Transient Hypertension Research Articles

Abstract B59: Cardiometabolic complications after pediatric cancer: Associations with chemotherapeutic agents and body-mass-index fluctuations

Abstract Introduction: Survivors of childhood cancer are at risk of cardiometabolic complications including dyslipidemia, obesity, insulin resistance, and hypertension. In addition, children undergoing chemotherapy often suffer from substantial side effects including rapid weight gain, transient hypertension, and elevated blood glucose and lipids. However, little is known about the cardiometabolic health of children shortly after cancer treatment. This study aims to describe the cardiometabolic profile of children after treatment and to study the factors associated with these complications. Methods: Participants were recruited at Sainte-Justine UHC in Montreal as part of the VIE Program (Valorization, Implication, Education). Cardiometabolic health was assessed with biochemical, clinical, and anthropometric measures. Data on treatment (diagnosis, chemotherapeutic agents, and doses) were obtained from medical files. Results: Evaluations were performed on 71 participants (45% boys; median age: 9.8 years; 42% with acute lymphoblastic leukemia; median time since last treatment: 1.4 years, range: 0.2-3.5 years). Our assessment showed that 28% had hypertension, 27% were obese, 19% had altered glucose metabolism, and 33% had dyslipidemia. The risk of having dyslipidemia was associated with higher age [relative risk (RR): 1.28, 95%CI: 1.14-1.44, P<0.01] and body mass index (BMI) (RR: 1.76, 95%CI: 1.11-2.78, P=0.02). Participants who increased their BMI during treatment were at higher risk of obesity (RR: 3.01, 95%CI: 1.44-6.29, P<0.01). The increase of BMI during treatment was associated with exposure to glucocorticoids (coefficient β: 0.56, 95%CI: 0.13-0.98, P=0.01) and to methotrexate (coefficient β: 0.73, 95%CI: 0.34-1.11, P<0.01). Conclusion: We found important alterations of children’s cardiometabolic profile shortly after the end of cancer treatment. Increased BMI during and after treatment and exposure to corticosteroids and methotrexate were factors associated with cardiometabolic health. This stresses the importance of maintaining a favorable nutritional status during cancer therapy. Early nutritional interventions promoting sustainable healthy eating habits may contribute to limit cardiometabolic complications in the short and long term. Citation Format: Veronique Belanger, Alexandre Warin, Elitsa Tonova, Isabelle Bouchard, Caroline Meloche, Daniel Curnier, Serge Sultan, Caroline Laverdiere, Daniel Sinnett, Valerie Marcil. Cardiometabolic complications after pediatric cancer: Associations with chemotherapeutic agents and body-mass-index fluctuations [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr B59.

Effectiveness and safety of irreversible electroporation for recurrent hepatocellular carcinoma ineligible for thermal ablation after surgery

ObjectivesTo preliminarily evaluate the clinical effectiveness and safety of computed tomography (CT) image-guided irreversible electroporation (IRE) for the treatment of recurrent hepatocellular carcinoma (HCC) after surgical resection. MethodsFrom January 2016 to February 2018, 18 patients diagnosed with recurrent HCC after surgical resection received IRE under CT image guidance for 22 tumors. Patients were enrolled for IRE when ineligible for thermal ablation due to tumor location. Clinical records and imaging data were reviewed to assess complete ablation rate, local tumor progression free rate (LTPFR), local tumor progression free survival (LTPFS) and complications after a median follow-up time of 14 months. ResultsSuccessful complete ablations were achieved in 20/22 (90.1%) tumors. Mean LTPFS was 10.5 ​± ​9.4 months. Overall 3-, 6- and 12-months LTPFR in 22 tumors following IRE were 68.2% (95% confidence interval [CI]: 45%–83%), 59.1% (95% CI: 33%–76%) and 36.4% (95% CI: 17%–56%), respectively. Complications included pneumothorax (2/18, 11.1%), localized pain (3/18, 16.7%), bile duct dilation (1/18, 5.6%) and transient hypertension (1/18, 5.6%). No major complications or treatment-related deaths were observed. The alpha-fetoprotein levels of two patients decreased to the normal range at 3 and 4 months, respectively. ConclusionsThis study showed that percutaneous CT image-guided IRE can serve as a safe and effective treatment for recurrent HCC not suitable for thermal ablation.

