Extra-cardiac management of cardiogenic shock in the intensive care unit.

Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.

Anticancer Effects of Mitoquinone via Cell Cycle Arrest and Apoptosis in Canine Mammary Gland Tumor Cells.

Treating female canine mammary gland tumors is crucial owing to their propensity for rapid progression and metastasis, significantly impacting the overall health and well-being of dogs. Mitoquinone (MitoQ), an antioxidant, has shown promise in inhibiting the migration, invasion, and clonogenicity of human breast cancer cells. Thus, we investigated MitoQ's potential anticancer properties against canine mammary gland tumor cells, CMT-U27 and CF41.Mg. MitoQ markedly suppressed the proliferation and migration of both CMT-U27 and CF41.Mg cells and induced apoptotic cell death in a dose-dependent manner. Furthermore, treatment with MitoQ led to increased levels of pro-apoptotic proteins, including cleaved-caspase3, BAX, and phospho-p53. Cell cycle analysis revealed that MitoQ hindered cell progression in the G1 and S phases in CMT-U27 and CF41.Mg cells. These findings were supported using western blot analysis, demonstrating elevated levels of cleaved caspase-3, a hallmark of apoptosis, and decreased expression of cyclin-dependent kinase (CDK) 2 and cyclin D4, pivotal regulators of the cell cycle. In conclusion, MitoQ exhibits in vitro antitumor effects by inducing apoptosis and arresting the cell cycle in canine mammary gland tumors, suggesting its potential as a preventive or therapeutic agent against canine mammary cancer.

Mechanical Circulatory Support in Cardiogenic Shock: Uses in the Emergency Setting.

Cardiogenic shock is a lethal condition with significant morbidity, characterized by myocardial insults leading to low cardiac output and ensuing systemic hypoperfusion. While mortality rates remain high, we have improved upon our recognition and definition of cardiogenic shock, now with an emphasis on defining stages of shock to help guide effective treatment strategies with either pharmacologic or mechanical circulatory support. In this review, the authors summarize these stages as well as discuss indications, function, selection, and troubleshooting of the various temporary mechanical circulatory support devices.

Impact of Age, Gender, and Body Mass Index on Short-Term Outcomes of Patients With Cardiogenic Shock on Mechanical Circulatory Support.

This single-center, observational study assessed the impact of age, gender, and body mass index (BMI) in patients with cardiogenic shock (CS) on temporary mechanical circulatory support. All adult patients admitted to the Cleveland Clinic main campus Cardiac Intensive Care Unit (CICU) between December 1, 2015, to December 31, 2019, CICU with CS necessitating mechanical circulatory support (MCS) with intra-aortic balloon pump, Impella, or venous arterial-extra corporeal membrane oxygenation were retrospectively analyzed for this study. Baseline characteristics and 30-day outcomes were collected through physician-directed chart review. The impact of age, gender, and BMI on 30-day mortality was assessed using multivariable logistic regression. Kaplan-Meier survival curves were used to analyze the survival difference in specific subsets. A total of 393 patients with CS on temporary MCS were admitted to our CICU during the study period. The median age of our cohort was 63 years (interquartile range 54 to 70 years), median BMI was 28.50 kg/m2 (interquartile range 24.62 to 29.72) and 70% (n = 276) were men. In total, 22 patients >80 years had received MCS compared with 372 patients <80 years. Patients >80 years on MCS had significantly higher 30-day mortality compared with those <80 years (81.8% vs 49.3%, p = 0.006). Upon stratifying patients by BMI, 161 (41%) patients were found to have BMI ≥30 kg/m2 whereas 232 (59%) patients had BMI <30 kg/m2. Comparison of 30-day mortality revealed that patients with BMI ≥30 did significantly worse than patients with BMI <30 (59.6% vs 45.3%, p = 0.007). There was no difference in 30-day mortality between men and women. On multivariable logistic regression, both age and BMI had a positive linear relation with adjusted 30-day mortality whereas gender did not have a major effect. Advanced age and higher BMI are independently associated with worse outcomes in patients with CS on MCS. Utilizing a strict selection criterion for patients in CS is pertinent to derive the maximum benefit from advanced mechanical support.

Quality and composition of archived nucleic acids after use in SARS-CoV-2 molecular testing.

