Stable Clinical State Research Articles

8630 Cardiorespiratory Failure in Thyroid Storm After C-section in a Patient with Untreated Hyperthyroidism

Abstract Disclosure: I.C. Arroyo: None. M. Ramirez: None. M. Alvarado: None. L.R. Sepulveda-Garcia: None. L. El Musa Penna: None. W. Medina-Torres: None. Z. Maisonet -Feliciano: None. J. Segarra-Villafane: None. Unrecognized hyperthyroidism during pregnancy increases the risk of maternal and fetal complications, including miscarriage, pre-eclampsia, maternal congestive heart failure, and intrauterine growth restriction (IUGR). Thyroid storm is a rare but life-threatening complication that can occur as well. Furthermore, it can present with cardiopulmonary failure which increases risk of death. Recognizing it early and providing intensive and ongoing therapy is imperative for a positive outcome.We report a case of a 29-year-old female G4P2A0 with triplet pregnancy who developed thyroid storm after an emergency C-section at 27 weeks of gestation due to sinus tachycardia and IUGR in one of the fetuses.Past medical history was remarkable for hyperthyroidism diagnosed on first pregnancy that did not require treatment.Upon questioning, she referred unintentional weight loss, palpitations, tremors, and heat intolerance in the past months.Physical examination showed sinus tachycardia, fine hand tremors, non-tender goiter, and thin/brittle hair.One day after C-section thyroid function tests (TFT) were remarkable for suppressed TSH <0.008uIU/mL, FT4 at 4.30 (0.89-1.76ng/dL) and positive thyroid stimulating antibodies. Burch-Warsofsky Point Scale (BWPS) for Thyrotoxicosis of 20 points didn’t indicate current or impending thyroid storm. Methimazole and propranolol were started. Two days after C- section patient developed worsening FT4 at 5.63ng/dl, worsening sinus tachycardia, increased temperature and respiratory failure requiring mechanical intubation. 2 D echocardiogram showed right ventricular overload with pulmonary hypertension, while CT angiogram of thorax suggested thyrotoxic cardiomyopathy. BWPS was now at 45 points compatible with thyroid storm (positive criteria for temperature of 38.4, heart rate of 117 bmp and heart failure). At this time methimazole was switched to propylthiouracil (PTU), propranolol was adjusted, and hydrocortisone, in addition to cholestyramine, were started. After these changes in therapy, TFTs improved markedly and a stable clinical state was achieved, with successful extubation.Untreated hyperthyroidism during pregnancy and post-partum period poses significant risks, including thyroid storm. Our patient had a C-section with worsening TFTs despite methimazole therapy, developing thyroid storm with cardiopulmonary failure. Cardiopulmonary failure is a rare, but deadly presentation of thyroid storm. In this case C-section was identified as a stressor for thyroid storm and cardiorespiratory failure as a complication. Prompt recognition and aggressive treatment of this potentially lethal condition is warranted to improve survival in thyrotoxic cardiomyopathy. Presentation: 6/1/2024

Prevalence of Erectile Dysfunction (ED) among People Living with HIV in Tehran, Iran.

Sexual problems are rarely addressed in human immunodeficiency virus (HIV) management, even though overt sexual dysfunctions are more prevalent in people living with HIV. This study aimed to ascertain the prevalence of erectile dysfunction (ED) among HIVinfected men in a stable clinical state, examine the relationship between antiretroviral therapy (ART) exposure and sexual dysfunction, and identify the associated risk factors. This cross-sectional study recruited HIV-positive males who visited the Voluntary Counseling and Testing (VCT) center of Imam Khomeini Hospital (Tehran) in 2020. The International Index of Erectile Function (IIEF) questionnaire was used to evaluate the ED in participants. Sociodemographic and clinical data were also collected. Of 65 patients who participated in this study, 27.7% had ED. The mean age of participants with and without ED was 39.4±11.5 and 40.4±7.6 years old, respectively. No significant difference was observed between patients with and without ED concerning the sociodemographic status and the use of ART drugs. The prevalence of ED is relatively high among men living with HIV. Future research is recommended among HIV-positive males to identify the underlying causes and explore the potential impact that associated psychological distress could have on sexual dysfunction.

