Aggressive Treatment Intervention Research Articles

Updates on Prognostication of Takotsubo Cardiomyopathy: A Literature Review

Abstract Takotsubo cardiomyopathy (TTC), commonly known as “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular (LV) systolic dysfunction, usually in the absence of significant obstructive coronary artery stenosis. The pathophysiology of TTC remains elusive; however, the three most common plausible mechanisms include catecholamine surge causing myocardial stunning, multivessel coronary spasm, and microvascular dysfunction. Although initially thought to be a benign, reversible, and transient disorder, newer research data demonstrate that TTC may sometimes have severe short-term complications and some long-term residual effects. Several risk factors have been associated with the outcomes of TTC. In this review, we aim to provide a comprehensive review of the prognostication of TTC in the context of different clinical variables presented in multiple research studies. Various clinical factors, including the types of TTC triggers, the patient’s sex, the presence of cardiogenic shock, atrial arrhythmias, LV tract obstruction, and the presence of certain other clinical comorbidities may significantly impact patient outcomes in TTC patients. A thorough understanding of these factors helps clinicians to better prognosticate the outcome of their patients. Furthermore, early institution of aggressive treatment interventions in the presence of these risk factors may improve the subsequent clinical course.

A Case Series on COVID-19 Associated Mucormycosis (CAM): Experience from a Tertiary Care Centre in India

Aim: During the second wave of the COVID 19 pandemic, a life threatening fungal infection, mucormycosis have been detected in patients post COVID 19 disease. Commonly known as the ‘black fungus’ can causes tissue necrosis, inflammation and necrosis of the head and neck regions, paranasal sinuses, facial bones, orbits and it can also cause intracranial spread. In the current study we describe a series of cases of COVID 19 associated mucormycosis (CAM), the clinical presentations, risk factors, diagnosis, management and follow up experience from a tertiary care centre in India.
 Methods: This is a retrospective observational study conducted over a period of one year (April 2021 to April 2022) at our tertiary care centre. The diagnosis of COVID 19 was done by RT PCR (reverse transcription-polymerase chain reaction). The diagnosis of Mucormycosis was done by Histopathology and fungal cultures. The demographic details of the patients were retrieved from the medical records.
 Results: In the present study we report four cases of Rhino-orbital-cerebral Mucormycosis, three cases of Rhino-orbital Mucormycosis, two cases of Pulmonary Mucormycosis and one case of Disseminated Mucormycosis. All the patients had undergone extensive surgical debridement and received Liposomal Amphotericin B as initial antifungal medication and Posaconazole or Isavuconazole as step down therapy. Six patients responded to treatment while four patients did not have a favorable outcome and succumbed to the illness. 
 Conclusion: Mucormycosis is a deadly disease with high mortality and morbidity if not diagnosed and treated at an early stage. Factors like poor control of blood sugars, inadvertent use of corticosteroids, immune dysfunction due to COVID 19 can result in poor outcome of the disease despite aggressive treatment interventions.

Lessons Learned from COVID-19 Pandemic: Outcomes after Sars-Cov-2 Infection in Hematopoietic Cell Transplant and Cell Therapy Recipients

