Exosomal glypican-1 discriminates pancreatic ductal adenocarcinoma from chronic pancreatitis.

BACKGROUND AND AIMS: Pancreatic ductal adenocarcinoma (PDAC) diagnosis can be difficult in a chronic pancreatitis (CP) background, especially in its mass forming presentation. We aimed to assess the accuracy of glypican-1-positive circulating exosomes (GPC1+crExos) to distinguish PDAC from CP versus the state-of-the-art CA 19-9 biomarker. METHODS: This was a unicentric prospective cohort. Endoscopic ultrasound with fine-needle aspiration or biopsy and blood tests (GPC1+crExos and serum CA 19-9) were performed. RESULTS: The cohort comprised 60 PDAC and 29 CP (7 of which mass forming - MF) patients. Median levels of GPC1+crExos were significantly higher in PDAC (99.7%) versus CP (28.4%; p<0.0001) with an AUROC of 0.96 with 98.3% sensitivity and 86.2% specificity for a cut-off of 45.0% (p<0.0001); this outperforms CA 19-9 AUROC of 0.82 with 78.3% sensitivity and 65.5% specificity at a cut-off of 37 U/mL (p<0.0001). The superiority of% GPC1+crExos over CA 19-99 in differentiating PDAC from CP was observed in both early (stage I) and advanced tumors (stages II-IV). CONCLUSION: Levels of GPC1+crExos coupled to beads enable differential diagnosis between PDAC and CP including its mass-forming presentation.

Endoscopic submucosal dissection of gastric lesions using the "yo-yo technique".

One of the main difficulties during endoscopic submucosal dissection (ESD) is the mobilization of the partially resected lesion in order to improve access to the lesion edges and the dissection plane. In the current study, the feasibility and safety of a new "yo-yo technique" to facilitate ESD procedures were evaluated. A total of 17 consecutive patients with gastric lesions were included. A standard hemoclip and snare were used to pull and push the lesion margins in order to increase the access to the lesion edges and to the submucosal space. All lesions were resected en bloc, without perforation or significant bleeding requiring blood transfusion, and all patients were discharged within 7 days. Resected specimens and lesions were 24 - 58 mm (mean 36 mm) and 18 - 45 mm (mean 25 mm) in size, respectively. The "yo-yo technique" is feasible, easy, and safe, and allows the lesion to be pulled and pushed during the ESD procedure. Further use of this technique may lead to the expansion of its indications to other gastrointestinal regions.

Clinical presentation, management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF).

PURPOSE: We performed a survey on acute heart failure (AHF) in nine countries in four continents. We aimed to describe characteristics and management of AHF among various countries, to compare patients with de novo AHF versus patients with a pre-existing episode of AHF, and to describe subpopulations hospitalized in intensive care unit (ICU) versus cardiac care unit (CCU) versus ward. METHODS AND RESULTS: Data from 4,953 patients with AHF were collected via questionnaire from 666 hospitals. Clinical presentation included decompensated congestive HF (38.6%), pulmonary oedema (36.7%) and cardiogenic shock (11.7%). Patients with de novo episode of AHF (36.2%) were younger, had less comorbidities and lower blood pressure despite greater left ventricular ejection fraction (LVEF) and were more often admitted to ICU. Overall, intravenous (IV) diuretics were given in 89.7%, vasodilators in 41.1%, and inotropic agents (dobutamine, dopamine, adrenaline, noradrenaline and levosimendan) in 39% of cases. Overall hospital death rate was 12%, the majority due to cardiogenic shock (43%). More patients with de novo AHF (14.2%) than patients with a pre-existing episode of AHF (10.8%) (p = 0.0007) died. There was graded mortality in ICU, CCU and ward patients with mortality in ICU patients being the highest (17.8%) (p < 0.0001). CONCLUSIONS: Our data demonstrated the existence of different subgroups based on de novo or pre-existing episode(s) of AHF and the site of hospitalization. Recognition of these subgroups might improve management and outcome by defining specific therapeutic requirements.

[Temporal QT dispersion in patients with systemic blood hypertension]. / Dispersão temporal do QT em pacientes com hipertensão arterial sistêmica.

