Cannabinoid hyperemesis syndrome in pregnancy: Challenges and opportunities

Antenatal cannabis consumption is common and associated with adverse perinatal outcomes, including low birthweight, pre-term birth and increased rates of admission to neonatal intensive care. Cannabinoid hyperemesis syndrome (CHS) comprises severe, cyclical episodes of vomiting, intractable nausea and abdominal pain observed in chronic cannabis users. CHS, particularly during pregnancy, poses a diagnostic dilemma with a tendency to be ineffectively managed secondary to reduced clinician awareness and a scarcity of available therapies. This clinical perspective explores the current literature on CHS in pregnancy, available pharmacotherapeutics, and recognises the current barriers to improving clinical care.

The value of mid-upper arm circumference for malnutrition screening in pediatric celiac disease

BACKGROUND

Malnutrition rates in pediatric celiac disease (CD) patients range from 20.2% to 67.3%.

OBJECTIVES

To investigate the prevalence of malnutrition in pediatric CD patients in Turkey using different anthropometric measurements, including mid-upper arm circumference (MUAC).

MATERIAL AND METHODS

This prospective study included 124 patients aged 1-18 years with a diagnosis of CD, admitted to the Pediatric Gastroenterology Outpatient Clinic of Adana City Training and Research Hospital, Turkey. The anthropometric measurements, including weight-for-age (WFA) Z-score, height-for-age (HFA) Z-score, body mass index (BMI)-for-age Z-score, MUAC [cm], and MUAC Z-score were calculated.

RESULTS

The study analyzed 75 female (60.5%) and 49 male (39.5%) patients with a mean age of 9.83 ±4.1 years. While 44 patients (35.5%) had malnutrition according to their BMI Z-scores, 60 patients (48.4%) had malnutrition based on their MUAC Z-scores. The number of patients with stunting (HFA value below -2) was 24 (19.4%), and the WFA value was below -2 in 27 (21.8%) patients. Furthermore, the BMI Z-score failed to identify chronic malnutrition in 70.9% of patients. There was a positive linear correlation (r = 0.396) between the BMI value and the MUAC value (p < 0.001). However, the degree of agreement between the BMI Z-scores and MUAC Z-scores was weak (κ: 0.300).

CONCLUSIONS

The MUAC Z-score successfully detected acute and chronic malnutrition and should be included in standard anthropometric measurements at follow-up nutritional assessments in CD patients.

Solid pseudopapillary neoplasms of the pancreas in childhood and adolescence-an analysis of the German Registry for Rare Pediatric Tumors (STEP)

Solid pseudopapillary neoplasms (SPNs) are the most common entity among pediatric pancreatic tumors. Still, these are rare tumors with an annual incidence of 0.1-0.2/1,000,000, and little is known about their optimal treatment. This analysis aimed to increase knowledge about the occurrence and treatment strategies of SPN in childhood. Data regarding diagnostics, treatment, and outcome of children aged 0-18 years with SPN recorded in the German Registry for Rare Pediatric Tumors (STEP) were analyzed. Thirty-eight patients were identified with a median age of 14.5 years at diagnosis (range: 8-18) and a female preponderance (81.6%). The most frequent location of the tumor was the pancreatic tail. In histopathological and immunohistochemical examination, pseudopapillary, solid, and cystic lesions as well as expression of beta-catenin, progesterone receptors, and cyclin D1 were the most common findings. All patients underwent surgical resection. Most patients underwent open resection, predominantly tail resection for tumors in the tail region and pylorus-preserving pancreaticoduodenectomy for tumors in the head region. The main postoperative sequela was exogenous pancreatic insufficiency (23.7%), especially with SPN in the pancreatic head. No recurrence occurred during follow-up, although two patients underwent resection with microscopic residue.

CONCLUSION

SPN of the pancreas in childhood are low-grade malignancies with usually favorable treatment outcomes. However, therapy can lead to relevant long-term sequelae. To prevent recurrence, complete surgical resection is recommended, sparing as much healthy pancreatic tissue as possible. Interdisciplinary collaboration between specialists is essential to optimize treatment. Molecular genetic analysis of these tumors could improve understanding of their genesis.

WHAT IS KNOWN

• Solid pseudopapillary neoplasms (SPNs) of the pancreas are very rare tumors in childhood. • Little is known about tumorigenesis, and there are no specific guidelines for treatment and follow-up in pediatric patients.

WHAT IS NEW

• Characteristics, treatment, and outcome were comprehensively assessed in a large cohort of pediatric patients with SPN. • We propose recommendations for diagnosis, treatment, and follow-up of children with SPN, based on our analysis and considering published experience.

Drug Rash with Eosinophilia and Systemic Symptoms Syndrome Caused by Itraconazole in a 17-Year-Old Girl

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe adverse drug-induced hypersensitivity reaction. We report a case of DRESS syndrome in a 17-year-old female caused by itraconazole, confirmed by patch testing, that required treatment with both corticotherapy and cyclosporine. Our case highlights the importance of clinical suspicion of this syndrome in pediatric age and the novelty of an antifungal drug being identified as the culprit.

Genetic Affinities and Adaptation of the South-West Coast Populations of India

Evolutionary event has not only altered the genetic structure of human populations but also associated with social and cultural transformation. South Asian populations were the result of migration and admixture of genetically and culturally diverse groups. Most of the genetic studies pointed to large-scale admixture events between Ancestral North Indian (ANI) and Ancestral South Indian (ASI) groups, also additional layers of recent admixture. In the present study, we have analyzed 213 individuals inhabited in South-west coast India with traditional warriors and feudal lord status and historically associated with migratory events from North/North West India and possible admixture with West Eurasian populations, whose genetic links are still missing. Analysis of autosomal Single Nucleotide Polymorphism (SNP) markers suggests that these groups possibly derived their ancestry from some groups of North West India having additional Middle Eastern genetic components. Higher distribution of West Eurasian mitochondrial haplogroups also points to female-mediated admixture. Estimation of Effective Migration Surface (EEMS) analysis indicates Central India and Godavari basin as a crucial transition zone for population migration from North and North West India to South-west coastal India. Selection screen using 3 distinct outlier-based approaches revealed genetic signatures related to Immunity and protection from Viral infections. Thus, our study suggests that the South-west coastal groups with traditional warriors and feudal lords' status are of a distinct lineage compared to Dravidian and Gangetic plain Indo-Europeans and are remnants of very early migrations from North West India following the Godavari basin to Karnataka and Kerala.

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature

Importance

Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes.

Objective

To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus.

Evidence Acquisition

PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included.

Results

We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries.