Scavenger receptor B1 involvement in chronic obstructive pulmonary disease pathogenesis

Objective Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality in the United States. Oxidative stress due to cigarette smoking seems to be one of the major driving mechanisms in COPD pathogenesis. Since the scavenger receptor B1 (SR-B1) appears to play a key role in mediating the uptake for ɑ-tocopherol and other antioxidants in lung tissue, we aimed to investigate its role in COPD pathogenesis. Methods Lung tissue biopsies were obtained from 12 subjects; 6 of these had a diagnosis of COPD in a stable clinical state, the others 6 were current (n = 1) or ex-smokers (n = 5) with normal lung function (controls). 4-Hydroxynonenal (4-HNE)–SR-B1 adducts were detected by immunoprecipitation. ɑ-tocopherol concentration was determined by HPLC. Results SR-B1 levels were lower in COPD patients and these results parallel with lower levels of vitamin E in lung tissue found in COPD patients. This effect can be the consequence of oxidative posttranslational modifications, confirmed by the binding of the peroxidation product 4-HNE to SR-B1 possibly leading to its degradation. Conclusions The loss of SR-B1 may be involved in lung ɑ-tocopherol content decrease with the consequence of making lung tissue more susceptible to oxidative damage as suggested by the SR-B1–4-HNE adduct formation, and more prone to COPD development. Thus, our findings suggest a novel role of SR-B1 in pathomechanisms underlying COPD. Significance statement Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality in the United States. Oxidative stress has been suggested to be the major driving mechanism in COPD pathogenesis. Loss of scavenger receptor BI (SR-B1) significantly decreases tocopherol lung content making lung tissue more susceptible to oxidative damage. The results of our study show that SR-B1 levels were lower in COPD patients and these results parallel with lower levels of vitamin E in lung tissue. Our findings suggest a novel role of SR- B1 in pathomechanisms underlying COPD.

Bilateral torsion of an ovarian dermoid cyst in a nullipara, exploratory laparotomy, right ovariectomy and left cystectomy: A case report

Background: Ovarian torsion is a common gynecological emergency prompt diagnosis and treatment results in favourable outcome. This may be unilateral or bilateral in rare cases. However, bilateral Adnexal torsion (AT) is a gynecological emergency which occurs in approximately 2.7-3.5% of women of all ages globally. Aim: To present this uncommon clinical condition and offer management modality. Presentation of case: AC was a 28 -year- old nulliparous woman, who presented to our institution with a history of sudden onset of severe lower abdominal pain and nausea. On physical examination, she was acutely ill-looking, in mild painful distress, and her vital signs were within normal limits. On abdominal examination, there was no distension but there was lower abdominal tenderness, with muscle guarding. A pelvic examination revealed bilateral adnexal tenderness. Ultrasound examination showed a right ovarian cyst of size about 9 × 7 cm poor visualization of the left ovary. An impression of torsion of right ovarian dermoid cyst was made. She had exploratory laparotomy for ovarian torsion, right ovariectomy and left cystectomy. Her post-operative period was uneventful and was discharged in her 6th post-operative day in stable clinical state. Conclusion: We have presented 28-year-old nullipara who had bilateral ovarian and laparotomy with cystectomy. Prompt intervention of similar cases results in better prognosis.

Bartter Syndrome in A Nigerian Child with Recurrent Vomiting

Bartter syndrome is a rare renal tubular disease characterized by hypokalemic metabolic alkalosis and renal salt wasting. There is paucity of report of this condition from Africa. We report a case of a four–year–old Nigerian boy who presented with growth failure, recurrent episodes of vomiting, features of severe dehydration and normal blood pressure warranting in–hospital care on several occasions over a period of 16 months. This patient had hypokalemia, hypochloremia, hyponatraemia and hypercalciuria. He also had abdominal x-ray findings of a triangular-shaped calcific density in the right renal bed suggestive of right medullary nephrocalcinosis. Diagnosis of Bartter syndrome was confirmed by elevated plasma renin of 8.1ng/ml/hr (normal 0.5 – 5.9). The patient was managed with intravenous normal saline, potassium chloride infusion, calcium gluconate, and then oral potassium, calcium and magnesium supplements. Follow up at the clinic revealed significant weight gain and stable clinical state. A high index of suspicion is needed for early diagnosis of this rare syndrome, particularly in children presenting with persistent vomiting, failure to thrive and dyselectrolytemia. This, invariably, will improve survival and health-related quality of life of such children, hence the need for this report.

Soluble Complement Component 1q Receptor 1 (sCD93) Is Associated with Graft Function in Kidney Transplant Recipients.

