Role of Iron Therapy in Heart Failure: A Consensus Statement from India.

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Choledochal Malformation in Children: Lessons Learned from a Dutch National Study.

INTRODUCTION: A choledochal malformation (CM) is a rare entity, especially in the Western world. We aimed to determine the incidence of CM in the Netherlands and the outcome of surgery for CM in childhood. METHODS: All pediatric patients who underwent a surgical procedure for type I-IV CM between 1989 and 2014 were entered into the Netherlands Study group on choledochal cyst/malformation. Patients with type V CM were excluded from the present analysis. Symptoms, surgical details, short-term (<30 days) and long-term (>30 days) complications were studied retrospectively. RESULTS: Between January 1989 and December 2014, 91 pediatric patients underwent surgery for CM at a median age of 2.1 years (0.0-17.7 years). All patients underwent resection of the extrahepatic biliary tree with restoration of the continuity via Roux-en-Y hepaticojejunostomy. Twelve patients (12%) were operated laparoscopically. Short-term complications, mainly biliary leakage and cholangitis, occurred in 20 patients (22%), without significant correlations with weight or age at surgery or surgical approach. Long-term postoperative complications were mainly cholangitis (13%) and anastomotic stricture (4%). Eight patients (9%) required radiological intervention or additional surgery. Surgery before 1 year of age (OR 9.3) and laparoscopic surgery (OR 4.4) were associated with more postoperative long-term complications. We did not observe biliary malignancies during treatment or follow-up. CONCLUSION: Surgery for CM carries a significant short- and long-term morbidity. Given the low incidence, we would suggest that (laparoscopic) hepatobiliary surgery for CM should be performed in specialized pediatric surgical centers with a wide experience in laparoscopy and hepatobiliary surgery.

Gout and rheumatoid arthritis, both to keep in mind in cardiovascular risk management: A primary care retrospective cohort study.

OBJECTIVES: To assess in one time window cardiovascular risks for both patients with gout and patients with rheumatoid arthritis in a Dutch primary care population. METHODS: Retrospective matched cohort study with data from the electronic health records of 51 Dutch general practices. Participants were patients aged 30 years or older with an incident diagnosis of gout (n=2655) or rheumatoid arthritis (n=513), and matched non-disease controls (n=7891 and n=1850 respectively). At disease incidence date, patients and controls were compared for prevalence of hypertension, diabetes mellitus, hypercholesterolemia, and prior cardiovascular diseases. Patients without prior cardiovascular disease were followed for a first cardiovascular disease, and compared to controls using Kaplan-Meier survival curves and Cox proportional hazard analyses. RESULTS: Compared to controls, gout patients suffered more from hypertension (44.8%), diabetes (20.1%), hypercholesterolemia (13.7%), and prior cardiovascular disease (30%) (P<0.01), whereas rheumatoid arthritis patients (hypertension 28.5%; diabetes 11.7%; hypercholesterolemia 7.4%; prior cardiovascular disease 11.3%) did not (P>0.05). After adjustment, both gout and rheumatoid arthritis patients without prior cardiovascular disease were more likely to get a cardiovascular disease: hazard ratio (95% confidence interval) 1.44 (1.18 to 1.76), and 2.06 (1.34 to 3.16) respectively. CONCLUSIONS: This primary care study indicates that gout and rheumatoid arthritis are both independent risk factors for cardiovascular diseases, rheumatoid arthritis to some greater extent, whereas gout patients at first diagnosis had already an increased cardiovascular risk profile. It gives strong arguments for implementation of both rheumatic diseases in primary care guidelines on cardiovascular risk management.

Intrinsic and extrinsic forces determine the distortion of the split cricoid ring.

OBJECTIVE: An anterior cricoid split (ACS) causes an immediate distortion of the cricoid cartilage resulting in an anterior gap due to retraction of the cut ends. The objective of this animal study is to investigate: (1) to what extent the distortion after ACS is influenced by non-cartilaginous structures like tunica elastica, membranes, ligaments and muscles, which are connected to the cricoid; (2) how distortion is changing with further development; (3) in what way the distortion is affected by scoring of the internal surface of the cricoid; and (4) whether an immediate or late injury-induced distortion is related to age. METHODS: Surgical interventions were performed in 20 young (8 weeks of age, 1300-1600 g) and 5 adult (28 weeks of age, 3500-4000 g) New Zealand White rabbits. The immediate effects were measured, and then the animals were followed for 20 weeks to study the long-term effects of the various procedures. RESULTS: (1) The gap, immediately following an ACS, increased after additional transection of the cricothyroid ligament and the cricotracheal membrane, and even more when the cricovocal membrane was elevated from the inner surface of the cricoid arch. (2) The degree of distortion after various interventions in young animals appeared to increase substantially during further growth. (3) When the above-mentioned successive surgical steps were combined with scoring of the internal surface of the cricoid arch, a marked malformation of the split cricoid did develop with warping of the cut ends in lateral direction and a latero-cephalic rotation, the latter due to the action of the cricothyroid muscles. (4) The immediate distortion appeared to be similar in young and adult animals. During a follow-up of 20 weeks, a progressive distortion of the split cricoid ring was observed in the young growing rabbits. In adult animals, no significant progression of the distortion was found. CONCLUSIONS: The immediate and long-term distortion of the split cricoid is determined by the release of intrinsic forces of the cartilage, and extrinsic forces from non-cartilaginous structures like ligaments, muscles, membranes and tunica elastica.