Effects of subcutaneous esketamine on blood pressure and heart rate in treatment-resistant depression

The impact of multiple subcutaneous (s.c.) esketamine injections on the blood pressure (BP) and heart rate (HR) of patients with unipolar and bipolar treatment-resistant depression (TRD) is poorly understood. This study aimed to assess the cardiovascular safety of multiple s.c. doses of esketamine in patients with TRD. Seventy TRD patients received 394 weekly s.c. esketamine injections in conjunction with oral antidepressant therapy for up to six weeks. Weekly esketamine doses were 0.5, 0.75 or 1.0 mg/kg according to each patient's response to treatment. Participants were monitored before each treatment and every 15 minutes thereafter for 120 minutes. We assessed systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR measurements for the entire treatment course. BP increased after the first s.c. esketamine injection, reaching maximum mean SBP/DBP levels of 4.87/5.54 mmHg within 30-45 minutes. At the end of monitoring, 120 minutes post dose, vital signs returned to pretreatment levels. We did not detect significant differences in BP between doses of 0.5, 0.75, and 1 mg/kg esketamine. Mean HR did not differ significantly between doses or before and after s.c. esketamine injection. The BP changes observed with repeated s.c. esketamine injections were mild and well tolerated for doses up to 1 mg/kg. The s.c. route is a simple and safe method of esketamine administration, even for patients with clinical comorbidities, including obesity, hypertension, diabetes, and dyslipidemia. However, 14/70 patients experienced treatment-emergent transient hypertension (SBP >180 mmHg and/or a DBP >110 mmHg). Therefore, we strongly recommend monitoring BP for 90 minutes after esketamine dosing. Since s.c. esketamine is cheap, requires less frequent dosing (once a week), and is a simpler procedure compared to intravenous infusions, it might have an impact on public health.

Preliminary clinical observations of the effect of posterior continuous curvilinear capsulorhexis with intraocular lens optic capture in the treatment of pediatric cataract

Objective: To observe the preliminary clinical effect of intraocular lens optic capture through posterior continuous curvilinear capsulorhexis in the treatment of pediatric cataract. Methods: It was a retrospective case series study. Forty-three eyes of 28 children underwent posterior continuous curvilinear capsulorhexis with posterior chamber intraocular lens optic capture to treat cataract from June 2017 to October 2018 in Qingdao Eye Hospital. Postoperative best corrected visual acuity, diopters, intraocular pressure, the position of intraocular lens, and postoperative complications were assessed. The distribution of preoperative and postoperative best corrected visual acuity was analyzed by Fisher's exact probability test. Results: Twenty-eight patients were 14 females and 14 males aged from 2 years old to 12 years old [mean age, (7±4) years]. All intraocular lenses were successfully captured in the posterior capsule. Patients were followed-up for 6.0 to 12.0 months (mean, 8.4 months). Except 2 eyes from one uncooperative child, the distribution of preoperative and postoperative best corrected visual acuity (<0.1, 0.1-<0.3, 0.3-<0.5, ≥0.5) had a significant difference (17, 17, 4, 3 eyes vs. 4, 4, 5, 28 eyes, P<0.01). At the last postoperative follow-up visit, the mean spherical equivalent was (0.21±0.74) D. Transient intraocular hypertension occurred in 3 eyes at 1 week after surgery and was controlled with stopping the use of corticosteroid eyedrops. No visual axis opacification or intraocular lens decentration or tilt was observed during the follow-up period. No other complications such as iris synechia, secondary glaucoma, retinal detachment, and cystoid macular edema were observed. Conclusions: Posterior continuous curvilinear capsulorhexis with intraocular lens optic capture is a safe and effective technique to treat pediatric cataract. It has a significant effect on the prevention of visual axis opacification after cataract surgery in children. (Chin J Ophthalmol, 2020, 56: 343-348).

Gastrointestinal trichobezoar: An experience with 17 cases

BackgroundTrichobezoar is an exceedingly rare entity in children and mimics other chronic ailments such as abdominal tuberculosis or malignancy. Delayed diagnosis and management result in various complications. The study was conducted to describe our experience with 17 consecutive cases of gastrointestinal tract (GIT) trichobezoars. Materials and methodsWe reviewed medical records of 17 consecutive cases of GIT trichobezoar managed in our department between January 2005 and December 2018. ResultsThere were 3 males and 14 females. The median age of presentation was 7 years. Fifteen patients (88%) presented with abdominal pain and vomiting, while 8 (47%) had abdominal distension. Seven (41%) patients developed complications secondary to the GIT trichobezoar (intussusception and gangrene in 1, small bowel obstruction in 4, gastric perforation and massive bleeding per rectum in 1, acute transient pancreatitis and hypertension in 1). At operation, 9 (54%) patients had Rapunzel syndrome, 6 (35%) had gastric trichobezoar, and 2 (12%) had small bowel trichobezoars.One patient presented with massive bleeding per rectum and gastric perforation, succumbed postoperatively. One patient developed a recurrent trichobezoar. ConclusionGIT trichobezoar is rare in children and simulates chronic gastrointestinal ailments. Trichobezoars may reside in the alimentary tract, remain unnoticed for years, and become overt with the onset of complications.The majority of trichobezoars had a tail in our series. Life threatening complications can occur with delayed presentations. Type of studyCase series. Level of evidenceLevel IV.

