Cardiovascular assessment in cirrhosis: is global longitudinal strain altered in cirrhosis? A meta-analysis and review.

BACKGROUND AND AIMS: Evaluation of cardiac function and determining the potential risk of cardiac complications with liver transplantation has been both a topic of contention and discussion. Global longitudinal strain (GLS) imaging has been used to identify subclinical myocardial dysfunction in other pathologies; however, its use in the cirrhosis population is unclear. A meta-analysis was performed to assess GLS values in patients with cirrhosis compared to healthy controls. METHODS: A literature search was conducted for studies that evaluated GLS in patients with cirrhosis compared to healthy controls published until September 18, 2020. Primary outcomes looked at differences in GLS values between these populations. RESULTS: Thirteen total studies were included in the meta-analysis. Overall, 802 patients with cirrhosis and 540 healthy controls were included in the analysis. The GLS values were numerically more negative in the healthy control group versus patients with cirrhosis (raw mean difference -2.5%, 95% CI -3 to -1.9, P = < .001), I2  = 81%. CONCLUSION: GLS can be used as an early marker of subclinical myocardial dysfunction. We noted a difference in GLS values in patients with cirrhosis compared to healthy control subjects in this meta-analysis. Other traditional systolic and diastolic echocardiographic parameters were not found to be significantly different between patients with cirrhosis versus healthy controls. This may indicate utilization of GLS when screening for cardiac dysfunction prior to liver transplantation.

Novel antineoplastics targeting genetic changes in colorectal cancer.

Cytotoxic chemotherapy remains the mainstay of the medical -management of colorectal cancer (CRC). Research over the last two decades has led to a molecular understanding of the oncogenic mechanisms involved in CRC and has contributed to the rational development of antineoplastics that target these mechanisms. During carcinogenesis, genetic changes often occur in molecules that play key functional roles in cancer such as cell proliferation, angiogenesis, apoptosis, cell death and immune-mediated destruction of cancer cells. Here, we review novel antineoplastics that are approved or in development for CRC that target molecules associated with genetic aberrations in CRC. Some of these targeted antineoplastics have proven effective against other solid tumors and hold promise in treating CRC whereas others are now routinely used in combination with cytotoxic agents. This article reviews antineoplastics that target genetic changes in CRC, their antitumor mechanisms, and their stage of development.

Nonadherence to lipid-lowering therapy and strategies to improve adherence in patients with atherosclerotic cardiovascular disease.

Despite the availability of effective therapies that lower low-density lipoprotein cholesterol (LDL-C) levels in patients with atherosclerotic cardiovascular disease, many eligible patients are inadequately treated and their LDL-C levels remain suboptimal. Patient nonadherence to lipid-lowering therapy (LLT) is a major contributor to the failure of LDL-C goal attainment. Several factors have been identified as contributing to LLT nonadherence, including healthcare disparities due to socioeconomic status, age, race, sex, and cost; limited access to healthcare; perceived side effects associated with LLT; health literacy; and the presence of comorbidities. Suboptimal LLT use has also been associated with clinician factors, including failure to identify patients who require LDL-C reassessment, insufficient LDL-C monitoring, and clinical inertia such as a lack of therapy intensification. Several strategies to enhance LLT adherence have been shown to be effective, including the implementation of educational initiatives and tools for both patients and physicians, the use of clinical protocols and algorithms to identify patients at risk and optimize treatment, and improvements in electronic healthcare records. Pharmacy-based programs designed to help patients with prescription refills, including reminders or the use of prescription delivery by mail, have also proven effective. Drugs requiring frequent administration can represent a barrier to treatment adherence; therefore, newer, more effective LLTs with lower frequency of administration and lower potential for polypharmacy may improve patient adherence to LLT. Implementation of strategies to identify patients at risk for LLT nonadherence and the use of flexible tools such as telemedicine to overcome geographical barriers may improve LLT adherence.

Platypnea-Orthodeoxia Syndrome With Normal Right Heart Pressures in an Octogenarian.

We describe a case of platypnea-orthodeoxia syndrome in an 88-year-old man who presented with progressive dyspnea. Right-to-left shunting through a patent foramen ovale (PFO) was seen in the setting of normal right-sided heart pressures. He was successfully treated with percutaneous transcatheter PFO closure. (Level of Difficulty: Beginner.).