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Slow transit constipation (STC) has an estimated prevalence of 2–4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.

Cardiac sympathetic denervation has been shown to reduce sustained ventricular arrhythmias and implantable cardioverter-defibrillator shocks by inhibiting sympathetic outflow to the heart. We describe the first case to our knowledge of cardiac sympathetic denervation in the left ventricular assist device population. (Level of Difficulty: Advanced.)

Nonbacterial thrombotic endocarditis is characterized by sterile thrombi on cardiac valves. This report describes the case of nonbacterial endocarditis without pathologic findings of fibrin or platelet deposition. Quadrivalvular endocarditis was found to be due to immunoglobulin M heavy chain deposition. This was a case of nonbacterial, nonthrombotic quadrivalvular endocarditis, which was termed noninfective endocarditis. (Level of Difficulty: Intermediate.)

Two experiments investigated the effects of a music and movement (M&M) programme on healthy first-time mothers and their 2-6-month-old infants over a five-week period. Experiment 1 (N?=?96) examined the effects of the M&M activities and the face-to-face (F2F) social contact of a group instruction method on the perception of mothers' interactions with their infants and maternal postnatal attachment. Generally, M&M increased mothers' interactions with their infants specific to music-type activities and mothers' attachment to their infants. Contrary results occurred for No M&M-control group mothers. The presence/absence of F2F had no effect. Experiment 2 ("N"?=?44) focused on behavioural effects of M&M on mothers' infant-directed speech (IDS) and mother-infant reciprocity. M&M increased dyadic reciprocity, and increased the duration, mean pitch and pitch range of mothers' IDS. Without M&M a decrease in attentional characteristics of mothers' IDS and dyadic reciprocity occurred.

Examined impact of a 5-week music/movement program involving relaxation, kinesics, singing, visual contact, and tactile stimulation on first-time mothers' use of music and movement with their infants. Found that the program extended mothers' use of relaxation to music and rhythmical movement with their infants but not the use of song and massage beyond that reported by control group mothers. (Author/KB)

Background: The transition toward value-based payment models increases focus on the radiologist's direct impact on hospital-provided patient care. Radiology trainees understand inpatient hospital workflows and decision-making paradigms and are well positioned to interface directly with hospital physicians regarding clinical decision making related to diagnostic imaging and/or image guided interventions. A radiology resident-led project with internal medicine residents focused on Clinical Decision Support was designed, implemented, and reviewed, with the objectives of educating clinical teams and positively impacting patient care.Materials and Methods: During the 2017-2018 academic year, senior radiology residents (PGY-5) led weekly rounds with medicine residents rotating through inpatient floor units. During these rounds, they discussed indications for and types of hospital inpatient imaging studies, exchanged clinical information, directed further imaging workup, and taught the essentials of image interpretation. Participating medical residents' degree of radiology-awareness and opinions were systematically surveyed at the conclusion of the academic year. Thirty-four out of a total of 161 (21%) Internal Medicine residents responded to the survey. Thirty one percent of these residents could identify an instance where radiology-led rounds altered patient management and 94% acknowledged an increase in medical knowledge. Sixty-one percent believed evidence-based choice for imaging orders was enhanced by attending radiology-led rounds and 64% developed a better understanding of resources available to guide image ordering. Forty-nine percent of residents made suggestions to their Internal Medicine attending physician or more senior trainee or otherwise applied something learned during radiology-led rounds and 42% cancelled or ordered a study based on what they learned or discussed in radiology rounds. Thirty-nine percent of medicine residents stated that these rounds changed their perception of the role of the radiologist and 75% expressed the desire to see increased participation by radiologists in their daily workflow. Radiology resident-led educational medicine rounds promote cross-specialty collaboration, further educate trainees, and directly affect patient management. It is therefore valuable for radiology trainees to directly engage in the teaching of other medical providers, to enhance their own consultative skill set, promote face-to-face interactions with other physicians, and to directly impact patient care. [ABSTRACT FROM AUTHOR]