Modified Intraocular Lens Intrascleral Fixation Technique Using Two Vitrectomy Ports as Lens Haptic Fixation Sites.

IntroductionWe developed a new technique that uses two of the vitrectomy ports as intraocular lens (IOL) haptic fixation sites and compared that with a conventional T-fixation method.MethodsA total of 33 eyes were retrospectively divided into the port-fixation (n=21) and conventional (n=12) groups. For the port-fixation group, supranasal and inferotemporal trocars (25-gauge) were placed in the center of a T-shaped lamellar scleral incision 2 mm from the corneal limbus and a supratemporal trocar at 3.5 mm. Following a vitrectomy, along with lens or IOL extraction as needed, the infusion cannula was changed from an inferotemporal to supratemporal trocar. The first IOL haptic and trocar were then simultaneously withdrawn from the eye by grasping with vitreoretinal forceps, with the same performed for the second IOL haptic and trocar, after which the infusion cannula was removed. In the conventional group, 2 T-shaped scleral incisions and three trocars were separately placed.ResultsPostoperatively, transient ocular hypotension and hypertension were observed in a few eyes in both groups. At 6 months after surgery, astigmatism was 1.71±1.13 D in the port-fixation group and 2.21±1.78 D in the conventional group (p=0.40, t-test).ConclusionThis new technique may be effective because of the lower number of scleral wounds.

Clinical characteristics of transient vision disorders and arterial hypertension.

A study of 104 patients with a transient ischemic attacks (TIA) in the form of visual disorders was conducted to assess the factors that affect the development and probable localization of TIA. Neurological and ophthalmological status, structural characteristics of the brain and major arteries of the head (MAH) with the use of magnetic resonance therapy (MRT) and ultrasonic dopplerography were assessed. The age of patients ranged from 33 to 79 years (65.4 years in average). The control group consisted of 46 patients with an average age of 67.8 years without cerebral ischemic events and visual disorders. During the MRI, the presence of microstructural pathology of the brain was assessed; “leukoaraiosis” was considered; foci up to 2-3 mm that are vascular by genesis. Significant differences in the frequency of TIA occurrence in terms of gender were not detected in all age subgroups. In young patients with TIA, arterial hypertension was associated with signs of microstructural pathology (MSP) of the brain in 85.58% cases. TIA localization did not correlate with the grade of structural disorders of the MAH and the nature of retinopathy in all age groups. Frequency of TIA tended to increase (in the a. ophthalmica pool) with an increase in the grade of stenosis of the MAH and retinopathy. The control group had retinopathy of the 1st stage in 12 or 26.09%, showing a qualitative difference with the group of study. The study did not reveal any differences in the frequency of TIA (according to presentations to a medical institution) in patients of different age groups, which indicates the influence of others factors that are not related to aging, such as TIA factors. The state of the MAH and microcirculation of vessels are their markers and probable causative factors. Determination of markers for the prognosis of the deve­lopment of cortical TIA or TIA in a. ophthalmica pools are still an open issue, as well as the chances of the TIA development in other areas of cerebral blood supply. Thus, according to clinical and anamnestic data, transient ischemia in the patients, who have applied to medical institutions with complaints of transient vision disorder (impairment) and who have been diagnosed with TIA is detected mainly in the a. ophthalmica blood supply pool (89 or 85.58%), more rarely (in 15 or 14.42%) in the cortical areas of visual analyzer without gender and age differences. All age groups had TIA associated with MAH structure impairment, retinopathy, MSP of the brain (in 82% of men and 67% of women), this leads to the interpretation of such TIA as non-random events preceded by systemic disorders, which are the basis for the prediction and prevention of such conditions.