PURPOSE: To evaluate QT dispersion in hypertensive patients, with and without left ventricular hypertrophy, and compare with normal persons. METHODS: Thirty eight patients (21 male and 17 female, age 55 +/- 15 years) underwent echocardiography and simultaneous 12 lead, vertically aligned, electrocardiogram at 50 mm/s speed. No patient was on antiarrhythmic therapy. There were 19 non-hypertensive patients that constituted the control group (G-I). Group II was constituted by the other 19 patients, who were hypertensives. This group was further divided in group II-A (9 patients without left ventricular hypertrophy) and group II-B (10 patients with left ventricular hypertrophy). QT dispersion was obtained by the difference between the longest and the shortest QT registered. RESULTS: QT dispersion was significantly increased on hypertensive patients, both with and without left ventricular hypertrophy, when compared to controls (G-I 31 +/- 9 ms, G-II 52 +/- 15 ms. P < 0.0001; G-IIa 46 +/- 10 ms and G-IIb 56 +/- 18 ms X G-I, p < 0.0005). In hypertensive patients, there was no statistically significant difference between group II-A and group II-B. CONCLUSION: We conclude that QT dispersion is significantly increased on hypertensive patients when compared to non-hypertensive individuals and that such increase, occurs before left ventricular hypertrophy develops. These findings suggest that, in hypertensive patients, electrical changes in left ventricular myocardium can precede structural and morphological abnormalities. Such findings offer new insights into the mechanisms related to enhanced mortality among hypertensive patients.

Dispersäo temporal do QT em pacientes com hipertensäo arterial sistêmica / QT dispersion in patients with hypertension

OBJETIVO - Avaliar a medida da dispersäo do QT (DQT) em portadores de hipertensäo arterial sistêmica, com e sem hipertrofia ventricular esquerda (HVE) e comparar com indivíduos normais. MÉTODOS - Foram submetidos a ecocardiograma e eletrocardiograma (ECG) de 12 derivaçöes simultâneas, alinhadas, na velocidade de 50mm/s, 38 pacientes (21 homens e 17 mulheres, com idade média 55ñ15 anos). Nenhum deles estava em uso de antiarrítmicos. Dezenove eram näo hipertensos constituindo o grupo controle (G-I); 19 hipertensos (GII), sendo 9 sem HVE (índice de massa 96ñ33g/m²=GIIa) e 10 portadores de HVE (índice de massa 163ñ33 g/m²=GIIb). A DQT foi obtida pela subtraçäo entre o mior e o menor QT medidos nas 12 derivaçöes, obtendo-se a média de 3 batimentos consecutivos. RESULTADOS - A DQT foi maior nos indivíduos hipertensos com ou sem HVE, quando comparada com indivíduos controles (G-I31ñ9ms, G-II52ñ15ms, P<0,001; G-IIa 46ñ10ms e G-IIb 56ñ18ms X G-I, p<0,0005). Entretanto, quando comparamos entre si os indivíduos hipertensos com e sem hipertrofia ventricular esquerda, apesar de ter havido diferença em valores absolutos quando testado estatisticamente, essa diferença näo foi identificada. CONCLUSÄO - A DQT é significativamente maior nos indivíduos hipertensos e estas modificaçöes ocorrem antes do aparecimento de HVE, sugerindo que alteraçöes elétricas do miocárdio podem preceder alteraçöes morfológicas e estruturais. Estes achados podem servir como subsídios para a compreensäo dos mecanismos relacionados à maior mortalidade dos hipertensos

Purpose - To evaluate QT dispersion in hypertensive patients, with and without left ventricular hypertrophy, and compare with normal persons. Methods - Thirty eight patients (21 male and 17 female, age 55±15 years) underwent echocardiography and simultaneous 12 lead, vertically aligned, electrocardiogram at 50mm/s speed. No patient was on antiarrythmic therapy. There were 19 non-hypertensive patients that constituted the control group (G-I). Group II was constituted by the other 19 patients, who were hypertensives. This group was further divided in group II-A (9 patients without left ventricular hypertrophy) and group II-B (10 patients with left ventricular hypertrophy). QT dispersion was obtained by the difference between the longest and the shortest QT registered. Results - QT dispersion was significantly increased on hypertensive patients, both with and without left ventricular hypertrophy, when compared to controls (G-I 31±9 ms, G-II 52±15ms, P<0.0001; G-IIa 46±10ms and GIIb 56±18ms X G-I, p<0.0005). In hypertensive patients, there was no statistically significant difference between group II-A and group II-B. Conclusion - We conclude that QT dispersion is significantly increased on hypertensive patients when compared to non-hypertensive individuals and that such increase, occurs before left ventricular hypertrophy develops. These findings suggest that, in hypertensive patients, electrical changes in left ventricular myocardium can precede structural and morphological abnormalities. Such findings offer new insights into the mechanisms related to enhanced mortality among hypertensive patients

[Hemodynamic evaluation during isotonic exercise of patients with orthotopic heart transplantation]. / Avaliação hemodinâmica durante exercício isotônico em pacientes submetidos a transplante cardíaco ortotópico.