Cluster of differentiation 93 (CD93), also known as complement component 1q receptor 1 is a transmembrane glycoprotein expressed in endothelial and hematopoietic cells and associated with phagocytosis, cell adhesion, angiogenesis and inflammation. The extracellular part, soluble CD93 (sCD93), is released to body fluids in inflammation. Data on sCD93 in kidney diseases are limited. Our aim was to evaluate serum sCD93 in long-term kidney transplant recipients as a marker of inflammation and endothelial dysfunction that may be potentially useful in early recognition of graft dysfunction. Seventy-eight adult patients with functioning kidney graft and stable clinical state were examined at least one year after kidney transplantation. Serum sCD93 was measured by enzyme immunosorbent assay. Estimated glomerular filtration rate (eGFR) and albuminuria or proteinuria were assessed at baseline and over one-year follow-up. Increased sCD93 was associated with lower baseline eGFR independently of the confounders. Moreover, sCD93 was negatively associated with eGFR during one-year follow-up in simple analysis; however, this was not confirmed after adjustment for confounders. Baseline sCD93 was positively associated with baseline albuminuria and with increased proteinuria during the follow-up. Serum sCD93 was not correlated with other studied inflammatory markers (interleukin 6, C-reactive protein, procalcitonin and C3 and C4 complement components). To the best of our knowledge, this is the first report regarding the concentrations of sCD93 in kidney transplant recipients and one of the first reports showing the inverse association between sCD93 and renal function. Serum sCD93 should be further evaluated as a diagnostic and prognostic marker in renal transplantation.

Transcatheter aortic valve replacement performed with selective telemetry monitoring: A prospective study

BackgroundTelemetry monitoring (TM) with or without intensive care unit (ICU) admission is the standard of care after Transcatheter aortic valve replacement (TAVR). Regarding to improvements of the technique and procedural results, TM may be considered only in selected patients. We aimed to confirm feasibility and safety of selective TM in patients undergoing TAVR. MethodsWe prospectively evaluated 449 consecutive patients undergoing TAVR. Patients were transferred to general cardiology ward (GCW) without TM after the procedure when stable clinical state, transfemoral access, no baseline right bundle branch block (RBBB), left ventricular ejection fraction (LVEF) > 40%, and no complication including any electrocardiogram (ECG) change within 1 h after the procedure (“low-risk” group). Others patients were considered for TM in ICU (“high-risk” group). The primary endpoint evaluated in-hospital major adverse events after unit admission according to VARC-2 criteria. ResultsThe mean age was 81.8 ± 7.5 years and mean EuroSCORE II was 7.5 ± 4.8%. In total, 116 patients (25.8%) were considered as “low-risk” patients and 163 patients (36.3%) were referred to GCW, including those with immediate pacemaker implantation. A total of 96 patients (21.3%) reached the primary endpoint including mainly conductive disorders (12.8%). No major adverse events, particularly no late severe conductive disorder, occurred in the “low-risk” group (negative predictive value of 100%). Baseline RBBB (p < 0.01), LVEF < 40% (p = 0.02) and “high-risk” group (p < 0.01) were predictive of outcomes. ConclusionsUsing rigorous periprocedural selection criteria, patients' admission in GCW without TM can be routinely and safely performed in 1/3 of patients after TAVR.

Congenital kaposiform hemangioendothelioma: don’t let the appearances fool you

Abstract Objectives To describe challenges in diagnosis and treatment of congenital Kaposiform hemangioendothelioma (KHE). Case presentation The neonate was born with an upper extremity vascular tumor and stable clinical state. His biopsy was inconclusive before discharge. At three weeks follow-up he presented with Kasabach-Merritt phenomenon (KMP), leading to the diagnosis of KHE, a rare locally aggressive vascular tumor that was managed with combination of steroids and mammalian target of rapamycin inhibitor (mTOR). Conclusions KMP in combination with the lesion biopsy can enhance KHE diagnosis, leading to successful treatment with mTOR inhibitor.

95TAVI performed without systematic intensive care unit admission: an update of a single center experience