Surgical Outcomes of Retropupillary-Fixated Iris-Claw Intraocular Lens

Purpose:To assess the visual outcome and complications following retropupillary-fixated iris-claw intraocular lens (IOL) implantation.Methods:For this retrospective, non-comparative study, chart review of patients who underwent retropupillary iris-claw IOL implantation for the correction of aphakia from July 2014 to October 2018 and had a minimum postoperative follow-up of 2 months was carried out. Postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complications were noted.Results:One hundred and twenty-two eyes of 122 patients (mean follow-up: 7.48 ± 5.2 months, range, 2 months-3.5 years) were enrolled in the study. The mean logMAR CDVA improved from 1.36 ± 0.52 preoperatively to 0.5 ± 0.42 postoperatively, at the last follow-up visit (P < 0.0001). The final CDVA improved in 110 eyes (90.2%), remained unchanged in 8 eyes (6.6%), and worsened in 4 eyes (3.3%). In cases of pre-existing cystoid macular edema (CME) or excessive intraoperative manipulations, 0.05 ml of 4 mg intravitreal triamcinolone acetonide (IVTA) was injected at the end of the surgery. Twenty eyes (16.4%) had transient ocular hypertension (OHT), 6 eyes (4.9%) had persistent OHT, and 2 eyes (1.6%) progressed to glaucoma. Choroidal detachment was noted in 2 eyes (1.6%), CME in 6 eyes (4.9%), 2 eyes (1.6%) had retinal detachment, 20 eyes (16.4%) had significant ovalization of pupil, 8 eyes (6.6%) had one haptic disenclavation, 1 eye (0.8%) had corneal decompensation, and 1 eye (0.8%) had endophthalmitis.Conclusions:Retropupillary iris-claw IOL provides good visual rehabilitation with a few complications. Its ease of insertion and short surgical time makes it a good option to correct aphakia in patients with an inadequate capsular support.

Comparing TEE‐ vs Non–TEE‐guided cardioversion of atrial fibrillation: The ENSURE‐AF trial

ENSURE-AF (NCT02072434) assessed therapy with edoxaban vs enoxaparin-warfarin in patients with nonvalvular atrial fibrillation (AF) undergoing elective electrical cardioversion (ECV). To evaluate clinical features and primary efficacy (composite of stroke, systemic embolic events, myocardial infarction and cardiovascular mortality during study period) and safety endpoints (composite of major and clinically relevant nonmajor bleeding during on-treatment period) in patients awaiting ECV of AF with a transesophageal echocardiography (TEE)-guided vs a non-TEE-guided strategy. In this prospective, randomized, open-label, blinded endpoint study, 2199 patients were randomized to edoxaban 60mg once-daily (30mg for creatinine clearance 15-50mL/min, weight ≤60kg and/or concomitant use of P-glycoprotein inhibitor) or enoxaparin-warfarin. Primary efficacy endpoint and safety endpoint were reported. Associates of TEE use, efficacy endpoint and safety endpoint were explored using multivariable logistic regression. In total, 589 patients from the edoxaban stratum and 594 from the enoxaparin-warfarin stratum were allocated to the TEE-guided strategy. Primary efficacy was similar regardless of TEE approach (P=.575). There were no significant differences in bleeding rates, regardless of TEE approach (P=.677). Independent predictors of TEE use were as follows: history of ischaemic stroke/ transient ischaemic attack, hypertension and valvular heart disease. Mean CHA2 DS2 VASc and HAS-BLED score were independent predictors of the efficacy endpoint whilst mean age was an independent predictor of the safety endpoint. Thromboembolic and bleeding events were not different between patients undergoing TEE-guided strategy and in those undergoing an optimized conventional anticoagulation approach for ECV of AF.

A Phase 3 Trial of Luspatercept in Patients with Transfusion-Dependent β-Thalassemia

BackgroundPatients with transfusion-dependent β-thalassemia need regular red-cell transfusions. Luspatercept, a recombinant fusion protein that binds to select transforming growth factor β superfamily ligands, may enhance erythroid maturation and reduce the transfusion burden (the total number of red-cell units transfused) in such patients.MethodsIn this randomized, double-blind, phase 3 trial, we assigned, in a 2:1 ratio, adults with transfusion-dependent β-thalassemia to receive best supportive care plus luspatercept (at a dose of 1.00 to 1.25 mg per kilogram of body weight) or placebo for at least 48 weeks. The primary end point was the percentage of patients who had a reduction in the transfusion burden of at least 33% from baseline during weeks 13 through 24 plus a reduction of at least 2 red-cell units over this 12-week interval. Other efficacy end points included reductions in the transfusion burden during any 12-week interval and results of iron studies.ResultsA total of 224 patients were assigned to the luspatercept group and 112 to the placebo group. Luspatercept or placebo was administered for a median of approximately 64 weeks in both groups. The percentage of patients who had a reduction in the transfusion burden of at least 33% from baseline during weeks 13 through 24 plus a reduction of at least 2 red-cell units over this 12-week interval was significantly greater in the luspatercept group than in the placebo group (21.4% vs. 4.5%, P<0.001). During any 12-week interval, the percentage of patients who had a reduction in transfusion burden of at least 33% was greater in the luspatercept group than in the placebo group (70.5% vs. 29.5%), as was the percentage of those who had a reduction of at least 50% (40.2% vs. 6.3%). The least-squares mean difference between the groups in serum ferritin levels at week 48 was −348 μg per liter (95% confidence interval, −517 to −179) in favor of luspatercept. Adverse events of transient bone pain, arthralgia, dizziness, hypertension, and hyperuricemia were more common with luspatercept than placebo.ConclusionsThe percentage of patients with transfusion-dependent β-thalassemia who had a reduction in transfusion burden was significantly greater in the luspatercept group than in the placebo group, and few adverse events led to the discontinuation of treatment. (Funded by Celgene and Acceleron Pharma; BELIEVE ClinicalTrials.gov number, NCT02604433; EudraCT number, 2015-003224-31.)

