Matthew Vorsanger

Anterior spinal fusion for thoracolumbar scoliosis: comprehensive assessment of radiographic, clinical, and pulmonary outcomes on 2-years follow-up.

Background There is a continued role for anterior spinal fusion (ASF) in the treatment of thoracolumbar scoliosis. Despite numerous previous reports of ASF in the treatment of thoracolumbar scoliosis, no single study has simultaneously evaluated clinical, radiographic, and pulmonary function outcomes. Methods Retrospective review of 31 consecutive thoracolumbar adolescent idiopathic scoliosis patients (Lenke type 5) who underwent ASF by a single surgeon. Patient records were comprehensively assessed for Scoliosis Research Society (SRS)-22 score, apical trunk rotation, radiographic changes, and pulmonary function before surgery and at 2-years follow-up. Results Thoracolumbar/lumbar curve correction averaged from 45 to 11 degrees (74%) and spontaneous correction of thoracic curves averaged from 26 to 15 degrees (42%). Instrumented segment lordosis increased by 11 degrees, whereas proximal junction kyphosis increased by 3 degrees. No significant changes were noted in T2-T12 kyphosis, distal junctional kyphosis, T12-S1 lumbar lordosis, or coronal balance. Thoracolumbar apical trunk rotation improved from 12 to 3 degrees. Average SRS scores significantly improved from 3.9 to 4.4. SRS assessments of self-image and pain also improved significantly from 3.6 to 4.5 and from 4.1 to 4.6, respectively. Absolute and percent predicted forced vital capacity and forced expiratory volume in 1 second were unchanged. Two patients suffered mild intercostal neuralgia postthoracotomy. There were no other complications. Conclusions The thoracoabdominal anterior approach for thoracolumbar scoliosis facilitates excellent clinical and radiographic outcomes, minimal blood loss, powerful apical trunk rotation correction, relative maintenance of lordosis, relatively short fusion constructs, and improved SRS-22 performance, without significant pulmonary function impairment at 2 years. It continues to be an efficacious treatment for thoracolumbar scoliosis. Level of Evidence Level IV.

Decreased Production of Nitric Oxide by Peripheral Blood Mononuclear Cells of Patients with Peripheral Vascular Disease

Although prior studies have implicated nitric oxide (NO), a molecular messenger, in the development and progression of atherosclerosis, most of these studies have centered on atherosclerotic plaques. The current investigation determines whether a correlation exists between the presence of altered levels of NO production by peripheral blood mononuclear cells (PBMCs) and atherosclerotic disease. Venous blood was collected from 8 surgical patients having severe peripheral vascular disease and 8 healthy controls. PBMCs were separated by gradient centrifugation, diluted to 105 cells per mL, and cultured. Lipopolysaccharide (LPS), at doses of 10, 25, and 50 ng/mL, was used to stimulate NO production. Total nitric oxide assay was performed to determine the levels of NO produced by PBMCs at 24 and 48 hours. When stimulated by LPS there was an increase in NO production in the PBMCs cultured from control as well as patient samples, as compared to basal NO levels. However, the data demonstrate a significant decrease in the nitric oxide production in the patients with atherosclerosis as compared to that in the control group (p<0.05). The differential production of nitric oxide by PBMCs of patients with atherosclerotic disease and healthy controls not only suggests that it has a role in the pathogenesis of this disease but also underlines its systemic nature. Blood cells circulating in the body with altered levels of NO production could have profound effects in the microvascular environment mediating molecular pathways and signaling cascades that activate and augment atherosclerosis.

Cardiovascular Effects of the New Weight Loss Agents.

The global obesity epidemic and its impact on cardiovascular outcomes is a topic of ongoing debate and investigation in the cardiology community. It is well known that obesity is associated with multiple cardiovascular risk factors. Although life-style changes are the first line of therapy, they are often insufficient in achieving weight loss goals. Liraglutide, naltrexone/bupropion, and phentermine/topiramate are new agents that have been recently approved to treat obesity, but their effects on cardiovascular risk factors and outcomes are not well described. This review summarizes data currently available for these novel agents regarding drug safety, effects on major cardiovascular risk factors, impact on cardiovascular outcomes, outcomes research that is currently in progress, and areas of uncertainty. Given the impact of obesity on cardiovascular health, there is a pressing clinical need to understand the effects of these agents beyond weight loss alone.

Positional Right Ventricular Obstruction in Pectus Excavatum

Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.

Transient right bundle branch block: A rare manifestation in cardiac contusion

Transient right bundle branch block following blunt cardiac injury is a known but under-recognized manifestation of cardiac contusion. The first case documented in the medical literature occurred in 1952 in a 22-year-old man who was thrown from a motorcycle. Due to their relatively anterior location, the right ventricle and right bundle branch are at particular risk of injury in contusion. We present here a case in which a 24-year-old man suffered a blunt chest trauma leading to a right bundle branch block and elevated troponin levels, consistent with cardiac contusion. His conduction system abnormalities rapidly resolved and he recovered completely, with no clinical sequelae. <Learning objective: Cardiac contusion is a heterogeneous syndrome with widely variable clinical manifestations and severity. Transient right bundle branch block has been described as a self-limited and benign manifestation of cardiac contusion. This case highlights the need for a better understanding of the natural history and predictors of serious complications of cardiac contusion, which can aid in determining appropriate diagnostic studies, risk stratification, and treatment.>.

New Treatment Approaches for Dyslipidemia and its Management

The field of lipidology is evolving rapidly. Two novel medications have recently been approved for use in homozygous familial hypercholesterolemia (HoFH); the Apolipoprotein B (Apo B) mRNA antisense oligonucleotide (ASO), mipomersen (Kynamro®) and the microsomal triglyceride transfer protein (MTP) inhibitor, lomitapide (Juxtapid®). Equally important have been the disappointments in cholesterol research; the halting of further investigation into the cholesteryl ester transfer protein (CETP) inhibitor dalcetrapib, yet two others remain in development. The failure of the combination of extended release niacin and laropiprant to show benefit when combined with statin therapy has lead to the discontinuation of this product in Europe. Perhaps one of the most exciting avenues of future research is into the inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9).