Ventricular Rupture due to Myocardial Infarction without Obstructive Coronary Artery Disease.

An 87-year-old woman presenting with myocardial infarction and ST-segment elevation in the electrocardiogram suffered from pericardial effusion due to left ventricular rupture. After ruling out obstructive coronary artery disease and aortic dissection, she underwent cardiac surgery showing typical infarct-macerated myocardial tissue in situ. This case shows that even etiologically unclear and small-sized myocardial infarctions can cause life-threatening mechanical complications.

The atherogenic index of plasma and its impact on recanalization of chronic total occlusion.

BACKGROUND: The plasma-derived atherogenic index (AIP) is associated with an increasing risk for cardiovascular diseases. Whether an increased AIP may predict the complexity of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), according to available research, has never been investigated before. METHODS: Three hundred seventeen patients were included prospectively and treated with PCI for at least one CTO between 2012 and 2017. High-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) plasma levels were measured 24 h before PCI. All patients were stratified into tertiles of AIP (defined as 0.11, 0.11-0.21, > 0.21) based on their TG/HDL-C (AIP) levels. RESULTS: Mean AIP of all patients undergoing CTO-PCI was 0.53 ± 0.29. The majority of patients were male (82.6%), and mean age was 61 ± 10.4 years. Increased AIP > 0.21 was associated with longer occlusion length (statistical trend p = 0.082) and stent routes (p = 0.022) and with a higher number of implanted stents (n > 4) (statistical trend p = 0.072). Success rates were similar in all AIP categories (p = 0.461). In-hospital PCI-related complications were rare and not statistically different (p = 0.852). CONCLUSIONS: This study demonstrates for the first time that an increased AIP may predict the complexity of CTO-PCI and additionally may help to improve planning and quality of CTO-PCI.

In-Hospital Outcome of Patients with Diabetes Mellitus after CTO Recanalization with Third-Generation Drug-Eluting Stents.

Background: Percutaneous coronary intervention (PCI) of total chronic coronary occlusions (CTOs) still remains a major challenge in interventional cardiology. There is little knowledge in the literature about differences in CTO-PCI between diabetic and nondiabetic patients in the era of third-generation drug-eluting stents (DESs). In this study, we analyzed the impact of diabetes mellitus (DM) on procedural characteristics, complications, and acute outcomes in a cohort of 440 patients. Methods: Between 2012 and 2016, we recruited 440 consecutive patients, 116 of them with DM. All the patients underwent PCI for at least 1 CTO. Antegrade and retrograde CTO recanalization techniques were applied. Only third-generation DESs were used. We used t-tests and the Pearson chi-quadrat test to test the significant differences in the variables between the 2 groups. Results: The patients with DM were older than the nondiabetics (64.5 y vs. 61.1 y; P=0.003), and they suffered more frequently from a chronic kidney disease (7.1% vs. 2.4%; P=0.001). The nondiabetics less frequently had arterial hypertension (75.3% vs. 89.7%; P=0.001); however, they more often had a family liability for CAD (32.1% vs. 22.4%; P=0.050) and had a higher left ventricular ejection fraction (59.2% vs. 56.7%; P=0.011). The success rate was 85.2% in the patients without DM and 81.2% in the patients with DM (P=0.403). The existence of DM had no impact on the procedural success and complication rates. Conclusion: Our study on 440 patients shows that diabetics and nondiabetics have similar success and complication rates after the recanalization of CTOs using third-generation DESs. It is a feasible and safe procedure and can be recommended as an alternative treatment.

Multiple procedures and cumulative individual radiation exposure in interventional cardiology: A long-term retrospective study.