West Syndrome: Clinical Characteristics, Therapeutics, Outcomes and Prognosis

Introduction: West syndrome (WS) is the most severe, devastating and/or catastrophic epileptic encephalopathy during the lactation period. However, until now, there are few comprehensive clinical studies in this regard in Cuba. Objective: To identify clinical characteristics of patients with WS, the related etiology, therapeutics and prognostic factors. Methods: An observational, descriptive and retrospective study of 39 patients with WS from the Centro Habana Teaching Pediatric Hospital, Havana, Cuba, comprising the period between January 2005 and December 2016 was carried out. Clinical data were recorded for each patient by review of clinical history. Statistical analysis was performed with use of the Statistical Package for Social Sciences. Results: The genetic, structural/metabolic etiology was predominant. Hypoxic ischemic encephalopathy (25.6%) and neurocutaneous syndromes (17.9%) were the cause more frequent of WS. The combined treatment of adrenocorticotropic hormone (ACTH) and vigabatrin (VGB) was used in 25 patients (64.1%). In 18 of them (72%) there was control of infantile spasms or reduction ≥ 50%, while in 14 patients (56%) the hypsarrhythmia disappeared in the first 6 months (p<0.05). All patients that used ACTH had transient hypertension as an adverse effect of this drug. 71.8% of the patients had moderate to severe delay in psychomotor development, 35.9% were diagnosed with Lennox-Gastaut syndrome and 43.6% with other epilepsies. There was an unfavorable evolution in 74.3% of the patients. The most significant prognostic factors for unfavorable evolution were male gender, symptomatic etiology, psychomotor delay and/or abnormality in the neurological examination, epileptic seizures, previous paroxysmal electroencephalogram, poor response to the treatment, persistence of hypsarrhythmia, and combination of more than three factors in 68.9% of the patients with unfavorable evolution (p <0.05). Conclusions: Our findings showed that the combined treatment with ACTH and VGB may decrease the time to disappearance of infantile spasms and hypsarrhythmia in patients with WS. Moreover, the unfavorable evolution of these patients is related with the etiology and combination of prognostic factors.

Transient Orthostatic Hypertension During Head-Up Tilt Test in Young Adults: A Phenotype of Blood Pressure Variability.

The mechanisms underlying orthostatic hypertension (OHT) remain poorly understood. The authors evaluated the cardiovascular, cerebrovascular dynamics, and autonomic response to head-up tilt test (HUTT) in young adults with symptoms of orthostatic intolerance and transient OHT. Forty-four female subjects were included (34 ± 13 years old) and categorized in three groups after a 30-minute 70° passive HUTT: symptomatic patients with OHT (surge of systolic blood pressure ≥20 mm Hg for at least 5 minutes at any given time during HUTT), orthostatic intolerance (symptomatic patients without orthostatic blood pressure changes), and healthy asymptomatic control subjects. At baseline, OHT patients had lower systolic blood pressure than orthostatic intolerance patients (103 ± 8 vs. 116 ± 10 mm Hg, p < 0.01) and lower baroreflex sensitivity than control subjects (15.8 ± 8.3 vs. 27.1 ± 11.7 ms/mm Hg, p = 0.01). On tilt, cardiac output decreased in OHT patients from 6.1 ± 1.4 L/minute during baseline to 5.2 ± 0.8 L/minute after 10 minutes of HUTT (p = 0.01). In OHT patients at 30 minutes of HUTT, sympathetic efferent heart activity was higher (77.4 ± 14.9 normalized units or nu) than orthostatic intolerant patients (63.5 ± 11.8 nu, p = 0.02) and control subjects (65.8 ± 11.2 nu, p = 0.05). Cerebrovascular resistance in OHT was higher than control subjects after 30 minutes (2.2 ± 0.8 vs. 1.6 ± 0.3 cm/second, respectively, p = 0.02). This study demonstrates that transient OHT can occur at any given time during HUTT. These patients exhibit a decrease in cardiac output and a hyperadrenergic response to tilt.

Long-term safety and efficacy of the PI3K inhibitor copanlisib in patients with relapsed or refractory indolent lymphoma: 2-year follow-up of the CHRONOS-1 study.

