99mTc-Tilmanocept Versus 99mTc-Sulfur Colloid in Lymphoscintigraphy: Sentinel Lymph Node Identification and Patient-Reported Pain.

Lymphoscintigraphy plays a vital role in sentinel lymph node (SLN) identification in oncologic breast surgery. The effectiveness of SLN localization and the degree of patient pain were compared between filtered 99mTc-sulfur colloid (99mTc-SC) and 99mTc-tilmanocept. Methods: A retrospective review of patients undergoing lymphoscintigraphy for breast cancer using 99mTc-SC (June 1, 2010, to December 31, 2011) or 99mTc-tilmanocept (June 1, 2013, to January 31, 2014) was performed. SLN appearance time and uptake, SLN pathology, proportion of positive SLNs removed, and pain scores were compared for each radiopharmaceutical using the χ2 test, Fisher exact test, and unequal variance t test, as appropriate. Results: In total, 76 patients, with 86 evaluated axillae, underwent lymphoscintigraphy: 29 with 99mTc-SC and 47 with 99mTc-tilmanocept. The mean SLN appearance time was 11.0 min for 99mTc-SC and 19.3 min for 99mTc-tilmanocept (P = 0.003). There was no difference in the mean transit uptake percentage: 2.2% for 99mTc-SC and 1.9% for 99mTc-tilmanocept (P = 0.55). 99mTc-tilmanocept identified a greater proportion of intraoperative blue nodes than did 99mTc-SC (P = 0.03). There was no significant difference between 99mTc-SC and 99mTc-tilmanocept in the number of SLNs removed, number of patients with positive SLNs, or pain score. Conclusion: 99mTc-SC use in lymphoscintigraphy is an acceptable alternative to 99mTc-tilmanocept for SLN detection in breast cancer, on the basis of the similarity in intraoperative SLN identification and pain scores.

Heart transplantation for infective endocarditis: Viable option for a limited few?

Active infection in the recipient is considered a relative contraindication for solid organ transplantation. However, heart transplantation (HT) can be curative in patients with ventricular assist device infections. For patients with infective endocarditis (IE), valve replacement is part of the management strategy based on emergent, acute, or elective indications. HT has been utilized as an uncommon and sporadic treatment option for carefully selected patients with refractory or recurrent IE after all other surgical treatment options have been exhausted or are not feasible. Herein, we review 19 published cases of IE in whom HT was undertaken in the setting of ongoing active infection with reported good outcomes. We attempt to propose general criteria for HT in the setting of IE and discuss challenges and hurdles that clinicians might encounter when considering HT for active IE in the absence of robust data or clearly defined criteria.

Progress in the Presence of Failure: Updates in Chronic Systolic Heart Failure Management.

OPINION STATEMENT: The therapeutic heart failure armamentarium has evolved from drugs to transplantation to devices through further understanding of its complex pathophysiology and pathogenesis. Current medications capitalize on our evolving understanding of the sympathetic and renin-angiotensin-aldosterone systems that subsequently promote both beneficial and maladaptive responses that ultimately yield a decrease in cardiac function. Despite these advancements, the prevalence of heart failure continues to rise and carries a significant burden on our patients and health care system. This presents a clinical dilemma on how best to care for a growing, complex, and heterogeneous cohort. Ideal treatments should decrease morbidity and mortality while providing an improvement in quality of life and functional capacity. New interventions will continue to become incorporated into everyday practice, but awareness and prevention should remain the mainstay followed by optimization of guideline-directed therapies. It is equally important to individually tailor our therapeutic approach. While strategies to treat heart failure with reduced ejection fraction continue to advance, our understanding of how best to treat specific etiologies remain in question. This review will focus on current and proposed novel interventions for the management of chronic, systolic heart failure including angiotensin receptor-neprilysin inhibitor, If channel antagonist, sodium-glucose cotransporter-2 inhibitors, and oral potassium binders.

Training medical students in the social determinants of health: the Health Scholars Program at Puentes de Salud.

PURPOSE: Given the large influence of social conditions on health, physicians may be more effective if they are trained to identify and address social factors that impact health. Despite increasing interest in teaching the social determinants of health in undergraduate medical education, few models exist. PARTICIPANTS AND METHODS: We present a 9-month pilot course on the social determinants of health for medical and other health professional students, which is based at Puentes de Salud, Philadelphia, PA, USA, a community health center serving a Latino immigrant population. This service-learning course, called the Health Scholars Program (HSP), was developed and implemented by volunteer medical and public health faculty in partnership with the community-based clinic. The HSP curriculum combines didactic instruction with service experiences at Puentes de Salud and opportunities for critical reflection. The HSP curriculum also includes a longitudinal project where students develop, implement, and evaluate an intervention to address a community-defined need. RESULTS: In our quantitative evaluation, students reported high levels of agreement with the HSP meeting stated course goals, including developing an understanding of the social determinants of health and working effectively with peers to implement community-based projects. Qualitative assessments revealed students' perception of learning more about this topic in the HSP than in their formal medical training and of developing a long-term desire to serve vulnerable communities as a result. CONCLUSION: Our experience with the HSP suggests that partnerships between academic medical centers and community-based organizations can create a feasible, effective, and sustainable platform for teaching medical students about the social determinants of health. Similar medical education programs in the future should seek to achieve a larger scale and to evaluate both students' educational experiences and community-defined outcomes.