Search Results (1,605)

Background: The association of intravenous prostacyclin therapy, essential for improving prognosis and survival in pulmonary arterial hypertension (PAH), with gastric epithelial neoplasms is uncertain. This study aimed to analyze the clinicopathologic features of gastric neoplasms in patients with PAH undergoing continuous intravenous prostacyclin therapy. Methods: We screened the registry of patients with pulmonary hypertension who visited the NHO Okayama Medical Center. Of the patients with PAH managed between January 2003 and December 2022, those who underwent esophagogastroduodenoscopy (EGD) were assessed for gastric neoplasms. Their clinical, endoscopic, and histopathological data were reviewed. Results: Among the 186 patients with PAH, 56 underwent EGD, revealing 4 patients (aged 37–50 years) with gastric epithelial neoplastic lesions. All four patients received continuous intravenous prostacyclin therapy for a median of 151 months. Of the 98 patients who received prostacyclin, 28 patients underwent EGD; the prevalence of gastric epithelial neoplasms was 4.1% (4/98) and the endoscopic detection rate was 14.3% (4/28). All patients had multiple tumors against a background of hypertrophic gastropathy (histologically being foveolar epithelial hyperplasia), with shared features of distal location, elevated morphology, and absent submucosal invasion. However, lymph node metastasis was observed in one lesion. By immunohistochemistry, the tumors exhibited gastric-predominant mucus phenotype and were managed by surgical or endoscopic resection without recurrence. Conclusions: The consistent clinicopathologic features of these cases suggest an association between continuous intravenous prostacyclin therapy and the development of hypertrophic gastropathy with potential progression to gastric epithelial neoplasia. Further prospective clinical trials are warranted to ensure safer prostacyclin use. Full article

Neonatal shock presents a complex clinical challenge and is one of the leading causes of mortality. Traditionally, neonatal shock is equated to hypotension, and therapeutics are often initiated based on low blood pressure (BP) values alone. This fails to address the underlying goal of optimizing the tissue perfusion resulting in both over- and under-treatment of neonatal shock. Also, what defines a normal BP in neonates is still a contentious topic. Further, the most appropriate way of measuring BP in neonates with shock is still debated. Shock secondary to transient circulatory instability and patent ductus arteriosus, conditions that are unique to preterm neonates, have not been researched adequately. Treatment of myocardial dysfunction secondary to perinatal asphyxia, a leading cause of neonatal mortality, is still a conundrum. Quite similarly, there are only a handful of controlled trials evaluating therapeutics in some of the other commonly encountered conditions, namely, septic shock and hypoperfusion secondary to pulmonary hypertension. Even the universally practiced intervention of volume expansion with crystalloid boluses in shock is not backed by high-certainty evidence in neonates. Though the diagnostic modalities of functional echocardiography and near-infrared spectroscopy have aided greatly in the management of neonatal shock in recent years, these have not been proven to be associated with improved critical clinical outcomes such as mortality and major brain injury. To conclude, neonatologists often rely on limited evidence, mostly anecdotal, when treating neonatal shock. This review critically examines the current evidence with respect to various aspects of neonatal shock with an objective to identify the lacunae in the literature that may fuel future research, eventually paving the way to efficacious, safe and evidence-based clinical practice. Full article

Chronic thromboembolic pulmonary disease (CTEPD) and chronic thromboembolic pulmonary hypertension (CTEPH) are debilitating complications of acute pulmonary embolism (PE) that are characterized by fibrosis and organization of the thrombotic material within pulmonary artery branches. This pathology leads to increased right ventricular afterload and dead space ventilation, posing a risk of progressive pulmonary hypertension, right-sided heart failure, and potentially death if left untreated. Pulmonary endarterectomy (PTE) is a technically complex open-heart surgery considered to be a first-line treatment as it is a potentially curative therapy. Although PTE is highly successful in proximal disease, it may not reach the very distal branches. On the other hand, pulmonary vasodilator therapy is very effective in improving microvasculopathy but does not address the obstructive fibrotic component of the larger vessels. Balloon pulmonary angioplasty (BPA) is a novel percutaneous revascularization therapy in which traditional angioplasty techniques are used to relieve obstruction in the pulmonary arteries. This review discusses the currently accepted indications, patient selection, technical considerations, outcomes, and complications of contemporary BPA. This review will address knowledge gaps and future perspectives in BPA research. Full article

