Unveiling the pathophysiology of gestational diabetes: Studies on local and peripheral immune cells.

Gestational diabetes mellitus (GDM) has been associated with impaired maternal immune response. Our aim was to review the available literature linking immune cells profile to GDM, in order to comprehend the role that different subpopulations play in the development of this pathology. We searched in PubMed for studies published in the last decade on circulating levels and placenta expression of immune cells on GDM. We identified 18 studies with several differences regarding the study design, clinical characteristics, number of participants, cell subpopulation and type of sample. Most studies assessed only one subpopulation either in peripheral blood or placenta and did not analyse functional properties of the cells. The most frequently evaluated immune cells were T lymphocytes, especially regulatory T (Tregs), and natural killer (NK) cells in the peripheral blood, and placental macrophages. No studies analysing B cells were identified, and only one study each evaluating γδT cells, dendritic cell (DC) and monocytes was found. Although there are controversies, at least one study reported positive association between GDM and CD4+ (activated), Tregs, Th17 and γδT cells; neutrophil/lymphocyte; NK cell (cytotoxic); macrophages; and monocytes. The number of studies is still small, so caution should be exercised in interpreting the data, and further research is required to validate these findings and establish the role of adaptive and innate immune cells in GDM pathophysiology.

Changes in serial B-type natriuretic peptide level independently predict cardiac allograft rejection.

BACKGROUND: Despite positive associations with rejection, the clinical value of B-type natriuretic peptide (BNP) monitoring in heart transplant recipients has not been established. We sought to determine the predictive value of changes in serial BNP level for identifying patients with acute allograft rejection. METHODS: BNP, hemodynamics and biopsies were obtained for 205 transplant recipients who underwent a total of 4,007 endomyocardial biopsy procedures. Samples analyzed were collected ≥ 180 days post-transplant, without evidence of rejection on the immediately preceding biopsy. Using a repeated-measures multivariate model, we assessed the association of change in BNP with Grade ≥ 3A (2R) rejection. We also determined predictive values of various cut-off thresholds of change in serial BNP levels to predict Grade ≥ 3A rejection. RESULTS: There were 47 episodes of Grade ≥ 3A rejection among the 1,350 samples analyzed. Median change in serial BNP (ΔBNP) for those with Grade ≥ 3A rejection was 20 pg/ml (IQR -26 to 169 pg/ml) and among those with Grade <3A rejection was -4 pg/ml (IQR -34 to 22 pg/ml, p = 0.003). On multivariate analysis, ΔBNP remained the most potent independent predictor of Grade ≥ 3A rejection (p = 0.001). ΔBNP >100 pg/ml predicted increased risk of Grade ≥ 3A rejection (OR = 5.3, p < 0.001) with high specificity (93.3%) and positive predictive value (13.0%) and excellent negative predictive value (97.3%). CONCLUSIONS: Change in serial BNP level is an independent predictor of cardiac allograft rejection. With wide availability, rapid turnaround, low cost, favorable positive predictive value and excellent negative predictive value, serial BNP monitoring has several advantages for non-invasive monitoring of heart transplant recipients for acute cardiac allograft rejection.

Versatility of hemisternotomy for cardiac surgery.

BACKGROUND: Hemisternotomy has been suggested as a way to reduce morbidity by limiting the invasiveness of surgical interventions but it is often limited to aortic valve disease. This study reviews the experience of one center employing hemisternotomy and compares patient outcomes, both in-hospital and post-discharge, with a matched group of full sternotomy patients. METHODS: Propensity scores were used to match all hemisternotomy valve cases (Hemi) to full sternotomy valve cases (Full) (1:2). An in-hospital composite outcome (COMP) was defined as mortality, stroke, deep sternal wound infection, sepsis, or return to operating room (OR) for bleeding or valve dysfunction. Provincial administrative health databases were used to determine freedom from mortality and hospital readmission for cardiac cause. RESULTS: During the study period, 70 patients received hemisternotomy for various cardiac surgical interventions with only 38 patients undergoing isolated aortic valve replacement. Examining valve surgery exclusively, 65 Hemi were matched to 130 Full. In-hospital complications were low in both groups, with 1.0% mortality and a non-significant trend toward COMP in the Full group (Hemi=4.6%; Full=8.5%; p=0.39). Ventilation time was significantly decreased in Hemi (median four vs. six hours; p=0.002). At two years follow-up, survival was excellent for both (Hemi=95.0%; Full=93.6%) and freedom from cardiac morbidity (Hemi=76.8%, Full=73.2%) was comparable. CONCLUSION: Hemisternotomy appears to be a safe, effective, and versatile alternative for many cardiac surgical interventions. With a median follow-up of four years, this study represents the longest cardiac morbidity follow-up for hemisternotomy patients. However, we were unable to conclusively show a morbidity benefit with this incision.

Preferred bonding motif for indium aminoethanethiolate complexes: structural characterization of (Me2NCH2CH2S)2InX/SR (X = Cl, I; R = 4-MeC6H4, 4-MeOC6H4).