Controlling incision-induced distortion of nasal septal cartilage: a model to predict the effect of scoring of rabbit septa.

Cartilage can be shaped by scoring. In an exploratory study in living adult animals, this phenomenon was demonstrated in cartilage of the nasal septum. Bending was observed immediately after superficial scoring of the cartilage surface, and the cartilage always warped in the direction away from the scored side. The scored piece of cartilage still showed its initially distorted shape 10 weeks after primary surgery. In ex vivo experiments, a clear relation between incision depth and bending of septal cartilage was observed. Under these controlled conditions, the variation between different septa was small. Deformation of the septal specimens was increased by introducing single superficial incisions deepening to half the thickness of the cartilage. A positive correlation between incision depth and bending was demonstrated. A model was used to accurately predict the degree of bending of the cartilage after making an incision of a particular depth. Hence, the effect of cartilage scoring can be predicted. Because the results of this controlled study showed excellent reproducibility for different septa, it is expected that this model can be extrapolated to human nasal septum cartilage. This would enable the surgeon to better predict the result of cartilage scoring, either preoperatively or perioperatively.

Fast-atom bombardment of the cyclic acetals: Evidence indicating the predominant involvement of condensed-phase processes in ionization.

A series of cyclic acetals, the 2-phenyl-l,3 dioxolanes, and their deuterated analogues were studied by electron ionization (EI), chemical ionization (CI), and fast-atom bombardment (FAB) mass spectrometry to gain insight into the primary ionization processes for these compounds in FAB/liquid secondary ion mass spectrometry. Comparison of EI and CI data with that of FAB led to the conclusion that the predominant [M - H]+ ion observed in FAB for the nondeuterated cyclic acetals cannot to a large extent be rationalized in thermodynamic terms by known gas-phase ion-molecule reactions. Instead, a condensed-phase model in which the multicharged transition state for hydride abstraction is better solvated than the transition state for proton transfer appears to be a plausible explanation for the FAB data obtained for the nonlabeled cyclic acetals; however, this explanation is not entirely sufficient to rationalize the FAB data for the deuterated cyclic acetals. For these compounds, a dramatic time dependence of protonation versus hydride abstraction is observed that suggests that beam-induced reactive species are responsible for hydride abstraction in the condensed phase. This time dependence can be interpreted in terms of a buildup of highly reactive beam-induced species in the bulk of solution. Comparison of the results obtained for deuterated acetals with different surface activities support this hypothesis. (J Am Sot Mass.

Let's practice malpractice prophylaxis.

There are some subjects which cannot be reviewed often enough; and malpractice prophylaxis is one such subject. In spite of numerous articles which appear in our professional literature, the problem still haunts us.

Comparison of X-ray film and photographic paper in recording CT images.

Because of a potential film cost savings of approximately 35% using photographic print paper instead of X-ray film in recording CT images, a comparison was undertaken of these hard copy recording methods. One hundred consecutive CT examinations were reviewed on the scanner display console and recorded on X-ray film and photographic print paper using a multi-imager camera. Hard copy images were compared for diagnostic adequacy. X-ray film adequately recorded the pathology in all cases. Photographic paper adequately recorded the pathology in 97% of cases. In 26% of cases X-ray film was felt to better display the CT diagnosis whereas in 2% of cases photographic paper better displayed the CT diagnosis. Test phantom scans recorded on both media showed no observable difference in spatial or contrast resolution.

State of the art: total parenteral nutrition: a guide for its use.

A brief review of TPN might more clearly point out and explain some of the major areas of this protocol. The use of subclavian vein catheterization for hyperosmolar solutions is the key to TPN. The tip of the catheter resides in the superior vena cava, so solutions with a concentration of 1,500-2,200 mOsm/l. (over five times the osmolarity of serum) can be infused at a rate of 2-3 ml./min. while being diluted by a blood flow of 2-5 l./min. (a dilution factor of a thousand). The site of the catheter is in a large vein. The cutaneous entry site of the catheter is in the pectoral skin below the clavicle; site must be kept scrupulously clean and dressed sterilely. Because of potential complications, the patient should be carefully observed and monitored.

Accessory renal hilus.

A defect in the renal margin secondary to extrahilar entry of renal vessels was detected at urography in three patients. Extrahilar entry of renal vessels is not uncommon and is well known to anastomists and surgeons. It has not been previously reported as a radiographic finding. In the past these marginal defects may have been assumed to be persistent fetal lobulation or scarring from previous renal infarction or pyelonephritis. Arteriography may be necessary to distinguish between these possibilities and occasionally to exclude a renal tumor or cyst.

The cortical rim sign in renal infarction.

The authors describe a case of unilateral renal artery occlusion in which a thin, dense rim was seen on infusion pyelography with subsequent marked atrophy of the kidney. This "cortical rim sign" appears to be due to collateral blood supply from the renal capsule, preserving a thin rim of viable cortex.