INTRODUCTION: Various studies address discrepancies between guideline recommendations for coronary angiographies and clinical practice. While the issue of the appropriateness of recurrent angiographies was studied focusing on the role of the cardiologist, little is known about individual patients' histories and the associated radiation exposures. METHODS: We analyzed all patients with coronary artery disease (CAD) in an academic teaching practice who underwent at least one angiography with or without intervention between 2004 and 2009. All performed angiographies in these patients were analyzed and rated by three physicians for appropriateness levels according to cardiology guidelines. Typical exposure data from the medical literature were used to estimate individual radiation exposure. RESULTS: In the cohort of 147 patients, a total of 441 procedures were analyzed: between 1981 and 2009, three procedures were performed per patient (range 1-19) on average. Appropriateness ratings were 'high/intermediate' in 71%, 'low/no' in 27.6% and data were insufficient for ratings in 1.4%. Procedures with 'low/no' ratings were associated with potentially avoidable exposures of up to 186 mSv for single patients. CONCLUSIONS: Using retrospective data, we exemplify the potential benefit of guideline adherence to decrease patients' radiation exposures. KEY POINTS: • A cohort study of 147 patients showed 27.6% low appropriateness procedures. • Potentially avoidable radiation exposure cumulated up to about 186 mSv for single patients. • Predisposing factors were prior bypass surgery and first treatment in a tertiary centre. • 7.5% of the patients received 58% of the potentially avoidable radiation exposure. • The benefits of guideline adherence in decreasing patient radiation exposure are exemplified.

General pediatric attending physicians' and residents' knowledge of inpatient hospital finances.

BACKGROUND AND OBJECTIVE: There is evidence suggesting that physicians have a limited foundation of knowledge on health care finances and limited awareness of hospital costs and charges. The objective was to analyze general pediatric attending physicians' and residents' knowledge of costs, charges, and reimbursements for care rendered in the inpatient setting. METHODS: An online survey was administered to all general pediatric attending physicians who work on the inpatient service and the entire pediatric residency program at The Children's Hospital of Philadelphia (CHOP) in spring of 2011. Participants' estimates of costs, charges, and reimbursements for several common tests, medications, and services were obtained and analyzed. RESULTS: A total of 38 attending physicians and 100 residents participated in the study (84% and 76% response rates, respectively). The majority of both attending physicians (71%) and residents (75%) characterized their understanding as "Minimally knowledgeable" or "Completely unaware". Only 15% of attending physicians' estimates and 11% of residents' estimates were within ±25% of true values across all surveyed costs, charges, and reimbursements. Percent error did not vary by level of experience or self-reported knowledge for attending physicians and residents. CONCLUSIONS: Attending physicians and residents demonstrated limited knowledge of costs, charges, and reimbursements as shown by a low accuracy of estimates and a high percent error, compared with the actual values. To meet expectations for competency in systems-based practice and to be effective stewards of medical resources, it appears that pediatricians need further financial education.

The structurally disordered KRAB repression domain is incorporated into a protease resistant core upon binding to KAP-1-RBCC domain.

The KRAB domain is a 75 amino acid transcriptional repression module that is encoded by more than 400 zinc finger protein genes, making it the most abundant repression domain in the human proteome. KRAB-mediated gene silencing requires a direct high affinity interaction with the RBCC domain of KAP-1 co-repressor. The structures of the free KRAB domain or the KRAB-RBCC complex are unknown. To address this, we have performed a systematic biophysical analysis of all KRAB isoforms using purified recombinant proteins. All KRAB domains are predominantly monomeric either alone or in a complex with KAP-1-RBCC protein, while a KRAB-SCAN isoform exists as a stable dimer. The KRAB:KAP-1-RBCC interaction requires only the A box in the context of the KRAB(Ab) or KRAB(AC) but both A and B boxes in the context of KRAB(AB). All isoforms bind the KAP-1-RBCC in a stable, zinc dependent fashion with a stoichiometry of KRAB1:3 RBCC with a zinc content of four atoms per RBCC monomer. Limited proteolysis, mass spectrometry and N-terminal sequence analyses suggest that a core complex comprises the entire RBCC domain of KAP-1 and the AB box of the KRAB domain rendering it resistant to proteolysis. NMR spectroscopy showed that unbound KRAB domain does not exist as a well-folded globular protein in solution but may fold into an ordered structure upon binding to the KAP-1-RBCC protein. This is the first example of a structurally disordered repressor domain that is the most widely conserved silencing domain in tetrapods.