Extracorporeal ultrafiltration in refractory heart failure

Сърдечната недостатъчност (СН) е значим здравен и социален проблем и, въпреки напредъка на медицината, продължава да бъде водеща причина за хоспитализациите в развитите страни. Основна изява на декомпенсация е хиперволемията, която при рефрактерна СН трудно може да бъде повлияна с познатите досега средства. В настоящия обзор е разгледана подробно ултрафилтрацията (УФ) като надежден, безопасен и ефективен метод за лечение на застойна рефрактерна СН. Описани са методиката, известните клинични проучвания в тази област, както и основните индикации и контраиндикации за нейното приложение.Heart failure (HF) is a major health and social problem and despite the advances in medicine it still remains the main cause for hospitalizations in the developed world. The main sign of decompensation is hypervolemia, which in refractory HF is difficult to treat with the currently available medications. This review studies in detail ultrafiltration (UF) as a safe, effective and promising method for management of refractory congestive HF. The procedure, the prominent clinical studies in this field, as well as the main indications and contraindications are described

Intensifying the treatment of familial hypercholesterolemia—the experience of a single center in Eastern Bulgaria

Introduction: Familial hypercholesterolemia (FH) is an established risk factor for the development of atherosclerotic cardiovascular diseases (CVD), which determines early morbidity and mortality. Intensive reduction of the high levels of low-density lipoprotein cholesterol (LDL-c) reduces the incidence of CVD.Aim: The aim of this article is to analyze changes in lipid levels after intensification of the treatment of patients with familial hypercholesterolemia.Participants and Methods: Lipid levels of 59 patients with familial hypercholestrolemia from Eastern Bulgaria were studied with the aim of optimizing the management at an FH treatment center at St. Marina University Hospital, Varna. The period covered was from October 2017 to July 2020. The diagnosis of FH was determined as probable or certain according to the Dutch Lipid Clinics Network (DLCN) with a score of ≥ 6 points. After evaluation of the inclusion criteria for initiating treatment with evolocumab, all patients were monitored every 6 months for their lipid status. Baseline demographic characteristics and changes in the levels of laboratory tests for total cholesterol, LDL-c, and HDL cholesterol (HDL-c) were analyzed. A t-test for grouped pairs was used to estimate the difference from the baseline.Results: Of all 59 who passed through the center, the majority were men (58%). The mean age was 57.66 ± 9.57 years, from 37 to 76 years. A total of 54% had ischemic heart disease, 30.5% had survived a myocardial infarction, and 12% had a previous stroke. The mean baseline of total cholesterol was 8.23 ± 3.65 mmol/L, that of LDL cholesterol was 5.31 ± 1.95 mmol/L, and that of HDL-c was 1.25 ± 0.4 mmol/L. After 6 months, LDL-c levels dropped down to an average of 2.46 ± 1.59 mmol/L (p <0.0001) and persisted for 2.5 years after onset. The same trend was observed for total cholesterol. Achieving different target levels of LDL-c was reached as early as the 6th month in 76% and 56% of the treated, respectively.Conclusion: The use of evolocumab in addition to statin therapy leads to a significant and lasting reduction in total and LDL cholesterol in patients with FH. A significant number of them achieve targeted levels of LDL-c, which reduces the risk of new cardiovascular events

Impact of KRAS mutation status on the efficacy of immunotherapy in lung cancer brain metastases

Immune checkpoint inhibitors (ICIs) have resulted in improved outcomes in non-small cell lung cancer (NSCLC) patients. However, data demonstrating the efficacy of ICIs in NSCLC brain metastases (NSCLCBM) is limited. We analyzed overall survival (OS) in patients with NSCLCBM treated with ICIs within 90 days of NSCLCBM diagnosis (ICI-90) and compared them to patients who never received ICIs (no-ICI). We reviewed 800 patients with LCBM who were diagnosed between 2010 and 2019 at a major tertiary care institution, 97% of whom received stereotactic radiosurgery (SRS) for local treatment of BM. OS from BM was compared between the ICI-90 and no-ICI groups using the Log-Rank test and Cox proportional-hazards model. Additionally, the impact of KRAS mutational status on the efficacy of ICI was investigated. After accounting for known prognostic factors, ICI-90 in addition to SRS led to significantly improved OS compared to no-ICI (12.5 months vs 9.1, p \u3c 0.001). In the 109 patients who had both a known PD-L1 expression and KRAS status, 80.4% of patients with KRAS mutation had PD-L1 expression vs 61.9% in wild-type KRAS patients (p = 0.04). In patients without a KRAS mutation, there was no difference in OS between the ICI-90 vs no-ICI cohort with a one-year survival of 60.2% vs 54.8% (p = 0.84). However, in patients with a KRAS mutation, ICI-90 led to a one-year survival of 60.4% vs 34.1% (p = 0.004). Patients with NSCLCBM who received ICI-90 had improved OS compared to no-ICI patients. Additionally, this benefit appears to be observed primarily in patients with KRAS mutations that may drive the overall benefit, which should be taken into account in the development of future trials

Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients

©AANS 2020. OBJECTIVE Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts. METHODS The authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed. RESULTS A total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p \u3c 0.001). Seventeen of 62 cases achieved an increased EOR \u3c 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months. CONCLUSIONS In this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection