In this study, we looked the MMR protein expression without consi

In this study, we looked the MMR protein expression without considering the family history or the result of previous Selleckchem Wortmannin tumour testing for microsatellite status in a prospective of newly diagnosed colorectal cancer patients. We identified three patients with loss of one or more MMR protein. The first patient (case 3) was less than 40 years Inhibitors,research,lifescience,medical old when diagnosed with caecal cancer. Although her family history was not fully documented (Figure 6), she showed history of colorectal and breast cancer in some members of her family. Her tumour loss the

expression of hMLH1 and hPMS2, making her more likely to have Lynch syndrome. The other two cases were more than 60 years of age when diagnosed with colorectal cancer which is not a typical age for tumour onset in Lynch syndrome Inhibitors,research,lifescience,medical patients. However; case 13 who loss the expression of hMSH6 in his proximal colon tumour can still have Lynch syndrome. Case 27 was

77 years old when developed a rectal cancer. The loss of hMLH1 expression in his tumour in addition to the lack of family history of cancer makes him more likely to have microsatellite instable sporadic cancer. Our results are in keeping with previous report by Hamplel et al. (23). They examined 1,066 patients with newly diagnosed colorectal adenocarcinoma for MSI. Among patients whose screening results Inhibitors,research,lifescience,medical were positive for MSI, they looked for Inhibitors,research,lifescience,medical germLine mutations in the 4 main MMR genes using IHC, genomic sequencing and deletion studies. MSI was detected in 19.5% of their study population and 2.2% were confirmed to have Lynch syndrome. Of the patients who were found to have Lynch syndrome 10 were more than 50 years and 5 did not meet Inhibitors,research,lifescience,medical the clinical criteria for diagnosis of HNPCC. Their data suggested the similar efficiency of IHC and the more complex genetic analysis for MSI testing. Our findings and the previous reports pointed out the importance of molecular screening of patients with colorectal cancer for MSI

using immunohistochemistry. This strategy managed to identify mutations in patients otherwise would not have been detected. Therefore, we recommend it as a policy for all newly diagnosed colorectal cancer patients due to its important prognostic aminophylline implications. Acknowledgements We would like to thank the National Breast Cancer Research Institute (NBCRI) for their financial support of the study Disclosure: The authors declare no conflict of interest.
Limited treatment options exist for isolated local recurrence of pancreatic ductal adenocarcinoma (PDA) following surgical resection accompanied by neoadjuvant or adjuvant chemoradiation therapy (CRT). While select patients are eligible for re-resection, recurrent lesions are often unresectable.

What is the magic number then? It seems that

we have a re

What is the magic number then? It seems that

we have a reasonable consensus – the 12 nodes are the accepted minimum worldwide. Our task is though to try achieve this number in all of the cancer resection cases in every hospital. The data of compliance with this from the earlier literature seems rather bleak (9), but improvements have been made. The review article of Denham et al. concludes that 12-15 lymph nodes, as currently suggested by CAP is appropriate. The question might arise – what is the significance of this all? Why are we chasing numbers? Inhibitors,research,lifescience,medical The ultimate aim is to achieve the best available treatment for everyone. This is only possible though, if we pay attention to all the details, collect and evaluate the evidence, then apply it carefully in practice. In addition, proper statistics need to be applied in order to draw the right conclusion. If we all provide more accurate staging information, our conclusions and follow-ups of the different stages will be more Inhibitors,research,lifescience,medical clear, and this will benefit all, and the review article has examined all of the relevant aspects in detail. Acknowledgements Disclosure: The author declares no conflict of interest.
A 64-year-old man with known Inhibitors,research,lifescience,medical Neurofibromatosis type 1 was brought to the hospital after he was found unconscious and pulseless. He had multiple cutaneous neurofibromas (Figure 1). He