Conclusions and relevance

Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

High-Altitude Pulmonary Edema in Women: A Scoping Review-UIAA Medical Commission Recommendations

Pichler Hefti, Jacqueline, Dominique Jean, Alison Rosier, Mia Derstine, David Hillebrandt, Lenka Horakova, Linda E. Keyes, Kastė Mateikaitė-Pipirienė, Peter Paal, Marija Andjelkovic, Beth Beidlemann, and Susi Kriemler. High-altitude pulmonary edema in women: a scoping review-UIAA Medical Commission Recommendations. High Alt Med Biol. 24:268-273, 2023. Background: High-altitude pulmonary edema (HAPE) can occur >2,500-3,000 m asl and is a life-threatening medical condition. This scoping review aims to summarize the current data on sex differences in HAPE. Methods: The International Climbing and Mountaineering Federation (UIAA) Medical Commission convened an international author team to review women's health issues at high altitude. Pertinent literature from PubMed and Cochrane was identified by keyword search combinations (including HAPE), with additional publications found by hand search. The primary search focus was for original articles that included minimum one woman and at least a rudimentary subgroup analysis. Results: The literature search yielded 7,165 articles, 416 of which were relevant for HAPE, and 7 of which were ultimately included here. Six were case series, consistently reporting a lower HAPE prevalence in women. The one retrospective case-control study reported male HAPE prevalence at 10/100,000 and female at 0.74/100,000. No studies were identified that directly compared sex differences in the prevalence of HAPE. No published data was found for topics other than epidemiology. Conclusions: Few studies and associated methodological limitations allow few conclusions to be drawn. Incidence of HAPE may be lower in women than in men. We speculate that besides physiological aspects, behavioral differences may contribute to this potential sex difference.

A laser free self-luminous nanosystem for photodynamic therapy of cervical cancer cells

Photodynamic therapy is a tumor treatment strategy. However, most of the photodynamic therapies rely on laser irradiation triggering, which limits their application in deep tissues. This study designed a self-luminescent nano system, hybrid protein oxygen nanocarrier coated graphene quantum dots (GQDs@HPOC) and mesoporous silica nanoparticles coated Luminol (L@MSNs), which self-assembled into GQDs@HPOC/L@MSNs without laser irradiation. The system utilized the weak acidic environment of tumors to trigger the release of Luminol and the chemiluminescence was catalyzed by HPOC. Next CRET occurred between Luminol and GQDs, producing 1O2, which could generate photodynamic damage to cervical cancer cells without the need for external laser irradiation. The system achieved the peak uptake in primary cervical cancer cells in 3 h, and had good biosafety before self-assembly. The system could significantly kill cells at a concentration of 16 μg/ml. The system will be further applied in in vivo experiments to investigate its therapeutic ability, providing a new strategy for the clinical treatment of cervical cancer.

Comparative investigation on synergistic changes in enzyme activities during vermicomposting of cereal grain processing industry sludge employing three epigeic earthworm species

The management of cereal grain processing industry sludge through vermicomposting is an emerging prospect for researchers interested in the green economy. This work is designed to enumerate the enzymatic influence of three epigeic earthworm species - Eisenia fetida, Eudrilus eugeniae, and Perionyx excavatus on the industrial sludge. The vermicomposting experiment was conducted in plastic pots by blending the waste materials with 5% cow dung. The dynamics in activities of cellulase, amylase, invertase, phosphatase, protease, dehydrogenase, and urease were studied on 15 days intervals till the harvesting period. The periodical observations confirmed that the enzyme activities (in terms of μg reducing sugar/g/hr) of cellulase (26.45-128.09) amylase (205.43-878.96), invertase (105.32-841.65), phosphatase (85.29-435.54), protease (64.21-359.47), dehydrogenase (111.17-587.72), and urease (94.16-476.71) was low in the first 15 days of the vermicomposting experiment followed by a sharp increase in the next 45 days accompanied by a steady decline until the harvesting is carried out. Emerging statistical tools such as principal component analysis were employed to study the synergistic deviations of the enzymes during the vermicomposting process. The results confirmed that the enzyme activity efficiently influences the bio-oxidation of industrial waste at an individual level as well as synergistic level thereby allowing the vermicompost to mature much before the appearance of any physical symptoms on the surface of the vermireactors.

Mechanisms underlying retardation of aging by dietary energy restriction

Moderate restriction of dietary energy intake, referred to here as dietary restriction (DR), delays aging and extends lifespan in experimental animals compared with a diet of ad libitum feeding (AL) control animals. Basic knowledge of the mechanisms underlying the effects of DR could be applicable to extending the healthspan in humans. This review highlights the importance of forkhead box O (FoxO) transcription factors downstream of the growth hormone-insulin-like growth factor 1 signaling in the effects of DR. Our lifespan studies in mice with heterozygous Foxo1 or Foxo3 gene knockout indicated differential roles of FoxO1 and FoxO3 in the tumor-inhibiting and life-extending effects of DR. Subsequent studies suggested a critical role of FoxO3 in metabolic and mitochondrial bioenergetic adaptation to DR. Our studies also verified hypothalamic neuropeptide Y (Npy) as a vital neuropeptide showing pleiotropic and sexually dimorphic effects for extending the healthspan in the context of nutritional availability. Npy was necessary for DR to exert its effects in male and female mice; meanwhile, under AL conditions, the loss of Npy prevented obesity and insulin resistance only in female mice. Overnutrition disrupts FoxO- and Npy-associated metabolic and mitochondrial bioenergetic adaptive processes, causing the acceleration of aging and related diseases.

Investigation of mortality rates and the factors affecting survival in out-of-hospital cardiac arrest patients

BACKGROUND

It is known that even if spontaneous circulation returns after cardiopulmonary resuscitation(CPR) in geriatric out-of-hospital cardiac arrests(OHCA), the overall one-year survival rate of these patients is very low. In our study, we aimed to investigate the factors affecting survival in OHCA cases.

METHODS

OHCA patients over 18 years of age were examined in two different groups as 18-64 years old and over 65 years old. Demographic data, comorbidities, cardiac arrest rhythms and minutes, and the number of days they were hospitalized in the intensive care unit were recorded.

RESULTS

The mean age was 65.9 ± 15.8 years and 39.9% (n = 110) of the patients were female. The number of intensive care unit stays was significantly higher in the over-65 age group (p = 0.011). The mortality rate and one-year survival rate were significantly lower in the over-65 age group (p < 0.001). Median CPR time was 21 min (IQR:14-32) in the entire patient population. The duration of CPR was 22 min (IQR:14-35) in patients with in-hospital mortality, and 15 min (IQR:13-25) in patients discharged from the hospital. In this comparison, the difference is statistically significant (p = 0.008).

CONCLUSION

In our study, it was determined that especially over 65 years of age, coronary artery disease, and post-arrest CPR duration were determinant and predictive factors in in-hospital and long-term survival.

Inflammatory markers in serum and placenta in a randomized controlled trial of group prenatal care

BACKGROUND

Racial and socioeconomic disparities in preterm birth and small for gestational age births are growing in the United States, increasing the burden of morbidity and mortality particularly among Black women and birthing persons and their infants. Group prenatal care is one of the only interventions to show potential to reduce the disparity, but the mechanism is unclear.

OBJECTIVE

The goal of this project was to identify if group prenatal care, when compared with individual prenatal care, was associated with a reduction in systemic inflammation during pregnancy and a lower prevalence of inflammatory lesions in the placenta at delivery.