Safety profiles of oral PI3K inhibitors have resulted in US FDA black box warnings regarding fatal/serious toxicities. The approved intravenous PI3K inhibitor copanlisib has low incidence of severe toxicities and no black box warnings, but chronic treatment effects were unknown. We provide an update on safety and efficacy of copanlisib with a minimum 2-year follow-up of the CHRONOS-1 study. A total of 142 patients with histologically confirmed indolent B-cell lymphoma who had relapsed after or were refractory to ≥2 prior treatments received intravenous copanlisib 60 mg on days 1, 8, and 15 (28-day cycle). The primary efficacy endpoint was objective response rate (ORR) after ≥4 cycles (independent assessment). The predominant histology was follicular lymphoma (n = 104). The ORR was 60.6% (seven additional complete responses since primary analysis). Secondary endpoints of median duration of response, progression-free survival, and overall survival were 14.1 months (median follow-up, 16.1 months), 12.5 months (median follow-up, 14.0 months), and 42.6 months (median follow-up, 31.5 months), respectively. Median safety follow-up was 6.7 months; 26% of patients received treatment for >1 year. Common treatment-emergent adverse events (TEAEs) (all grade/grade 3/grade 4) were transient hyperglycemia (50.0%/33.1%/7.0%), diarrhea (35.2%/8.5%/0%), transient hypertension (29.6%/23.9%/0%), and neutropenia (28.9%/9.2%/14.8%). Serious AEs were largely unchanged, with no new cases of pneumonitis (4.2%), diarrhea (2.8%), or grade 5 events. Note, TEAEs showed no evidence for increased incidence or worsening following longer exposure in patients treated >1 year. Long-term follow-up of patients with relapsed/refractory indolent B-cell lymphoma treated with intravenous copanlisib demonstrated durable, enhanced responses without evidence of worsening TEAEs, as reported for orally administered PI3K inhibitors.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Eclampsia risk factors during pregnancy at donka national hospital maternity, university teaching hospital Conakry. Guinea

Objectives: The objectives of this work were to calculate the frequency of arterial hypertension during pregnancy, describe the epidemiological profile and identify risk factors for eclampsia. Methodology: This was a prospective of six (6) month descriptive study carried out in the obstetrics gynecology Department of the Donka National Hospital a University Teaching Hospital (CH) in Conakry. The study took place from 1 st to December 31st, 2018. Results: The frequency of arterial hypertension during pregnancy was 8.82% in the department. The epidemiological profile was that of an adolescent (32.8%), nulliparous (56%), coming from home (69.2%), having not performed ANC (52%), not schooled (68%) and housewives. Primigestity was the main risk factor (52.4%). Gestational age greater than 37 weeks was the most affected (62%). The reasons for consultation are dominated by headache (76%) and dizziness (68%). The main type of hypertension was preeclampsia (48%) followed by transient hypertension (28%) The dominant clinical form when received was pre-eclampsia (47.2%) followed by eclampsia (23%). Eclampsia was the major complication (48%). We recorded 6 cases of death that is 2.4%. At the first minute, 35.68% of new-borns had an APGAR score below 7 and by the fifth 25.5% scored below 7. Foetal morbidity was dominated by foetal hypotrophy (30.19%) followed by prematurity (23.92%). We recorded 30 cases of MFIU and 7 cases of neonatal death out of 255 births, ie 14.50%. Conclusion: The detection of risk factors by a good prenatal follow-up and the regular training of care providers for an adequate and multidisciplinary management (obstetrician, nephrologist and pediatrician) of hypertensive pregnant women and their new-borns can improve the maternal prognosis and foetal.

Comparison of the efficacy of two doses of dexmedetomidine in attenuating the hemodynamic response to intubation in patients undergoing elective cardiac surgery: A randomized double-blinded study.

Background and Aims:Transient tachycardia and hypertension associated with laryngoscopy and intubation may be hazardous to patients presenting for cardiac surgery. The α 2 agonist dexmedetomidine may blunt this stress response, but the optimal dose which will accomplish this without causing hypotension and bradycardia is not well established. The primary objective of this study was to compare the efficacy of two doses of dexmedetomidine (0.5 and 1 μg/kg) as a 15 min infusion in attenuating the hemodynamic stress response to laryngoscopy and endotracheal intubation in elective cardiac surgery.Material and Methods:Seventy six patients scheduled for elective cardiac surgery received a single preoperative dose of dexmedetomidine of either 0.5 μg/kg (low dose) or 1 μg/kg (high dose) as a 15-min infusion prior to induction. The hemodynamic response to laryngoscopy and endotracheal intubation (heart rate, systolic blood pressure, mean arterial pressure, and diastolic blood pressure) were recorded at different times. Independent sample t-test, Chi-square test of association, and repeated measures analysis of variance were used to analyze the collected data.Results:The incidence of hypertension following intubation was significantly more in the low-dose group. Administration of 1 μg/kg dexmedetomidine was not accompanied by hypotension or bradycardia.Conclusion:Dexmedetomidine in a dose of 1 μg/kg is more effective than 0.5 μg/kg for attenuation of hemodynamic stress response to intubation in cardiac surgery. A more graded increase in the dose of dexmedetomidine may lead to an optimum dose in attenuating the hemodynamic response to intubation.