was revived with CPR and defibrillation. He then underwent cardiac catheterization which revealed three-vessel coronary artery disease and was recommended to undergo coronary artery bypass graft (CABG) surgery. During the course of acute management, CT scans of the thorax and the abdomen and pelvis were obtained to rule Inhibitors,research,lifescience,medical out any hemorrhage or aortic dissection. Note was made of a large inhomogeneous pelvic mass with Inhibitors,research,lifescience,medical dimensions of 8.6 cm × 10 cm × 7.8 cm (Figure 2). A CT-guided biopsy of the mass revealed palisaded-appearing long spindle cells (Figure 3). A schwannoma was considered on morphologic grounds, but an S-100 stain was negative. There was focal, weak staining for smooth muscle actin (SMA). The neoplastic cells

were strongly and diffusely positive for CD117 (c-KIT) (Figure 4) and CD34 (Figure 5), indicating a GIST. The KIT and PDGFR mutations were found to be negative on the mutational isothipendyl analysis. The tumor was considered to be marginally resectable and so the patient was ERK inhibitor research buy started on imatinib 400 mg daily with the hope of making subsequent surgery feasible. A repeat CT abdomen/pelvis done after 3 months of imatinib therapy, showed multiple foci of air suggestive of necrosis, though the size of the tumor remained stable. The tumor was then resected en-bloc. A cavity was noted within the tumor along with fistula formation necessitating excision of part of the small intestine. After the surgery he was restarted on imatinib 400 mg daily with surveillance CT scans planned every six months.

The psychologist’s training has all come back to me now and I thi

The psychologist’s training has all come back to me now and I think it is impressive. However, at the time I felt it wasn’t viable or even relevant and I am now very surprised to find that I’ve absorbed so much from the course. The problem with the ‘Mind Lock’ course is that you cannot gain from it when your OCD is extreme; you have to be ‘within reach’, if you like. This is Inhibitors,research,lifescience,medical the hardest part and this new drug could provide the answer. Case 3 This 44-year-old divorced man had had worsening OCD symptoms from childhood. His childhood had been blighted by emotional neglect and he and his siblings were abandoned by their parents and brought up in care. His life was taken over by obsessional

thoughts concerning dirt and contamination with compensatory compulsions of cleaning, checking and

mental counting. He also had the compulsion to shave off all his body hair so as to ensure that his person was rendered as Inhibitors,research,lifescience,medical germ free as possible. His marriage had broken down as a result of his OCD and he had been unable to work for 12 years on account of his OCD symptoms. He was significantly depressed. Although he was bright, insightful and articulate, his educational attainment was poor and he was unable to read and write, which was probably the result of unrecognized childhood ADHD coupled with emotional Inhibitors,research,lifescience,medical abuse and neglect. As an adult he still manifested the ADHD symptoms of fidgeting, poor concentration span and explosive, staccato speech, which rendered him socially awkward and unable to sit still and to watch a TV programme through to the end, although distraction caused by his OCD symptoms also contributed to this difficulty. At the time of referral he was taking fluoxetine 40 mg daily without any impact

Inhibitors,research,lifescience,medical on his OCD symptoms (Y-BOCS 36). Increasing the fluoxetine Inhibitors,research,lifescience,medical to 60 mg daily did not result in improvement so he was switched to clomipramine and the dose increased in stages to 175 mg at night, but later reduced to 150 mg at night on account of the side effects of postural hypotension. This resulted in significant improvement in his depressive symptoms but made little impact on his OCD symptoms. Quetiapine XL was EPZ004777 research buy introduced and the dose however increased in stages to 200 mg at night. This resulted in further improvement in his depressive symptoms and some improvement in his OCD symptoms (Y-BOCS 34) in that he was not checking as much and was able to watch TV for longer without being distracted by his OCD. He participated in a CBT ‘Brain Lock’ group, which he found very supportive, although there were no improvements in his OCD symptoms. He agreed to a trial of buprenorphine augmentation and was started on sublingual buprenorphine 200 μg twice a day, which after 2 days resulted in substantial improvement in his OCD (Y-BOCS 20). His symptoms returned some 4 days after the buprenorphine was discontinued.