STUDY DESIGN

The Psychosocial Intervention and Inflammation in Centering Study was a prospective cohort study that exclusively enrolled participants from a large randomized controlled trial of group prenatal care (the Cradle study, R01HD082311, ClinicalTrials.gov: NCT02640638) that was performed at a single site in Greenville, South Carolina, from 2016 to 2020. In the Cradle study, patients were randomized to either group prenatal care or individual prenatal care, and survey data were collected during the second and third trimesters. The Psychosocial Intervention and Inflammation in Centering Study cohort additionally provided serum samples at these 2 survey time points and permitted collection of placental biopsies for inflammatory and histologic analysis, respectively. We examined associations between group prenatal care treatment and a composite of z scored serum inflammatory biomarkers (C-reactive protein, interleukin-6, interleukin-1 receptor antagonist, interleukin-10, and tumor necrosis factor α) in both the second and third trimesters and the association with the prevalence of acute and chronic maternal placental inflammatory lesions. Analyses were conducted using the intent to treat principle, and the results were also examined by attendance of visits in the assigned treatment group (modified intent to treat and median or more number of visits) and were stratified by race and ethnicity.

RESULTS

A total of 1256 of 1375 (92%) Cradle participants who were approached enrolled in the Psychosocial Intervention and Inflammation in Centering Study, which included 54% of all the Cradle participants. The Psychosocial Intervention and Inflammation in Centering Study cohort did not differ from the Cradle cohort by demographic or clinical characteristics. Among the 1256 Psychosocial Intervention and Inflammation in Centering Study participants, 1133 (89.6%) had placental data available for analysis. Among those, 549 were assigned to group prenatal care and 584 of 1133 were assigned to individual prenatal care. In the intent to treat and modified intent to treat cohorts, participation in group prenatal care was associated with a higher serum inflammatory score, but it was not associated with an increased prevalence of placental inflammatory lesions. In the stratified analyses, group prenatal care was associated with a higher second trimester inflammatory biomarker composite (modified intent to treat: B=1.17; P=.02; and median or more visits: B=1.24; P=.05) among Hispanic or Latine participants.

CONCLUSION

Unexpectedly, group prenatal care was associated with higher maternal serum inflammation during pregnancy, especially among Hispanic or Latine participants.

Planned cesarean delivery vs planned vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

There are over 145 million births worldwide, with over 30 million cesarean deliveries yearly. There are limited data comparing the perinatal and maternal outcomes between planned cesarean delivery and planned vaginal delivery. This study aimed to evaluate perinatal and maternal morbidity and mortality by meta-analysis of randomized controlled trials that randomly assigned patients to either planned cesarean delivery or planned vaginal delivery.

DATA SOURCES

Scopus, PubMed, CINAHL, Cochrane Library, and the World Health Organization clinical trial databases were searched from inception through August 2022.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared planned cesarean delivery with planned vaginal delivery at any gestational age and for any delivery indication were included.

METHODS

Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. The primary outcome was perinatal mortality. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals. Pooled odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel random-effects models for outcomes.

RESULTS

In 15 primary randomized controlled trials, 3265 patients were randomized to planned cesarean delivery and 3353 to planned vaginal delivery. The incidence of perinatal deaths was not different (1.3% vs 1.3%; relative risk, 0.71; 95% confidence interval, 0.33-1.52). Planned cesarean delivery was associated with lower neonatal incidences of low umbilical artery pH (0.3% vs 2.4%; relative risk, 0.18; 95% confidence interval, 0.05-0.67), birth trauma (0.3% vs 0.7%; relative risk, 0.46; 95% confidence interval, 0.22-0.96), tube feeding requirement (2.5% vs 7.1%; relative risk, 0.36; 95% confidence interval, 0.19-0.66), and hypotonia (0.4% vs 3.5%; relative risk, 0.11; 95% confidence interval, 0.03-0.47), compared to planned vaginal delivery. Chorioamnionitis was less frequent in the planned cesarean delivery group (0.3% vs 1.0%; relative risk, 0.27; 95% confidence interval, 0.08-0.98). Wound infection was more common in the planned cesarean delivery group (1.9% vs 1.1%; relative risk, 1.61; 95% confidence interval, 1.04-2.52). Lower rates were observed in the planned cesarean delivery group for urinary incontinence at both ≤3 months (8.7% vs 12.2%; relative risk, 0.71; 95% confidence interval, 0.59-0.85) and 1 to 2 years (16.9% vs 22%; relative risk, 0.77; 95% confidence interval, 0.67-0.88) and for a painful perineum at 2 years (4% vs 6.2%; relative risk, 0.64; 95% confidence interval, 0.47-0.87) compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death (0.69% vs 1.81%; relative risk, 0.45; 95% confident interval, 0.21-0.93).

CONCLUSION

Planned cesarean delivery and planned vaginal delivery were associated with similar rates of perinatal and maternal mortality in this meta-analysis of randomized controlled trials. Planned cesarean delivery was associated with significant decreases in adverse neonatal outcomes such as low umbilical artery pH, birth trauma, tube feeding requirement, and hypotonia, and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. Planned vaginal delivery was associated with significant decreases in need for general anesthesia and wound infection. Further randomized trials are needed to assess the risks and benefits of planned cesarean delivery vs planned vaginal delivery in lower-risk patients and in the general population.

Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study

BACKGROUND

Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum recommended worldwide is hysterectomy. However, adverse outcomes after hysterectomy, including surgical complications, such as difficulty in performing the procedure, and sequelae, such as infertility and psychological issues, cannot be ignored. Several surgical approaches for conservative treatment have been proposed. There are few reports on the effectiveness, safety, and long-term complications of conservative treatments, especially subsequent pregnancy outcomes.

OBJECTIVE

This study aimed to investigate the clinical outcomes and identify risk factors of subsequent pregnancies among patients with placenta accreta spectrum who had undergone conservative surgery.

STUDY DESIGN

This was a retrospective cohort study of subsequent pregnancy cases after cesarean delivery with conservative treatment for placenta accreta spectrum from 2011 to 2019 at The First Affiliated Hospital of Zhengzhou University to identify clinical outcomes of subsequent pregnancies and the risk factors of adverse pregnancy outcomes.

RESULTS

A total of 883 patients undergoing conservative surgery were included in this study, among which 604 (68.4%) were successfully followed up. There were 75 successful pregnancies in 72 patients, including 22 full-term or near-term deliveries, 1 induced labor in the second trimester of pregnancy, 6 cesarean scar pregnancies (8.0%), 2 ectopic pregnancies, and 44 first-trimester pregnancies (3 miscarriages and 41 elective abortions and 12 medical abortions and 32 vacuum aspirations). All newborns survived in the 22 full-term or near-term deliveries. Moreover, 5 placenta accreta spectrum cases (22.7%) and 6 placenta previa cases were observed. Postpartum hemorrhage was observed in 2 cases, with an incidence rate of 9.1%. All parameters, including age at subsequent pregnancy, gravidity, number of cesarean deliveries, type of previous placenta accreta spectrum, gestational week of pregnancy termination, interpregnancy interval, and the use of vascular occlusion techniques, were not found to be associated with recurrent placenta accreta spectrum and cesarean scar pregnancy.

CONCLUSION

Our findings show that treatment for placenta accreta spectrum does not automatically preclude a subsequent pregnancy. However, patients should be fully informed about the risk of recurrent placenta accreta spectrum, scar pregnancy, and postpartum hemorrhage.

MRI brain findings of Abamectin toxic encephalopathy: a case report with review of literature

Abamectin is an insecticidal/miticidal compound derived from the soil bacterium "Streptomyces avermitilis". Abamectin toxicity in humans is very rare. We present a case of acute neurotoxicity induced by Abamectin, showcasing distinctive MRI brain findings in a 33-year-old female who exhibited a favourable recovery with the aid of supportive care. In a patient with known exposure to toxins, even with a lack of knowledge of the specific type or class of toxin, recognition of anatomical distribution of lesions on brain MRI and their characteristic appearance can help exclude other causes of neurologic impairment and aid in timely management.

