Changes in estimated glomerular filtration rate over the first year following repeat heart transplant in children and young adults.

BACKGROUND: Renal function is reduced in patients undergoing heart transplant due to hemodynamic compromise, cardiorenal syndrome, and nephrotoxin exposure. No current studies evaluate renal function in retransplants. METHODS: We reviewed all heart transplants at our center from 1995 to 2021 and matched first-time heart transplants with retransplants, based on age at transplant, sex, and race. Estimated glomerular filtration rate (eGFR) was derived from CKiD-U25 calculator using creatinine and measured prior to transplant, 1-week post-transplant, 1-3, 6, and 12 months post-transplant, and recent follow-up. Changes in eGFR were measured within and between patients using a piecewise linear mixed effect model with matching. Exploratory univariate analysis was performed to evaluate pre-transplant risk factors for decreased eGFR. RESULTS: The unmatched cohort included 393 heart transplant recipients, with 47 being retransplants. Thirty-eight patients in both groups with at least 1 year of follow-up underwent matching. Both retransplants and first-time transplants had an initial decline in eGFR. eGFR rebounded to baseline or above baseline at 1-3 months post-transplant, but eGFR in retransplants remained significantly lower. At 1-year post-transplant, the average eGFR was 67.8 ± 4.3 mL/min/1.73 m2 versus 104.7 ± 4.3 mL/min/1.73 m2 (p < .001) in the retransplants and first-time transplants group, respectively. CONCLUSION: This study provides data on anticipated renal trajectory following retransplantation.

Sudden Cardiac Arrest in the Postpartum Period Due to Long QT Syndrome and Dilated Cardiomyopathy.

We describe the case of a previously healthy patient presenting with sudden cardiac arrest in the postpartum period as a result of concomitant congenital type 1 long QT syndrome and BAG3 dilated cardiomyopathy. This case highlights the increased rate of cardiac events for patients with long QT syndrome in the postpartum period. (Level of Difficulty: Advanced.).

Thromboxane biosynthesis in cancer patients and its inhibition by aspirin: a sub-study of the Add-Aspirin trial.

BACKGROUND: Pre-clinical models demonstrate that platelet activation is involved in the spread of malignancy. Ongoing clinical trials are assessing whether aspirin, which inhibits platelet activation, can prevent or delay metastases. METHODS: Urinary 11-dehydro-thromboxane B2 (U-TXM), a biomarker of in vivo platelet activation, was measured after radical cancer therapy and correlated with patient demographics, tumour type, recent treatment, and aspirin use (100 mg, 300 mg or placebo daily) using multivariable linear regression models with log-transformed values. RESULTS: In total, 716 patients (breast 260, colorectal 192, gastro-oesophageal 53, prostate 211) median age 61 years, 50% male were studied. Baseline median U-TXM were breast 782; colorectal 1060; gastro-oesophageal 1675 and prostate 826 pg/mg creatinine; higher than healthy individuals (~500 pg/mg creatinine). Higher levels were associated with raised body mass index, inflammatory markers, and in the colorectal and gastro-oesophageal participants compared to breast participants (P < 0.001) independent of other baseline characteristics. Aspirin 100 mg daily decreased U-TXM similarly across all tumour types (median reductions: 77-82%). Aspirin 300 mg daily provided no additional suppression of U-TXM compared with 100 mg. CONCLUSIONS: Persistently increased thromboxane biosynthesis was detected after radical cancer therapy, particularly in colorectal and gastro-oesophageal patients. Thromboxane biosynthesis should be explored further as a biomarker of active malignancy and may identify patients likely to benefit from aspirin.

Concordance of ICD-10 Codes and the Clinical Diagnosis of Alcoholic Hepatitis.

INTRODUCTION: Many studies on alcoholic hepatitis (AH) use the International Classification of Disease (ICD) coding to identify patients. Data regarding the diagnostic accuracy of ICD codes for AH are limited. METHODS: A total of 151 patients with ICD-10 codes for AH were reviewed for the presence or absence of AH using standardized diagnostic criteria. RESULTS: Sixty-eight of the 151 patients met AH criteria, corresponding to a positive predictive value of 45%. Patients with AH experienced higher model for end-stage liver disease and mortality than those who did not ( P < 0.05). DISCUSSION: Our results suggest ICD-10 codes are not reliable for identifying AH. Studies using the ICD codes should be interpreted cautiously.