Adenosine-Induced Transient Asystole During Surgical Treatment of Basilar Artery Aneurysms

To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Duration and magnitude of bidirectional fluctuation in blood pressure: the link between cerebrovascular dysfunction and cognitive impairment following spinal cord injury.

Individuals with spinal cord injury (SCI) have a significantly increased risk for cognitive impairment that is associated with cerebrovascular remodeling and endothelial dysfunction. The sub-acute stage following high thoracic SCI is characterized by increased fibrosis and stiffness of cerebral arteries. However, a more prolonged duration after SCI exacerbates cerebrovascular injury by damaging endothelium. Endothelial dysfunction is associated with reduced expression of transient receptor potential cation channel 4 that mediates the production of nitric oxide and epoxyeicosatrienoic acids following shear stress and the response to carbachol and other endothelium-dependent vasodilators. Reduced expression of CD31 in cerebral arteries also suggests the loss of endothelial cell integrity following chronic SCI. Repetitively transient hypertension and intermittent hypotension contribute to cerebrovascular endothelial dysfunction in the animals with a sub-acute stage of high thoracic SCI. The increase in vascular remodeling and endothelial dysfunction ultimately reduce cerebral blood flow, which promotes cerebral hypoperfusion and cognitive dysfunction in the chronic phase of SCI. In conclusion, the duration and magnitude of fluctuations in blood pressure after SCI play a vital role in the onset and progress of cerebrovascular dysfunction, which promotes the development of cognitive impairment.

Congenital Dyserythropoietic Anemia Type I Due to Biallelic CDAN1 mutations: Report from the Congenital Dyserythropoietic Anemia Registry (CDAR)

Congenital dyserythropoietic anemias (CDA) are rare hereditary diseases of abnormal erythropoiesis. The CDA Registry of North America (CDAR) (NCT02964494) was opened in 2016 to investigate the natural history and molecular biology of CDA. CDA type I (CDA-I) is a recessive form of CDA characterized by macrocytic anemia, hemolysis with inadequate reticulocytosis, and iron overload. The bone marrow shows binucleated erythroblasts with chromatin bridges by light microscopy and spongy heterochromatin in erythroblasts by electron microscopy. The phenotypic heterogeneity in presentation and course of CDA-I is remarkable. Most CDA-I cases are caused by biallelic mutations in CDAN1or C15orf41, and 10-20% do not have an identifiable mutation. Non-hematological features, especially skeletal features, were historically reported in 10-20% of patients (Wickramasinghe, 1998). Due to the rarity of CDA-I and its clinical overlap with several disorders, the diagnosis is often missed or delayed by up to 17 yrs (median) (Roy, 2019). We describe in this study the characteristics and clinical course of CDA-I patients due to CDAN1 mutations enrolled in CDAR. Patients with a phenotypic diagnosis of CDA and their family members were enrolled in CDAR. Clinical and demographic data were gathered from participants at study entry and updated periodically thereafter. Participants elect to give blood, bone marrow, and DNA samples to the biorepository associated with CDAR. Participants with a phenotypic diagnosis of CDA-I and confirmed mutations in CDAN1 were included in this study. Six participants had a diagnosis of CDA-I due to biallelic CDAN1 mutations, comprising 18% (6/33) of affected CDAR participants. CDAN1 mutations were found in 75% of cases diagnosed phenotypically as CDA-I. All six participants presented early in life with a variable degree of non-immune hemolysis, and the diagnosis was confirmed within a median of 2 years from presentation. The characteristics of participants are summarized in table 1. Two had family history of stillbirth or fetal demise in older siblings due to hydrops fetalis. One participant presented prenatally with fetal anemia and started intrauterine transfusions at 24 weeks of gestation; 2 presented with severe anemia and signs of hydrops, pulmonary hypertension, transaminitis, severe hyperbilirubinemia, and thrombocytopenia at birth; and 3 presented with neonatal jaundice and moderate anemia. All participants required blood transfusions in the neonatal period. Three had spontaneous improvement and did not require transfusions after the first year of life. One remained transfusion-dependent at last follow up at the age of 4 yrs. One became transfusion-independent after starting interferon-alpha at 1 yr of age and did not need further transfusions even after discontinuation at 3 yrs of age. One had splenectomy at 11 y.o because he was misdiagnosed to have a membrane disorder but presented in adulthood with hemolytic anemia and pulmonary hypertension and was diagnosed at that time with CDA-I by genetic sequencing. All participants had one or more non-hematological manifestations, including hypertrophic skin folds, onychocryptosis, curved toenails, syndactyly, café-au-lait spots, macrocephaly, spinal fusion, scoliosis, and short stature. One participant suffered a thalamic stroke in the postnatal period, 2 had transient neonatal pulmonary hypertension in the setting of severe anemia, and one had pulmonary hypertension post-splenectomy in adulthood. Ferritin was high in all participants at last follow up, and 4 received chelation therapy. In summary, mutations in CDAN1 are the most common identified mutations in CDAR. CDA-I causes early-onset macrocytic anemia, which may present prenatally, with variable severity of hemolysis ranging from hydrops to mild neonatal jaundice and anemia. Non-hematological manifestations, mainly skeletal, nail and skin abnormalities are more common in CDA-I than previously reported, and their presence in infants with unexplained anemia should raise suspicion for the diagnosis. The availability of molecular testing has significantly accelerated the diagnosis. Management of patients with CDA-I requires multidisciplinary approach from an early age to improve outcome. Collaboration between clinicians, scientists, patients, and families is needed to advance the understanding and treatment of this rare disease. Disclosures Chonat: Alexion: Other: advisory board; Agios Pharmaceuticals, Inc.: Other: advisory board. Kalfa:Agios: Other: local PI of clinical research trial; FORMA: Other: sponsored research agreement.

