Citations

Hepatic steatosis, characterized by the accumulation of triacylglycerol in hepatocytes, complicates liver transplantation by increasing the risk of ischemia-reperfusion injury (IRI), leading to suboptimal graft outcomes. This condition has become a major cause of liver graft discarding, exacerbating the ongoing organ shortage for transplantation. Recent advances in ex vivo normothermic perfusion machines (NMPs) have provided promising solutions for reconditioning and preserving steatotic liver. NMP supports cellular metabolism and mitigates IRI by maintaining the physiological conditions. In addition, pharmacological strategies to reduce hepatic steatosis have been explored to increase graft viability. In this review, we summarize current insights into hepatic lipid metabolism and the molecular mechanisms underlying steatosis, while discussing emerging pharmacological defatting approaches. These interventions have the potential to address the challenges posed by hepatic steatosis, improve graft quality, expand the availability of transplantable livers, and enhance clinical outcomes of transplant candidates. Finally, we highlight current limitations and outline directions for future research and clinical applications.

Pain management after thoracotomy is particularly complex in lung transplant recipients on extracorporeal membrane oxygenation (ECMO), where anticoagulation significantly limits available treatment options. Coagulopathy constitutes a contraindication to neuraxial and deep peripheral nerve blocks due to hemorrhagic complications. Uncontrolled thoracotomy pain, hypoxia due to increasing opioid use, and hemodynamic instability can delay successful weaning from ECMO. We present the case of a patient on bivalirudin after undergoing a thoracotomy for a right lung transplantation. This case highlights the successful use of a serratus anterior plane block (SAPB) as an alternative approach to neuraxial anesthesia in an anticoagulated patient, optimizing analgesia and facilitating recovery postthoracotomy.

Objectives On rare occasions, hiccups can cause morbidity, such as sleep deprivation, aspiration and even death. At times, palliative invasive procedures are considered. This study tested the hypothesis that invasive procedures can provide hiccup palliation with an acceptable safety profile. Methods Multi-site electronic medical data were used to assess adult patients who underwent an invasive procedure for hiccups between January 1995 and January 2022. Hiccup palliation was defined as documented improvement in severity or frequency of this sign/symptom after the procedure. Results A total of 69 patients underwent one or more invasive procedures for hiccups (144 total procedures). Fifty-nine patients (86%) were men. The most frequent initial procedure was a phrenic nerve block (n=10) followed by oesophageal dilation (n=9). Only 31 patients (45%) manifested hiccup palliation after their first procedure. Nearly half, or 32 patients (46%), underwent more than one procedure (2 underwent nine procedures). Of these subsequent procedures, 35 resulted in palliation. Five adverse events arose from 144 procedures: post-esophagectomy atrial fibrillation, haematoma after cardiac device removal, vocal cord immobility after craniotomy, vocal cord immobility after vagal nerve manipulation, and a cerebral spinal leak after vagal nerve decompression. Conclusions Invasive procedures can palliate hiccups with an acceptable safety profile. However, these procedures appear to palliate hiccups in only about half of patients and sometimes do so only transiently.

Introduction Lactating physicians face considerable challenges in achieving lactation goals due to inflexible schedules and a lack of break time. While federal mandates have outlined the necessity of lactation breaks, the frequency and duration of breaks are unspecified. The objective of this study was to fill this gap by designing and implementing an outpatient neurology resident clinic schedule with protected lactation breaks, ensuring support and quality of trainees’ educational experience. Methods This quality improvement study began with developing a prototype schedule with input from lactating physicians, a lactation consultant, and neurology residency program leadership. Neurology residents and fellows with prior lactation experience were surveyed to determine if the proposed schedule would have fit their individual needs. The clinic schedule with protected lactation break time was then implemented, and lactating neurology residents were surveyed regarding their experience. Results Eleven previously lactating neurology residents and fellows who were surveyed about the proposed schedule agreed that the prototype schedule would suffice for their personal lactation needs. The clinic schedule was implemented for 5 neurology residents returning from maternity leave in 2022 to 2023, and 4 residents completed a survey of their experience. There was unanimous agreement that protected lactation breaks helped residents achieve their lactation goals and strongly benefited work/life balance and overall well-being. Despite this intervention, 75% of respondents stopped breastfeeding earlier than intended, and 100% of respondents experienced complications perceived to be related to inadequate pumping, such as diminished milk supply. Ongoing barriers to achieving breastfeeding goals included work interrupting lactation breaks, lack of lactation rooms, and lack of computer workstations in lactation rooms. Conclusions Inclusion of protected lactation breaks in outpatient clinic schedules helped neurology residents achieve their lactation goals as well as promoted work/life balance and overall well-being. However, more work is needed to address other barriers to achieving lactation goals.