The impact of different types of regional wall motion abnormalities (RWMAs), including the Takotsubo syndrome–like (TTS-like) phenotype, on posttransplant outcomes when using donor hearts with transient left ventricular systolic dysfunction (LVSD) is unknown. We evaluated the prevalence, clinical characteristics, and prognostic association of different RWMAs including TTS-like hypokinesis and posttransplant outcomes when using donor hearts with transient LVSD. From all adult (≥18 years) heart transplants in United Network of Organ Sharing between January 2007 and September 2015, we identified 472 donor hearts with improving or transient LVSD, defined as left ventricular ejection fraction ≤ 40% on initial transthoracic echocardiogram (TTE) that improved to ≥50% on follow-up TTE during donor evaluation. These improved LVSD donors were then subdivided into 3 groups based on RWMAs on the initial TTE, TTS-like (49, 10.38%), non-TTS RWMAs (74, 15.68%), and diffuse global hypokinesis (349, 73.94%), and compared for baseline characteristics and posttransplant outcomes with follow up until June 2018. Donors with TTS-like LVSD were older and more likely to be female. The type of RWMA on initial TTE (including TTS-like) of transient LVSD donor hearts was not associated with 1-year or 5-year posttransplant mortality. Posttransplant functional status scores of recipients (at 1 year) and donor left ventricular ejection fraction (at median follow-up of 3.6 years) improved in all 3 subgroups. Rates of stroke or pacemaker predischarge were also similar. In the largest analysis of transplanted donor hearts with transient LVSD, 1 in 4 had RWMAs on the initial TTE, but this was not associated with adverse posttransplant outcomes. Donor hearts with initial LVSD should be pursued irrespective of TTS-like hypokinesis or other RWMAs. [ABSTRACT FROM AUTHOR]

Cardiac allograft vasculopathy (CAV) remains the leading long-term cause of death and re-transplantation in heart transplant (HT) recipients. An estimated 30% of HT recipients develop CAV at 5-10 years after transplant. Several immunologic and non-immunologic risk factors are thought to contribute to the development of CAV, however the impact of modifiable traditional cardiovascular risk factors such as hypertension on the risk of CAV has not been well described. In this single center retrospective analysis, we sought to evaluate the relationship between blood pressure control and prevalence of CAV at 5 years post-transplant. : Hypertension is associated with increased risk of CAV at 5 years post-HT. We retrospectively identified adults (>18 years) who had undergone HT at our institution between 2011-2020. In-office blood pressure readings were recorded from visits timed 2 months, 1, 3, 5, and 10 years post-HT and averaged until first CAV event or until duration of follow up in those without CAV. Coronary angiograms performed for CAV surveillance at 2 months, 1, 3, 5, and 10 years were reviewed by two cardiologists and CAV was graded per the International Society of Heart and Lung Transplant classification. Subjects were categorized as high systolic blood pressure (SBP) (defined as average SBP >130) or controlled (≤130) and compared for development of CAV. Of a total of 313 HT recipients, those with missing data or who did not make it to their first angiogram were excluded; the remaining 260 were included in the study. The mean age at HT was 54 ± 14 years and 83 HT recipients (32%) were female. In total, 77 recipients (30%) had CAV over a median follow-up time of 3.1 years. Of the ninety-six recipients who completed 5 year follow up, 23 (24%) had evidence of CAV on 5-year surveillance angiogram. Nearly two thirds (66%) of the patients received antihypertensives. On time to event analysis for the overall cohort (Figure 1), patients with an average systolic blood pressure of over 130 mmHg were at higher risk for CAV compared to those with an average systolic BP of ≤130 mmHg (unadjusted HR 2.4, 95% CI 1.122-5.176, p =0.02). Hypertension is associated with the development of CAV post-HT. Further therapeutic studies on whether appropriate BP control can mitigate risk of CAV are required. [ABSTRACT FROM AUTHOR]