4, P = 0 001) Four

4, P = 0.001). Four I-BET-762 price patients developed congestive heart failure, 3 of them in the doxorubicin arm. The calculated mean cumulative dose

until cardiotoxicity occurrence was 580mg/m2 for doxorubicin and 780mg/m2 for the liposomal formulation (HR: 4.8, P = 0.001). A further Phase III study [36] randomized 160 patients to receive cyclophosphamide 600mg/m2 plus either epirubicin 75mg/m2 or liposomal doxorubicin 75mg/m2. No significant differences were observed in the rate of asymptomatic reduction in LVEF (11 versus 10%). In this study, no patient developed clinical heart failure. It must be noted Inhibitors,research,lifescience,medical that epirubicin dosing was lower than the equipotent doxorubicin. In 2010, the Cochrane Library reported a systematic review of the different anthracycline compounds Inhibitors,research,lifescience,medical and their cardiotoxicity [48]. Studies by Harris and Batist were analyzed together and authors concluded that nonpegylated liposomal anthracyclines reduced the overall risk of cardiotoxicity (RR = 0.38, P < 0.0001) and the risk of clinical heart failure (RR = 0.20, P = 0.02). Efficacy and safety Inhibitors,research,lifescience,medical of pegylated liposomal doxorubicin (PLD) combined with other cytostatic agents were studied in two Phase III studies. Sparano et al. [37] randomized 751 patients previously treated with anthracyclines (as adjuvant or neoadjuvant) with a PFI over 12 months to receive either docetaxel

75mg/m2 (373p) or the combination of PLD 30mg/m2 plus docetaxel 60mg/m2 every 21 days (378p) until disease progression or unacceptable toxicity occurred. Combined treatment improved PFS significantly from 7.0 to 9.8 months (HR 0.65; 95% CI, 0.55 −0.77; P < 0.00001). OS was similar: 20.6 months in the docetaxel arm and 20.5 in the combined treatment arm (HR 1.02; 95% CI, 0.86–1.22). The incidence of hand-foot syndrome Inhibitors,research,lifescience,medical was higher in the combined treatment arm (24% versus 0%) and symptomatic cardiac toxicity was similar: 4% in the docetaxel group and 5% in the PLD-docetaxel group. Patients with metastatic breast cancer progressing

after taxanes and anthracyclines had fewer treatment options Inhibitors,research,lifescience,medical and often anthracyclines were not used again, due to the cumulative risk of cardiotoxicity. Ketanserin Based on the safety and efficacy data for PLD, a Phase III study was proposed [49] in which 301 patients with metastatic breast cancer progressing to taxanes (<6 months) were randomized to receive one of the following three alternatives: PLD 50mg/m2 every 4 weeks (150p); vinorelbine 30mg/m2 every week (129p); or mitomycin-C 10mg/m2, on days, on 1 and 28 plus vinblastine 5mg/m2 on days 1, 14, 28, and 42 every 6–8 weeks (22p). 83% of patients had received prior anthracyclines, in 10% of them cumulative doses above 450mg/m2 had been reached. No patient treated with PLD showed clinical symptoms of cardiotoxicity. PFS was similar (2.86 months in the PLD group versus 2.53 months in the other two control groups) (HR 1.26; 95% CI, 0.98–1.62).

18 Significantly more patients relapsed in the phase-delay protoc

18 Significantly more patients relapsed in the phase-delay protocol

compared with the phase advance protocol (Figure 1). This indicates that the high response rate after SD and phase advance cannot be explained by a placebo phenomenon alone and supports the hypothesis that, in depressed subjects, sleeping at certain phases of the circadian rhythm, ie, especially late in the night and in the morning, has depressogenic effects. Unfortunately, one major issue has been almost completely neglected by researchers: docs SD produce any lasting effects after 4 to 6 weeks, which is the typical period for measuring the effects of antidepressants? There is only one controlled Inhibitors,research,lifescience,medical study using such a design.21 Twenty-four patients Inhibitors,research,lifescience,medical received amitriptylinc without additional SD, whereas 27 patients received amitriptyline plus a series of 6 partial SDs. Observer ratings, but not patient ratings, demonstrated superiority of the combined treatment after 4 weeks. By the standards of evidence -based medicine, there is little evidence to date that SD therapy has lasting effects over the course of several weeks. Figure 1 Antidepressant effects of total sleep