Background Many guidelines list migraine with aura (MwA) as a contraindication to estrogen-containing combined hormonal contraceptives (CHCs) due to vascular risks. However, current evidence is based on small sample studies with potential influence by confounding factors. Additionally, few studies have examined the vascular risk associated with modern CHCs with lower dose estrogen, particularly in relation to aura status. The present study aims to investigate the vascular risk of modern CHCs in women with migraine with and without aura. Methods We used a de-identified electronic medical record database with 120 million patients across multiple health systems in the United States of America. We included female patients aged 18–45 years who received a migraine diagnosis code, had at least three office visits within three years, and were prescribed at least one migraine-specific medication within 6 months following the first outpatient visit. All data after 2010 were included. Patients with prior cardiovascular events were excluded. Our composite endpoint consisted of acute ischemic stroke, acute myocardial infarction, deep vein thrombosis/pulmonary embolism and intravenous thrombolytic administration. We stratified our analysis according to CHC exposure and aura status and compared the incidence of the endpoint with high-dimensional propensity score-matching between CHC users and non-users in (i) the overall cohort, (ii) MwA and (iii) migraine without aura (MwoA); between MwA and MwoA in (iv) patients prescribed CHCs; and in (v) those without CHC prescriptions. Results We included 5535 patients who received CHC prescriptions and 21,520 who did not. 114 (2.06%) of CHC users and 547 (2.54%) of CHC non-users had at least one vascular event. With propensity score-matched comparison, the composite endpoint did not significantly differ between CHC and non-CHC in the overall migraine group, those with MwA and the MwoA group. In those prescribed CHC, MwA and MwoA did not differ in all the outcomes. For CHC non-users, MwA was associated with a higher incidence of acute ischemic stroke (hazard ratio = 2.45; 95% confidence interval = 1.58–3.78; p < 0.001; n = 6201 in each group) and the composite endpoint (hazard ratio = 1.34; 95% confidence interval = 1.08–1.67; p = 0.008). Conclusions Our real-world study showed that exposure to modern CHC was not associated with a significant increase in vascular risk in women aged 18–45 years with migraine, MwA or MwoA who have no prior cardiovascular events. However, in those who never received CHC, MwA was associated with higher vascular risks compared to MwoA. While limitations exist using large scale electronic medical record databases for analysis, our results suggest that carefully designed prospective studies should be conducted to reassess the vascular risk associated with CHC use in women with migraine, especially MwA.

Autoantibodies contribute to many autoimmune diseases, yet there is no approved therapy to neutralize them selectively. A popular mouse model, experimental autoimmune encephalomyelitis (EAE), could serve to develop such a therapy, provided we can better understand the nature and importance of the autoantibodies involved. Here, we report the finding of autoantibody-secreting extrafollicular plasmablasts in EAE induced with specific myelin oligodendrocyte glycoprotein (MOG) antigens. Single-cell RNA sequencing reveals that these cells produce nonaffinity-matured IgG antibodies. These include pathogenic antibodies competing for shared binding space on MOG’s extracellular domain. Interestingly, the synthetic anti-MOG antibody 8-18C5 can prevent the binding of pathogenic antibodies from either EAE mice or people with MOG antibody disease. Moreover, an 8-18C5 variant carrying the NNAS mutation, which inactivates its effector functions, can reduce EAE severity and promote functional recovery. In brief, this study provides not only a comprehensive characterization of the humoral response in EAE models but also a proof of concept for a therapy to antagonize pathogenic anti-MOG antibodies.

Hemodynamic progression of valvular aortic stenosis was studied in 54 patients who had serial cardiac catheterizations. There were 47 men and 7 women with a mean age of 61.2 years. The time interval between studies was 4.4 years (range, 0.4‐12.2). Associated coronary artery disease was present in 37 patients (69%). The initial mean aortic valve area (Hakki's formula) was 1.26 cm 2 (range, 0.66‐2.85), and the aortic valve area at last follow‐up was 0.77 cm 2 (range, 0.29‐1.95), with mean reduction of 0.49 cm 2 . The mean peak systolic gradient increased from 23.3 ± 15.1 mm Hg at initial study to 52.6 ± 27.5 mm Hg at last study, a mean increase of 29.3 ± 23.6 mm Hg. Patients with no or mild left ventricular impairment and no or mild coronary artery disease are more likely to have progression than patients with more severe left ventricular impairment or coronary artery disease (P < 0.05). Aortic valve replacement for progressive aortic stenosis was required at a later date after coronary artery bypass grafting in a small group of nine patients. In this small group, there was a high intraoperative mortality of 33%.