Jugular venous pressure (JVP) is a widely used estimate of central venous pressure (CVP). It is unclear how accurate JVP measurement is by physicians in different stages of clinical practice. We investigated the accuracy of JVP measurement across different levels of medical training by comparing JVP measurements to the peripheral venous pressure (PVP) measurement, which has been shown to have a high degree of correlation to CVP measurements. JVP will be better correlated with CVP when measured by physicians of higher level of clinical training. A prospective, cross-sectional study in which 82 participants (13 third or fourth-year medical students, 26 interns, 21 residents, and 22 attending internal medicine physicians) measured JVP in patients admitted for acute decompensated heart failure (ADHF) to the general medicine ward. JVP measurements were compared to the PVP measured from a peripheral intravenous catheter by standard technique. Forty-five patients were enrolled with a mean age of 69±14 years, mean body mass index (BMI) of 31±9 kg/m2, mean ejection fraction (EF) of 47±20%, and mean B-type natriuretic peptide (BNP) of 1242±1161 pg/ml. Mean JVP was 8.6 (4-18) cmH 2 O for medical students, 8.7 (4-16) cmH 2 O for interns, 9.1 (5-20) cmH 2 O for residents, and 9.2 (4-15) cmH 2 O for attending physicians. Mean PVP was 8.7 (1-20) mmHg. The JVP and CVP were found to have a moderate correlation (r=0.42, p=0.005) for attending physicians and a low correlation for medical students or residents. High-degree correlation among attending physicians was noted in patients with EF < 50% (r=0.60, p=0.009), BMI < 30 (r=0.55, p=0.008) and BNP > 1000 (r=0.56, p=0.01). JVP is a reliable estimation of volume status in those admitted with ADHF when examined by an attending-level internal medicine physician, specifically in patients with a low BMI, low EF, and a high BNP. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 77-year-old man who was admitted for investigation of an acute kidney injury after intravenous cefepime treatment for malignant otitis externa with temporal bone osteomyelitis and diagnosis of acute kidney injury.

Supplemental Digital Content is available in the text. Background: Gastrointestinal bleeding (GIB) is one of the principal adverse events affecting patients with continuous-flow left ventricular assist devices (CF-LVADs). Despite the early recognition that GIB is commonly because of gastrointestinal angiodysplasia (GIAD), the exact pathophysiology of this process remains elusive. It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients may activate the angiogenesis signaling cascade via the HIF (hypoxia-inducible factor)-1α/angiopoietin-2 pathway leading to formation of GIADs. Digoxin is a potent inhibitor of HIF-1α synthesis, and we hypothesized that its use reduces the incidence of GIAD and GIB in patients with CF-LVAD. Methods and Results: Charts of all adult patients implanted with CF-LVAD between February 2006 and February 2017 were reviewed with particular emphasis on occurrence and cause of GIB. Fifty-four of 199 patients (27%) experienced a GIB. Overall frequency of GIB was lower in the 64 patients receiving digoxin compared with the 135 patients not receiving digoxin (16% versus 33%, P =0.01). Multivariable-adjusted Cox regression analysis confirmed that digoxin use was independently associated with a reduced risk for overall GIB (hazard ratio, 0.49; 95% CI, 0.24–0.98; P =0.045). GIBs were then categorized as non-GIAD, GIAD, or likely GIAD. Although the incidence of non-GIAD was similar in both groups (11% versus 7%, P =0.41), the frequency of GIAD/likely GIAD bleeding was significantly reduced in the digoxin group (5% versus 25%, P =0.0003). Multivariable-adjusted analysis confirmed that digoxin use was independently associated with a reduced risk for GIAD/likely GIAD bleeding (hazard ratio, 0.18; 95% CI, 0.06–0.6; P =0.005). However, digoxin use was not associated with reduced risk for non-GIAD GIB (hazard ratio, 1.54; 95% CI, 0.58–4.08; P =0.39). Conclusions: Use of digoxin was associated with a significant reduction in GIAD-related GIB in patients with CF-LVAD. [ABSTRACT FROM AUTHOR]

