Cardiac amyloidosis-interdisciplinary approach to diagnosis and therapy.

The vast majority of cardiac amyloidosis (CA) cases are caused by light chain (AL) or transthyretin (ATTR) amyloidosis. The latter is divided into hereditary (ATTRv) and wild-type forms (ATTRwt). The incidence of ATTRwt amyloidosis has significantly increased, particularly due to the improved diagnosis of cardiac manifestations, with relevant proportions in patient populations with heart failure (HF) and preserved ejection fraction (HFpEF). Cardiac amyloidosis should be suspected in HF with indicative clinical scenarios/"red flags" with typical signs of CA in echocardiography. Further noninvasive imaging (cardiovascular magnetic resonance imaging, scintigraphy) and specific laboratory diagnostics are important for the diagnosis and typing of CA into the underlying main forms of ATTR and AL amyloidosis. The histopathologic analysis of an endomyocardial biopsy is necessary if noninvasive diagnostic methods do not enable reliable typing of CA. This is crucial for initiating specific therapy. Therapy of HF in CA is largely limited to the use of diuretics in the absence of evidence on the benefit of classic HF therapy with neurohormonal modulators. Innovative therapies have been developed for amyloidosis with improvement in organ protection, prognosis, and quality of life. These include specific cytoreductive therapies for monoclonal light-chain disease in AL amyloidosis and pharmacologic stabilization or inhibition of transthyretin expression in ATTR amyloidosis. Since the CA underlying amyloidosis is a systemic disease also affecting other organ systems, close interdisciplinary cooperation is crucial for rapid and effective diagnosis and therapy.

Dilated cardiomyopathies and non-compaction cardiomyopathy.

Dilated cardiomyopathy (DCM) is the most common form of cardiomyopathy and one of the most common causes of heart failure. It is characterized by left or biventricular dilation and a reduced systolic function. The causes are manifold and range from myocarditis to alcohol and other toxins, to rheumatological, endocrinological, and metabolic diseases. Peripartum cardiomyopathy is a special form that occurs at the end of or shortly after pregnancy. Genetic mutations can be detected in approximately 30-50% of DCM patients. Owing to the growing possibilities of genetic diagnostics, increasingly more triggering variants and hereditary mechanisms emerge. This is particularly important with regard to risk stratification for patients with variants with an increased risk of arrhythmias. Patient prognosis is determined by the occurrence of heart failure and arrhythmias. In addition to the treatment of the underlying disease or the elimination of triggering harmful toxins, therapy consists in guideline-directed heart failure treatment including drug and device therapy.

Current drug therapy for heart failure with reduced ejection fraction.

The prevalence of heart failure has been steadily increasing during the past few years, with a further increase predicted in the years to come. Without treatment, the syndrome of heart failure has a very poor prognosis. Advances in drug treatments and the consequent implementation of a guideline-recommended drug therapy have significantly improved the prognosis in heart failure with reduced ejection fraction (HFrEF). Besides angiotensin-converting enzyme (ACE) inhibitors (ACEi) or angiotensin receptor blockers, beta-blockers and diuretics treatment with mineralocorticoid receptor antagonists and ivabradine have become standard in the therapy of symptomatic patients with HFrEF. Recently, the impact of the adequate dosage of ACEi and beta-blockers was emphasized again. Angiotensin receptor-neprilysin inhibition is an auspicious new therapeutic approach and is predicted to play a crucial role in heart failure treatment in the coming years. The role of cardiac glycosides in the modern era of heart failure therapy is the focus of a current randomized controlled trial. Last but not least, potassium binders such as the new substance patiromer might help in overcoming the problem of hyperkalemia, which frequently limits the dosing of vital heart failure drugs. These advances offer optimism for further improvements in the prognosis and quality of life of HFrEF patients.

CRP genetic variants are associated with mortality and depressive symptoms in chronic heart failure patients.

OBJECTIVE: Heart failure (HF) is a complex medical condition with a multitude of genetic and other factors being involved in the pathogenesis. Emerging evidence points to an involvement of inflammatory mechanisms at least in subgroups of patients. The same is true for depression and depressive symptoms, which have a high prevalence in HF patients and are risk factors for the development and outcomes of cardiovascular disease. METHODS: In 936 patients of the Interdisciplinary Network Heart Failure (INH) program, CRP and IL-6 protein blood levels were measured and genetic variants (single nucleotide polymorphisms) of the CRP and IL6 gene analyzed regarding their influence on mortality. RESULTS: Less common recessive genotypes of two single nucleotide polymorphisms in the CRP gene (rs1800947 and rs11265263) were associated with significantly higher mortality risk (p < 0.006), higher CRP levels (p = 0.029, p = 0.006) and increased depressive symptoms in the PHQ-9 (p = 0.005, p = 0.003). Variants in the IL-6 gene were not associated with mortality. CONCLUSION: Our results hint towards an association of less common CRP genetic variants with increased mortality risk, depressive symptoms and peripheral CRP levels in this population of HF patients thereby suggesting a possible role of the inflammatory system as link between poor prognosis in HF and depressive symptoms.

Drug treatment of heart failure in the elderly.

The prevalence of heart failure increases with age. Changes in the age distribution and growing life expectancy will lead to a further rise. However, data concerning drug treatment of heart failure especially in the elderly are scarce. Subgroup analyses of the heart failure trials suggest that drug therapy in older patients should follow the recommendations in the current guidelines. In doing so, several common comorbidities in these patients (e. g., impaired renal function) have to be considered and may have an influence on the therapy (e. g., drug dose, choice of active pharmaceutical ingredient, etc.). Especially in old, multimorbid patients, possible interaction of drugs might play a substantial role. In many cases the main goal of the therapy, especially in the very elderly, is to improve symptoms and quality of life.

Reverse epidemiology in different stages of heart failure.

BACKGROUND: In heart failure (HF), traditional cardiovascular risk factors (RF) as body mass index (BMI), total cholesterol (TC) and systolic blood pressure (SBP) are associated with better survival. It is unknown at which time point along the disease continuum the adverse impact of these RF ceases and may 'start to reverse'. We analyzed the distribution of RF and their association with survival across HF stages. METHODS: We pooled data from four cohort studies from the German Competence Network HF. Employing ACC/AHA-criteria, patients were allocated to stage A (n=218), B (n=1324), C1 (i.e., New York Heart Association [NYHA] classes I & II; n=1134), and C2+D (NYHA III & IV; n=639). RESULTS: With increasing HF severity median age increased (63/67/67/70 years), whereas the proportion of females (56/52/37/35%), median BMI (26.1/28.8/27.7/26.6 kg/m(2)), TC (212/204/191/172 mg/dl), and SBP (140/148/130/120 mmHg) decreased (P<0.001 for trend for all). In the total cohort, higher levels of all RF were associated with better survival, even after extensive adjustment for multiple confounders. If analyses were stratified, however, a higher RF burden predicted better survival only in clinically symptomatic patients: hazard ratio (HR) per +2 kg/m(2) BMI 0.91 (95% confidence interval 0.88; 0.95); per +10 mg/dl TC 0.93 (0.92; 0.95); per +5 mmHg SBP 0.94 (0.92; 0.95). CONCLUSION: In this well-characterized sample of patients representing the entire HF continuum, reverse associations were only consistently observed in symptomatic HF stages. Our data indicate that the phenomenon of a "reverse epidemiology" in HF is subject to significant selection bias in less advanced disease.

Behavioral and electrophysiological effects of androstadienone, a human pheromone.

Androstadienone is the most prominent androstene present on male human axillary hair and on the male axillary skin surface. We have previously shown that this volatile steroid is able to stimulate [corrected] the human female vomeronasal organ in picogram (pg) quantities, resulting in changes in autonomic activity. These effects are gender-specific. The purpose of the present study was to ascertain whether androstadienone could be considered a human pheromone by altering behavior as well as autonomic function. Forty normal female subjects were randomized in a double-blind manner to receive either control or 100 pg of androstadienone directly to the vomeronasal organ. We report that administration of this steroid under these conditions results in a significant reduction of nervousness, tension and other negative feeling states. Concordant changes were observed in autonomic physiology.

Modulation of serum testosterone and autonomic function through stimulation of the male human vomeronasal organ (VNO) with pregna-4,20-diene-3,6-dione.

In mammals, external chemosensory signals from conspecifics of the opposite sex acting on vomeronasal organ receptors can modulate the release of gonadotropins. There is developmental, anatomical and functional evidence showing that the human vomeronasal organ (VNO) has the characteristics of a chemosensory organ. We have been using naturally occurring human pheromones to serve as models for designing novel synthetic compounds that we call vomeropherins. In previous publications we reported that vomeropherin pregna-4,20-diene-3,6-dione (PDD) delivered to the VNO of normal female and male human volunteers significantly affected male subjects only, decreasing respiration and cardiac frequency, augmenting alpha brain waves, and significantly decreasing serum luteinizing hormone (LH) and follicle stimulating hormone (FSH). Results of the present work confirm that PDD produces a local dose-dependent effect in the male human VNO. This is followed by a mild parasympathomimetic effect characterized by 10% increase of vagal tone, together with decreased frequency of electrodermal activity events. Furthermore, PDD locally delivered to the male human VNO significantly decreases serum LH and testosterone (p < 0.01). The present results contribute additional evidence supporting the functionality of the human VNO and its repercussions in autonomic and psychophysiological functions, as well as in neuroendocrine secretions.

The human vomeronasal system. A review.

Recent publications show that the human vomeronasal organ (VNO) develops and grows during gestation, and is present in all adult humans. The human VNO has a unique ultrastructure, with elongated bipolar microvillar cells that stain with several immunomarkers. These cells show physiological properties similar to chemosensory receptor cells of other mammalian species. The adult human VNO displays species-specific, gender-dimorphic and highly stereospecific responses to ligands. The organ's local response, or electrovomerogram, is followed by gender-specific behavioral changes, modulation of autonomic nervous system function, or the release of gonadotropins from the pituitary gland. Functional brain imaging studies revealed consistent activation of the hypothalamus, amygdala and cingulate gyrus-related structures during adult human VNO stimulation. These findings present new information supportive of a functional vomeronasal system in adult humans.

The functionality of the human vomeronasal organ (VNO): evidence for steroid receptors.

The human vomeronasal organ (VNO) is an anatomical entity which is generally considered to be vestigial or non-functional. Nevertheless, a steroidal vomeropherin applied to the human VNO, results in changes of autonomic function, pulsatile release of luteinizing and follicle-stimulating hormones, autonomic and electroencepholographic activity. The vomeropherin pregna-4,20-diene-3,6-dione (PDD) was delivered as pulses in an air stream directed into the lumen of the VNO or to the surface of the olfactory epithelium and respiratory epithelium of the nasal septum. Single stimuli at a concentration of 10(-10) to 10(-8) M produced dose-dependent changes of the electrovomerogram. No significant effects were observed when the same applicator delivered identical stimuli to the nasal respiratory epithelium or to the olfactory epithelium. Administration of the vomeropherin to male subjects changed gonadotropin pulsatility. In males, PDD (5 x 10(9) M) decreased luteinizing hormone (LH) pulsatility which resulted in a statistically significant reduction of plasma LH levels (P < 0.009) and follicle-stimulating hormone (FSH) pulsatility (P < 0.021), but it produced no significant effects in female subjects. Prolactin (PRL) was not significantly affected by this vomeropherin in either male or female subjects. These data demonstrate, for the first time, the existence of a functional vomeronasal-pituitary pathway in adult humans. In addition to the effect on gonadotropin pulsatility, the vomeropherin also produces concurrent reflex autonomic effects after VNO stimulation. These included decreased respiratory frequency, increased cardiac frequency, and event-related changes of electrodermal activity and EEG pattern. Therefore, this investigation also provides evidence for functional connections between the VNO and a variety of hypothalamic areas in adult humans.

The human vomeronasal system.

We studied the functional characteristics of the vomeronasal system in clinically normal adult subjects of both sexes (ages 20-45). Chemosensory substances were administered in punctate pulses in a continuous air stream from the tip of a multifunctional miniprobe, which contained a nonpolarizable electrode. Negative potentials with the characteristics of receptor potentials were recorded from the surface of the vomeronasal organ (VNO) and olfactory epithelium (OE) in response to certain substances defined here as vomeropherins (see definition in the introduction of the main text) and to olfactants. Stimulation of the VNO with femtomole amounts of vomeropherins produced a local depolarization with the characteristics of a receptor potential. The same substances produced only a small response from the OE, and no response from the nasal respiratory mucosa. Three vomeropherins PH15, PH78, and PH84 were particularly well recognized by the VNO of most male subjects (p < .01; n = 30). Substances PH30, PH56, and PH94B, produced similar effects in the VNO of most female subjects (p < .01; n = 30). Responses to virtually all vomeropherins exhibited a sexual dimorphism. Stimulation of the OE with the same quantity of odorants 1,8-cineole and l-carvone produced depolarization of 6.8 +/- 2.6 mV, but little or no response in the VNO. Therefore, the human VNO seems to have a unique specificity for certain chemosensory substances when compared to the OE. Administration of PH15 and PH78 to the VNO of male subjects (but not to female subjects) significantly increased electrodermal activity (p < .02) and skin temperature (p < .01). On the other hand, administration of PH84 to the VNO of male subjects decreased skin temperature but had little effect on electrodermal activity. Autonomic changes were accompanied by an increased percentage of alpha-cortical activity for all three vomeropherins. In female subjects (but not in male subjects) vomeropherins PH56 and PH94B significantly increased electrodermal activity (p < .01), skin temperature (p < .01), and alpha-cortical activity (p < .01). Local application of the olfactants 1,8-cineole and l-carvone to the VNO did not trigger autonomic responses or significant changes in the electroencephalographic pattern in male or in female subjects. Our studies indicate the adult human VNO is a functional chemosensory organ with a sexually dimorphic specificity and the ability to transduce signals which modulate certain autonomic parameters.

Vomeronasal epithelial cells of the adult human express neuron-specific molecules.

Immunohistochemical localization of three molecular markers, neuron-specific enolase (NSE) and protein gene product (PGP) 9.5 for neurons and neuroendocrine cells, and olfactory marker protein (OMP) for olfactory receptor neurons (ORNs) was investigated in the vomeronasal epithelium (VNE) of adult humans. NSE- and PGP 9.5-immunoreactive cells were identified in the VNE. ORNs in the olfactory epithelium of approximately age-matched controls were immunoreactive for the three markers. Most NSE-immunoreactive cells in the VNE were bipolar and similar in shape to the NSE- and PGP 9.5-immunoreactive ORNs. The results indicate that the adult human VNE contains cells expressing two molecular markers characteristic of neurons and that these cells bear a striking morphological similarity to ORNs.

Ultrastructure of the human vomeronasal organ.

Virtually all vertebrates have a vomeronasal system whose involvement in pheromone detection plays a crucial role in reproduction. In humans, the vomeronasal organ has been assumed to be vestigial or absent and without functional significance. In the present study involving over 400 subjects, vomeronasal pits were observed in all individuals except those with pathological conditions affecting the septum. Electron microscopy of the adult human vomeronasal organ indicates the presence of two potential receptor elements in the pseudostratified epithelial lining: microvillar cells, and unmyelinated, intraepithelial axons. In addition, unmyelinated axons are common in the lamina propria surrounding the organ. They appear to constitute the components essential for a functional chemosensory system, and may thus provide the basis for a pheromone detection system as in other animals.

The human skin: fragrances and pheromones.

Non-human mammalian pheromones are commonly used as perfumery ingredients. The actual purpose for using these compounds is as a fixative or carrier for the odor effects of the other ingredients as well as a contributor, in part, to the over-all scent of the perfume. Although such materials are used for their fixative and odor qualities rather than their pheromonal effects, perfumes are generally marketed as having the ability to enhance sexual attractiveness. While providing a scent may elicit a positive pleasant response, this should not be confused with a pheromone response. The attractive effect of perfumes is principally related to the effect of the pleasant scent. A more logical approach would be to use human pheromones which, for humans, are both more natural and more effective as true sensual attractants. It seems likely that implementation of this approach will constitute an important paradigm in the perfume industry as perfumery moves from the realm of art to that of science.

Implications of emerging isoniazid resistance in Mycobacterium tuberculosis in Korea.