Management of Steroid-Resistant Nephrotic Syndrome in Children.

Nephrotic syndrome (NS) affects 115-169 children per 100,000, with rates varying by ethnicity and location. Immune dysregulation, systemic circulating substances, or hereditary structural abnormalities of the podocyte are considered to have a role in the etiology of idiopathic NS. Following daily therapy with corticosteroids, more than 85% of children and adolescents (often aged 1 to 12 years) with idiopathic nephrotic syndrome have full proteinuria remission. Patients with steroid-resistant nephrotic syndrome (SRNS) do not demonstrate remission after four weeks of daily prednisolone therapy. The incidence of steroid-resistant nephrotic syndrome in children varies between 35 and 92 percent. A third of SRNS patients have mutations in one of the important podocyte genes. An unidentified circulating factor is most likely to blame for the remaining instances of SRNS. The aim of this article is to explore and review the genetic factors and management of steroid-resistant nephrotic syndrome. An all language literature search was conducted on MEDLINE, COCHRANE, EMBASE, and Google Scholar till September 2021. The following search strings and Medical Subject Headings (MeSH) terms were used: "Steroid resistance", "nephrotic syndrome", "nephrosis" and "hypoalbuminemia". We comprehensively reviewed the literature on the epidemiology, genetics, current treatment protocols, and management of steroid-resistant nephrotic syndrome. We found that for individuals with non-genetic SRNS, calcineurin inhibitors (cyclosporine and tacrolimus) constitute the current mainstay of treatment, with around 70% of patients achieving full or partial remission and an acceptable long-term prognosis. Patients with SRNS who do not react to calcineurin inhibitors or other immunosuppressive medications may have deterioration in kidney function and may develop end-stage renal failure. Nonspecific renal protective medicines, such as angiotensin-converting enzyme inhibitors, angiotensin 2 receptor blockers, and anti-lipid medications, slow the course of the illness. Recurrent focal segmental glomerulosclerosis in the allograft affects around a third of individuals who get a kidney transplant, and it frequently responds to a combination of plasma exchange, rituximab, and increased immunosuppression. Despite the fact that these results show a considerable improvement in outcome, further multicenter controlled studies are required to determine the optimum drugs and regimens to be used.

Characteristics of Conversion Disorder in an Urban Academic Children's Medical Center.

Background. Literature on childhood conversion disorder (CD) is sparse and is mostly limited to the outpatient population. Method. Our study retrospectively examines the characteristics of childhood CD in 42 children and adolescents seen by the psychiatric consultation-liaison service in an urban academic medical center with a large minority population. Results. CD accounted for 11% of our consultations. The majority of patients were female adolescents, but in the younger cohort, the male-to-female ratio equalized. Other somatic symptoms and additional psychiatric diagnoses were common, anxiety disorders in particular. Antecedent stressors were identified in 95% of patients, most commonly related to family stressors. Recent or remote history of abuse was rare. Neurological presentations were complex, with almost half of the patients presenting with multiple distinct neurological symptoms. Hyperkinetic symptoms were more common than hypokinetic symptoms, and paroxysmal symptoms were more common than non-paroxysmal. No distress (la belle indifference) was found in only 25% of patients and about half of patients had no socio-academic impairment. High resource utilization was noted based on multiple specialist consultants, diagnostic studies, and length of stay. Conclusion. Much of our data confirms previous findings and contributes to what is becoming a more robust characterization of this population.

NEDD9 stimulated MMP9 secretion is required for invadopodia formation in oral squamous cell carcinoma.

Neural precursor cell expressed developmentally downregulated 9 (NEDD9) is a component of the metastatic signatures of melanoma, breast cancer, glioblastoma, lung cancer and head and neck squamous cell carcinoma (HNSCC). Here we tested the efficacy of NEDD9's domains in stimulating matrix metalloproteinase (MMP) secretion and invadopodia formation in cells stably expressing various NEDD9 mutants. Replacement of the 13 YxxP motif substrate domain (SD) tyrosines and the C-terminal Y629 with phenylalanines (F14NEDD9) eliminated tyrosine phosphorylation, MMP9 secretion and loss of invadopodia formation. Mutation of the N-terminal SH3 domain Y12 to glutamic acid (Y12ENEDD9) or phenylalanine (Y12FNEDD9) reduced MMP9 secretion and inhibited invadopodia formation. SH3 domain deletion (∆SH3NEDD9) resulted in the loss of MMP9 secretion and a lack of invadopodia formation. The SH3-SD domain (SSNEDD9) construct exhibited tyrosine phosphorylation and stimulated MMP9 secretion, as did ∆CTNEDD9 which lacked the C-terminus (∆C-terminal; ∆CT). E13NEDD9 expression blocked MMP9 secretion and invadopodia formation. MICAL1 (molecule interacting with Cas-L1) silencing with a short hairpin RNA reduced MMP9 secretion, vimentin and E-cadherin levels while increasing N-cadherin and Rab6 levels, consistent with reduced invasive behavior. These findings indicate that NEDD9 SD phosphorylation and SH3 domain interactions are necessary for increasing MMP9 secretion and invadopodia formation.

Rhabdomyolysis as a rare paraneoplastic presentation of acute myeloid leukemia.

We present the case of a 56-year-old man who presented with rhabdomyolysis and was found to have acute myeloid leukemia (AML). Our case is the first to show an association of rhabdomyolysis with AML. Although rhabdomyolysis is likely a very rare clinical presentation of AML, our case raises awareness for workup for AML in patients who present with rhabdomyolysis and other suspicious findings. Both conditions are medical emergencies and require immediate treatment.

Formation of a Spin-Forbidden Product, (1)[MnO4](-), from Gas-Phase Decomposition of (6)[Mn(NO3)3](.).

The manganese nitrate complex, [Mn(NO3)3](-), was generated via electrospray ionization and studied by tandem quadrupole mass spectrometry. The complex is assumed to decompose into [MnO(NO3)2](-) by elimination of NO2(•). The [MnO(NO3)2](-) product undergoes elimination of NO2(•) to yield [MnO2(NO3)](-), or elimination of NO(•) to yield [MnO3(NO3)](-). Both [MnO2(NO3)](-) and [MnO3(NO3)](-) yield [MnO4](-) via the transfer of oxygen atoms from the remaining nitrate ligand. The mechanism of permanganate formation is interesting because it can be generated through two competing pathways, and because the singlet ground state is spin-forbidden from the high-spin sextet [Mn(NO3)3](-) precursor. Theory and experiment suggest [MnO2(NO3)](-) is the major intermediate leading to formation of [MnO4](-). Theoretical studies show crossing from the high-spin to low-spin surface upon neutral oxygen atom transfer from the nitrate ligand in [MnO2(NO3)](-) allows formation of (1)[MnO4](-). Relative energy differences for the formation of (1)[MnO4](-) and (1)[MnO3](-) predicted by theory agree with experiment.

Synthesis of HCV replicase inhibitors: base-catalyzed synthesis of protected α-hydrazino esters and selective aerobic oxidation with catalytic Pt/Bi/C for synthesis of imidazole-4,5-dicarbaldehyde.

A robust convergent synthesis of the prodrugs of HCV replicase inhibitors 1-5 is described. The central 5H-imidazo[4,5-d]pyridazine core was formed from acid-catalyzed cyclocondensation of an imidazole-4,5-dicarbaldehyde (20) and a α-hydrazino ester, generated in situ from the bis-BOC-protected precursors 25 and 33. The acidic conditions not only released the otherwise unstable α-hydrazino esters but also were the key to avoid facile decarboxylation to the parent drugs from the carboxylic ester prodrugs 1-5. The bis-BOC α-hydrazino esters 25 and 33 were prepared by addition of ester enolates (from 23 and 32) to di-tert-butyl azodicarboxylate via catalysis with mild inorganic bases, such as Li2CO3. A selective aerobic oxidation with catalytic 5% Pt-Bi/C in aqueous KOH was developed to provide the dicarbaldehyde 20 from the diol 27.

The association between EMS workplace safety culture and safety outcomes.

BACKGROUND: Prior studies have highlighted wide variation in emergency medical services (EMS) workplace safety culture across agencies. OBJECTIVE: To determine the association between EMS workplace safety culture scores and patient or provider safety outcomes. METHODS: We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. A panel of medical directors, emergency medical technicians and paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures. RESULTS: Sixteen percent of all respondents reported experiencing an injury in the past three months, four of every 10 respondents reported an error or adverse event (AE), and 89% reported safety-compromising behaviors. Respondents reporting injury scored lower on five of the six domains of safety culture. Respondents reporting an error or AE scored lower for four of the six domains, while respondents reporting safety-compromising behavior had lower safety culture scores for five of the six domains. CONCLUSIONS: Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes.