BACKGROUND: Reverse transcription real-time PCR (rRT-PCR) has been a gold-standard method to detect SARS-CoV-2, for which quality assessment of nucleic acids (NAs) is not needed. In order to prepare for future use, we evaluated NA quality from archived SARS-CoV-2 rRT-PCR samples. METHODS: NA samples were collected in February 2021 and extracted using the QIAamp DSP Virus Spin Kit, (53 SARS-CoV-2-positive and 100 SARS-CoV-2-negative). Quality, quantity, and purity of NA were measured spectrophotometrically or fluorescently. Droplet digital PCR was used to characterize the double strand DNA (dsDNA) origin and composition by quantifying 16S rDNA and RPP30. RESULTS: The RIN and purity were not significantly different between groups (p = 0.3828). RNA quantity was significantly higher than dsDNA in both groups (p < 0.0001); both dsDNA and RNA quantity were significantly higher in positive samples (dsDNA, RNA p = 0.021). For dsDNA, 16S rDNA copies were significantly greater than RPP30 in both groups (p < 0.0001), and RPP30 were significantly higher in positive samples (p < 0.0001). CONCLUSIONS: Archived NA quality after SARS-CoV-2 rRT-PCR was guaranteed for subsequent molecular research using human or bacterial DNA, especially for short targets.

Diuron-induced fetal Leydig cell dysfunction in in vitro organ cultured fetal testes.

Diuron is a phenylurea herbicide widely used in the agricultural industry. In recent years, the risk of infertility and developmental defects has increased due to exposure to environmental pollutants. In this study, we investigated the toxicity of diuron in fetal mouse testes using three-dimensional organ cultures. Fetal testes derived from embryonic day (E) 14.5 were cultured with 200 µM diuron for 5 days. The results revealed that diuron did not impair fetal germ cell proliferation or the expression levels of germ cell markers such as Ddx4, Dazl, Oct 4, Nanog, Plzf, and TRA 98. Similarly, the gene or protein expression of the Sertoli cell markers Sox9 and Wt1 in diuron-exposed fetal testes did not change after 5 days of culture. In contrast, diuron increased fetal Leydig cell markers (FLC), Cyp11a1, Cyp17a1, Thbs2, and Pdgf α, and decreased adult Leydig cell (ALC) markers, Sult1e1, Hsd173, Ptgds, and Vcam1. However, 3-ßHSD, an FLC and ALC marker, was consistently maintained upon exposure to diuron in fetal testes compared to non-treated groups. In conclusion, our study demonstrates that diuron negatively impacts Fetal Leydig cell development, although it does not affect germ and Sertoli cells.

Evaluation of enoxaparin for bridging of warfarin in outpatients with left ventricular assist devices (LVADs).

BACKGROUND: Patients with left ventricular assist devices (LVADs) require systemic anticoagulation. The use of enoxaparin for bridging to warfarin remains understudied in this population. METHODS: This single-center retrospective study was performed to characterize enoxaparin use and associated thrombotic and bleeding outcomes in adult outpatients with LVADs from January 2018 to July 2021. RESULTS: Fifty-four enoxaparin bridging events were evaluated in 49 patients. Most patients with HeartMate II (HM2) and HeartWare (HVAD) devices received enoxaparin dosed 1 mg/kg every 12 h. In patients with HeartMate 3 (HM3) devices, an equal number of patients received 0.5 mg/kg every 12 h and 1 mg/kg every 12 h, with a smaller subset receiving intermediate doses. The median duration of bridging was 6 days (4-8 [IQR]). One major bleeding event required discontinuation of enoxaparin and hospitalization in a patient with an HM3 device. Thrombotic events occurred in four patients with two incidents of pump thrombosis requiring pump exchange and two ischemic strokes. All thrombotic events occurred in patients with HVAD or HM2 devices. CONCLUSION: These results suggest that enoxaparin bridging in LVAD patients was well-tolerated with low bleeding and thrombotic rates, particularly with the HM3 device.

The Anti-Inflammatory Effects of Broccoli (Brassica oleracea L. var. italica) Sprout Extract in RAW 264.7 Macrophages and a Lipopolysaccharide-Induced Liver Injury Model.