deprivation (TSD) in one night with a consecutive phase advance of the sleep period (blue circles) in comparison with a phase delay of the sleep period (gray circles). Inhibitors,research,lifescience,medical In the phase-advance group, the antidepressant … Neurobiology of SD in Sotrastaurin in vivo Depression There is no generally accepted hypothesis concerning the mechanism of action of SD, nor an explanation for the observation that subsequent sleep after SD leads Inhibitors,research,lifescience,medical to relapses. A variety of neurobiological effects point toward potential mechanisms of action of the procedure (Table III).22-32 Table III. Neurobiological Inhibitors,research,lifescience,medical effects of sleep deprivation. In humans some of the studies were performed in depressed patients, while other studies were in healthy subjects or in depressed patients and healthy subjects. Based on the observations that hyperarousal and a high level of activation

predict a favorable SD response,4 the antidepressant effect was explained using the two-process model of sleep regulation (Figure 2).33 In this model, depressed patients have a deficiency of process S (ie, sleep need) with process C (circadian rhythm) remaining unaffected. Depression is characterized by a deficient build-up of process S (Figure 2) . SD transiently leads to an increase Adenylyl cyclase in process S to normal, whereas relapse occurs after “recovery sleep” due to a return to low levels of S. Figure 2 Two-process mode! of sleep deprivation (SD) and depression . This model can explain the antidepressant effect of SD by assuming that an insufficient build-up of process S (S stands for sleep need), SD transiently increases the level of process S, thus, … Several brain imaging studies have tried to correlate the SD response with metabolic states of certain brain areas.

Overall, 6 of 101 patients (6%) in the splenectomy group and 3 of

Overall, 6 of 101 patients (6%) in the splenectomy group and 3 of 94 patients (3%) in the non-splenectomy group died within 30 days of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

(not statistically different). Cytopenia contributed to death from sepsis in 4 patients (4%) in the splenectomy group and 1 patient (1%) in the non-splenectomy group (not statistically different). Table 1 Tumor characteristics by splenectomy group The average hospital stay was significantly Inhibitors,research,lifescience,medical different (P=0.001) between the two groups, with the splenectomy group average being 20 days (median 11 days) and the average stay for the non-splenectomy group being 12 days (median 9 days). Dose reduction of mitomycin Inhibitors,research,lifescience,medical C was required in 2 patients in the non-splenectomy group and 2 patients in the splenectomy group. For patients in the splenectomy group, the average white blood cell nadir was 6.1 +/- 3.4 (range 0.3 to 14.7) on day

7.2. The average absolute neutrophil count was 5.2 +/- 3.6 (range 0.1 to 13.4), the average 5HT Receptor inhibitor Platelet nadir was 172.0 +/- 81.9 (range 3.0 to 381.0), and the average hemoglobin nadir was 7.5 +/- 1.0 (range 4.9 to 10.3). For patients in the non-splenectomy group, the average white blood cell nadir was 4.6 +/- 2.4 (range 0.5 to Inhibitors,research,lifescience,medical 13.2) on day 6.0. The average absolute neutrophil count was 3.9 +/- 2.7 (range 0.2 to 14.5), the average platelet nadir was 164.1 +/- 73.0 (range 6.0 to 426.0), and the average hemoglobin nadir was 8.2 +/- 1.8 (range 4.4 to 13.9). Hematologic toxicity grade by National Cancer Institute criteria is shown for white blood cell, platelets, and hemoglobin in Table 2. White blood cell toxicity was significantly lower in the splenectomy group compared to the non-splenectomy Inhibitors,research,lifescience,medical group (P=0.048). Platelet toxicity was not statistically significantly different between the two groups (P=0.24). Hemoglobin toxicity was significantly worse in the splenectomy group (P=0.003). There was no statistically significant difference in hematologic Inhibitors,research,lifescience,medical toxicity between those receiving mytomycin C and those receiving oxaliplatin (P=0.754). Table 2 Hematotoxicity