The pathology of canine mammary candidiasis with embolic dissemination in a dog

Candidiasis is a fungal disease caused by Candida albicans or other members of the genus Candida. Descriptions of candidiasis are comparatively reduced in veterinary relative to human medicine, with no cases of mammary candidiasis being identified in pet animals. This report presents the cytological, pathological, and molecular findings of mammary candidiasis with embolic dissemination in a postpartum dog. A 1-year-old, female Shih-tzu dog that had recently given birth was admitted to a veterinary teaching hospital in Southern Brazil after repeated episodes of intermittent mammary disease and a neurological syndrome. The dog was euthanized due to worsened clinical status and poor prognosis despite adequate clinical therapy and was submitted for routine post-mortem evaluation to determine the cause of the neurological manifestations. Cytological analysis of purulent mastitis identified intralesional fungal hyphae. Gross evaluation revealed multiple masses within the kidneys, liver, myocardium, pancreas, and brain. Routine histopathology and histochemistry identified fungal nephritis, hepatitis, myocarditis, pancreatitis, and encephalitis associated with intralesional fungal hyphae, frequently with fungal emboli and vasculitis. Pure cultures of C. albicans were obtained from fragments of the masses observed at the myocardium and kidneys, with the typical germ tube of C. albicans being identified by microscopic evaluation. A PCR assay that targeted the ITS1 and 4 generic regions of fungi, amplified the desired amplicon, and direct sequencing confirmed C. albicans. Immunohistochemical and molecular assays designed to identify common infectious disease pathogens of dogs did not confirm the participation of canine distemper virus, canine parvovirus, or canine adenovirus in the target tissues of this dog. These findings suggest that this dog suffered an initial cutaneous lesion, that probably served as portal of entry to the mammary gland, resulting in mammary candidiasis with subsequent embolic dissemination to multiple organs. This report represent the first description of mammary candidiasis in pet animals and probably one of the few pathological descriptions of mammary candidiasis in domestic animals. In this case, the cause of the fungal infection was probably associated with factors intrinsic to abdominal surgery, pregnancy, and the utilization of antibiotics.

Parameniscal Cyst Arthroscopic Excision by the Modified Fat Pad Approach Can Shorten Recovery Time-A New Surgical Method with Retrospective Study

OBJECTIVES

Parameniscal cysts can be removed without meniscectomy, but for large or multiloculated meniscal cysts, traditional arthroscopic excision may leave the meniscus unstable. This study aimed to describe a modified fat pad approach for parameniscal cyst arthroscopic excision that retains a stable structure of the synovial margin of the meniscus and to compare the clinical outcomes between the traditional cyst excision and modified excision techniques.

METHODS

Fifty-six patients with parameniscal cysts between 2014 and 2018 were retrospectively included in this study with 28 patients in each group. All patients underwent arthroscopic parameniscal cyst excisions with traditional and modified excision techniques respectively in each group. The International Knee Documentation Committee subjective (IKDC) score, Lysholm score, visual analogue scale (VAS) score, Tegner score, active range of motion (ROM) and time to recover full ROM were used to evaluate the clinical outcomes by using the t-test.

RESULTS

The patient population included 21 males and 35 females, with a mean follow-up of 29 months. Of these, 28 patients underwent traditional arthroscopic cyst excisions and meniscal sutures, and 28 patients underwent arthroscopic excisions by the modified fat pad approach. There were no significant differences in the IKDC score, Lysholm score, Tegner score or VAS score between the traditional and modified excision groups at the final follow-up time point. However, the postoperative time to recover full ROM in the modified excision group was significantly lower than those in the traditional excision group (p < 0.05).

CONCLUSION

Arthroscopic excision with the modified fat pad approach yielded a shorter pain phase and less time to recover full ROM during recovery compared with the traditional arthroscopic excision. The new method seemed to be effective, as evidenced by the positive clinical outcomes of patients.

Impact of pulmonary vein anatomy and ostial dimensions on long-term outcome after single-shot device-guided cryoablation for paroxysmal atrial fibrillation

BACKGROUND

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). This observational study aimed to assess the role of individual anatomical characteristics to predict long-term freedom from arrhythmia recurrence after CB-guided PVI for paroxysmal AF (PAF).

METHODS

Three hundred fifty three consecutive patients (58 ± 11 years, 56% males), undergoing PVI between 2012 and 2018 were analysed. Individual pulmonary vein (PV) anatomy was assessed using preprocedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional area (CSA) was calculated. The impact of PV characteristics and CSA on long-term AF-free survival was evaluated.

RESULTS

Acute PVI was achieved in all patients. Two hundred twenty-three patients (63%) had a normal PV anatomy (2 left- and 2 right-sided PV). Variant PV anatomy was present in 130 patients (37%). During the observation period of 48 months, AF-recurrence was documented in 167 patients (47 %). Patients with AF-recurrence presented with significantly enlarged right-sided PVs and left superior PVs (LSPVs) (p < 0.001). The presence of left common PVs (LCPVs) (n = 75, Log-rank p < 0.001) as well as right variant PVs (n = 35, Log rank p < 0.001) was associated with a significantly impaired long-term AF-free survival rate as compared to patients with normal PV characteristics.

CONCLUSION

Variant PV anatomy is a good predictor for AF-recurrence. A correlation between an enlarged CSA of right-sided PVs as well as LSPVs and AF-recurrence was documented.

Program Evaluation and Preliminary Efficacy of Fitness and Skill-Based High-Intensity Interval Training in Physical Education

Previous school-based high-intensity interval training (HIIT) interventions have focused on the quantity of physical activity (PA) achieved during physical education (PE) rather than students' PE experiences, including enjoyment. Purpose: To evaluate the feasibility of a fitness- and skill based HIIT intervention guided by the Self Determination Theory. Method: For this pretest-posttest randomized controlled 6-week pilot study, 4-5th grade students (15 boys, 30 girls; age = 10.5 ± 0.9 years) completed a 16-19-minute HIIT circuit (INT); whereas, 22 students (10 boys, 12 girls; age = 10.5 ± 0.9 years) engaged in regular PE (CON). Two-way mixed ANCOVA tests were performed to assess preliminary efficacy. Results: Participants reported favorable program satisfaction (mean 3.6 ± 1.5 out of 5). The physical educator reported a high feasibility survey score (31/35), and themes emerging from a program acceptability interview included positive perceptions of the HIIT program and strategies for future implementation. A large effect size was evident for cardiorespiratory fitness (ηp2 = 0.26), as VO2peak increased in INT from 53.6 ± 6.1 to 56.9 ± 7.3 ml/kg/min and decreased in CON (53.9 ± 7.0 to 52.4 ± 10.4 ml/kg/min). Students in INT exhibited greater amounts of moderate-to-vigorous PA and vigorous PA during PE versus CON, based on accelerometer data (23.4 ± 5.0 vs. 15.7 ± 4.7 min/hr, ηp2 = 0.45; 4.5 ± 2.6 vs. 2.3 ± 1.3 min/hr; ηp2 = 0.27, respectively). Conclusions: Findings support the feasibility of this fitness- and skill-based HIIT program and may be a valuable addition to elementary school PE programs.