Abstract Background Systematic admission to the intensive care unit (ICU) was considered as a standard of care after transcatheter aortic valve implantation (TAVI). However, regarding to improvements in procedural results, our team pointed out feasibility and safety of TAVI without ICU admission in selected patients referred in our center in 2015 Purpose The aim of this study was to evaluate the evolution of our practice after the first study to confirm the feasibility and safety of TAVI without ICU in a large population of patients. Methods We evaluate prospectively 451 consecutive patients undergoing TAVI between January 2017 and december 2017. The same “low-risk” criteria were applied to this cohort of patients to allow admission to conventional cardiology unit: stable clinical state, transfemoral access, no right bundle branch block at baseline, left ventricular ejection fraction &gt;40% and no complications occurring during the procedure. Any new conduction disturbance was considered as indication for ICU. Results The mean age was 81.8±7.5 years and the mean logistic Euroscore was 9.1±3.3%. The balloon-expandable Sapien 3 was used in 181 patients (40.1%) and the transfemoral route was the main vascular approach (n=412, 91.3%). According to the predefined criteria, 289 patients (64.1%) were considered at “high-risk”. In-hospital major complications occurred in 52 patients (11.5%) including 3 deaths (0.7%), 6 major vascular complications (1.3%), 1 stroke (0.2%), 7 heart failures (1.5%), 2 tamponades (0.4%), 2 ventricular perforations (0.4%) and 31 high-degree conduction disorders (6.9%) including 26 patients undergoing immediate pacemaker implantation allowing a non-ICU decision. All complications occurred in the “high-risk” group (figure) and the negative predictive value of the “low-risk” criteria to predict complications was 100%. In multivariate analysis, right bundle branch block (p&lt;0.ehz747.00241), first degree atrioventricular block (p=0.02), low LVEF (p=0.01) were found as pre procedural predictive factors of adverse events. ICU and non-ICU admission after TAVI Conclusion Our results confirm that with a rigorous selection of patients and using simple criteria, TAVI can be routinely performed without ICU admission in nearly 40% of patients with a stable proportion of patients not referred to ICU between 2015 and 2017.

Sleep-disordered breathing in patients with cardiovascular diseases cannot be detected by ESS, STOP-BANG, and Berlin questionnaires

Sleep-disordered breathing (SDB) is highly prevalent in patients with cardiovascular diseases (CVD) and associated with poor outcome. At least 50% of heart failure (HF) patients present with SDB, equally divided in obstructive sleep apnea (OSA) and central sleep apnea (CSA). CVD patients with SDB do not always present with typical SDB symptoms. Therefore, we asked whether established questionnaires allow for the reliable detection of SDB. In this prospective cohort study, 89 CVD patients (54 male, 59 ± 15 years, BMI 30 ± 6kg/m2) in stable clinical state underwent an ambulatory polygraphy. SDB was defined as an apnea-hypopnea index (AHI) ≥ 15/h. We evaluated the Epworth Sleepiness Scale (ESS), STOP-BANG and Berlin questionnaires as well as anthropometric data and comorbidities regarding their ability to predict SDB. The ESS showed no correlation with SDB. The sensitivity of the Berlin Questionnaire to detect SDB was 73%, specificity was 42%. The STOP-BANG questionnaire showed a sensitivity of 97% while specificity was 13%. Coronary heart disease and/or history of myocardial infarction, hyperuricemia and age significantly contributed to a logistic regression model predicting presence of SDB. However, our regression model explains only 36% of the variance regarding the presence or absence of SDB. The approach to find variables, which would allow an early and reliable differentiation between patients with CVD and coexistence or absence of SDB, failed. Thus, as CVD patients show a high SDB prevalence and poor outcome, only a systematic screening based on measures of respiration-related parameters (i.e., respiratory flow, blood oxygen saturation, etc.) allows for a reliable SDB assessment.

Soluble Receptor for Advanced Glycation End Products (sRAGE) is Up-Regulated in Multiple Sclerosis Patients Treated with Interferon β-1a

Background/Aims: Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Considering the role of immune system in its pathogenesis, researchers have focused on evaluation of the expression of immune-related genes or proteins in MS patients. Among proteins whose participation in inflammatory process has been documented is the receptor for advanced glycation end products (RAGE). Methods: In the present study, we compared RAGE transcript levels by means of quantitative real-time PCR as well as the serum level of soluble RAGE (sRAGE) by means of enzyme- linked immunosorbent assay (ELISA) in 50 IFNβ-1a responsive relapsing-remitting MS patients when compared with age and sex-matched healthy subjects. Results: Elevated expression of RAGE as well as higher levels of sRAGE were detected in IFN-β responsive MS patients compared with the controls. A significant inverse correlation between sRAGE plasma concentrations and the expanded disability status scale (EDSS) was also detected in which each unit of increase in sRAGE level resulted in a 0.308 unit decrease in EDSS. Conclusion: Considering the stable clinical state of the MS patients in this study and their response to IFNβ-1a, the elevated levels of sRAGE in patients compared with healthy subjects could be related to the effects of this kind of treatment.