Gastrointestinal bleeding (GIB) in LVAD patients is most commonly caused by gastrointestinal angiodysplasia (GIAD). Non-pulsatile blood flow in LVAD patients can cause splanchnic submucosal hypoperfusion and hypoxia leading to activation of a HIF1-α /Angiopoietins (Ang) signaling cascade, that can trigger pathological angiogenesis. We have recently shown that the use of digoxin, a potent inhibitor of HIF1-α, is associated with a significant reduction in GIAD related GIB in HeartMate (HM) II and HeartWare HVAD patients. However, HM3 support is associated with less GIB then previous generation pumps. We now hypothesize that dysregulation of Ang-1 and Ang-2 levels in patients with HM3 can be restored by digoxin treatment and may contribute to decreased incidence of GIB. We have collected blood samples from 7 patients supported with HM3 before and after two weeks of digoxin therapy (0.125 mg daily). Ang-1 and Ang-2 levels were measured in patients' serum by ELISA. In single-center retrospective study, charts of all patients implanted with HM3 between June 2015 and October 2019 were reviewed with emphasis on the occurrence of GIB and digoxin therapy. Pearson's chi-squared test was used to assess the frequency of overall GIB and their association with digoxin therapy. Digoxin treatment in HM3 patients increased Ang-1 (11.5 to 30.7 ng/ml, p=0.02), and decreased Ang-2 levels (14.9 to 9.4 ng/ml, p=0.04), reversing angiogenic switch. Seven of 72 patients (10%) supported by HM3 during median observation time (236, IQR76-620) days experienced a GIB. We identified 38 patients treated and 34 not treated with digoxin (age 52.38 vs. 52.65, p=0.97). The frequency of GIB was significantly lower in the patients receiving compared to the ones not receiving digoxin (3% vs. 17% p=0.03; Fig.1), respectively. Digoxin, an inhibitor of HIF1-α signaling cascade, may contribute to a lower risk of GIB in HM3 patients by restoring angiogenic equilibrium. [ABSTRACT FROM AUTHOR]

Despite the recent advances in Left Ventricular Assist Device (LVAD) therapy, gastrointestinal bleeding (GIB) remains a frequent and severe complication. A growing body of evidence suggests that the combination of hypoperfusion and hypoxia in the microcirculation may activate the angiogenesis cascade and promote the formation of arteriovenous malformations. We hypothesized that LVAD patients with concomitant significant restrictive or obstructive lung diseases may have an increased risk of GIB due to their chronic hypoxemic state. We retrospectively identified 99 patients on HeartMate II LVAD support (age 54±13 y, 77% male, 36% ischemic etiology) who had a pulmonary function test (PFT) performed. Significant lung disease was defined as a moderate or severe obstructive/restrictive pattern detected during PFT and the concomitant use of inhaler therapy. GIB was defined as clinical evidence of GI bleeding and a decrease in hemoglobin of at least 1 g/dL. 11 patients (11%) had significant lung disease and 27 patients (27%) experienced a GIB. The risk of GIB was increased in patients with significant lung diseases (Hazard Ratio 2.59, 95% confidence interval 1.038 to 6.452). Freedom from GIB was significantly higher in patients without significant lung disease in Kaplan-Meier analysis (Figure). Significant obstructive or restrictive lung diseases were associated with an increase in the risk of GIB. Further studies on the association of tissue hypoxia and activation of the angiogenesis cascade/bleeding diathesis in LVAD patients are warranted. [ABSTRACT FROM AUTHOR]

Purpose Gastrointestinal bleeding (GIB) in patients supported by Continuous-Flow Left Ventricular Assist Devices (CF-LVAD) is most commonly caused by gastrointestinal angiodysplasia (GIAD). It has been postulated that the abnormal hemodynamic profile in CF-LVAD patients can cause splanchnic submucosal hypoperfusion and activate a Hypoxia Inducible Factor (HIF)1-alpha /Angiopoietins (Ang) signaling cascade that triggers pathological neoangiogenesis. Specifically, it has been established in CF-LVAD recipients that the increased levels of Ang-2, decreased Ang-1 and resultant increase in the ratio of Ang-2/Ang-1, presents angiogenic switch that may favor GIAD development. We have recently shown that use of digoxin, a potent inhibitor of HIF1-alpha, is associated with a significant reduction in GIAD related GIB in CF-LVAD patients. We now hypothesize that dysregulation of Ang-2 and Ang-1 levels in patients with CF-LVADs can be restored by digoxin treatment. Methods Blood samples were collected from 10 patients supported with CF-LVAD before and 2 weeks after they were started on digoxin. Ang-1 and Ang-2 was measured in patients' serum by ELISA. Statistical difference between the groups was tested with paired t-test. Results Digoxin treatment in CF-LVAD patients decreased Ang-2 (14.1 to 8.8 ng/ml, p=0.015) and increased Ang-1 levels (11.6 to 29.8 ng/ml, p=0.002), reversing angiogenic switch (Fig.1). Conclusion Digoxin may restore angiogenic equilibrium in patients supported by CF-LVADs. The relevance of this finding for development of GIB needs to be prospectively studied. [ABSTRACT FROM AUTHOR]