Background: Coronavirus disease 2019 (COVID-19), a respiratory illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020. Over 500 million cases of SARS-CoV-2 have been reported worldwide, with over 90 million being in the US. More than 6 million lives, with over 1 million only from the US, have been claimed by the pandemic. Hematopoietic cell transplant (HCT) or chimeric antigen receptor-T (CART) cell therapy recipients have a higher risk of mortality with COVID-19. In this updated analysis, we investigated the outcomes after SARS-CoV-2 infection in HCT/CART recipients. Methods: We conducted a single-center prospective study, including all (n=196) adult HCT/CART recipients who were diagnosed with COVID-19 at the University of Kansas Medical Center from March 2020 to March 2022. Baseline and disease-related characteristics were ascertained from medical records. Data were analyzed using SPSS version 21 (SPSS Inc, Chicago, IL). Bivariate analyses, using the chi-square and t-test, were performed. Kaplan-Meier and cox regression analyses were conducted. Results: The study included 196 HCT/CART recipients who acquired SARS-CoV-2 infection, including allogeneic HCT (n=91, 46%), autologous HCT (n=89, 46%), and CART (n=16, 8%) recipients. The median age was 59.8 (21.9-79.5) years; 76.5% were Caucasians and 58% were males. The median time since HCT/CART to SARS-CoV-2 infection was 25.4 (0.2-201.9) months, and 12% of patients acquired SARS-CoV-2 within the first 100 days post-HCT/CAR-T. Plasma cell (37%), myeloid (34%), lymphoid (28%) or solid (1%) malignancies were primary diagnoses. Myeloablative conditioning was performed in 64% of patients. Donors were autologous (53%), matched sibling (12%), matched unrelated (21%), and haploidentical (14%). Prior acute graft-versus-host disease (GVHD), prior chronic GVHD, active GVHD, and current immunosuppressive therapy (IST) were noted in 20%, 26.5%, 23.5%, and 25.5% of patients respectively. Concurrent infections were observed in 12% of patients. COVID-19 severity was mild (n=136, 70%), moderate (n=24, 12%), severe (n=20, 10%) or critical/fatal (n=16, 8%). Clinical findings included pneumonia or abnormal chest imaging (31%), hypoxia (19%), intensive care unit admission (9%), and mechanical ventilation (6%). Therapies included remdesivir (31%), convalescent plasma (11%), dexamethasone (15%), monoclonal antibodies (32%), and tocilizumab/baricitinib (5%). At least one dose of SARS-CoV-2 vaccine was reported in 70% of patients (45% pre-COVID, 25% post-COVID) while 3% of patients had received pre-exposure prophylaxis. The median duration of viral shedding (positive SARS-CoV-2 PCR) was 6.5 (0.3-23.4) weeks. After a median follow-up of 5.4 (0.3-24.8) months, the mortality rate was 12% with COVID-specific mortality of 8%. Of allogeneic HCT patients, 18% (n=16) developed subsequent GVHD after COVID-19 requiring systemic steroids and additional immunosuppression. Eighty-four (43%) patients were diagnosed with COVID after Sep 2021 and had the lowest COVID-specific mortality (2% compared to 12.5% in preceding months of the pandemic). Significant predictors of COVID-19 mortality included allogeneic HCT (HR 3.7, 95% CI 1.2-11.6, p=0.023), COVID-19 within 100 days of HCT/CART (HR 4.8, 95% CI 1.7-13.2, p=0.002), COVID-19 diagnosis earlier in the pandemic (HR 5.2, 95% CI 1.1-24.4, p=0.037), prior acute GVHD (HR 3.2, 95% CI 1.2-8.5, p=0.022), active GVHD (HR 3.5, 95% CI 1.3-9.2, p=0.013), and concurrent IST (OR 7.0, 95% CI 2.4-20.1, p<0.001) while prior SARS-CoV-2 vaccination significantly reduced the COVID-19 mortality (HR 0.19, 95% CO 0.05-0.68, p=0.010). In 15 patients with available data, vaccination induced protective anti-spike protein antibody response (>100 U/mL) in 67% of patients with a median titer of 656 (9-688,000) U/mL after completion of the primary vaccination series. Conclusion: Hematopoietic stem cell transplant and CART cell therapy recipients have a higher risk of morbidity and mortality with SARS-CoV-2 infection. Our findings highlight factors associated with COVID-19 mortality in HCT/CAR-T recipients. In HCT/CART recipients, strict vigilance, infection prevention measures, vaccination prioritization, close monitoring, and early aggressive treatment interventions are suggested for COVID-19 and future emerging infectious diseases. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Biomarkers for Detecting Kidney Dysfunction in Type-2 Diabetics and Diabetic Nephropathy Subjects: A Case-Control Study to Identify Potential Biomarkers of DN to Stratify Risk of Progression in T2D Patients