The impact of positive expiratory pressure vs airway clearance techniques other therapy on quality of life and hospitalization rates in bronchiectasis patients: A systematic review

Background: As per global guidelines, the present approach to treating bronchiectasis is to reduce additional harm to the airways by reducing inflammation and infection and enhancing airway clearance. The aim of this study was to compare the quality of life and hospitalization rates of individuals with bronchiectasis between positive expiratory pressure and other methods for airway clearance. Method: Following the PRISMA guideline (9), this systematic review investigation was carried out. We looked through the electronic databases of PubMed, Google Scholar, and Cochrane for randomized controlled studies comparing the use of prescription PEP therapy to alternative ACTs for patients with stable or acute exacerbations of bronchiectasis. We focused on English-language publications that were released between 2003 and 2016. Result: Included in this systematic review were four studies that were published between 2003 and 2015. Three studies involved individuals in clinical stability, while one study included adults experiencing a sudden exacerbation of bronchiectasis. According to the inclusion criteria, bronchiectasis was determined by HRCT in two investigations and by medical diagnosis in the other two studies. Conclusion: PEP therapy appears to have comparable effects to other ACTs on dyspnea symptoms, health-related Qol, and sputum expectoration when administered in a stable clinical state or during an acute exacerbation.

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

People with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques (ACTs). A common type of ACT prescribed is positive expiratory pressure (PEP) therapy. A previous review has suggested that ACTs including PEP therapy are beneficial compared to no treatment in people with bronchiectasis. However, the efficacy of PEP therapy in a stable clinical state or during an acute exacerbation compared to other ACTs in bronchiectasis is unknown. The primary aim of this review was to determine the effects of PEP therapy compared with other ACTs on health-related quality of life (HRQOL), rate of acute exacerbations, and incidence of hospitalisation in individuals with stable or an acute exacerbation of bronchiectasis.Secondary aims included determining the effects of PEP therapy upon physiological outcomes and clinical signs and symptoms compared with other ACTs in individuals with stable or an acute exacerbation of bronchiectasis. We searched the Cochrane Airways Group Specialised Register of Trials, PEDro and clinical trials registries from inception to February 2017 and we handsearched relevant journals. Randomised controlled parallel and cross-over trials that compared PEP therapy versus other ACTs in participants with bronchiectasis. We used standard methodological procedures as outlined by Cochrane. Nine studies involving 213 participants met the inclusion criteria, of which seven were cross-over in design. All studies included adults with bronchiectasis, with eight including participants in a stable clinical state and one including participants experiencing an acute exacerbation. Eight studies used oscillatory PEP therapy, using either a Flutter or Acapella device and one study used Minimal PEP therapy. The comparison intervention differed between studies. The methodological quality of studies was poor, with cross-over studies including suboptimal or no washout period, and a lack of blinding of participants, therapists or personnel for outcome measure assessment in most studies. Clinical heterogeneity between studies limited meta-analysis.Daily use of oscillatory PEP therapy for four weeks was associated with improved general health according to the Short-Form 36 questionnaire compared to the active cycle of breathing technique (ACBT). When applied for three sessions over one week, minimal PEP therapy resulted in similar improvement in cough-related quality of life as autogenic drainage (AD) and L'expiration Lente Totale Glotte Ouverte en Decubitus Lateral (ELTGOL). Oscillatory PEP therapy twice daily for four weeks had similar effects on disease-specific HRQOL (MD -0.09, 95% CI -0.37 to 0.19; low-quality evidence). Data were not available to determine the incidence of hospitalisation or rate of exacerbation in clinically stable participants.Two studies of a single session comparison of oscillatory PEP therapy and gravity-assisted drainage (GAD) with ACBT had contrasting findings. One study found a similar sputum weight produced with both techniques (SMD 0.54g (-0.38 to 1.46; 20 participants); the other found greater sputum expectoration with GAD and ACBT (SMD 5.6 g (95% CI 2.91 to 8.29: 36 participants). There was no difference in sputum weight yielded between oscillatory PEP therapy and ACBT with GAD when applied daily for four weeks or during an acute exacerbation. Although a single session of oscillatory PEP therapy was associated with less sputum compared to AD (median difference 3.1 g (95% CI 1.5 to 4.8 g; one study, 31 participants), no difference between oscillatory PEP therapy and seated ACBT was evident. PEP therapy had a similar effect on dynamic and static measures of lung volumes and gas exchange as all other ACTs. A single session of oscillatory PEP therapy (Flutter) generated a similar level of fatigue as ACBT with GAD, but greater fatigue was noted with oscillatory PEP therapy compared to ACBT alone. The degree of breathlessness experienced with PEP therapy did not differ from other techniques. Among studies exploring adverse events, only one study reported nausea with use of oscillatory PEP therapy. PEP therapy appears to have similar effects on HRQOL, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation. The number of studies and the overall quality of the evidence were both low. In view of the chronic nature of bronchiectasis, additional information is needed to establish the long-term clinical effects of PEP therapy over other ACTs for outcomes that are important to people with bronchiectasis and on clinical parameters which impact on disease progression and patient morbidity in individuals with stable bronchiectasis. In addition, the role of PEP therapy during an acute exacerbation requires further exploration. This information is necessary to provide further guidance for prescription of PEP therapy for people with bronchiectasis.