Brassica oleracea var. italica (broccoli), a member of the cabbage family, is abundant with many nutrients, including vitamins, potassium, fiber, minerals, and phytochemicals. Consequently, it has been used as a functional food additive to reduce oxidative stress and inflammatory responses. In the current study, the effects of sulforaphane-rich broccoli sprout extract (BSE) on the inflammatory response were investigated in vitro and in vivo. Comparative high-performance liquid chromatography analysis of sulforaphane content from different extracts revealed that 70% ethanolic BSE contained more sulforaphane than the other extracts. qPCR and enzyme immunoassay analyses revealed that BSE markedly reduced the expression of proinflammatory cytokines and mediators, including cyclooxygenase 2, interleukin (IL)-1ß, IL-6, IL-1, inducible nitric oxide synthase (iNOS), and tumor necrosis factor-α (TNF-α), in lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. Pretreatment with BSE improved the survival rate and suppressed alanine aminotransferase and aspartate aminotransferase expression in LPS-induced endotoxemic mice, while proinflammatory cytokines such as IL-1ß, TNF-α, IL-6, cyclooxygenase-2, and iNOS decreased dramatically in the LPS-induced liver injury model via BSE treatment. Additionally, F4/80 immunostaining showed that BSE suppressed hepatic macrophage infiltration in the liver after lipopolysaccharide injection. In conclusion, BSE may be a potential nutraceutical for preventing and regulating excessive immune responses in inflammatory disease.

Effects of Melatonin on Liver of D-Galactose-Induced Aged Mouse Model.

Melatonin, a hormone secreted by the pineal gland of vertebrates, regulates sleep, blood pressure, and circadian and seasonal rhythms, and acts as an antioxidant and anti-inflammatory agent. We investigated the protective effects of melatonin against markers of D-galactose (D-Gal)-induced hepatocellular aging, including liver inflammation, hepatocyte structural damage, and non-alcoholic fatty liver. Mice were divided into four groups: phosphate-buffered saline (PBS, control), D-Gal (200 mg/kg/day), melatonin (20 mg/kg), and D-Gal (200 mg/kg) and melatonin (20 mg) cotreatment. The treatments were administered once daily for eight consecutive weeks. Melatonin treatment alleviated D-Gal-induced hepatocyte impairment. The AST level was significantly increased in the D-Gal-treated groups compared to that in the control group, while the ALT level was decreased compared to the melatonin and D-Gal cotreated group. Inflammatory genes, such as IL1-ß, NF-κB, IL-6, TNFα, and iNOS, were significantly increased in the D-Gal aging model, whereas the expression levels of these genes were low in the D-Gal and melatonin cotreated group. Interestingly, the expression levels of hepatic steatosis-related genes, such as LXRα, C/EBPα, PPARα, ACC, ACOX1, and CPT-1, were markedly decreased in the D-Gal and melatonin cotreated group. These results suggest that melatonin suppresses hepatic steatosis and inflammation in a mouse model of D-Gal-induced aging.

Implementing an Interdisciplinary Procedure Curriculum.

INTRODUCTION: This curriculum was designed to improve access to procedures for our internal medicine residents. METHODS: We created an interdisciplinary procedure course (IDPC) composed of two simulation sessions and a one-week procedural rotation supervised by multiple specialties including nephrology, cardiology, cardiothoracic anesthesiology, general anesthesiology, and interventional radiology. After the course, residents completed two surveys documenting the number of procedures and their level of confidence on a Likert scale (1 = very unconfident to 5 = very confident) prior to and after completing the curriculum. RESULTS: Sixteen residents participated in the course from September 2021 to June 2022. The collective number of procedures performed by these 16 residents increased from 176 to 343 after a one-week rotation. For arterial lines, the proportion of residents that reported an improvement in confidence scores was 0.44 (95% confidence interval 0.23 to 1, p-value of 0.60). The proportion of residents that had an increase in their confidence performing central lines was 0.63 (95% confidence interval 0.39 to 1, p-value of 0.23). For intubations, the proportion of residents that reported an improvement in confidence was 0.94 (95% confidence interval 0.72 to 1, p-value of 0.0006). CONCLUSION: By collaborating with multiple specialties, residents almost doubled the number of procedures performed during training and reported an increased level of confidence in procedural performance for airway intubation. We learned residents want to improve their access to procedures and described a curriculum that was easily implemented.

Training Pathways in Critical Care Cardiology: Competencies and Considerations for Cardiologists.

PURPOSE OF REVIEW: Critical care cardiology (CCC) is a rapidly developing field undergoing a renaissance of interest and growth to meet the well-documented population shift in the cardiac intensive care unit (CICU). With this has come the emergence of novel training paradigms that seek to combine specialties with meaningful overlap. RECENT FINDINGS: The benefit of having critical care expertise in the CICU has been clearly established; however, there is no formal or uniform CCC training pathway. Contemporary approaches seek to provide appropriate clinical and procedural experience while minimizing opportunity cost. The combination of additional cardiology subspecialties, specifically advanced heart failure or interventional cardiology, has been demonstrated. Educational tracks that integrate critical care training have generated interest but have not yet manifested. CCC training strives to meet the needs of an increasingly sick and diverse patient population while preparing trainees for fulfilling and meaningful careers. The hope is for ongoing development of novel training pathways to satisfy evolving needs.