The validity and reliability of the Turkish version of the 12-item Örebro musculoskeletal screening questionnaire (ÖMSQ-12-TR)

PURPOSE

The 12-item Örebro Musculoskeletal Screening Questionnaire (ÖMSQ-12) is a multidimensional questionnaire assessing general musculoskeletal problems. This study aimed to investigate its construct validity and reliability.

MATERIALS AND METHODS

Confirmatory factor analysis (CFA) was performed for construct validity. The Tampa Scale for Kinesiophobia (TSK) and the SF-12 and Pain Numerical Rating Scale (P-NRS) were used for convergent validity. Reliability (ICC), internal consistency (Cronbach's alpha), reproducibility, and known-group validity were assessed. The cut-off value was measured.

RESULTS

A total of n = 378 individuals (aged 35.7 ± 12.4 years, female = 73.3%) with a musculoskeletal problem participated in the study. P-NRS score of the individuals was 5. Results showed that a 3-factor model did fit well under CFA (χ2/df = 2.76 ≤ 3). The questionnaire had good reliability (ICC = 0.865) and internal consistency (α = 0.810). There were no floor or ceiling effects (<%15). Total ÖMSQ-12-TR scores had a correlation with the TSK, SF-12 and P-NRS (r = 0.303-0.609). The AUC for the risk of absenteeism from work was obtained as 0.738 (p < 0.001). The risk of absenteeism was high in individuals with an ÖMSQ-12-TR score of ≥57.5.

CONCLUSIONS

The ÖMSQ-12-TR is a valid and reliable questionnaire that can be used in determining the risk of absenteeism in musculoskeletal disorders and is convenient for online use.

CLINICAL TRIAL NUMBER

NCT04723615.

Racial disparities in satisfaction with maternal healthcare

OBJECTIVE

To determine if there is a racial disparity in satisfaction with maternal healthcare, and examine the quality of care mothers of color receive.

METHODS

An online survey of women in the United States who had been pregnant at least once was conducted. The study received an exempt determination by our Institution's Review Board.

RESULTS

Race, age, income, were all significant indicators for whether a woman was satisfied with maternal healthcare measures.

CONCLUSION

Race is one of many indicators for dissatisfaction with maternal healthcare. More in-depth research on patient perception of care is recommended.

Retrospective evidence for pediatric benefit of U.S. assault weapons ban as rationale for implementing an even more effective ban

BACKGROUND

With data available since 1981, firearm death rates in American children and adolescents can be evaluated for trends during the 13 years before, the decade of, and during 16 years since the United States (U.S.) 1994-2004 Federal Assault Weapons Ban (FAWB).

METHODS

National and regional firearm mortality trends in the U.S. during 1981-2020 were assessed with joinpoint regression applied to Centers for Disease Control and Prevention data.

RESULTS

After increasing exponentially before the FAWB, the national firearm death rate in 0-14 year-olds promptly reversed course and declined throughout the FAWB and then reversed again after the FAWB and resumed an exponential increase (all phases p<0.001). The reduction in firearm death rate occurred within 1-3 years of the start of the FAWB, in both sexes, in all four census regions of the U.S., and in all four major race/ethnicity subgroups, especially non-Hispanic blacks. No other form of violence in 0-14 year-olds had this temporal relationship with the FAWB. The firearm mortality reduction during the FAWB is strongly-highly correlated with the concomitant reduction in handgun manufacturing in 91 % of 24 sex, race/ethnicity and region subsets analyzed, These FAWB-related trends were also apparent in older adolescents and young adults and less so in older persons.

CONCLUSIONS

Firearm death rates in 0-14 year-olds before, during, and after the FAWB, and no other type of injury, implicate the FAWB as having had a beneficial effect. Legislation to mitigate firearm mortality and injury inclusive of a FAWB should be especially beneficial to children and young adolescents, and regardless of sex, race/ethnicity or region in the U.S.

"The constant worry": Urinary incontinence self-management in rural women: A qualitative study

Urinary incontinence (UI) is experienced by approximately 60% of women in the United States and has a negative impact on self-esteem, sexual function, social participation, and quality of life. Rural women, who are underrepresented in the UI literature, face many health disparities and unique barriers to accessing care. The purpose of this qualitative descriptive study was to explore UI self-management behaviors in rural women with UI, including the contextual factors that influence their approach to self-management. This study recruited rural women, ages 30-60 years, using purposive sampling via social media. Demographic information was collected. A semi-structured interview guide was used to conduct individual, in-depth interviews via Zoom. Interview data were analyzed using qualitative description. Sections of interview text were coded using a priori and emergent codes, grouped into categories, and distilled into themes. A total of 31 participants (mean age = 47.2 years) met inclusion/exclusion criteria, enrolled, and completed the study. Qualitative analysis revealed rural as a cross-cutting theme and five major themes: self-management behaviors, familial influence, medical encounters, talking about UI, and resource scarcity. Participants described the rural environment as having a substantial impact on their approach to UI self-management. Specifically, rural social enmeshment made seeking care for UI in rural communities challenging. Findings shed light on how the rural environment influences various aspects of UI self-management in midlife women. Diverse perspectives in UI self-management are needed to advance knowledge in this field.

A deep supervised transformer U-shaped full-resolution residual network for the segmentation of breast ultrasound image

PURPOSE

Breast ultrasound (BUS) is an important breast imaging tool. Automatic BUS image segmentation can measure the breast tumor size objectively and reduce doctors' workload. In this article, we proposed a deep supervised transformer U-shaped full-resolution residual network (DSTransUFRRN) to segment BUS images.

METHODS

In the proposed method, a full-resolution residual stream and a deep supervision mechanism were introduced into TransU-Net. The residual stream can keep full resolution features from different levels and enhance features fusion. Then, the deep supervision can suppress gradient dispersion. Moreover, the transformer module can suppress irrelevant features and improve feature extraction process. Two datasets (dataset A and B) were used for training and evaluation. The dataset A included 980 BUS image samples and the dataset B had 163 BUS image samples.

RESULTS

Cross-validation was conducted. For the dataset A, the proposed DSTransUFRRN achieved significantly higher Dice (91.04 ± 0.86%) than all compared methods (p < 0.05). For the dataset B, the Dice was lower than that for the dataset A due to the small number of samples, but the Dice of DSTransUFRRN (88.15% ± 2.11%) was significantly higher than that of other compared methods (p < 0.05).

CONCLUSIONS

In this study, we proposed DSTransUFRRN for BUS image segmentation. The proposed methods achieved significantly higher accuracy than the compared previous methods.

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

Increasing expression of STING by ERα antagonizes LCN2 downregulation during chronic endometritis

Chronic endometritis has a high incidence in infertile women, which is caused by endometrial microbiome infection. In response to microbial infection, the role of defensins during chronic endometritis need explored. Besides, the expression of estrogen and its receptors vary in different menstrual cycles, but their roles in chronic endometritis are still unclear. In this study, we used the human endometrial tissues to examine the expression of antimicrobial peptides (AMPs) α-defensin hNP-1 and β-defensins hBD-1, hBD-2, hBD-3, hBD-4 and LCN2. We found the expression of hBD-1 and LCN2 were downregulated in endometritis tissues, while the expressions of hBD-2, hBD-3, hBD-4, hNP-1, and estrogen and ERα were upregulated in chronic endometritis tissues compared to normal tissues. The expression and phosphorylation of STING, which is a crucial mediator of mammalian innate immunity in response to pathogens, was regulated with the treatment of ERα inhibitor raloxifene (Rx). Furthermore, using with the estrogen receptor inhibitor Rx and STING inhibitor H-151 significantly decreases the LCN2 expression. Taken together, these results suggested ERα was upregulated to modulate STING expression inducing LCN2 antimicrobial peptide expression to modulate the mucosal immunity during chronic endometritis.