Thalidomide by splenectomy group Granulocyte colony stimulating factor was administered in 29% of splenectomy patients versus 43% of non-splenectomy patients (P=0.043). Granulocyte colony stimulating factor was administered for an average of 2.9 +/- 2.1 days (range 1.0 to 8.0) in the splenectomy group, versus an average of 3.3 +/- 3.3 days (range 1.0 to 18.0) in the non-splenectomy group. The difference in the average number of days treated with granulocyte colony stimulating factor was not statistically significant (P=0.61). During the post-operative period, there were significant differences in the number of red blood cell transfusions required for the splenectomy group compared to the non-splenectomy group (Table 3).

Concomitant medication was significantly higher in patients on qu

Concomitant medication was PKI587 significantly higher in patients on quetiapine IR during hospitalization, with 27% more concomitant medications seen than for patients on quetiapine XR. This finding supports the interpretation that quetiapine XR more often is used as the main antipsychotic drug, whereas quetiapine IR is more often used as an add-on medication in schizophrenia. Overall, patients had two or more – and in some cases up to seven or eight – antipsychotic medications during hospitalization, reflecting the typical situation faced by physicians of severely ill patients. The most common historical combination of medications in this setting is

that of a typical plus Inhibitors,research,lifescience,medical an atypical antipsychotic [Bingefors et al. 2003; McCue et al. 2006]. This was also the case here, the most common typical antipsychotics being zuclopenthixol and haloperidol when used for at least 7 days. Patients with comorbid substance abuse were significantly more likely to receive treatment with quetiapine XR than IR. Also, patients treated with quetiapine XR were reported to have more somatic Inhibitors,research,lifescience,medical disease than those on quetiapine IR. Further, significant differences in the reported reasons for treatment between quetiapine XR and IR were seen. Patients on quetiapine XR were more often treated for schizophrenia per se and those on quetiapine

IR more often for psychosis, although this result should be interpreted Inhibitors,research,lifescience,medical with caution as reported reasons for treatment may not be consistent across prescribers and patients. Further, although statistically not significant, lower GAF scores at hospital admission, longer duration of hospitalization, and higher use of ECT was reported for patients receiving quetiapine XR Inhibitors,research,lifescience,medical compared with IR. Taken together, the present study points to a different use of quetiapine XR compared with quetiapine IR in this setting. Medication adherence should arguably increase in importance with disease severity. In fact, adherence is a considerable challenge

in schizophrenia [Goff et al. 2011]. Llorca (2008) estimates that at least 50% of patients are partially compliant or noncompliant within 1 year Inhibitors,research,lifescience,medical and 75% within 2 years of hospital discharge. However, however any improvement in adherence will improve patient outcomes [Ascher-Svanum et al. 2010; Laan et al. 2010]. A complex dosing regimen is one factor that may have a considerable negative impact on drug adherence. Once daily dosing has been shown to be significantly associated with improved adherence in patients with schizophrenia, also when controlling for various covariates [Remington et al. 2007; Diaz et al. 2004]. In this study, patients receiving quetiapine IR (twice daily dosing) reported nonadherence as a reason for discontinuation of treatment significantly more often than those on quetiapine XR (once daily dosing). Thirty-three patients (19% of total study population) used both formulations of quetiapine during their hospital stay.