IntroductionCurrently there are no biomarkers that are predictive of when patients with type-2 diabetes (T2D) will progress to more serious kidney disease i.e., diabetic nephropathy (DN). Biomarkers that could identify patients at risk of progression would allow earlier, more aggressive treatment intervention and management, reducing patient morbidity and mortality.Materials and MethodsStudy participants (N=88; control n=26; T2D n=32; DN n=30) were recruited from the renal unit at Antrim Area Hospital, Antrim, UK; Whiteabbey Hospital Diabetic Clinic, Newtownabbey, UK; Ulster University (UU), Belfast, UK; and the University of the Third Age (U3A), Belfast, UK; between 2019 and 2020. Venous blood and urine were collected with a detailed clinical history for each study participant.ResultsIn total, 13/25 (52.0%) biomarkers measured in urine and 25/34 (73.5%) biomarkers measured in serum were identified as significantly different between control, T2D and DN participants. DN patients, were older, smoked more, had higher systolic blood pressure and higher serum creatinine levels and lower eGFR function. Serum biomarkers significantly inversely correlated with eGFR.ConclusionThis pilot-study identified several serum biomarkers that could be used to predict progression of T2D to more serious kidney disease: namely, midkine, sTNFR1 and 2, H-FABP and Cystatin C. Our results warrant confirmation in a longitudinal study using a larger patient cohort.

Analysis of Factors Contributing to the Occurrence of Systemic Toxicity in Patients with Hydrofluoric Acid Skin Exposure Injury: An Individual Participant Data Meta-Analysis of 125 Clinical Cases from 1979 to 2020.

The purpose of this study is to analyze the factors contributing to the occurrence of systemic toxicity in patients injured after skin exposure to hydrofluoric acid (HFA) and to present guidelines for active treatment intervention based on this analysis. Data were acquired from EMBASE, PubMed, and Cochrane library for individual participant data (IPD) meta-analysis. Key searching terms included calcium gluconate (CAG), hydrofluoric acid, and case. This research consisted of case studies published between 1979 and 2020. Systemic toxicity was set as the main outcome. Data sets from 50 case studies (N = 125 participants) were analyzed. Multivariate binary logistic regression analyses of IPD found significant association effect of the total body surface area (TBSA) burned, indicating systemic toxicity [Regression coefficient estimate, 0.82; SE, 0.41; Odds ratio, 2.28; [95% confidence interval, 1.03-5.06], and p = 0.0424]. The optimal cutoff point (sensitivity; specificity) of the receiver operating characteristic curve of the total body surface area (TBSA) burned for contributing occurrence of systemic toxicity was 2.38(0.875; 0.959). IPD meta-analysis indicates that existing evidence supports the positive proportional association of the TBSA burned for systemic toxicity. If the TBSA burned (%) in patients exposed to hydrofluoric acid is greater than 2.38, early aggressive treatment intervention, including decontamination and various CAG application, should be recommended as the guideline.

Development and Validation of an Autophagy Score Signature for the Prediction of Post-operative Survival in Colorectal Cancer.

Background: Survival rates for Colorectal cancer (CRC) patients who experienced early relapse have usually been relatively low. Our study aims at developing an autophagy signature that could help to detect early relapse cases in CRC.Methods: Propensity score matching analysis was carried out between patients from the early relapse group and the long-term survival group from GSE39582. For both groups, respectively, global autophagy expression changes were then analyzed to identify the differentially expressed prognostic autophagy related genes by conducting Linear Models for Microarray data method analysis. Then, the multi-gene signature was validated in TCGA and Fudan University Shanghai Cancer Center (FUSCC) cohorts. Time-dependent ROC were used to test the efficiency of this signature feature in predicting the prognosis of CRC patients.Results: 5 autophagy genes were finally identified to build an early relapse classifier. With specific risk score formula, patients were classified into low- or high-risk group. Time-dependent ROC analyses proved its prognostic accuracy, with AUC 0.841 and 0.803 at 1 and 3 years, respectively. Then, we validated its prognostic value in two external validation series (GSE17538 and GSE33113) and proved that the result is indeed significant irrespective of datasets in two external independent validation cohorts (TCGA and FUSCC cohorts). A nomogram was constructed to guide individualized treatment of patients with CRC.Conclusions: The identification of robust autophagy-related features can effectively classify CRC patients into groups with low and high risk of early relapse. This signature may be used to help select high-risk CRC patients who require more aggressive treatment interventions.