Family Engagement in the Adult Cardiac Intensive Care Unit: A Survey of Family Engagement Practices in the Cardiac Critical Care Trials Network.

BACKGROUND: Cardiovascular and critical care professional societies recommend incorporating family engagement practices into routine clinical care. However, little is known about current family engagement practices in contemporary cardiac intensive care units (CICUs). METHODS: We implemented a validated 12-item family engagement practice survey among site investigators participating in the Critical Care Cardiology Trials Network, a collaborative network of CICUs in North America. The survey includes 9 items assessing specific engagement practices, 1 item about other family-centered care practices, and 2 open-ended questions on strategies and barriers concerning family engagement practice. We developed an engagement practice score by assigning 1 point for each family engagement practice partially or fully adopted at each site (max score 9). We assessed for relationships between the engagement practice score and CICU demographics. RESULTS: All sites (N=39; 100%) completed the survey. The most common family engagement practices were open visitation (95%), information and support to families (85%), structured care conferences (n=82%), and family participation in rounds (77%). The median engagement practice score was 5 (interquartile range, 4). There were no differences in engagement practice scores by geographic region or CICU type. The most commonly used strategies to promote family engagement were family presence during rounds (41%), communication (28%), and family meetings (28%). The most common barriers to family engagement were COVID-related visitation policies (38%) and resource limitations (13%). CONCLUSIONS: Family engagement practices are routinely performed in many CICUs; however, considerable variability exists. There is a need for strategies to address the variability of family engagement practices in CICUs.

Mechanical Circulatory Support and Critical Care Management of High-Risk Acute Pulmonary Embolism.

Hemodynamically significant pulmonary embolism (PE) remains a widely prevalent, underdiagnosed condition associated with mortality rates as high as 30%. The main driver of poor outcomes is acute right ventricular failure that remains clinically challenging to diagnose and requires critical care management. Treatment of high-risk (or massive) acute PE has traditionally included systemic anticoagulation and thrombolysis. Mechanical circulatory support, including both percutaneous and surgical approaches, are emerging as treatment options for refractory shock due to acute right ventricular failure in the setting of high-risk acute pulmonary embolism.

Tebuconazole Induces ER-Stress-Mediated Cell Death in Bovine Mammary Epithelial Cell Lines.

Tebuconazole (TEB) is a triazole fungicide used to increase crop production by controlling fungi, insects, and weeds. Despite their extensive use, people are concerned about the health risks associated with pesticides and fungicides. Numerous studies have defined the cellular toxicity of triazole groups in pesticides, but the mechanisms of TEB toxicity in bovine mammary gland epithelial cells (MAC-T cells) have not yet been studied. Damage to the mammary glands of dairy cows directly affects milk production. This study investigated the toxicological effects of TEB on MAC-T cells. We found that TEB decreases both cell viability and proliferation and activates apoptotic cell death via the upregulation of pro-apoptotic proteins, such as cleaved caspases 3 and 8 and BAX. TEB also induced endoplasmic reticulum (ER) stress via the upregulation of Bip/GRP78; PDI; ATF4; CHOP; and ERO1-Lα. We found that TEB induced mitochondria-mediated apoptotic MAC-T cell death by activating ER stress. This cell damage eventually led to a dramatic reduction in the expression levels of the milk-protein-synthesis-related genes LGB; LALA; CSN1S1; CSN1S2; and CSNK in MAC-T cells. Our data suggest that the exposure of dairy cows to TEB may negatively affect milk production by damaging the mammary glands.

Large Left Ventricular Pseudoaneurysm Presenting as an Embolic Stroke After a "Silent" Myocardial Infarction.