While at the hypothalamic level the interregulations of DA and 5-

While at the hypothalamic level the interregulations of DA and 5-HT systems are complex and not fully understood, preclinical studies have shown that dopamine D2 receptors stimulate the release of hypothalamic

TRH and inhibit. TSH production at the pituitary level. In turn, TRH and thyroid hormones stimulate the DA system, and induce a downregulation of D2 receptors. To examine the functional relationships between HPT axis activity and DA CPI-613 datasheet function in Inhibitors,research,lifescience,medical depressed patients, especially in those with a history of suicidal behavior, we measured hormonal responses to 8 am and 11 pm TRH tests and to apomorphine (APO) test in 64 drug-free inpatients with DSM-FV 12 major depression (35 with a history of suicide attempt, 29 without) and 34 hospitalized healthy controls. APO, a direct-acting DA agonist with high Inhibitors,research,lifescience,medical affinities for D2 and D3 receptors and a partial agonist at the D1 receptor, decreases PRL and

stimulates growth hormone (GH), ACTH, and Cortisol secretion.22 Compared with controls, patients demonstrate lower TRH and TSH responses and lower APO-induced PRL suppression (Table III). PRL response to APO provides an indirect index of central neurotransmission by assessing postsynaptic D2 receptor sensitivity at the pituitary level. A lower PRL response to APO may reflect a decreased D2 receptor function. This abnormality may represent (i) a primary deficit in D2 receptor Inhibitors,research,lifescience,medical sensitivity in the pituitary in depressed patients; or (ii) a downregulation of D2 receptors secondary to increased presynaptic DA activity. Cooccurrence of HPT axis and tuberoinfundibular DA dysregulation is compatible with a decreased TRH and D2 receptor function, Inhibitors,research,lifescience,medical possibly secondary to increased TRH tone, since TRH stimulates the DA system and induces a downregulation of D2 receptors. Table III. Demographic characteristics and biological data for depressed patients and normal control subjects. Δ, peak concentration minus baseline value; TRH, thyrotropin-releasing hormone; TSH, thyroid-stimulating hormone; PRL, prolactin; PRL suppression … When classifying Inhibitors,research,lifescience,medical patients according to

their history of suicidal behavior, those with a negative history more frequently have reduced AATSH values (Figure 3), but comparable hormonal APO responses (ie, PRL, ACTH, and Cortisol), than those with a positive history. In patients without a history of suicide attempt, a negative correlation is Sodium butyrate found between AATSH values and post- APO ACTH (p=-0.44, P=0.02) and Cortisol (p=-0.50,P<0.008) levels. This correlation is found neither in patients with a history of suicide attempt (Figure 4) nor in control subjects. Figure 3 Differences between 11 pm and 8 am maximum increments in thyroid-stimulating hormone (ΔΔTSH) in controls and in depressed patients with a suicidal history (SH) and without an SH. Blunted ΔΔTSH, defined as a response below …

Large intersubject variability in the neurobiologie effects of ag

Large intersubject variability in the neurobiologie effects of aging has been noted by several investigators.44,45 These reports, individually limited by small sample sizes, suggest, that aging effects on brain function are likely highly variable, affected by structural brain changes and systemic factors, and may differ between “successful aging” and individuals with substantial medical burden. Alterations in SB939 cell line neurotransmitter systems The functional integrity of several neurotransmitter systems is

altered by the aging process. Characterizing the profile of normal aging changes in neurotransmittcrmediated synaptic processes is the foundation upon Inhibitors,research,lifescience,medical which we will come to decipher the biological basis of behavioral and mood alterations accompanying aging. Further, the potential interaction between age effects and neurochemical

disturbances associated with neuropsychiatrie disease states may influence the susceptibility of the elderly to certain neurobehavioral disorders. Our knowledge of the effect of age on neuroreceptor function is primarily Inhibitors,research,lifescience,medical inferred by postmortem studies, with limited and variable regional sampling of the brain, and by animal models, which may not Inhibitors,research,lifescience,medical appropriately represent, human brain aging. In contrast to studies of pathological changes in aging, there are many problems associated with the biochemical study of neurotransmission in humans. These include the effects of postmortem delay, hypoxia, and drug treatment, as well as the fundamental point that the material is removed most often removed following a terminal illness, which may itself influence neurotransmission regardless of the age at which the patient died. Inhibitors,research,lifescience,medical ‘ITtic reader is referred to a comprehensive review