JAK2 V617F Mutation and Large Cerebral Artery Disease in Patients with Myeloproliferative Neoplasms

AIM

The aim of the present study was to clarify the association between the Janus kinase 2 (JAK2) V617F mutation and large cerebral artery disease (LCAD) in patients with myeloproliferative neoplasms (MPNs).

METHODS

We retrospectively analysed patients diagnosed with MPNs between June 1992 and June 2022 who underwent brain magnetic resonance imaging. LCAD was defined as extracranial or intracranial large artery stenosis (≥ 50%) or occlusion on magnetic resonance angiography.

RESULTS

A total of 86 patients (47 males; median age, 69 years old) were enrolled in this study. JAK2 V617F mutation was detected in 63 (73.3%) patients and LCAD in 35 (40.7%) patients. Univariate analysis showed that history of ischaemic stroke (LCAD, 62.9% vs. non-LCAD, 11.8%; P＜0.001), JAK2 V617F mutation (91.4% vs. 60.8%, P=0.002), and age ≥ 60 years (85.7% vs. 60.8%, P=0.016) were significantly associated with LCAD. Multiple logistic regression analysis showed that, in addition to ischaemic stroke, age ≥ 60 years and diabetes mellitus, JAK2 V617F mutation (odds ratio 29.2, 95% confidence interval 1.2-709.8, P=0.038) was independently associated with LCAD. LCAD was frequently observed in the intracranial carotid (14/35, 40.0%) and middle cerebral (13/35, 37.1%) arteries.

CONCLUSIONS

This study revealed a significant association between the JAK2 V617F mutation and LCAD in patients with MPNs. This suggests that the JAK2 V617F mutation may promote cerebrovascular atherosclerosis and could be very important in determining therapeutic strategies for patients with not only JAK2 V617F-mutated MPNs but also LCAD-related stroke.

Post-COVID-19 distress and unhealthy behavior

BACKGROUND

COVID-19 is one of the most devastating pandemics in history. It is important to understand post-COVID-19 mental health issues and unhealthy behaviors.

AIMS

Investigate whether and how distress levels and unhealthy behaviors might differ across population segments after the end of a nationwide COVID-19 outbreak.

METHODS

Using random sampling, this large-scale study analyzed post-COVID-19 distress and unhealthy behaviors of individuals in Wuhan vs. Beijing in China (which were differentially impacted by the pandemic).

RESULTS

Higher percentages of individuals residing in Wuhan (vs. Beijing) experienced moderate or severe post-COVID-19 distress. Higher percentages of men (vs. women) experienced moderate distress. Larger percentages of people with (vs. without) children experienced a severe level of distress. Post-COVID-19, higher percentages of people decreased (vs. increased) smoking and drinking, but the opposite was true for unhealthy snacking. Importantly, higher post-COVID-19 distress predicted higher consumption in all three unhealthy domains. Men (vs. women) were more likely to increase smoking and drinking; younger individuals were more likely to increase drinking and unhealthy snacking.

CONCLUSIONS

Some population segments were disproportionately susceptible to post-COVID-19 distress and unhealthy behaviors. Post-pandemic policies and interventions are needed to help people, especially the most vulnerable, improve their mental health and physical well-being.

Educational level and the risk of mental disorders, substance use disorders and self-harm in different age-groups: A cohort study covering 1,6 million subjects in the Stockholm region

OBJECTIVE

To investigate the associations between low education and risk of mental disorders, substance use disorders and self-harm in different age-groups.

METHODS

All subjects in Stockholm born between 1931 and 1990 were linked to their own or their parent's highest education in 2000 and followed-up for these disorders in health care registers 2001-2016. Subjects were stratified into four age-groups: 10-18, 19-27, 28-50, and 51-70 years. Hazard Ratios with 95% Confidence Intervals (CIs) were estimated with Cox proportional hazard models.

RESULTS

Low education increased the risk of substance use disorders and self-harm in all age-groups. Males aged 10-18 with low education had increased risks of ADHD and conduct disorders, and females a decreased risk of anorexia, bulimia and autism. Those aged 19-27 years had increased risks of anxiety and depression, and those aged 28-50 had increased risks of all mental disorders except anorexia and bulimia in males with Hazard Ratios ranging from 1.2 (95% CIs 1.0-1.3) for bipolar disorder to 5.4 (95% CIs 5.1-5.7) for drug use disorder. Females aged 51-70 years had increased risks of schizophrenia and autism.

CONCLUSION

Low education is associated with risk of most mental disorders, substance use disorders and self-harm in all age-groups, but especially among those aged 28-50 years.

Novel Anaplasma (Rickettsiales: Anaplasmataceae) strain and Hepatozoon sp. cf. H. procyonis (Apicomplexa, Hepatozoidae) detected in Procyon cancrivorus (Carnivora, Procyonidae) from Argentina, with note of tick-host association

The aim of this work is to report the first detection of Procyon cancrivorus naturally co-infected with Hepatozoon sp. cf. H. procyonis and a novel Anaplasma strain from South America and potential vector tick species associated. On August 30, 2016, a specimen of P. cancrivorus was found dead on the route in Chaco province, Argentina. A tick and a blood sample by cardiac puncture was collected from the specimen. DNA was extracted from blood sample and the tick was morphological identity as a female of Amblyomma ovale. Molecular detection of Anaplasmataceae family and Hepatozoon spp. agents was performed targeting two different loci: 16 S rRNA and 18 S rRNA gene. The phylogenetic analyses show that the Anaplasma sp. strain detected in P. cancrivorus in this study is similar to Anaplasma sp. strains previously detected in Nasua nasua and A. ovale from Brazil. Furthermore, Hepatozoon sp. of the H. procyonis group was amplified that is phylogenetically closely related to H. procyonis reported in N. nasua from Brazil. Since it was not exactly the same as the latter, it was decided to name at Hepatozoon sp. cf. H. procyonis. It is possible that, this potential new species of Anaplasma would be specific for Procyonidae family and there are two species of Hepatozoon linked to this family in South America. These results added to other published studies suggest that A. ovale could be a potential vector both for the new potential strain of Anaplasma and for the Hepatazoon sp. of the H. procyonis group.

The German version of the Revised Children's Anxiety and Depression Scale-Psychometric properties and normative data for German 8- to 17-year-olds

OBJECTIVES

Anxiety and depression are internalizing mental disorders often commencing in childhood and manifesting in adolescence. The Revised Anxiety and Depression Scale (RCADS) is an internationally widely used standardized diagnostic tool, but the German version has only been validated in a pediatric chronic pain sample; normative data are not available. The aim of this study is to test its reliability (internal consistency) and validity (factorial, convergent, known-groups) in a representative German school sample and to provide norm data.