Feasibility and Safety of Transcatheter Aortic Valve Implantation Performed Without Intensive Care Unit Admission

Admission to the intensive care unit (ICU) is a standard of care after transcatheter aortic valve implantation (TAVI); however, the improvement of the procedure and the need to minimize the unnecessary use of medical resources call into question this strategy. We evaluated prospectively 177 consecutive patients who underwent TAVI. Low-risk patients, admitted to conventional cardiology units, had stable clinical state, transfemoral access, no right bundle branch block, permanent pacing with a self-expandable valve, and no complication occurring during the procedure. High-risk patients included all the others transferred to ICU. In-hospital events were the primary end point (Valve Academic Research Consortium 2 criteria). The mean age of patients was 83.5 ± 6.5years, and the mean logistic EuroSCORE was 14.6 ± 9.7%. The balloon-expandable SAPIEN 3 valve was mainly used (n= 148; 83.6%), mostly with transfemoral access (n= 167; 94.4%). Among the 61 patients (34.5%) included in the low-risk group, only 1 (1.6%) had a minor complication (negative predictive value 98.4%, 95% confidence interval [CI] 0.91 to 0.99). Conversely, 31 patients (26.7%) from the high-risk group had clinical events (positive predictive value 26.7%, 95% CI 0.19 to 0.35), mainly conductive disorders requiring pacemaker (n= 26; 14.7%). In multivariate analysis, right bundle branch block (odds ratio [OR] 14.1, 95% CI 3.5 to 56.3), use of the self-expandable valve without a pacemaker (OR 5.5, 95% CI 2 to 16.3), vitamin K antagonist treatment (OR 3.8, 95% CI 1.1 to 12.6), and female gender (OR 2.6, 95% CI 1.003 to 6.9) were preprocedural predictive factors of adverse events. In conclusion, our results suggested that TAVI can be performed safely without ICU admission in selected patients. This strategy may optimize efficiency and cost-effectiveness of procedures.

0022 : Transcatheter aortic valve implantation without intensive care unit admission

The aim of the study was to evaluate feasibility and safety of transcatheter aortic valve implantation (TAVI) performed without subsequent intensive care unit (ICU) admission using simple clinical, ECG and echocardiographic criteria. We included prospectively 177 consecutive patients who underwent TAVI in our center. Low-risk patients, admitted to conventional cardiology unit, had stable clinical state, LVEF > 40%, transfemoral access, no right bundle branch block (RBBB), permanent pacing with self-expandable valve and no complication during the procedure. High-risk group included other patients who were transferred to ICU. The primary endpoint concerned in-hospital events (VARC-2 criteria). Mean age of patients was 83.5±6.5 years and mean logistic Euroscore was 14.6±9.7%. The balloon expandable SAPIENS 3 valve was mainly used (n=148; 83.6%), mostly with transfemoral access (n=167; 94,4%). Among the 61 patients (34.5%) included in the low-risk group, only 1 (1.6%) had a minor complication (NPV: 98.4%; 95% CI: 0.91-0.99). Conversely, 47 patients (40.5%) from the high-risk group had clinical events (PPV: 40.5%; 95% CI: 0.31-0.50), mainly conductive disorders requiring pacemaker (n=26; 22.4%). In multivariate analysis, RBBB (OR: 14.1; 95% CI: 3.5-56.3), use of self-expandable valve without pacemaker (OR: 5.5; 95% CI: 2-16.3), vitamin K antagonist treatment (OR: 3.8; 95% CI: 1.1-12.6) and female gender (OR: 2.6; 95% CI 1.003-6.9) were pre-procedural predictive factors of in-hospital adverse events. Our results suggested that TAVI can be performed safely without ICU admission in selected patients. This strategy may optimize efficiency and cost-effectiveness of the procedure. The author hereby declares no conflict of interest Table In hospital major adverse events in the two groups of patients. Post TAVI adverse events Low risk group ( n=61; 34.5% ) High risk group (n=116: 65.5%) Death ( n=1; 0.6% ) 0 1 (0.9%) Acute pulmonary oedema ( n=1; 0.6% ) 0 1 (0.9%) New high conductive disorder (n=36; 20.2%) 0 36 (31%) Permanent pacing requiring (n=26; 14.7%) 0 26 (22.4%) Major vascular complication (n=1; 0.6%) 0 1 (0.9%) Pericardial effusion requiring medical intervention (n=2; 1.2%) 0 2 (1.8%) Acute kidney injury (Akin 2 or 3) (n=3; 1.8%) 0 3 (2.7%) Secondary transfer to ICU ( n=1 ) (pericardial effusion) 1 (1.6%) Total of patient with at least one complication (n=48; 27.1%) 1 (1.6%) 47 (40.5%)