Competing mortality in patients diagnosed with bladder cancer: evidence of undertreatment in the elderly and female patients

Background:Bladder cancer (BC) predominantly affects the elderly and is often the cause of death among patients with muscle-invasive disease. Clinicians lack quantitative estimates of competing mortality risks when considering treatments for BC. Our aim was to determine the bladder cancer-specific mortality (CSM) rate and other-cause mortality (OCM) rate for patients with newly diagnosed BC.Methods:Patients (n=3281) identified from a population-based cancer registry diagnosed between 1994 and 2009. Median follow-up was 48.15 months (IQ range 18.1–98.7). Competing risk analysis was performed within patient groups and outcomes compared using Gray's test.Results:At 5 years after diagnosis, 1246 (40%) patients were dead: 617 (19%) from BC and 629 (19%) from other causes. The 5-year BC mortality rate varied between 1 and 59%, and OCM rate between 6 and 90%, depending primarily on the tumour type and patient age. Cancer-specific mortality was highest in the oldest patient groups. Few elderly patients received radical treatment for invasive cancer (52% vs 12% for patients <60 vs >80 years, respectively). Female patients with high-risk non-muscle-invasive BC had worse CSM than equivalent males (Gray's P<0.01).Conclusion:Bladder CSM is highest among the elderly. Female patients with high-risk tumours are more likely to die of their disease compared with male patients. Clinicians should consider offering more aggressive treatment interventions among older patients.

Hyperpigmented burn scar improved with a fractionated 1550 nm non-ablative laser

Scars sustained following injury in patients with darker skin types can present a treatment challenge. These scars often hyperpigment and may remain refractory to first line treatments such as topical retinoids and hydroquinone. Additionally, more aggressive treatment interventions such as ablative resurfacing, chemical peels, and Q-switched laser therapy may actually worsen the pigmentation. We describe a 22-year female with a hyperpigmented scar and Fitzpatrick type IV skin that improved markedly following treatment with a fractionated erbium doped fiber laser. The improvement was maintained at least 1 year following the last procedure.

Diabetes management: optimizing roles for nurses in insulin initiation.

Type 2 diabetes is a major public health concern. Screening and early diagnosis followed by prompt and aggressive treatment interventions can help control progression of diabetes and its complications. Nurses are often the first healthcare team members to interact with patients and are being called on to apply their specialized knowledge, training, and skills to educate and motivate patients with diabetes about insulin use and practical ways to achieve treatment goals. Clinical nurse specialists possess specific training and skills to provide this level of care, while staff or office-based nurses may be trained by physicians to fulfill a task-specific role. This manuscript reviews the benefits of intensive glycemic control in type 2 diabetes, therapeutic goals and guidelines, advances in insulin therapy, and contribution of nurses in overcoming barriers to insulin initiation and related aspects of diabetes care. Nurses are particularly well positioned to fill the gap and improve efficiency in diabetes-related healthcare by assisting patients with insulin initiation and other aspects of glycemic self-management.

Current treatment for vitreous floaters

Vitreous floaters are a common complaint in the ophthalmic care setting. Patients seek explanation and advice regarding possible treatment options. Because the condition is considered benign, ophthalmic care practitioners have little to offer regarding treatment options. The majority of cases encountered are managed with patient education and reassurance. Although almost all patients accept the conservative management option, there is a small subset of patients who may desire a more aggressive treatment intervention for resolution of their visual symptoms. Information with regard to treatment options is readily available to patients through Internet searches and non–peer reviewed educational Web sites. The risks and benefits for these treatment options are not fully covered. Management of floaters should include education regarding “off-label” procedures as well as discussion about benefits and risks associated with such treatment options. It is vital that eye care practitioners advise and counsel patients with symptomatic floaters for optimum ocular health care. This article reviews the current conventional and “off-label” treatment options for symptomatic patients with vitreous floaters.

Left ventricular systolic performance in asymptomatic aortic stenosis

Some asymptomatic patients with aortic stenosis (AS) are at higher risk of impending symptom onset or adverse clinical outcome than others. This article explores whether parameters of left ventricular (LV) systolic performance may identify asymptomatic patients with AS who are most likely to benefit from aggressive treatment interventions. Studies evaluating the influence of LV systolic function on outcomes in asymptomatic patients with AS were reviewed. Several factors are associated with poor outcomes in AS, including low chamber function (assessed by LV ejection fraction; LVEF) and depressed myocardial contractility (assessed by low midwall fractional shortening; MFS). In most patients, LV wall stress is inversely correlated with LVEF; LV hypertrophy and LV systolic dysfunction develop from the high wall-stress and afterload mismatch. Depressed myocardial contractility may as well identify patients with poor prognoses before clinical symptoms. High global afterload (reflected by a valvulo-arterial impedance Zva ≥5.5 mmHg/mL/m2) seen in patients with paradoxically low-flow/low-gradient AS can identify patients at high risk of adverse outcomes, and finally high LV stroke work loss (≥25%) can also identify patients at risk. Parameters of LV systolic performance can identify patients with asymptomatic AS who are at high risk of impending symptoms of heart failure and adverse clinical outcomes. Such patients may benefit from more aggressive treatment interventions, including aortic valve replacement.