The metathesis reaction of InCl3 with Me2NCH2CH2SNa or the redox reaction of indium metal with elemental iodine and the disulfide (Me2NCH2CH2S)2 yield the indium bis(thiolate) complexes (Me2NCH2CH2S)2InX [X = Cl (3) and I (4)], respectively. Compounds 3 and 4 may be further reacted with the appropriate sodium thiolate salts to afford the heteroleptic tris(thiolate) complexes (Me2NCH2CH2S)2InSR [R = 4-MeC6H4 (5), 4-MeOC6H4 (6), and Pr (7)]. Reaction of 2,6-Me2C6H3SNa with 4 affords (Me2NCH2CH2S)2InS(2,6-Me2C6H3) (8), while no reaction is observed with 3, suggesting a greater reactivity for 4. All isolated compounds were characterized by elemental analysis, melting point, and Fourier transform IR and 1H and 13C{1H} NMR spectroscopies. X-ray crystallographic analyses of 3-6 show a bicyclic arrangement and a distorted trigonal-bipyramidal geometry for In in all cases. The two sulfur and one halogen (3 and 4) or three sulfur (5 and 6) atoms occupy equatorial positions, while the nitrogen atoms of the chelating (dimethylamino)ethanethiolate ligands occupy the axial positions. The metric parameters of the (Me2NCH2CH2S)2In framework were found to change minimally upon variation of the X/SR ligand, while the solubility of the corresponding compounds in organic solvents varied greatly. 1H NMR studies in D2O showed that 6 and 7 react slowly with an excess of the tripeptide l-glutathione and that the rate of reaction is affected by the pendant thiolate ligand -SR.

Brain natriuretic peptide predicts serious cardiac allograft rejection independent of hemodynamic measurements.

BACKGROUND: Serum brain natriuretic peptide (BNP) has been reported to be elevated in heart transplant recipients with both cellular and vascular rejection. Whether BNP can be used to help predict the severity of rejection is not well established. METHODS: We analyzed serial BNP measurements obtained during endomyocardial biopsy procedures in consecutive heart transplant patients occurring >45 days after transplantation. To eliminate potential confounding from prior rejection episodes, we included only observations in which the previous biopsy grade was 0 or 1A. Multivariable linear regression was performed examining the outcome of increasing seriousness of rejection, defined as grade 0 < 1A < 2 < 1B < 3A < vascular rejection. A univariable logistic regression model was performed using log-transformed BNP as a predictor of vascular rejection. RESULTS: There were 77 patients, with 161 separate observations. Median time between transplantation and first assessment was 6.0 months (interquartile range, 2.1, 31.6). Using multivariable linear regression, 3 factors were significantly associated with biopsy score: pulmonary capillary wedge pressure (p < 0.0001), BNP (p = 0.003), and heart rate (p = 0.01). Even after other significant univariable predictors (including pulmonary capillary wedge pressure) were forced into the model, BNP remained a significant predictor of biopsy score (p = 0.02). Log BNP was a significant univariable predictor of vascular rejection, with an odds ratio of 12.55 (per 1 unit increase, 95% confidence interval 3.43-45.84; p = 0.0001) and a model c-statistic of 0.91. CONCLUSIONS: BNP predicts new episodes of serious cardiac allograft rejection, particularly vascular rejection, independent of hemodynamic measurements, and may be a useful part of rejection surveillance.

Successful treatment of vancomycin resistant Enterococcus faecium mediastinitis associated with left ventricular assist devices.

We present 2 cases of vancomycin-resistant Enterococcus faecium mediastinitis associated with left ventricular assist devices in the setting of heart transplantation. Despite complicated operative courses and deep infection secondary to antimicrobial resistant organisms, both patients were successfully treated and have remained infection free in the long term.

Nosocomial infections in left ventricular assist device recipients.

Infection remains a serious complication of left ventricular assist device (LVAD) implantation. We performed a cohort study to assess infections among patients who underwent LVAD implantation from October 1996 through May 1999. Thirty-six LVADs were implanted in 35 patients; the mean duration (+/- standard deviation) of LVAD use was 73+/-60 days (total for all patients, 2565 days). Sixteen patients developed surgical site infections (SSIs; rate, 6.2 infections per 1000 LVAD days); 9 were deep-tissue or organ/space infections and 7 were superficial. Other infections included 7 cases of pneumonia (rate, 2.7 cases per 1000 LVAD days), 6 venous infections (rate, 2.3 per 1000 LVAD days), 2 bloodstream infections (rate, cases 0.8 per 1000 LVAD days), 3 urinary tract infections, and 2 skin and soft-tissue infections. Deep SSIs were associated with the requirement for postoperative hemodialysis (P=.02). Overall use of antibiotics was extensive, and a trend toward infection with antibiotic-resistant organisms was noted. Infections were a frequent complication of LVAD implantation. Further studies of interventions for preventing infection in LVAD recipients are warranted.

Sindrome de Guillain-Barre com disturbio autonomico cardiocirculatorio / Guillain-Barre syndrome with autonomic dysfunction cardiocirculatory

A sindrome de Guillain-Barre e um disturbio inflamatorio agudo do sistema nervoso periferico, com envolvimento imunomediado...

Dynamic cardiomyoplasty: left ventricular diastolic compliance at different skeletal muscle tensions.

The possible limitation of left ventricular (LV) relaxation during diastole is a concern for clinicians and researchers utilizing dynamic cardiomyoplasty. This study was designed to evaluate the LV compliance at three different skeletal muscle tensions, in a normal heart and in a failing heart, created by propranolol infusion (11.6 mg/kg). A biventricular latissimus dorsi muscle (LDM) wrap was performed in 10 dogs. The LV pressure (Millar) and two minor axis dimensions (endocardial crystals) were measured. LV pressure-volume loops were constructed, and LV diastolic compliance was calculated. The measurements were obtained before wrap and after wrap at different LDM tensions with 0, 5, and 10 volts stimulation each time. These measurements were repeated after propranolol treatment. The results showed that LV diastolic compliance (dV/dP) was 1.79 before wrap and about 0.7 after wrap, and after propranolol, at various tensions and stimulations. LDM wrap decreased LV compliance significantly. LV compliance was not significantly affected by changing tension or voltage of stimulation in either the failing or the non-failing heart. The reduction in compliance may be an indication that LDM wrap causes a limitation of LV relaxation, which is one of wrap's deleterious effects.