Unraveling the Link Between Fibromuscular Dysplasia and Acute Coronary Syndrome: A Comprehensive Case Report and Analysis.

We present a rare case of fibromuscular dysplasia (FMD) manifesting in the mid to distal segment of the left anterior descending (LAD) artery, which led to the development of acute coronary syndrome (ACS) in our patient, highlighting the severe consequences of this vascular disorder. During the investigation of the patient's clinical symptoms, an unexpected incidental finding emerged, indicating bilateral FMD involvement of the renal arteries. This serendipitous discovery underscores the importance of comprehensive evaluation and thorough exploration when managing patients with FMD. We aim to shed light on the intriguing nature of FMD and emphasize the need for vigilant assessment to identify potential multi-vessel abnormalities, even beyond the primary affected site. We also aim to highlight the coronary artery manifestation of FMD as ACS and discuss its medical management.

The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.

Wellens' syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens' syndrome is seen in RCA and circumflex artery stenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens' syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery. The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens' syndrome is a precordial lead disease with T wave abnormalities that present with critical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens' syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens' syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.

Effect on intrinsic peroxidase activity of substituting coevolved residues from Ω-loop C of human cytochrome c into yeast iso-1-cytochrome c.

Naturally-occurring variants of human cytochrome c (Cytc) that induce thrombocytopenia IV occur within Ω-loop C (residues 40-57). These variants enhance the peroxidase activity of human Cytc apparently by facilitating access to the heme by destabilizing Ω-loops C and D (residues 70-85). Given the importance of peroxidase activity in the early stages of apoptosis, we identified three sites with the EVmutation algorithm in or near Ω-loop C that coevolve and differ between yeast iso-1-Cytc and human Cytc. We prepared iso-1-Cytc variants with all possible combinations of the S40T, V57I and N63T substitutions to determine if these residues decrease the peroxidase activity of iso-1-Cytc to that of human Cytc producing an effective off state for a peroxidase signaling switch. At pH 6 and above, all variants significantly decreased peroxidase activity. However, the correlation of peroxidase activity with local and global stability, expected if cooperative unfolding of Ω-loops C and D is required for peroxidase activity, was generally poor. The m-values derived from the guanidine hydrochloride dependence of the kinetics of imidazole binding to horse Cytc, which is well-characterized by native-state hydrogen exchange methods, and K72A/K73A/K79A iso-1-Cytc show that local structural fluctuations and not subglobal cooperative unfolding of Ω-loops C and D are sufficient to permit binding of a small molecule like peroxide to the heme. A 2.46 Å structure of N63T iso-1-Cytc identifies a change to a hydrogen bond network linking Ω-loops C and D that could modulate the local fluctuations needed for the intrinsic peroxidase activity of Cytc.

Learning curves for robot-assisted and laparoscopic partial nephrectomy.

OBJECTIVES: To evaluate the learning curve of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) between two surgeons at a single institution. METHODS: A prospectively maintained, Institutional Review Board (IRB)-approved kidney surgery database was reviewed retrospectively and the first 116 consecutive LPNs performed by one surgeon (Hyung Kim) and 116 consecutive RPNs performed by a second surgeon (Thomas Schwaab) were identified. The learning curve was evaluated by examining the operative times, warm ischemia times (WITs), estimated blood loss, the postoperative estimated glomerular filtration rate (eGFR), and intra- and postoperative complications in the quartiles of 29 patients. The LPNs performed by Hyung Kim were done following completion of a minimally invasive fellowship. Thomas Schwaab had minimal experience with LPN and no fellowship training before starting RAPN. RESULTS: The RAPN and LPN groups had similar patient and tumor characteristics. The RAPN group had a higher preoperative eGFR (74.1±22.04 vs. 80.95±21.25 mL/minutes, p=0.015) and a worse Eastern Cooperative Oncology Group (ECOG) performance status (ECOG 1+ in 12% vs. 2.6%, p<0.001) compared with the LPN group. Rates of intraoperative (p=0.203) and postoperative (p=0.193) complications were similar. In the RAPN group, operating room (OR) time (161±51 vs. 203±55 minutes, p<0.001) and WIT (17.7±14.8 vs. 21.8±9.1 minutes, p<0.001) were shorter. Postoperative stay was longer in the RAPN group (2.4±2.2 vs. 1.67±1.1 days, p<0.001). The percentage decrease in postoperative eGFR was lower in the RAPN group versus the LPN (9.6% vs. 10%). The learning curves differed for log tumor size, log WIT, and postoperative complications. CONCLUSIONS: The variables of the learning curve for RAPN can be obtained earlier than the same variables for LPN. RAPN had a shorter OR time and WITs. The shorter WITs, earlier in the series, led to consistently lower fluctuations in GFR and preservation of the renal function. The learning curves for each procedure need to be re-evaluated at longer intervals to ensure their accuracy.