Exercise oxidative skeletal muscle metabolism in adolescents with cystic fibrosis.

What is the central question of this study? Do intrinsic abnormalities in oxygenation and/or muscle oxidative metabolism contribute to exercise intolerance in adolescents with mild cystic fibrosis? What is the main finding and its importance? This study found no evidence that in adolescents with mild cystic fibrosis in a stable clinical state intrinsic abnormalities in skeletal muscle oxidative metabolism seem to play a clinical significant role. Based on these results, we concluded that there is no metabolic constraint to benefit from exercise training. Patients with cystic fibrosis (CF) are reported to have limited exercise capacity. There is no consensus about a possible abnormality in skeletal muscle oxidative metabolism in CF. Our aim was to test the hypothesis that abnormalities in oxygenation and/or muscle oxidative metabolism contribute to exercise intolerance in adolescents with mild CF. Ten adolescents with CF (12-18 years of age; forced expiratory volume in 1 s >80% of predicted; and resting oxygen saturation >94%) and 10 healthy age-matched control (HC) subjects were tested with supine cycle ergometry using near-infrared spectroscopy and (31)P magnetic resonance spectroscopy to study skeletal muscle oxygenation and oxidative metabolism during rest, exercise and recovery. No statistically significant (P > 0.1) differences in peak workload and peak oxygen uptake per kilogram lean body mass were found between CF and HC subjects. No differences were found between CF and HC subjects in bulk changes of quadriceps phosphocreatine (P = 0.550) and inorganic phosphate (P = 0.896) content and pH (P = 0.512) during symptom-limited exercise. Furthermore, we found statistically identical kinetics for phosphocreatine resynthesis during recovery for CF and HC subjects (P = 0.53). No statistically significant difference in peak exercise arbitrary units for total haemoglobin content was found between CF and HC subjects (P = 0.66). The results of this study provide evidence that in patients with mild CF and a stable clinical status (without signs of systemic inflammation and/or chronic Pseudomonas aeruginosa colonization), no intrinsic metabolic constraints and/or abnormalities in oxygenation and/or muscle oxidative metabolism contribute to exercise intolerance.

Effects of dialyzer reuse on dialysis adequacy, anemia control, erythropoieting-stimulating agents use and phosphate level.

Almost 50 years have passed since the first time the concept of dialyzer reuse in hemodialyzed patients was introduced for primarily economic reasons [1]. Hemodialyzers are labeled by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) as single use only. In recognition of the widespread practice of reuse in the United States, in 1996 the FDA required manufacturers to label dialyzers for multiple use and to back up this claim with data showing that the performance of the dialyzer is sustained over multiple uses [2]. In Poland there is also a tendency to stop the reuse of dialyzers. There are three major concerns with reuse: the risk of infection; biochemical and immunologic effects; and loss of performance with impairment in clearance and/or ultrafiltration [3].

Airway clearance techniques for bronchiectasis.

