Abstract
There are limited data on the effects of anthracyclines on right ventricular (RV) structure, function, and tissue characteristics. The goal of this study was to investigate the effects of ...anthracyclines on the RV using cardiac magnetic resonance (CMR). This was a post-hoc analysis of a prospective study of 27 breast cancer (BC) patients (51.8 ± 8.9 years) using CMR prior, and up to 3-times after anthracyclines (240 mg/m
2
) to measure RV volumes and mass, RV extracellular volume (ECV) and cardiomyocyte mass (CM). Before anthracyclines, LVEF (69.4 ± 3.6%) and RVEF (55.6 ± 9%) were normal. The median follow-up after anthracyclines was 399 days (IQR 310–517). The RVEF reached its nadir (46.3 ± 6.8%) after 9-months (
P
< 0.001). RV mass-index and RV CM decreased to 13 ± 2.8 g/m
2
and 8.13 ± 2 g/m
2
, respectively, at 16-months after anthracyclines. The RV ECV expanded from 0.26 ± 0.07 by 0.14 (53%) to 0.40 ± 0.1 (
P
< 0.001). The RV ECV expansion correlated with a decrease in RV mass-index (r = −0.46;
P
< 0.001) and the increase in CK-MB. An RV ESV index at baseline above its median predicted an increased risk of LV dysfunction post-anthracyclines. In BC patients treated with anthracyclines, RV atrophy, systolic dysfunction, and a parallel increase of diffuse interstitial fibrosis indicate a cardiotoxic response on a similar scale as previously seen in the systemic left ventricle.
ABSTRACT
André Brouillet’s (1857-1914) famous group tableau ‘A Clinical Lesson at
La Salpêtrière
’ (French:
Une leçon clinique à la Salpêtrière
) is possibly the most celebrated painting in the ...history of neurology. His depiction of one of Jean-Martin Charcot’s legendary “
Tuesday Lessons
” includes portraits of not only one of the master’s most famous patients, but also of his pupils, the heirs to the founder of modern neurology. However, the painter himself has long been neglected, and even his other paintings on medical subjects are little acknowledged. The authors aim to bring attention to Brouillet’s life and times, as well as the remainder of his notable works; and in giving a proper context to the famous painting, neurologists today may be able to appreciate better the early history of our field and its cultural impact.
ABSTRACT
First described by Retzius at the end of the 19th century, the structure in the posterior medulla oblongata, then named area postrema, underwent an intense investigation into its function in ...the decades that followed. Findings, mainly in animal studies, have partially elucidated its role as an emetic center in the central nervous system. In the second half of the 20th century, this function was associated with reports of syndromes characterized by uncontrollable nausea and vomiting related to structural damage in the area postrema, mainly in the context of demyelinating diseases. At the beginning of the 21st century, the so-called area postrema syndrome has been consolidated as a diagnostic factor in diseases related to the spectrum of neuromyelitis optica, more than 100 years after its first description.
Abstract
At the beginning of the 20th century, cerebrospinal fluid (CSF) collection and analysis emerged as a promising aid in the diagnosis of diseases of the central nervous system. It was obtained ...through the established procedure of lumbar puncture, described by Heinrich Quinke in 1891. The search for an alternative way to gather the CSF emerged in animal research, highlighting the cisterna magna as a promising source, with relative safety when performed by someone trained. Described initially and in detail by James Ayer in 1920, the procedure was widely adopted by neurologists and psychiatrists at the time, featuring its multiple advantages and clinical applications. After a period of great procedure use and exponential data collection, its complications and risks relegated the puncture of the cisterna magna as an alternative route that causes fear and fascination in modern Neurology.
ABSTRACT
Aloysio de Castro (1881-1959) is now remembered as one of Brazil's greatest physicians and is considered the father of Brazilian neurological semiology. However, his interests went far ...beyond the realm of Medicine, and he became one of the most illustrious intellectuals of his time. In 1927, he gave a speech at the São Paulo Society of Artistic Culture on Frédéric Chopin and embarked on a journey across the composer's life and times, discussing the medical issues involving his death, as well as his lovers, his compositions, and the spiritual aspects of musical interpretation. Thus, Castro reinforced the bonds of music and Medicine and provided lessons on Musicology that may very well be as suited to a hospital as they are to a concert hall.
