Participants performed tasks representative of daily activities, as well as guided visualization exercises for a total of 10 sessions. Main Outcome Measure: Preand post-session pain scale measurements (Short Form McGill Pain Questionnaire, Visual Analog Scale, and Wong-Baker FACES) and subjective feedback were collected with each session. Results: Four of the six participants that completed the study reported subjective improvement of their pain and daily function. However, objective pain scales had limited correlation to reported subjective relief. Conclusions: Immersive virtual reality might provide subjective analgesia and functional improvement in select patients with upper limb complex regional pain syndrome, but objective data is lacking.

Immersive virtual reality in traumatic brain injury rehabilitation: A literature review.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality in the United States with its sequelae often affecting individuals long after the initial injury. Innovations in virtual reality (VR) technology may offer potential therapy options in the recovery from such injuries. However, there is currently no consensus regarding the efficacy of VR in the setting of TBI rehabilitation. OBJECTIVE: The aim of this review is to evaluate and summarize the current literature regarding immersive VR in the rehabilitation of those with TBI. METHODS: A comprehensive literature search was conducted utilizing PubMed, Google Scholar, and the Cochrane Review using the search terms "virtual reality," "traumatic brain injury," "brain injury," and "immersive." RESULTS: A total of 11 studies were evaluated. These were primarily of low-level evidence, with the exception of two randomized, controlled trials. 10 of 11 studies demonstrated improvement with VR therapy. VR was most frequently used to address gait or cognitive deficits. CONCLUSIONS: While the current literature generally offers support for the use of VR in TBI recovery, there is a paucity of strong evidence to support its widespread use. The increasing availability of immersive VR technology offers the potential for engaging therapy in TBI rehabilitation, but its utility remains uncertain given the limited studies available at this time.

Virtual and augmented reality in the treatment of phantom limb pain: A literature review.

BACKGROUND: Phantom limb pain (PLP), the perception of discomfort in a limb no longer present, commonly occurs following amputation. A variety of interventions have been employed for PLP, including mirror therapy. Virtual Reality (VR) and augmented reality (AR) mirror therapy treatments have also been utilized and have the potential to provide an even greater immersive experience for the amputee. However, there is not currently a consensus on the efficacy of VR and AR therapy. OBJECTIVE: The aim of this review is to evaluate and summarize the current research on the effect of immersive VR and AR in the treatment of PLP. METHODS: A comprehensive literature search was conducted utilizing PubMed and Google Scholar in order to collect all available studies concerning the use of VR and/or AR in the treatment of PLP using the search terms "virtual reality," "augmented reality," and "phantom limb pain." Eight studies in total were evaluated, with six of those reporting quantitative data and the other two reporting qualitative findings. RESULTS: All studies located were of low-level evidence. Each noted improved pain with VR and AR treatment for phantom limb pain, through quantitative or qualitative reporting. Additionally, adverse effects were limited only to simulator sickness occurring in one trial for one patient. CONCLUSIONS: Despite the positive findings, all of the studies were confined purely to case studies and case report series. No studies of higher evidence have been conducted, thus considerably limiting the strength of the findings. As such, the current use of VR and AR for PLP management, while attractive due to the increasing levels of immersion, customizable environments, and decreasing cost, is yet to be fully proven and continues to need further research with higher quality studies to fully explore its benefits.

Repeated administration of AMPA or a metabotropic glutamate receptor agonist into the rat ventral tegmental area augments the subsequent behavioral hyperactivity induced by cocaine.

RATIONALE: Glutamate receptors and their related second messengers in the ventral tegmental area (VTA) are known to play critical roles in the initiation of behavioral sensitization to cocaine. OBJECTIVES: To evaluate the hypothesis that repeated intra-VTA microinjections of the ionotropic glutamate agonist, AMPA, or the metabotropic glutamate agonist, t-ACPD, augment the behavioral hyperactivity induced by a subsequent challenge injection of cocaine. In addition, the dependency of the t-ACPD effect on activation of the calcium/calmodulin-dependent kinases (CaM-Ks) was assessed. METHODS: Male Sprague-Dawley rats received four once-daily microinjections of saline, AMPA, t-ACPD, or t-ACPD plus the CaM-KII inhibitor KN-93 directly into the VTA; locomotor activity was measured for 120 min after each of the daily treatments. One week after the 4 treatment days, all animals received a challenge injection of cocaine (15 mg/kg, IP) and behavioral activity was monitored for 120 min. RESULTS: Intra-VTA administration of t-ACPD increased behavioral activity only on the first 2 treatment days, an effect that was blocked by pre-treatment with KN-93. Administration of AMPA into the VTA, in contrast, produced behavioral hyperactivity that sensitized over the 4 treatment days. Following the cocaine challenge injection, there was an augmentation of cocaine-induced behavioral hyperactivity in the groups pretreated with AMPA or t-ACPD but not in the animals administered t-ACPD plus KN-93. CONCLUSIONS: These results indicate that repeated stimulation of AMPA or metabotropic glutamate receptors in the VTA mimics the initiation of behavioral sensitization to cocaine. The present findings also suggest that glutamate agonist-induced activation of CaM-KII in the VTA plays a critical role in the behavioral and neuronal plasticity induced by repeated cocaine injections.

Impact of healthy steps on developmental referral rates.