People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production, features that may be associated with progressive decline in clinical and functional status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear. Primary: to determine effects of ACTs on rates of acute exacerbation, incidence of hospitalisation and health-related quality of life (HRQoL) in individuals with acute and stable bronchiectasis. Secondary: to determine whether:• ACTs are safe for individuals with acute and stable bronchiectasis; and• ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis. We searched the Cochrane Airways Group Specialised Register of trials from inception to November 2015 and PEDro in March 2015, and we handsearched relevant journals. Randomised controlled parallel and cross-over trials that compared an ACT versus no treatment, sham ACT or directed coughing in participants with bronchiectasis. We used standard methodological procedures as expected by The Cochrane Collaboration. Seven studies involving 105 participants met the inclusion criteria of this review, six of which were cross-over in design. Six studies included adults with stable bronchiectasis; the other study examined clinically stable children with bronchiectasis. Three studies provided single treatment sessions, two lasted 15 to 21 days and two were longer-term studies. Interventions varied; some control groups received a sham intervention and others were inactive. The methodological quality of these studies was variable, with most studies failing to use concealed allocation for group assignment and with absence of blinding of participants and personnel for outcome measure assessment. Heterogeneity between studies precluded inclusion of these data in the meta-analysis; the review is therefore narrative.One study including 20 adults that compared an airway oscillatory device versus no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). Data were not available for assessment of the impact of ACTs on time to exacerbation, duration or incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in HRQoL on both disease-specific and cough-related measures. The median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 7.5 units (P value = 0.005 (Wilcoxon)). Treatment consisting of high-frequency chest wall oscillation (HFCWO) or a mix of ACTs prescribed for 15 days significantly improved HRQoL when compared with no treatment (low-quality evidence). Two studies reported mean increases in sputum expectoration with airway oscillatory devices in the short term of 8.4 mL (95% confidence interval (CI) 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02). HFCWO improved forced expiratory volume in one second (FEV1) by 156 mL and forced vital capacity (FVC) by 229.1 mL when applied for 15 days, but other types of ACTs showed no effect on dynamic lung volumes. Two studies reported a reduction in pulmonary hyperinflation among adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05; difference in total lung capacity (TLC) of 703 mL, P value = 0.02) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared with no ACTs. Low-quality evidence suggests that ACTs (HFCWO, airway oscillatory devices or a mix of ACTs) reduce symptoms of breathlessness and cough and improve ease of sputum expectoration compared with no treatment (P value < 0.05). ACTs had no effect on gas exchange, and no studies reported effects of antibiotic usage. Among studies exploring airway oscillating devices, investigators reported no adverse events. ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis and may account for improvements in sputum expectoration, selected measures of lung function, symptoms and HRQoL. The role of these techniques in acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, additional data are needed to establish the short-term and long-term clinical value of ACTs for patient-important outcomes and for long-term clinical parameters that impact disease progression in individuals with stable bronchiectasis, allowing further guidance on prescription of specific ACTs for people with bronchiectasis.

Relapse in Psychosis

Relapse—including symptom exacerbations and a deterioration in functioning that often requires hospitalization—can be demoralizing for persons with a severe mental illness like psychosis. Relapses can interfere with independent living, work, and community adjustment; therefore, minimizing relapses is a common treatment goal. 1In fact, for many years the primary goal of treatment for these disorders was the prevention of relapses and the successful maintenance of a stable clinical state. Although relapse prevention continues to be an important focus of treatment, stable clinical functioning is no longer a sufficient long-term treatment goal. Patients with major mental illnesses can achieve much more than just a stable clinical state; they can continue to grow as individuals and lead rewarding, productive, and meaningful lives, despite experiencing some symptoms or impairments, if proper relapse prevention guidelines are implemented.

Evaluation of Activity Limitation in Patients With Idiopathic Pulmonary Fibrosis Grouped According to Medical Research Council Dyspnea Grade

ObjectiveTo investigate the relations between Medical Research Council (MRC) dyspnea grade and peripheral muscle force, activities of daily living (ADL) performance, health status, lung function, and exercise capacity in subjects with idiopathic pulmonary fibrosis (IPF). DesignProspective cross-sectional observational study. SettingUniversity hospital. ParticipantsSubjects with IPF (N=65, 46 men) in a stable clinical state with a mean age of 68±7 years. InterventionsNot applicable. Main Outcome MeasuresRight ventricular systolic pressure (RVSP) via transthoracic echocardiography, pulmonary function, isometric quadriceps force (QF) and handgrip force (HF), 6-minute walk distance (6MWD), ADL score, and health status (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) were assessed and compared between subjects grouped according to MRC grade. ResultsOf the participants, 16 were in MRC grade 2, 17 were in MRC grade 3, 17 were in MRC grade 4, and 15 were in MRC grade 5. RVSP, pulmonary function, QF, HF, 6MWD, ADL, and SF-36 scores decreased with increasing MRC grade (all P<.001). All measures were lower (P<.05) in subjects with grades 4 and 5 than subjects with grades 2 and 3. Strong associations were found between MRC grade and 6MWD (ρ=−.89, P=.001) and ADL score (ρ=−.82, P=.001). MRC grade was also associated with RVSP, pulmonary function, QF, and HF (all ρ≥.56, P=.001). ConclusionsThe MRC dyspnea scale provides a simple and useful method of categorizing individuals with IPF with respect to their activity limitation and may assist in understanding the impact of IPF on an individual.