Issue Highlights

HomeCirculationVol. 114, No. 3Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published18 Jul 2006https://doi.org/10.1161/circ.114.3.183Circulation. 2006;114:183PLASMA PHOSPHOLIPIDTRANSFATTY ACIDS, FATAL ISCHEMIC HEART DISEASE, AND SUDDEN CARDIAC DEATH IN OLDER ADULTS: THE CARDIOVASCULAR HEALTH STUDY, by Lemaitre et al.Higher dietary consumption of trans fatty acids has been associated with elevated risk of coronary heart disease. Data are limited, however, regarding variation in coronary risk according to the type of trans fatty acid, eg, trans-isomers of oleic acid (trans-18:1) versus trans-isomers of linoleic acid (trans-18:2). In this issue of Circulation, Lemaitre and colleagues conducted a nested case-control study using data from elderly participants in the Cardiovascular Health Study. The investigators compared plasma trans-18:1 and trans-18:2 levels (collected 3 years before occurrence of events) in 214 individuals (cases) with fatal coronary heart disease with plasma levels of these trans fatty acids in 214 matched controls. They report that higher plasma trans-18:2 levels were associated with greater risk of fatal ischemic heart disease and sudden cardiac death in multivariable analyses that adjusted for clinical and lifestyle risk factors including plasma levels of n-3 polyunsaturated fatty acids. In contrast, higher levels of trans-18:1 were associated with lower risk. These observations suggest that different types of trans-isomers in the diet may influence coronary risk differentially. If confirmed, these findings suggest that current efforts at decreasing trans fatty acid intake in foods should take into consideration their trans-18:2 content. See p 209.PREVALENCE, CLINICAL PROFILE, AND SIGNIFICANCE OF LEFT VENTRICULAR REMODELING IN THE END-STAGE PHASE OF HYPERTROPHIC CARDIOMYOPATHY, by Harris et al.A minority of patients with hypertrophic cardiomyopathy (HCM) enter a phase known as “end-stage,” thought to be represented by systolic dysfunction, left ventricular dilation, and thinning of previously hypertrophied walls. In this issue of Circulation, Harris and colleagues provide results of the largest group of end-stage patients reported to date, culled from a large multicenter cohort of over 1200 HCM patients. These data demonstrate a far more diverse pattern of left ventricular (LV) remodeling than has been appreciated—including a significant number of patients who, despite an abnormal ejection fraction, still maintain normal LV cavity size and/or persistently hypertrophied LV walls. Furthermore, the clinical course appears largely unfavorable, with a substantial number of sudden arrhythmic deaths as well as heart failure events or transplantations occurring over a short period following clinical recognition. This study provides broader insight into the prevalence, morphology, and clinical course of this unique subset of HCM patients, with the hope of earlier disease recognition and with implications for aggressive treatment interventions. See p 216.ANGIOTENSIN II TYPE I RECEPTOR BLOCKADE PREVENTS ALCOHOLIC CARDIOMYOPATHY, by Cheng et al.The mechanism responsible for alcoholic cardiomyopathy is not known. Cheng et al caused myocardial dysfunction in dogs by feeding them alcohol once daily accounting for 33% of daily calorie intake. Alcohol caused activation of the renin-angiotensin system (RAS) at virtually all levels, including increased plasma angiotensin, renin activity, myocardial angiotensin-converting-enzyme activity and cardiac myocyte angiotensin II type 1 receptor expression. Alcohol was also associated with abnormalities in myocardial contractility, and at the isolated myocyte level, with reduced shortening, prolonged relaxation, and decreased calcium transient amplitude. Treatment with the angiotensin receptor blocker ibresartan reduced the activation of the RAS and corrected the functional abnormalities at the myocardial and isolated myocyte levels. These observations thus implicate the RAS in the pathophysiology of alcoholic myocardial dysfunction, and suggest a potentially useful therapeutic role for the angiotensin receptor blocker. See p 226.Visit http://circ.ahajournals.org:Clinician UpdateAcute Pulmonary Embolism: Part II: Treatment and Prophylaxis. See p e42.Images in Cardiovascular MedicineHereditary Hemorrhagic Telangiectasia With Pulmonary Arteriovenous Fistulas. See p e48.Iatrogenic Left Ventricle-to-Coronary Venous Fistula. See p e50.Epicardial Radiofrequency Catheter Ablation of Ventricular Tachycardia in the Vicinity of Coronary Arteries Is Facilitated by Fusion of 3-Dimensional Electroanatomical Mapping With Multislice Computed Tomography. See p e51. Download figureDownload PowerPointCorrespondenceSee p e53. Previous Back to top Next FiguresReferencesRelatedDetails July 18, 2006Vol 114, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.114.3.183 Originally publishedJuly 18, 2006 PDF download Advertisement SubjectsHeart Failure

New developments in the diagnosis, prognosis and treatment of chronic lymphocytic leukemia

The remarkable progress witnessed over the past few years in the diagnosis, prognosis, and therapy of chronic lymphocytic leukemia has profoundly changed the clinical approach to this disease. This review focuses on the most recent advances in the diagnostic and prognostic examination of patients with chronic lymphocytic leukemia, with particular emphasis on their implications in clinical management, taking into account the broadening of the therapeutic possibilities available today. Through the biologic improvements achieved during the past few years it is now possible to effectively stratify chronic lymphocytic leukemia patients prognostically at presentation on the basis of several laboratory parameters. Furthermore, the availability of purine analogs and monoclonal antibodies and the extension of autografting and allografting procedures have allowed the achievement of higher response rates, including molecular remissions. With the aim of investigating whether early and aggressive treatment intervention may improve the survival of patients with a poor prognosis, new therapeutic trials have been specifically designed. A complete biologic and clinical examination now allows the establishment of a correct diagnostic characterization of patients with chronic lymphocytic leukemia and to identify patients with early disease with a different prognostic likelihood. Multicenter prospective trials, in which the enrolled patients are stratified and treated according to their prognostic risk, will determine the best treatment for the different categories of patients. It is likely that in the near future each chronic lymphocytic leukemia patient can be offered a targeted treatment algorithm based on the clinical and biologic characteristics at presentation.