METHODS

Data were collected from N = 1562 German schoolchildren (Mage  = 12.2; SDage  = 2.33; range 8-17 years; 52.4% girls).

RESULTS

Cronbach's α ranged from 0.73 to 0.96 for the total and the six subscales (five anxiety and one depression). Confirmatory factor analysis showed the 6-factor model had acceptable to good model fit with CFI = 0.93, TLI = 0.93, RMSEA = 0.05, SRMR = 0.05, which was better than 1- and 2-factor models. The (sub)scales correlated moderate to high negatively with health-related quality of life (-0.31 ≤ τ ≤ -0.51; p < 0.001) and positively with functional impairment (0.31 ≤ τ ≤ 0.48; p < 0.001). Mean scores of anxiety and depression scales were significantly higher in girls and partly in adolescents.

CONCLUSION

Findings provide support for the good psychometric properties of the German RCADS in a community sample.

Network-Based Spreading of Gray Matter Changes Across Different Stages of Psychosis

Importance

Psychotic illness is associated with anatomically distributed gray matter reductions that can worsen with illness progression, but the mechanisms underlying the specific spatial patterning of these changes is unknown.

Objective

To test the hypothesis that brain network architecture constrains cross-sectional and longitudinal gray matter alterations across different stages of psychotic illness and to identify whether certain brain regions act as putative epicenters from which volume loss spreads.

Design, Settings, and Participants

This case-control study included 534 individuals from 4 cohorts, spanning early and late stages of psychotic illness. Early-stage cohorts included patients with antipsychotic-naive first-episode psychosis (n = 59) and a group of patients receiving medications within 3 years of psychosis onset (n = 121). Late-stage cohorts comprised 2 independent samples of people with established schizophrenia (n = 136). Each patient group had a corresponding matched control group (n = 218). A sample of healthy adults (n = 356) was used to derive representative structural and functional brain networks for modeling of network-based spreading processes. Longitudinal illness-related and antipsychotic-related gray matter changes over 3 and 12 months were examined using a triple-blind randomized placebo-control magnetic resonance imaging study of the antipsychotic-naive patients. All data were collected between April 29, 2008, and January 15, 2020, and analyses were performed between March 1, 2021, and January 14, 2023.

Main Outcomes and Measures

Coordinated deformation models were used to estimate the extent of gray matter volume (GMV) change in each of 332 parcellated areas by the volume changes observed in areas to which they were structurally or functionally coupled. To identify putative epicenters of volume loss, a network diffusion model was used to simulate the spread of pathology from different seed regions. Correlations between estimated and empirical spatial patterns of GMV alterations were used to quantify model performance.

Results

Of 534 included individuals, 354 (66.3%) were men, and the mean (SD) age was 28.4 (7.4) years. In both early and late stages of illness, spatial patterns of cross-sectional volume differences between patients and controls were more accurately estimated by coordinated deformation models constrained by structural, rather than functional, network architecture (r range, >0.46 to <0.57; P < .01). The same model also robustly estimated longitudinal volume changes related to illness (r ≥ 0.52; P < .001) and antipsychotic exposure (r ≥ 0.50; P < .004). Network diffusion modeling consistently identified, across all 4 data sets, the anterior hippocampus as a putative epicenter of pathological spread in psychosis. Epicenters of longitudinal GMV loss were apparent in posterior cortex early in the illness and shifted to the prefrontal cortex with illness progression.

Conclusion and Relevance

These findings highlight a central role for white matter fibers as conduits for the spread of pathology across different stages of psychotic illness, mirroring findings reported in neurodegenerative conditions. The structural connectome thus represents a fundamental constraint on brain changes in psychosis, regardless of whether these changes are caused by illness or medication. Moreover, the anterior hippocampus represents a putative epicenter of early brain pathology from which dysfunction may spread to affect connected areas.

Transformation from acute promyelocytic leukemia in pregnancy to acute myeloid leukemia with MLL-AF9 fusion gene: A case report and literature review

RATIONALE

Because there are few evidence-based guidelines and an extremely low incidence rate, managing and treating patients who have transitioned from acute promyelocytic leukemia (APL), which was diagnosed during pregnancy, to acute myeloid leukemia (AML), can be difficult.

PATIENT CONCERNS

In this case, a 34-year-old pregnant patient was diagnosed with APL in medium-risk group in June 2017. After the all-trans retinoic acid and arsenic trioxide-based full-course treatment, the patients achieved complete remission (CR) and were well-tolerated. After 5 years, the patient complained of fatigue for 3 months.

DIAGNOSIS

Bone marrow examination revealed hypercellularity with approximately 50% immunophenotypic abnormal myeloblasts with MLL-AF9 fusion gene. Based on the AML diagnosis criteria of the World Health Organization, the patient was eventually diagnosed with a rare transformation from APL to AML.

INTERVENTIONS

The patient was treated with two cycles of induction chemotherapy and an allogeneic hematopoietic stem cell transplantation (allo-HSCT).

OUTCOMES

Until now, the patient is in continuous remission with no signs of APL and AML.

LESSIONS

Despite the rarity of APL to AML transformation, it is crucial to track the disease's progress and administer treatment on time. It remains uncertain whether the risk stratification and clinical outcomes of secondary AML with MLL-AF9 are equivalent to those of de novo AML with MLL-AF9. The management and treatment of these patients should be personalized and require further observation.

A case report of a patient with ductal carcinoma and a malignant phyllodes tumor in situ in 2 separate breasts

RATIONALE

Breast malignant phyllodes tumors (MPT) are quite uncommon. It is rarely reported that they occur in conjunction with breast cancer. We detailed a case in which an MPT and ductal carcinoma in situ carcinoma occurred simultaneously in 2 different breasts.

PATIENT CONCERNS

A 79-year-old female patient was seen for a rapidly growing lump in the upper left quadrant of her breast. The lump was described as huge, hard, irregular, and palpable. MRI of the breasts revealed a big mass in the left breast and a smaller lump in the right.

DIAGNOSIS

Ductal carcinoma in situ with breast MPT.

INTERVENTIONS

We performed a double mastectomy. Post-operative endocrine treatment was suggested.

OUTCOMES

During the 18-month follow-up period, no signs of recurrence or metastasis were seen. The ultrasound examination of the chest wall showed no abnormality. Bilateral axillary and supraclavicular ultrasonography showed no lymphadenectasis and a CT scan of the lungs showed no suspicious cancer nodules.

LESSONS

It is possible for MPT and ductal carcinoma in situ to occur simultaneously in different breasts. Surgeons need to integrate clinical observations, imaging tools, and patient history to make an early diagnosis. Before undergoing surgery, a thorough examination of both breasts is required.

Epidemiology and clinical features of hypnic headache: A systematic review and meta-analysis

BACKGROUND

Hypnic headache is a neurological disorder characterized by recurrent headache attacks that occur exclusively during sleep, leading to awakening. Synthesizing the available epidemiological data might inform clinical decision-making.

METHODS

We searched PubMed and Embase for observational studies on hypnic headache published between 1 May 2004, and 22 December 2022. Two investigators independently screened titles, abstracts, and full-text articles. We performed a random-effects meta-analysis with meta-regression to estimate the prevalence of hypnic headache and its clinical features based on epidemiologic data from population-based and clinic-based studies.