Recent evidence indicates a potential therapeutic role of fluvoxamine for COVID-19. In the TOGETHER trial for acutely symptomatic patients with COVID-19, we aimed to assess the efficacy of ...fluvoxamine versus placebo in preventing hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to a tertiary hospital due to COVID-19.
This placebo-controlled, randomised, adaptive platform trial done among high-risk symptomatic Brazilian adults confirmed positive for SARS-CoV-2 included eligible patients from 11 clinical sites in Brazil with a known risk factor for progression to severe disease. Patients were randomly assigned (1:1) to either fluvoxamine (100 mg twice daily for 10 days) or placebo (or other treatment groups not reported here). The trial team, site staff, and patients were masked to treatment allocation. Our primary outcome was a composite endpoint of hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to tertiary hospital due to COVID-19 up to 28 days post-random assignment on the basis of intention to treat. Modified intention to treat explored patients receiving at least 24 h of treatment before a primary outcome event and per-protocol analysis explored patients with a high level adherence (>80%). We used a Bayesian analytic framework to establish the effects along with probability of success of intervention compared with placebo. The trial is registered at ClinicalTrials.gov (NCT04727424) and is ongoing.
The study team screened 9803 potential participants for this trial. The trial was initiated on June 2, 2020, with the current protocol reporting randomisation to fluvoxamine from Jan 20 to Aug 5, 2021, when the trial arms were stopped for superiority. 741 patients were allocated to fluvoxamine and 756 to placebo. The average age of participants was 50 years (range 18–102 years); 58% were female. The proportion of patients observed in a COVID-19 emergency setting for more than 6 h or transferred to a teritary hospital due to COVID-19 was lower for the fluvoxamine group compared with placebo (79 11% of 741 vs 119 16% of 756); relative risk RR 0·68; 95% Bayesian credible interval 95% BCI: 0·52–0·88), with a probability of superiority of 99·8% surpassing the prespecified superiority threshold of 97·6% (risk difference 5·0%). Of the composite primary outcome events, 87% were hospitalisations. Findings for the primary outcome were similar for the modified intention-to-treat analysis (RR 0·69, 95% BCI 0·53–0·90) and larger in the per-protocol analysis (RR 0·34, 95% BCI, 0·21–0·54). There were 17 deaths in the fluvoxamine group and 25 deaths in the placebo group in the primary intention-to-treat analysis (odds ratio OR 0·68, 95% CI: 0·36–1·27). There was one death in the fluvoxamine group and 12 in the placebo group for the per-protocol population (OR 0·09; 95% CI 0·01–0·47). We found no significant differences in number of treatment emergent adverse events among patients in the fluvoxamine and placebo groups.
Treatment with fluvoxamine (100 mg twice daily for 10 days) among high-risk outpatients with early diagnosed COVID-19 reduced the need for hospitalisation defined as retention in a COVID-19 emergency setting or transfer to a tertiary hospital.
FastGrants and The Rainwater Charitable Foundation.
For the Portuguese translation of the abstract see Supplementary Materials section.
The placement of an intragastric balloon (IGB) plays an increasingly important role in the treatment of obesity. The authors describe the cases of 2 female patients, 34 and 62 years old, who were ...submitted to the implantation of a Spatz3® IGB to treat obesity. Ten to fourteen weeks later, the patients presented complaints of epigastric pain, vomiting, and abdominal distension. A bulging of the upper abdominal wall was noticed upon physical examination. Upper gastrointestinal endoscopy confirmed the clinical suspicion of IGB hyperinflation. It was decided to remove the 500 mL of saline solution with methylene blue from inside the balloon. During the same procedure, the IGB was refilled with 500 mL of fresh saline solution, methylene blue, and empiric β-lactam antibiotic. The extracted content of the hyperinflated IGB was sent for microbiological culturing and was found to be positive for Streptococcus viridans in one of the cases. In the other case, the culture examination was negative, and after 8 weeks, the patient presented again with hyperinflation of the IGB. It was then decided to substitute the IGB with another balloon; the procedure was uneventful. The content of the removed IGB was sent for microbiological testing, and colonization by Candida tropicaliswas confirmed. This is a rare but potentially serious complication of IGB placement. Randomized trials are needed to clarify the role of antibiotics and antifungals in primary and secondary prophylaxis against IGB hyperinflation.