THE TUMOR PLOP WHO CRIED WOLF: A CASE OF METASTATIC CARDIAC ANGIOSARCOMA

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cardiac sarcomas are extremely rare, primary malignant tumors arising from the heart or great vessels. Due to their complex nature and infrequency, there is often a delay in diagnosis and thus, a dismal prognosis. Here, we review the case of a patient who presented with a constellation of symptoms that, over many weeks, led to the final diagnosis of metastatic cardiac angiosarcoma. CASE PRESENTATION: Our patient is a 63 year-old female with history of type 2 diabetes. She was undergoing an outpatient workup for multiple myeloma and was found to have worsening anemia, renal function and hip pain, secondary to a pathologic ischial fracture. On initial presentation, her chief complaint was progressive dyspnea. Physical exam was notable for tachypnea and tachycardia, and she was found to have an elevated D-dimer. CT angiogram of her chest was negative for pulmonary embolism, however, revealed a large left atrial mass with possible extension into the ventricle and bilateral pleural effusions. The multi-lobulated mass measured approximately 3 x 4 cm on echocardiogram. Secondary metastasis to the heart or primary benign myxoma was initially suspected. Further study with cardiac MRI determined that the mass was centered over the ostium of the left inferior pulmonary vein and covered in thrombus, thus favoring the diagnosis of sarcoma. Biopsy of the pathologic hip fracture was also consistent with metastatic sarcoma. Upon further staging, she was noted to have several abdominal soft tissue nodules, scattered lytic bony lesions, and a filling defect within the proximal jejunum. Initial treatment consisted of diuresis, steroids, bisphosphonates, as well as Lovenox for the associated thrombus. Later, she developed sharp abdominal discomfort and was found to have jejunal intussusception. EGD revealed an adjacent duodenal ulcer and biopsy with immunohistochemical studies was consistent with metastatic cardiac angiosarcoma. Given the location and size of the atrial tumor, surgical resection was not an option. The patient was started on a trial of olaratumab, typically used in soft-tissue sarcomas, and doxorubicin with possible future palliative radiation. Over the next six months, after multiple admissions with various complications and worsening pain, she elected to pursue hospice care. She passed away peacefully at home, approximately one year after her initial presentation. DISCUSSION: This case illustrates a complex case of metastatic cardiac angiosarcoma. Given the late presentation with distant metastasis to various sites within the abdomen and bone, it serves as an example of the devastating effects this rare form of cancer can have. CONCLUSIONS: The complex location of the mass and its paroxysmal extension through the mitral valve into the left ventricle likely caused transient mitral regurgitation and pulmonary hypertension, which likely caused her initial dyspnea on presentation. Reference #1: Patel SD, Peterson A, Bartczak A, et al. Primary cardiac angiosarcoma - a review. Med Sci Monit. 2014;20:103-9. Published 2014 Jan 23. https://doi.org/10.12659/MSM.889875 DISCLOSURES: No relevant relationships by Logan Rhea, source=Web Response