Background: Systemic sclerosis-associated pulmonary hypertension (SSc-PH) is widely recognized as the most severe subtype of connective tissue disease-associated pulmonary hypertension (CTD-PH), particularly in patients with complicating factors such as interstitial lung disease (ILD) and biventricular failure. This condition is associated with the poorest clinical outcomes among PH subtypes, presenting significant challenges in both management and prognosis. Despite the use of conventional therapies, including intravenous administration of epoprostenol, a promising prostacyclin analogue, treatment outcomes for SSc-PH remain suboptimal. While epoprostenol has demonstrated efficacy in reducing pulmonary arterial pressures, its clinical application is often constrained by the risk of ventilation–perfusion (V-Q) mismatch, particularly at higher doses. Case presentation: We report the case of a 73-year-old woman with SSc-PH complicated by ILD, who experienced progressive hemodynamic deterioration despite receiving optimized therapy with intravenous epoprostenol. Efforts to escalate the dose of epoprostenol were limited by the development of severe V-Q mismatch, precluding further dose increases. In light of these challenges, inhaled treprostinil was introduced as an adjunctive therapy. There were significant improvements in her pulmonary hypertension and hemodynamic parameters, ultimately allowing the discontinuation of intravenous dobutamine and stabilization of her hemodynamics, as well as her respiratory function, exercise capacity, and quality of life. Conclusions: This case highlights the potential clinical utility of combining inhaled treprostinil with intravenous epoprostenol for the treatment of SSc-PH in patients with concurrent ILD. By addressing the limitations associated with high-dose intravenous prostacyclin therapy, this combination approach may represent a promising therapeutic strategy for improving outcomes in this difficult-to-treat patient population. Further investigation is warranted to establish the efficacy and feasibility of this combination therapy in larger cohorts of patients with SSc-PH and associated ILD. Full article

Background: New-onset postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, occurring approximately in one-third of the patients. This study considered all-comer patients who underwent cardiac surgery to build a predictive model for POAF. Methods: A total of 3467 (Center 1) consecutive patients were used as a derivation cohort to build the model. The POLARIS score was then derived proportionally from the odds ratios obtained following multivariable logistic regression (MLR). The Brier Score, the area under the receiver operating characteristic curve, and the Hosmer–Lemeshow goodness-of-fit test were used to validate the model. Then, 2272 (Center 2) consecutive patients were used as an external validation cohort. Results: In the overall population (n = 5739), POAF occurred in 32.7% of patients. MLR performed in the derivation cohort showed that age, obesity, chronic renal failure, pulmonary hypertension, minimally invasive surgery, and aortic and mitral valve surgery were predictors of POAF. The derived POLARIS score was used to further stratify the population into four risk clusters: low (1.5–3), intermediate (3.5–5), high (5.5–7), and very high (7.5–9), each progressively showing an increase in POAF incidence. This was confirmed in a correlation analysis (Spearman’s rho: 0.636). Conclusions: The POLARIS score is a simple-to-use tool to stratify patients at higher risk of POAF. Precise identification of such patients might be used to implement clinical practice with the introduction of preoperative antiarrhythmic prophylaxis, further reducing the incidence of POAF and, potentially, its clinical sequelae, despite further investigations being warranted to test this model in prospective studies. Full article

A 2-month-old Shiba Inu was presented to an emergency veterinary clinic with decreased activity and was diagnosed with pulmonary hypertension secondary to a ventricular septal defect. The dog was referred to the TUAT Veterinary Medical Center for further evaluation. During treatment, a diverticulum was incidentally identified at the apex of the left ventricle. While the diverticulum caused no clinical symptoms, a cardiac synchronous computed tomography (CT) scan was performed to accurately assess its anatomical location and size. This case highlights the value of advanced imaging techniques in diagnosing complex congenital cardiac anomalies. Full article

Pulmonary hypertension associated with lung diseases and/or hypoxia is classified as group 3 in the clinical classification of pulmonary hypertension. The efficacy of existing selective pulmonary vasodilators for group 3 pulmonary hypertension is still unknown, and it is currently associated with a poor prognosis. The mechanisms by which pulmonary hypertension occurs include hypoxic pulmonary vasoconstriction, pulmonary vascular remodeling, a decrease in pulmonary vascular beds, endothelial dysfunction, endothelial-to-mesenchymal transition, mitochondrial dysfunction, oxidative stress, hypoxia-inducible factors (HIFs), inflammation, microRNA, and genetic predisposition. Among these, hypoxic pulmonary vasoconstriction and subsequent pulmonary vascular remodeling are characteristic factors involving the pulmonary vasculature and are the focus of this review. Several factors have been reported to mediate vascular remodeling induced by hypoxic pulmonary vasoconstriction, such as HIF-1α and mechanosensors, including TRP channels. New therapies that target novel molecules, such as mechanoreceptors, to inhibit vascular remodeling are awaited. Full article