PURPOSE: To evaluate the hemodynamic response of patients submitted to orthotopic heart transplantation during progressive isotonic exercise. METHODS: Eight patients who underwent orthotopic heart transplantation have been evaluated through invasive hemodynamic study during isotonic exercise. The mean right atrial pressure (RAP), pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), arterial blood pressure (ABP), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), heart rate (HR) and cardiac output (CO) have been determined in three distinct situations: at rest in the supine position (R), at rest with the legs up (RU) and during progressive isotonic exercise (E). The hemodynamic results at rest have been compared to the ones before transplantation. Phase RU and E results have been compared with each other. RESULTS: Comparing to the phase before transplantation at the R phase we found normalization of mean PAP (34.9 +/- 14.0 to 17.0 +/- 3.5 mmHg), RAP (7.3 +/- 4.3 to 2.9 +/- 1.9 mmHg) and CO (2.9 +/- 0.98 to 5.7 +/- 0.99 l/min), otherwise there was an increase in HR (89 +/- 15 to 94 +/- 13 bpm) mean ABP (84 +/- 25 to 115 +/- 12 mmH) and SVR (30 +/- 15 to 22 +/- 7 units Wood), (p < 0.05). Comparing phase E to phase RU, there was a significant increase in RAP (3.1 +/- 1.8 to 9.4 +/- 3.9 mmHg), mean PAP (21.0 +/- 2.8 to 37.0 +/- 10.0 mmHg), PAWP (8.1 +/- 2.1 to 15.0 +/- 5.8 mmHg), CO (5.8 +/- 0.8 to 9.9 +/- 2.4 l/min), HR (93 +/- 8 to 116 +/- 18 bpm) and a decrease in SVR (22.0 +/- 3.0 to 13.3 +/- 3.8 units Wood), (p < 0.05), otherwise there was no statistically significant modifications in PVR (2.2 +/- 0.7 to 2.3 +/- 1.2 units Wood) and mean ABP (129 +/- 12 to 129 +/- 15 mmHg), (p = NS). CONCLUSION: Patients submitted to heart transplantation may improve cardiac output mainly from increasing in stroke volume, associated with an increase in RAP and PAP. Nevertheless, the improvement increase in CO is compatible to exercise capacity after heart transplantation.

[Acute liver failure secondary to cardiogenic shock in patients with congestive heart failure]. / Falência hepática aguda secundária a choque cardiogênico em portadores de insuficiência cardíaca congestiva.

Fulminant hepatic failure is a complication of severe cardiocirculatory failure, with high morbidity and mortality, and is frequently misdiagnosed as fulminant viral hepatitis. We report three cases of patients with chronic severe heart failure who developed cardiogenic shock complicated by elevation of aminotransferase levels above 1,000 soon after the most severe episode of hypotension. All the three patients presented regression of hepatic enzymes 72h after admission. Two patients developed hepatic encephalopathy and renal failure. One underwent the implantation of an artificial left ventricle, followed by orthotopic heart transplantation. One died of systemic multiple organ failure, after he had showed improvement on his hepatic profile, and one was sent to the ward, after 15 days with marked improvement on his clinical status and no signs of hepatic disease.

[Arrhythmias following orthotopic heart transplantation]. / Arritmias após transplante cardíaco ortotópico.

PURPOSE: To correlate the incidence of arrhythmias to the degree of allograft rejection on endomyocardial biopsy. METHODS: Seventeen patients who underwent orthotopic heart transplantation were submitted to ambulatory Holter monitoring 24h prior to endomyocardial biopsy. The biopsy results were compared to Holter monitoring results. RESULTS: The mean study period was 252 +/- 166 days (15 to 515). We found a high incidence of ventricular premature beats (> 70%), except in patients with severe rejection (25%), but there was no statistically significant difference between the groups with no rejection, mild and moderate rejection. Atrial premature beats were more common in patients with mild and moderate rejection (53% and 70%, respectively) when compared to patients with no rejection (33%) and patients with severe rejection (9%), (p < 0.05). Sinus bradycardia was present in 50% of patients with severe rejection, but only in 9% of moderate, 3% of mild and 5% of the patients with no rejection (p < 0.05). CONCLUSION: Supraventricular tachycardia and atrial premature beats are related to moderate rejection. Ventricular premature beats are not related to degree of rejection. Sinus bradycardia occurring in the first year after transplantation should suggest severe cardiac allograft rejection.

[Percutaneous transluminal coronary angioplasty after orthotopic heart transplantation]. / Angioplastia coronariana transluminal percutânea após transplante cardíaco ortotópico.

We report the case of 22 year-old male who developed coronary artery disease two years after orthotopic cardiac transplantation, manifested as congestive heart failure NYHA functional class III. The left ventricular radioisotopic evaluation at rest revealed worsening of left ventricular ejection fraction from 50% to 39% (normal value > or = 55%) and septal hypokinesia. The hemodynamic and coronariographic study showed two subocclusive lesions at the mid portion and distal portion of the left descending coronary artery and the patient underwent PTCA of both lesions, successfully reducing them to 30%. A new radionuclide and echocardiographic evaluation of left ventricular function at rest, showed marked improvement of global function no regional abnormalities, increasing the ejection fraction from 39% to 45%. The patient showed improvement of NYHA functional class, passing to functional class II and was discharged home. We conclude that PTCA could be performed in a successful manner in this patient.