The goal of this study was to demonstrate that cardiac magnetic resonance could reveal anthracycline-induced early tissue remodeling and its relation to cardiac dysfunction and left ventricular (LV) ...atrophy.
Serum biomarkers of cardiac dysfunction, although elevated after chemotherapy, lack specificity for the mechanism of myocardial tissue alterations.
A total of 27 women with breast cancer (mean age 51.8 ± 8.9 years, mean body mass index 26.9 ± 3.6 kg/m2), underwent cardiac magnetic resonance before and up to 3 times after anthracycline therapy. Cardiac magnetic resonance variables were LV ejection fraction, normalized T2-weighted signal intensity for myocardial edema, extracellular volume (ECV), LV cardiomyocyte mass, intracellular water lifetime (τic; a marker of cardiomyocyte size), and late gadolinium enhancement.
At baseline, patients had a relatively low (10-year) Framingham cardiovascular event risk (median 5%), normal LV ejection fractions (mean 69.4 ± 3.6%), and normal LV mass index (51.4 ± 8.0 g/m2), a mean ECV of 0.32 ± 0.038, mean τic of 169 ± 69 ms, and no late gadolinium enhancement. At 351 to 700 days after anthracycline therapy (240 mg/m2), mean LV ejection fraction had declined by 12% to 58 ± 6% (p < 0.001) and mean LV mass index by 19 g/m2 to 36 ± 6 g/m2 (p < 0.001), and mean ECV had increased by 0.037 to 0.36 ± 0.04 (p = 0.004), while mean τic had decreased by 62 ms to 119 ± 54 ms (p = 0.004). Myocardial edema peaked at about 146 to 231 days (p < 0.001). LV mass index was associated with τic (β = 4.1 ± 1.5 g/m2 per 100-ms increase in τic, p = 0.007) but not with ECV. Cardiac troponin T (mean 4.6 ± 1.4 pg/ml at baseline) increased significantly after anthracycline treatment (p < 0.001). Total LV cardiomyocyte mass, estimated as: (1 − ECV) × LV mass, declined more rapidly after anthracycline therapy, with peak cardiac troponin T >10 pg/ml. There was no evidence for any significant interaction between 10-year cardiovascular event risk and the effect of anthracycline therapy.
A decrease in LV mass after anthracycline therapy may result from cardiomyocyte atrophy, demonstrating that mechanisms other than interstitial fibrosis and edema can raise ECV. The loss of LV cardiomyocyte mass increased with the degree of cardiomyocyte injury, assessed by peak cardiac troponin T after anthracycline treatment. (Doxorubicin-Associated Cardiac Remodeling Followed by CMR in Breast Cancer Patients; NCT03000036)
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The sheer magnitude of Jean-Martin Charcot's contributions to neurology, pathology, psychiatry, and internal medicine has allowed for the common usage of eponyms bearing the master's name in ...recognition of his work. However, these are so numerous that confusion has naturally arisen concerning the exact nature of each eponym, allowing for different specialists to refer to completely different ailments or symptoms, while using the very same expression. Previous compilations of his eponyms were often incomplete. Therefore, the authors aimed to bring some clarification into the nature and origin of each known eponym with Charcot's name.
Intragastric balloon (IGB) is a minimally invasive and reversible therapy for weight loss with a good efficacy and safety profile. Introduced in the 1980s, IGBs have significantly evolved in the last ...couple of decades. They mechanically act by decreasing the volume of the stomach and its reservoir capacity, delaying gastric emptying, and increasing satiety leading to a subsequent weight loss. Despite the low rates of complications and mortality associated with IGBs, adverse events and complications still occur and can range from mild to fatal. This review aims to provide an update on the current scientific evidence in regard to complications and adverse effects of the use of the IGB and its treatment. This is the first comprehensive narrative review in the literature dedicated to this subject.
Graphical abstract
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