BACKGROUND AND OBJECTIVES: Diagnosis and treatment of pediatric mental, physical, and behavioral issues are essential for optimal growth and development. Our family medicine residency program implemented a change in our pediatric curriculum by incorporating aspects of Healthy Steps into well-child visits 1 day a week. This study was done to determine the impact on developmental referral rates after incorporating Healthy Steps. METHODS: We did a retrospective medical records review at a rural California family medicine residency clinic on children through 5 years of age receiving well-child care. We collected developmental referrals as documented in the chart and in a referral log for 1 year before the curriculum change and 3 years after implementation. This retrospective case-control study included a pre-intervention group (Pre) and two post-intervention groups, usual care control (UC) and Healthy Steps intervention (HS). The three groups were compared using Fisher's exact tests. RESULTS: Developmental referrals assessed by chart review were 0% (0/154) in Pre, 0.6% (1/159) in UC, and 5.4% (4/74) in HS groups. When assessed by referral logs, developmental referral rates were 1.2% (10/864) in Pre, 1.1% (14/1,251) in UC, and 9.9% (14/141) in HS groups. For both sources, the HS group had significantly higher referral rates than the other groups. There was no statistical difference in referrals between the Pre and UC groups. CONCLUSIONS: After incorporating aspects of Healthy Steps into our curriculum, developmental referrals rose significantly in the intervention group compared to pre-intervention. Referral rates did not change in the non-intervention control group.

Renal Complications in Patients Undergoing Transcatheter Aortic Valve Replacement.

Acute kidney injury in hospitalized patients is associated with significantly increased mortality across a broad spectrum of conditions. According to the Society of Thoracic Surgeons database, patients with chronic kidney disease undergoing surgical aortic valve replacement with or without coronary artery bypass grafting had a more than 50% reduction in observed 8-year survival compared with those without chronic kidney disease. Transcatheter aortic valve replacement is an exciting new approach for the treatment of aortic stenosis in high-risk or inoperable patients with severe aortic stenosis. This article discusses the incidence, predictors, impact, and potential avoidance and management strategies of renal dysfunction associated with transcatheter aortic valve replacement.

Tricuspid regurgitation in patients with pacemakers and implantable cardiac defibrillators: a comprehensive review.

Implantable cardiac devices, including defibrillators and pacemakers, may be the cause of tricuspid regurgitation (TR) or may worsen existing TR. This review of the literature suggests that TR usually occurs over time after lead implantation. Diagnosis by clinical exam and 2-dimensional echocardiography may be augmented by 3-dimensional echocardiography and/or computed tomography. The mechanism may be mechanical perforation or laceration of leaflets, scarring and restriction of leaflets, or asynchronized activation of the right ventricle. Pacemaker-related TR might cause severe right-sided heart failure, but data regarding associated mortality are lacking. This comprehensive review summarizes the data regarding incidence, mechanism, and treatment of lead-related TR.

Evaluation of the role of endomyocardial biopsy in 851 patients with unexplained heart failure from 2000-2009.

BACKGROUND: Endomyocardial biopsy (EMB) is often considered when the pathogenesis of heart failure cannot be determined by noninvasive testing. Uncertainty remains about the diagnostic and clinical use of EMB in various clinical scenarios. METHODS AND RESULTS: We examined the characteristics of a cohort of patients with unexplained heart failure who underwent EMB at a tertiary care medical center. We categorized each patient into a clinical scenario as outlined by the 2007 AHA/ACC/ESC guidelines and determined the number of times EMB provided a diagnosis or altered the clinical course. A total of 851 patients underwent EMB from 2000-2009. Overall, 25.5% of EMBs provided a diagnosis and 22.7% of EMBs changed clinical course. Heart failure associated with unexplained restrictive cardiomyopathy was the most common clinical scenario, comprising 33.6% (286/851) of EMBs, and 84 (29.4%) of these EMBs were diagnostic. EMB for unexplained heart failure of <2 weeks duration had a diagnostic yield at 35% (39/109). There were 4 uncommon scenarios where EMB had a high diagnostic and clinical yield. There were 16 complications for an overall rate of 1.9%. CONCLUSIONS: We confirm that EMB is useful in acute onset unexplained cardiomyopathy. We demonstrate a role for EMB in suspected infiltrative disease and in the management of rare clinical scenarios, such as suspected hypersensitivity myocarditis, anthracycline cardiomyopathy, cardiac tumors, and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Our results suggest low use of EMB in chronic heart failure that responds to usual care.

Increased lipofuscin on endomyocardial biopsy predicts greater cardiac improvement in adolescents and young adults.

BACKGROUND: The presence of interstitial fibrosis and lipofuscin in endomyocardial biopsies may indicate the chronicity of heart failure. Fibrosis is known to increase in the failing heart. Lipofuscin increases with age, but its relationship to heart function is unknown. This study investigated whether lipofuscin or fibrosis had predictive utility in indicating function or adverse event (death, transplant, assist device placement) at 1 year postbiopsy in adolescents and young adults. METHODS: A retrospective analysis was performed on nontransplant endomyocardial biopsies between 2000 and 2009 from individuals aged 10-40 years. Clinical and demographic information including ejection fraction (EF), EF at 1 year, and adverse events were obtained as available. Lipofuscin and fibrosis were scored retrospectively in a blinded fashion for 201 biopsies. Linear regression and Cox proportional hazard models were used for multivariable analysis. RESULTS: Increasing lipofuscin strongly correlated with patient age (P<.0001). Higher lipofuscin levels were correlated with a better EF at 1 year (P=.02). This remained significant (P=.04) after adjusting for age. The degree of fibrosis did not associate with any clinical variable and had no predictive capabilities in this study. CONCLUSIONS: This is the first study to incorporate lipofuscin in predicting future heart function. We found that more lipofuscin correlates with better EFs at 1 year, suggesting that lipofuscin is a marker for improved cardiac compensation. This information can help clinicians devise treatment plans for individuals in this age group.