A 72-year-old woman with no history of coronary artery disease presented with an acute left middle cerebral artery stroke and was found to have a large left ventricular pseudoaneurysm measuring 8.7 × 7.6 cm and 2 large left ventricular thrombi, the source of her systemic embolization. Despite initial medical management, she developed refractory New York Heart Association functional class III heart failure, uncontrolled atrial fibrillation, and further enlargement of her pseudoaneurysm to 5.5 × 10.6 × 9.2 cm. She underwent urgent aneurysmectomy. Left ventricular pseudoaneurysms are rare and most commonly occur following an acute myocardial infarction when a ventricular free-wall rupture is contained by pericardium or thrombi. Historically, left ventricular angiography displaying a lack of an overlying coronary artery was the gold standard for diagnosis. Now, noninvasive imaging such as computed tomography, magnetic resonance imaging, and echocardiogram with ultrasound-enhancing agent, are reliable diagnostic tools. They can distinguish a pseudoaneurysm from a true left ventricular aneurysm using characteristic findings such as a narrow aneurysm neck, bidirectional doppler flow between the pseudoaneurysm and the left ventricle, and abrupt changes in the cardiac wall structures. Progressive dilation, wall thinning, and dyskinesis can result in refractory heart failure, arrhythmias, and thrombi formation from venous stasis. Pseudoaneurysms have a 30% to 45% risk of rupture and can be treated with left ventricular aneurysmectomy.

Nanoscale level gelatin-based scaffolds enhance colony formation of porcine testicular germ cells.

The extracellular matrix is important in cell growth, proliferation, and differentiation. Gelatin, a support for adhering cells, is used for coating culture plate surfaces of several primary and stem cells. However, gelatin characteristics on culture plates and its cell interactions are not understood. Here, we aimed to identify the effect of gelatin topography on culture plates on the proliferation and colony formation of porcine spermatogonial germ cells (pSGC). To generate different surface topographies, gelatin powder was dissolved in H2O at varying melting temperatures (40, 60, 80, and 120 °C) and coated on the surface of the culture plates. At 40 °C, the pores of the gelatin scaffold were regular ellipses 5-6 µm in diameter and 10-30 nm in thickness. However, at 120 °C, irregular pores 20-30 µm in diameter and 10-20 nm in thickness were obtained. Additionally, the number of attached cells and pSGC colonies were significantly more at 40 °C than at 120 °C after a week of culture. Interestingly, the feeder cells did not settle properly at 120 °C but detached easily from the culture dishes. PSGC colonies were 100 µm in diameter at 40 °C, with small and detached colonies observed at 120 °C. Thus, optimal topography of gelatin was obtained at 40 °C, which was sufficient for the proliferation of feeder cells and the formation of pSGC colonies. Thus, gelatin scaffold conditions at 40 °C and 60 °C were optimal for the derivation and culture of pSGC, and gelatin surface morphology is important for the maintenance of supportive feeder cells for pSGC proliferation and colony formation.

Association between vitamin D level and respiratory distress syndrome: A systematic review and meta-analysis.

BACKGROUND: Growing evidence suggests an association between the vitamin D levels and respiratory outcomes of preterm infants. The objective of this systematic review and meta-analysis was to explore whether premature neonates with a vitamin D deficiency have an increased risk of respiratory distress syndrome (RDS). METHODS: We searched PubMed, EMBASE, and the Cochrane Library up through July 20, 2021. The search terms were 'premature infant', 'vitamin D', and 'respiratory distress syndrome'. We retrieved randomized controlled trials and cohort and case-control studies. For statistical analysis, we employed the random-effects model in Comprehensive Meta-Analysis Software ver. 3.3. We employed the Newcastle-Ottawa Scales for quality assessment of the included studies. RESULTS: A total of 121 potentially relevant studies were found, of which 15 (12 cohort studies and 3 case-control studies) met the inclusion criteria; the studies included 2,051 preterm infants. We found significant associations between RDS development in such infants and vitamin D deficiency within 24 h of birth based on various criteria, thus vitamin D levels < 30 ng/mL (OR 3.478; 95% CI 1.817-6.659; p < 0.001), < 20 ng/mL (OR 4.549; 95% CI 3.007-6.881; p < 0.001), < 15 ng/mL (OR 17.267; 95% CI 1.084-275.112; p = 0.044), and < 10 ng/ml (OR 1.732; 95% CI 1.031-2.910; p = 0.038), and an even lower level of vitamin D (SMD = -0.656; 95% CI -1.029 to -0.283; p = 0.001). CONCLUSION: Although the vitamin D deficiency definitions varied and different methods were used to measure vitamin D levels, vitamin D deficiency or lower levels of vitamin D within 24 h of birth were always associated with RDS development. Monitoring of neonatal vitamin D levels or the maintenance of adequate levels may reduce the risk of RDS.