In 1981, the Korean National Institute of Health (KNIH) reported that 17% of all tuberculosis patients had primary resistance to isoniazid while an additional 17% acquired isoniazid resistance during chemotherapy. This 34% isoniazid resistance rate in the Republic of Korea, where an estimated 6-8% of the total population have active tuberculosis, poses significant concerns regarding management of U.S. military health care beneficiaries who develop tuberculosis or have tuberculosis skin test conversion while residing in or after departure from Korea. To address this issue, the prevalence of Korean acquired isoniazid resistance was estimated in U.S. beneficiaries by performing antibiotic sensitivities on all positive cultures from October 1981 through December 1982. Of 42 patient isolates, six were isoniazid resistant (14.3%). When the data was analyzed further, it was determined that as many as 9.5% of those U.S. beneficiaries infected had primary isoniazid resistance. This is higher than the most recent U.S. population-based drug resistance study, in which 6.9% of tuberculosis patients had primary drug resistance. This data comparison points toward the need for judicious management of Korean acquired infections and skin test conversions. Emphasis is on criteria necessary to warrant use of chemotherapeutic agents other than isoniazid to prevent further introduction of resistant organisms into locales where isoniazid resistance is not as prevalent as reported in Korea.

Prevalence of penicillinase-producing Neisseria gonorrheae in Korea.

An almost two-fold increase in the monthly reported case rate for sexually transmitted disease (STD) in U.S. military members assigned in the Republic of Korea in April 1981 prompted an epidemiologic assessment of that population. Inasmuch as previously nonexistent treatment failures for Neisseria gonorrheae were also being reported, a demographic slice of 253 symptomatic military members was surveyed in June and July, 1981, for gonorrhea prevalence and the proportion of this that could be attributed to penicillinase-producing Neisseria gonorrheae (PPNG). Using standard and accepted methods, the gonorrhea prevalence rate in symptomatic military members was found to be 100% while the proportion that could be attributed to PPNG was 43%. In order to compare this to the contact population of local prostitutes, 116 asymptomatic women who presented to local STD clinics for routine, often legally-mandated examinations, were surveyed. The expected lower gonorrhea prevalence rate was 13.9% but the proportion attributed to PPNG was 27.6%. This data was similar to the sudden increase in PPNG experienced by U.S. military forces at Subic Bay in the Philippines in 1979 and reflected the slow but steady migration of this resistance throughout Asia. The long-accepted norm for gonorrhea treatment using penicillin was changed to spectinomycin in the U.S. military population and was being considered for implementation by the Korean official health community. Further organism resistance can be expected, and close monitoring is taking place.

Transcutaneous temporary pacing in the operating room.

The safety and efficacy of transcutaneous temporary pacing were assessed in 21 patients undergoing elective surgical procedures under general anesthesia. Complete capture was achieved in all patients. The pacing threshold was 50 mamp in two patients, 100 mamp in nine, and 200 mamp in ten. The threshold was influenced by electrode position and also, possibly, by age, heart size, and chest size. No adverse effects of pacing were encountered. Transcutaneous pacing is a rapid, safe, and effective means of temporary pacing in the operating room.

Resistance trends of Neisseria gonorrhoeae in the Republic of Korea.

Penicillinase-producing Neisseria gonorrhoeae has increased in the Far East to the point that penicillin can no longer be recommended as the drug of choice, mandating a change to spectinomycin. As part of an ongoing surveillance of antibiotic susceptibilities, minimal inhibitory concentrations of penicillin, tetracycline, spectinomycin, trimethoprim-sulfamethoxazole, cefoxitin, ceftriaxone, cefotaxime, and moxalactam were determined. A disturbing, steady increase in resistance to spectinomycin was documented.

Crew rest and nap-of-the-eart flying.

Nap-of-the-earth flying was conceived by the U.S. Army to evade enemy detection of rotary wing aircraft, requiring the stressful technique of aircraft movement only inches above the ground terrain. The 100st Airborne Division (Airmobile), Fort Campbell, Ky, tested the nap-of-the earth (NOE) concept from 12 June, 1973, to 30 June, 1974, flying 3267.6 h in NOE training. Four aircraft incidents occurred during this training period, with three of these taking place prior to 1 March, 1974. At that point, after 59.2% of the total hours had been flown, NOE pilot training was curtailed from 8 h/d to 4 h/d. Objective and subjective data infer that pilot (crew) rest and the length of the flying day are important factors in the safety of NOE flying.