Elucidating the pathways of degradation of denagliptin.

Stress testing or forced degradation studies of denagliptin (1) tosylate in solution and solid-state, its blends with excipients, and capsules were conducted in order to elucidate degradation pathways, aid formulation development, and generate data to support regulatory filings. In solution, denagliptin was stressed in acid, water, and base using organic cosolvents. In the solid-state, denagliptin was stressed under heat, humidity, and light. Blends of denagliptin with various excipients were stressed under heat and humidity in order to evaluate whether tablet was a viable dosage form. Capsules were stressed under heat, humidity, and light. It was found that denagliptin was stable in the solid-state, but degraded in solution, in blends with all excipients, and in capsules predominantly by cyclization to (3S,7S,8aS) amidine (2), which epimerized to (3S,7S,8aR) amidine (3). (3S,7S,8aR) amidine (3) subsequently hydrolyzed to the corresponding diketopiperazine (4). The purpose of this manuscript is to discuss the results of stress testing studies conducted during the development of denagliptin and the elucidation of its key degradation pathway.

The role of interferons in the treatment of osteosarcoma.

Interferons, a group of cytokines with antiangiogenic, direct antitumour and immunostimulating properties, have shown significant activity against osteosarcoma in vitro and in xenograft models. They have also been used in osteosarcoma clinical trials as a single adjuvant to surgery, with an apparent increase in relapse-free survival. In the ongoing EURAMOS 1 clinical trial, interferon alpha-2b is evaluated as an adjuvant treatment in osteosarcoma. This article reviews the rationale for the use of interferon in cancer with special reference to the treatment of osteosarcoma, including all published data of clinical efficacy in this disease.

Glucarpidase following high-dose methotrexate: update on development.

Glucarpidase (Carboxypeptidase G2 or Voraxaze) is a recombinant enzyme that belongs to the class of carboxypeptidases which are naturally occurring enzymes. Glucarpidase is able to cleave methotrexate (MTX) into non-cytotoxic metabolites that may help prevent or minimise subsequent toxicities such as renal failure. In this review, the authors outline the discovery of the carboxypeptidase class of enzymes and the pre-clinical data demonstrating that glucarpidase is highly effective in the rapid reduction of MTX levels. The authors summarise the compassionate use studies of glucarpidase for patients with nephrotoxicity following high dose MTX or with very high post-MTX levels and the current developmental status of the drug. In conclusion, glucarpidase has been shown to be very useful in emergency situations following administration of high-dose MTX. Glucarpidase has yet to receive marketing approval in the EU or USA, and we await further data from In conclusion, glucarpidase Phase I/II studies assessing routine prophylactic administration following high-dose methotrexate.

Workforce priorities: three steps to determine what they are & move forward.

In recent years, considerable media attention has been given to the shortage of EMTs and paramedics.(1-8) Reports appear often enough to raise concern among the public, the medical community and policymakers alike that an ongoing or pending nationwide "crisis" or "shortage" of EMS professionals is upon us. Rural challenges are particularly prevalent in media coverage.(5,6,9) The recent inclusion of a special rural EMS session at the National Conference of State Legislatures 2007 annual meeting suggests that concern among local politicians has reached a tipping point, which may prompt action.

Technology insight: water diffusion MRI--a potential new biomarker of response to cancer therapy.

Diffusion-weighted MRI (DW-MRI) is a functional imaging technique that displays information about the extent and direction of random water motion in tissues. Water movement in tissues is modified by interactions with hydrophobic cellular membranes, intracellular organelles and macromolecules. DW-MRI provides information on extracellular-space tortuosity, tissue cellularity and the integrity of cellular membranes. Images can be sensitive to large or small displacements of water, therefore, macroscopic water flows and microscopic water displacements in the extracellular space can be depicted. Preclinical and clinical data indicate a number of potential roles of DW-MRI in the characterization of malignancy, including determination of lesion aggressiveness and monitoring response to therapy. This Review outlines the biological basis of observations made on DW-MRI and describes how measurements are acquired and quantified, and discusses the interpretation of images and limitations of the technique. The strength of evidence for adoption of DW-MRI as a biomarker for the assessment of tumor response is presented.