Background/Objectives: Pulmonary arterial hypertension (PAH) is a complication of systemic sclerosis (SSc), and several screening algorithms have been proposed for the early detection of PAH in SSc. This study aimed to evaluate the predicting values of the DETECT algorithm for SSc-PAH screening in patients with SSc undergoing right heart catheterization (RHC) based on 2015 ESC/ERS echocardiographic criteria in a real-life setting. Methods: Patients fulfilling the 2013 ACR/EULAR classification criteria for SSc and with available data for PAH screening with the DETECT algorithm and the 2015 ESC/ERS echocardiographic criteria were retrospectively enrolled from January to June 2017 and then followed for 5 years. Baseline and annual clinical, laboratory, and instrumental data were collected. Results: A total of 33 out of 131 (25%) patients were selected based upon the ESC/ERS echocardiographic criteria, but 30 (23%) underwent RHC, while 51 (39%) patients with SSc were positive based on the DETECT algorithm. PAH diagnosis was confirmed in 28/30 cases (93.3%). The DETECT algorithm showed lower specificity and positive predictive value (PPV) (p < 0.0001) but higher sensitivity and negative predictive value (NPV) (p < 0.0001) than ESC/ERS criteria. Notably, patients with SSc with a negative DETECT screening at baseline had a low probability of developing PAH during a 5-year follow-up (OR 0.15, 95% CI 0.10–0.60—p < 0.0001). Conclusions: The DETECT algorithm has proven to be an easy, fast, and inexpensive tool for screening PAH in patients with SSc. Overall, a low probability of PAH using DETECT is highly predictive of a good prognosis. Full article

Background and Objectives: The aging population has led to a rise in cognitive impairments, including dementia, often associated with multimorbidity. Early diagnosis of cognitive decline is crucial, especially in primary care, where time constraints and the limitations of diagnostic tools may hinder accurate detection. This study aims to assess the cognitive functions of multimorbid patients using the Mini-Mental State Examination (MMSE) and the Lithuanian version of the General Practitioner Assessment of Cognition (LT-GPCOG). We hypothesized that the LT-GPCOG would perform similarly to the MMSE in suspecting cognitive impairments. Materials and Methods: This cross-sectional study, conducted from 2021 to 2022, included 796 patients aged 40–85, with arterial hypertension and at least one other chronic disease, recruited from seven Lithuanian primary health care centers. Cognitive function was assessed using the MMSE and LT-GPCOG, and statistical analyses were performed using SPSS to determine the association between cognitive impairment and various demographic and clinical variables. Results: Out of 796 participants, 793 completed the study. Cognitive impairment was suspected in 5.1% of participants based on MMSE and 4.2% based on the LT-GPCOG. Statistically significant associations were found between cognitive impairment and chronic obstructive pulmonary disease (COPD) (p = 0.008 and p = 0.003) in both tests and chronic kidney disease (CKD) (p = 0.005) while testing with the MMSE. Lower education and unemployment were also correlated with cognitive impairment (p = 0.008 and p < 0.001). Conclusions: The findings suggest that regular cognitive assessments should be integrated into the management of multimorbid patients, particularly those with COPD and CKD. The LT-GPCOG proved to be an efficient alternative to the MMSE in primary care settings, demonstrating comparable diagnostic accuracy. Further studies are also needed to assess the sensitivity and specificity of the LT-GPCOG test. Full article

Background: Treprostinil, which is administered via continuous subcutaneous or intravenous infusion, is a medication applied in the treatment of pulmonary arterial hypertension (PAH). The dose of treprostinil is adjusted on an individual basis for each patient. A number of factors determine how well patients respond to treatment. Objectives: The aim of this study was to identify factors that may influence the clinical response to the dose of treprostinil at 3 months after the start of therapy. Methods: The factors influencing treatment response were analyzed in consecutive PAH patients who started receiving treprostinil treatment. The treatment efficacy was assessed as improvement in 6 min walk distance (6MWD) and WHO functional class (WHO FC), a reduction in N-terminal prohormone of brain natriuretic peptide (NTproBNP), and the percentage of patients achieving low-risk status after 12 months of treatment. Results: A total of 83 patients were included in this analysis. Classification of patients according to the tertiles of treprostinil dose achieved at 3 months after drug inclusion shows that after 12 months of follow-up, the median WHO FC in the highest dose group was lower than that in the intermediate dose group (WHO FC II vs. WHO FC III, p = 0.005), the median NTproBNP was lower (922 pg/mL, vs. 1686 pg/mL, p = 0.036) and 6MWD was longer (300 m vs. 510 m, p = 0.015). The French Noninvasive Criteria (NIFC) scale score was higher (2 vs. 0, p = 0.008), and the Reveal scale score was lower (5.0 vs. 8.5, p = 0.034). In the group of patients who exceeded a dose of 19.8 ng/kg/min within 3 months, an improvement in 6MWD was observed significantly more often after one year of therapy, and they were more likely to show an increase in NIFC scale scores after one year of therapy than the group of patients who received the lower dose (65% vs. 30%, p = 0.02). In the group of patients younger than 50 years of age, a statistically significant correlation was observed between the dose of treprostinil achieved after three months of treatment and the parameters assessed after 12 months of treatment, including WHO FC, 6MWD, and NIFC prognostic scale scores (all p < 0.05). Conclusions: The clinical effect of treatment is critically dependent on the rapid escalation of the treprostinil dose during the first three months of treatment. Full article