of the subject, Inhibitors,research,lifescience,medical by DeKosky and Palmer.46 With the development of highly selective radioligands for neuroreceptors, transporters, and other markers of neuronal function, it is possible to study the effects of aging and disease on brain neurotransmitter systems in vivo with PET. This approach permits whole-brain quantitative imaging in well-characterized subjects, with the potential for obtaining longitudinal measures. Such work has demonstrated specific aging reductions in dopamine and serotonin (5-hydroxytryptamine [5-HT]) receptor subtypes (Figure 1).47-50 Interestingly, there is evidence that some neuroreceptors SB-3CT actually increase in density with age, a finding of note in the opiate system.51 PET techniques are desirable relative to neuroendocrine challenge studies, which lack spatial localizing information and physiologic specificity. However, the combination of PET with neuropharmacologic probes is a powerful technique for localizing and quantifying neurotransmitter-mediated function in aging and disease. Figure 1. [18F]Altanserin positron emission tomography (PET) imaging of the 5-hydroxytryptamine (serotonin) type-2A receptor (5-HT2A). Left.

Angiotensin converting enzyme

inhibitors should be avoide

Angiotensin converting enzyme

inhibitors should be avoided in the second and third trimester but are safe to use postpartum. Beta-blockers can be used when not contraindicated during pregnancy, and they can be used postpartum. During pregnancy, β-1 selective agents are preferred because β-2 receptor blockade may have an antitocolytic effect. Inotropic agents should be used in patients with signs of low cardiac output or with persistent congestion despite diuretics/afterload-reducing agents. Anticoagulation is recommended in patients with PPCM as these patients have a high incidence of LV thrombus, Inhibitors,research,lifescience,medical especially patients with an LVEF <35%. Heparin (unfractionated and low-molecular-weight) is favored in pregnancy since, unlike warfarin, it doesn’t cross the placenta. Warfarin should Inhibitors,research,lifescience,medical be avoided as it is teratogenic in early pregnancy and has a risk of causing fetal cerebral hemorrhage in the second and third trimester. After delivery, PPCM should be treated according to current guidelines for heart failure.22 Specific Experimental Treatment Strategies Awaiting Further Validation Immunosuppressive agents: The prevalence of myocarditis in PPCM varies from 9–78%.32, 33 A single nonrandomized study

suggested that immunosuppression Inhibitors,research,lifescience,medical may benefit women with biopsy-proven myocarditis.34 However, the Myocarditis Treatment Trial did not show any benefit of immunosuppressive medications Inhibitors,research,lifescience,medical and, given the risks of immunosuppressive therapy, they are currently not widely utilized.33, 35 Intravenous immune globulin (IVIG): The

role of IVIG in PPCM was evaluated in a retrospective study of six women treated with IVIG and 11 controls treated conventionally.36 After a 6-month follow-up, the absolute increase in LVEF was greater in those treated with IVIG compared to controls Inhibitors,research,lifescience,medical (26% vs. 13%). However, the IMAC trial (Controlled Trial of Intravenous Immune Globulin in Recent-Onset Dilated Cardiomyopathy) showed that despite the potential therapeutic efficacy suggested by previous uncontrolled studies, immune globulin treatment of adult patients with recent-onset Cardiomyopathy in this placebo-controlled trial did not affect improvements in LVEF or functional capacity during follow-up.36 Bromocriptine: This treatment strategy is based on an experimental observation of preventing Sodium butyrate PPCM in mice via prolactin blockade with bromocriptine.11 In a randomized open-label study performed in South Africa, 20 women with newly diagnosed PPCM were randomly assigned to receive either standard care plus bromocriptine or standard care alone.37 The 10 women receiving bromocriptine demonstrated significantly greater improvement in LVEF compared to the 10 women receiving standard care only (27% to 58% vs. 27% to 36%). One patient in the bromocriptine group died compared to four in the standard care group.