Screening for hypoglycemia in healthy term neonates: effects on breastfeeding

Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth. Research has demonstrated that in the term, healthy newborn, this dynamic process is self-limiting and is not considered pathologic. The American Academy of Pediatrics and the World Health Organization recommend that neonatal blood glucose screening be reserved for newborns who are at risk or symptomatic and conclude that universal hypoglycemia screening is inappropriate, unnecessary, and potentially harmful. Nevertheless, many hospital nurseries continue the clinical practice of routine early glucose screening on healthy, term newborns. This results in the misidentification of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir who are then diagnosed with pathologic neonatal hypoglycemia. Subsequent to this misdiagnosis, further surveillance and unnecessary, aggressive treatment interventions will follow that are potentially harmful to the successful establishment of positive maternal-infant interactions and the breastfeeding experience. Research studies indicate that routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based and result in a serious disruption of the initiation process and duration patterns of lactation. Using the perspective of the theory of technology dependency, this inquiry explores the potential adverse sequelae of inappropriate glucose screening in the healthy breastfeeding newborn and describes selected outcome variables including: 1) the consequences of early maternal-infant separation, 2) the influence of early formula supplementation on breastfeeding discontinuance rates, 3) the effect of separation and supplementation on the onset of lactogenesis, and 4) the impact of hospital staff and provider recommendations of formula supplementation on maternal confidence to independently nurture her baby.

Mechanisms and consequences of arterial hypertension after renal transplantation.

The high incidence of hypertension after renal transplantation contributes to the risk of cardiovascular morbidity and mortality in renal transplant recipients. Although cyclosporine has been influential in the improvement of transplant outcome, it has emerged as a major cause of hypertension after organ transplantation. The underlying pathophysiological mechanisms of cyclosporine-induced hypertension include enhanced sympathetic nervous system activity, renal vasoconstriction, and sodium/water retention. Hypertension is also significantly associated with reduced graft survival and thereby requires aggressive treatment intervention. Calcium channel blockers may offer some advantages over angiotensin-converting enzyme inhibitors for the treatment of hypertension in stable renal transplant recipients. Nevertheless, selection of the most appropriate antihypertensive agent should take into account the possibility of pharmacokinetic interactions with immunosuppressive agents. There is evidence to suggest that the use of tacrolimus-based immunosuppression induces less hypertension compared with cyclosporine. Not only do patients receiving tacrolimus tend to require less antihypertensive therapy, but converting patients from cyclosporine to tacrolimus has been shown to result in significant reductions in blood pressure. Thus, tacrolimus may be associated with an improved cardiovascular risk profile in renal transplant recipients.

REM latency and the recovery from depression: getting over divorce

The authors' goal was to address five questions: 1) What is the frequency of early REM sleep in subjects in the process of divorce who meet diagnostic criteria for major depressive disorder? 2) What is the frequency of this sign in subjects in the process of divorce who are not depressed? 3) How often does this sign persist following remission of depressive symptoms? 4) What is the predictive value of early REM sleep among depressed subjects for later adjustment to the process of divorce? and 5) What is the role of a family history of depression or alcoholism in the presence and persistence of early REM sleep? Two hundred fourteen volunteers undergoing marital separation were recruited; 70 of these subjects were selected for a 3-night sleep study. Forty of the 70 subjects met criteria for depression and 30 did not; 61 (87%) returned for repeat studies 1 year later. Fifteen (38%) of the 40 depressed subjects had short REM latency. Seven of these continued to have short REM latency 1 year later, but none of these met the criteria for depression at that time. A higher proportion of these subjects had made a good adjustment to their new life than did depressed subjects whose initial and follow-up REM latencies fell within the normal range. These data suggest that depressed individuals with normal REM latency may need more aggressive treatment intervention.