Background: Hydrophilic polymer embolization (HPE) is a scarcely reported complication associated with endovascular procedures where the hydrophilic coating dislodges and disseminates to more distal vascular beds, leading to ischemic complications. The aim of this study is to assess the clinical outcomes associated with HPE in the literature and try to quantify it in a scoping manner. Methods: All reports with regard to HPE in the PubMed database where clinical data were available were included. Reports were excluded if no clinical data were available and only histopathological descriptions are available, if the language of the report was not in English, and if access could not be obtained to that specific report. Results: A total of 60 publications containing 111 patients were identified. The majority (N = 45, 75%) of the publications were “single-patient” case reports. An overwhelming minority of the reports reported underlying hypertension (N = 27, 45.0%) and ischemic heart disease (N = 28, 46.7%). The most common implicated procedures for HPE occurence were cardiac procedures (N = 28, 46.7%), intracranial procedures (N = 13, 21.7%) and aortic procedures (N = 10, 16.7%). Steroids were trialled in nine (15%) of the reports, mainly for HPE to the CNS (7/9), with no mortality in that specific group. However, HPE-related mortality, identified in 48/111 patients, was largely due to HPE with pulmonary and cardiac involvement (combined 36/48 of all deaths). Conclusions: HPE seems to be a rare occurrence, although low-quality evidence (mainly case reports) comprises most of the research on the subject. Fatal outcomes seem relatively common, and steroid therapy may be trialled in select cases. Further research, potentially through prospective registry studies may aid in providing more knowledge on HPE. Full article

Background: Undiagnosed and untreated atherosclerotic renal artery stenosis (ARAS) can result in end-stage kidney disease (ESKD). To obtain an accurate diagnosis, it is crucial to recognize the symptoms and signs suggesting renal artery stenosis (RAS) and perform appropriate diagnostic and treatment procedures afterward. Case Presentation: We present a case of a 60-year-old female patient with hypertensive crisis, acute heart failure (HF), and pulmonary edema as the initial signs of acute kidney injury (AKI) caused by right RAS and left renal artery occlusion in the presence of severe aortic atherosclerosis revealed on computed tomography angiography (CTA) of the abdomen. The patient’s renal function recovered completely following percutaneous transluminal angioplasty (PTA) with stent implantation in the right renal artery at the site of subocclusion. Conclusions: Even in patients with concomitant disorders like type-2 diabetes mellitus (T2DM), hypertension (HTN), or HF, the dilatation of significantly narrowed renal arteries due to severe calcifications can result in complete renal function recovery. Full article

Background/Objectives: Patients on chronic anticoagulation undergoing metabolic surgery represent an increased risk of complications, including both bleeding and thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The optimal perioperative management of patients who are receiving chronic anticoagulation therapy (CAT) is complex. In the colorectal surgery literature, patients on CAT have a 10% rate of peri-procedural bleeding and a 3% rate of thromboembolism. The aim of this study was to evaluate and compare the safety and postoperative outcomes between patients with and without CAT undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a tertiary referral center in the United Arab Emirates (UAE). Methods: All patients who underwent primary bariatric surgery between September 2015 and July 2019 were retrospectively reviewed. The first group included patients with CAT, and the second group included patients without CAT. Demographics, perioperative outcomes, and postoperative results were examined. Results: Our study included 542 patients, 22 (4%) with CAT and 520 (96%) without CAT. Mean age was 46.3 ± 10.5 years in the CAT group and 36.0 ± 11.7 years in the non-CAT group (p < 0.001); median BMI was 41.8 (range 33.1–61.3) and 42.7 (range 30.1–78.4) kg/m², respectively (p = 0.52). The CAT group had significantly higher rates of hypertension (77.2% vs. 32.5%, p < 0.001), obstructive sleep apnea (81.8% vs. 31.5%, p < 0.001), and coronary artery disease (31.8% vs. 2.8%, p < 0.001). In the CAT group, 8/22 (36.4%) patients underwent Roux-en-Y gastric bypass and 14/22 (63.6%) sleeve gastrectomy, compared to 228/520 (43.8%) and 292/520 (56.2%), respectively, in the non-CAT group (p = 0.51). There were no statistically significant differences in postoperative emergency department (ED) visits (18.1% vs. 24.2%, p = 0.51), early major complications (4.5% vs. 3.4%, p = 0.54), readmission rates within 30 days (4.5% vs. 3.6%, p = 0.56), or late complications (4.5% vs. 4.2%, p = 0.60). Mean length of stay was significantly longer in the CAT group (4.6 vs. 2.6 days, p < 0.001). The mean follow-up was 10 ± 7.3 months for the CAT cohort and 11 ± 9.7 months for the non-CAT cohort (p = 0.22). Weight loss outcomes at 12 months were comparable, with a percent total body weight loss (TBWL) of 27.0 ± 7.3% in the CAT group and 28.9 ± 8.3% in the non-CAT group (p = 0.29). There were no deaths in either group. Conclusions: In this series, at a tertiary referral center in the UAE, metabolic surgery is safe for CAT patients. Multidisciplinary preoperative preparation might be warranted to avert potential complications. Full article

The anterior lumbar interbody fusion (ALIF) and lumbar disc arthroplasty (LDA) procedures are both commonly performed to improve the quality of life and pain in people with lower back pain. However, few recent studies have compared 30-day complications on a large scale. The objectives of this study were to compare the 30-day complications seen after ALIF and LDA and identify risk factors for these complications. The National Surgical Quality Improvement Program (NSQIP) database was queried between the years 2012–2021 (10 years in total) for records of patients who underwent either ALIF or LDA as a primary procedure. Patients in each group underwent a 1:1 propensity match for age, gender, BMI, ASA status, diabetes mellitus (DM), hypertension requiring medication, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), inpatient/outpatient status, smoking status, and bleeding disorders. Bivariate and multivariate analyses were performed to determine significant differences in complications and risk factors between these cohorts. A total of 1218 propensity-matched subjects, with 609 receiving ALIF and 609 receiving LDA, were included in the analyses of this study. The incidence of extended length of stay (LOS) (>4 days) was higher in the ALIF cohort compared to the LDA cohort (14.6% vs. 4.76%, p < 0.001). Multivariate analysis demonstrated that subjects who underwent LDA had lower odds (Odds Ratio [OR]: 0.457; 95% Confidence Interval [CI]: 0.283–0.738, p = 0.001) of experiencing extended LOS compared to the ALIF cohort. Longer operative times increased the odds of prolonged LOS in both cohorts. The results of this study suggest that ALIF is associated with longer LOS than LDA when baseline demographic data are controlled. Further, longer operative times increase the odds that subjects receiving either ALIF or LDA will experience a prolonged LOS. Besides extended LOS, ALIF and LDA produce a relatively similar 30-day complication profile. Full article

Chronic lung diseases such as Chronic Obstructive Pulmonary Disease, Interstitial Lung Disease (ILD), and Pulmonary Hypertension (PH) are characterized by progressive symptoms such as dyspnea, fatigue, and muscle weakness, often leading to physical inactivity, and reduced quality of life. Many patients also experience significantly impaired exercise tolerance. While pulmonary, cardiovascular, respiratory, and peripheral muscle dysfunction contribute to exercise limitations, recent evidence suggests that hypoxia and impairments in cerebral oxygenation may also play a role in exercise intolerance. This narrative review (i) summarizes studies investigating cerebral oxygenation responses during exercise in patients with different types of chronic lung diseases and (ii) discusses possible mechanisms behind the blunted cerebral oxygenation during exercise reported in many of these conditions; however, the extent of cerebral desaturation and the intensity at which it occurs can vary. These differences depend on the specific pathophysiology of the lung disease and the presence of comorbidities. Notably, reduced cerebral oxygenation during exercise in fibrotic-ILD has been linked with the development of dyspnea and early exercise termination. Understanding the effects of chronic lung disease on cerebral oxygenation during exercise may improve our understanding of exercise intolerance mechanisms and help identify therapeutic strategies to enhance brain health and exercise capacity in these patients. Full article