RESULTS

Fourteen studies, one population-based and 13 clinic-based, met our eligibility criteria. The population-based study did not identify any people with hypnic headache. From 11 clinic-based studies, the pooled relative frequency of hypnic headache was 0.21% (95%CI, 0.13 to 0.35%; I2 = 87%) in adult patients evaluated for headache. The pooled mean age of onset was 60.5 years, with a slight female predisposition. Hypnic headache was typically bilateral (71%), pressing (73%), of moderate (38%) or severe (44%) pain intensity, and lasted about 115 minutes per attack.

CONCLUSIONS

Our data should be cautiously interpreted due to between-study heterogeneity. The identified clinical presentation of hypnic headache can guide clinical diagnosis, in addition to the International Classification of Headache Disorders.

Mortality and Morbidity Among Individuals With Hypertension Receiving a Diuretic, ACE Inhibitor, or Calcium Channel Blocker: A Secondary Analysis of a Randomized Clinical Trial

Importance

The long-term relative risk of antihypertensive treatments with regard to mortality and morbidity is not well understood.

Objective

To determine the long-term posttrial risk of primary and secondary outcomes among trial participants who were randomized to either a thiazide-type diuretic, calcium channel blocker (CCB), or angiotensin-converting enzyme (ACE) inhibitor with up to 23 years of follow-up.

Design, Setting, and Participants

This prespecified secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a multicenter randomized, double-blind, active-controlled clinical trial, followed up with participants aged 55 years or older with a diagnosis of hypertension and at least 1 other coronary heart disease risk factor for up to 23 years, from February 23, 1994, to December 31, 2017. Trial participants were linked with administrative databases for posttrial mortality (N = 32 804) and morbidity outcomes (n = 22 754). Statistical analysis was performed from January 2022 to October 2023.

Interventions

Participants were randomly assigned to receive a thiazide-type diuretic (n = 15 002), a CCB (n = 8898), or an ACE inhibitor (n = 8904) for planned in-trial follow-up of approximately 4 to 8 years and posttrial passive follow-up for up to 23 years.

Main Outcomes and Measures

The primary end point was mortality due to cardiovascular disease (CVD). Secondary outcomes included all-cause mortality, combined fatal and nonfatal (morbidity) CVD, and both mortality and morbidity for coronary heart disease, stroke, heart failure, end-stage renal disease, and cancer.

Results

A total of 32 804 participants (mean [SD] age, 66.9 [7.7] years; 17 411 men [53.1%]; and 11 772 Black participants [35.9%]) were followed up for all-cause mortality and a subgroup of 22 754 participants (mean [SD] age, 68.7 [7.2] years; 12 772 women [56.1%]; and 8199 Black participants [36.0%]) were followed up for fatal or nonfatal CVD through 2017 (mean [SD] follow-up, 13.7 [6.7] years; maximum follow-up, 23.9 years). Cardiovascular disease mortality rates per 100 persons were 23.7, 21.6, and 23.8 in the diuretic, CCB, and ACE inhibitor groups, respectively, at 23 years after randomization (adjusted hazard ratio [AHR], 0.97 [95% CI, 0.89-1.05] for CCB vs diuretic; AHR, 1.06 [95% CI, 0.97-1.15] for ACE inhibitor vs diuretic). The long-term risks of most secondary outcomes were similar among the 3 groups. Compared with the diuretic group, the ACE inhibitor group had a 19% increased risk of stroke mortality (AHR, 1.19 [95% CI, 1.03-1.37]) and an 11% increased risk of combined fatal and nonfatal hospitalized stroke (AHR, 1.11 [95% CI, 1.03-1.20]).

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial in an adult population with hypertension and coronary heart disease risk factors, CVD mortality was similar between all 3 groups. ACE inhibitors increased the risk of stroke outcomes by 11% compared with diuretics, and this effect persisted well beyond the trial period.

Trial Registration

ClinicalTrials.gov Identifier: NCT00000542.

Risk of gastric cancer in relation with serum cholesterol profiles: A nationwide population-based cohort study

Obesity is a known risk factor for gastric cancer. However, the relationship between serum lipids and gastric cancer risk has not been fully established. We investigated the relationship between serum cholesterol levels and gastric cancer risk using a nationwide population cohort. Adults who received health care screening in 2009 from the Korean National Health Insurance Service were enrolled. Gastric cancer risk in relation to quartiles of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) were compared according to sex, using adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Among 9690,168 subjects enrolled, 92,403 gastric cancer cases were diagnosed. Higher HDL-C levels were associated with lower gastric cancer risk in the total population, men, and women (aHR [for the highest quartile] = 0.98 [0.96-0.99, P < .0001], aHR = 0.98 [0.96-1.004, P = .0004], and aHR = 0.91 [0.88-0.94, P < .0001], respectively). HDL-C showed consistent trends regardless of age or statin use. Higher LDL-C levels were also associated with lower gastric cancer risk in the total population (aHR = 0.92 [0.91-0.94], P < .0001) and men (aHR = 0.94 [0.91-0.96], P < .0001), but not in women (P = .4073). A subgroup analysis of LDL-C showed significant interactions with age and statin use (Pinteraction < .0001 and Pinteraction = .0497, respectively). The risk of gastric cancer was higher in subjects with elevated LDL-C levels in the younger group (age < 55, HR [for the highest quartile] = 1.02 [0.99-1.04] in the total population; HR = 1.03 [1.003-1.06] in men), the risk was lower in subjects with elevated LDL-C in the elderly (age ≥ 55, HR = 0.93 [0.91-0.95] in the total population; HR = 0.94 [0.92-0.96] in men). Elevated TC was associated with lower gastric cancer risk in the total population (aHR = 0.95 [0.94-0.97], P < .0001), but not in each sex separately (P = .3922 in men; P = .1046 in women). Overall, higher HDL-C levels may play a protective role in gastric cancer pathogenesis. The association between LDL-C/TC and gastric cancer seems to vary according to sex, age, and statin use. Especially in young males under age 55, high LDL-C and TC levels were associated with higher risk of gastric cancer.

Radiographical presentations of inadvertent subdural placement of an epidural catheter for successful labor analgesia: A case report

RATIONALE

Lumbar epidural analgesia is the gold standard for labor pain control. However, misplacement of epidural catheters into the subdural space may inadvertently happen. Unrecognized subdural administration of local anesthetics could result in serious consequences, including high spinal and brainstem blocks. This case report describes a case where subdural epidural catheter placement was recognized early but labor pain was adequately managed by dosage titration of subdural analgesia.

PATIENT CONCERNS

This case report describes a 29-year-old primiparous pregnant woman who was admitted to our obstetric unit for labor induction at the gestational age of 38 weeks. An epidural catheter was inserted via the L2-3 intervertebral space using the standard loss of resistance to air technique.

DIAGNOSES

The parturient experienced weakness in the lower extremities and numbness in the upper extremities within 15 minutes after administration of 5 mL of 2% v/v lidocaine as a loading dose and systolic blood pressure also dropped by 25%.

INTERVENTIONS

The dose regimen (a mixture of 0.1% ropivacaine and 4 μg/mL fentanyl) for patient-controlled analgesia was given with bolus doses of 0.1 mL per demand and lockout intervals of 20 minutes. The analgesic effects were adequately maintained below the T8 dermatome for more than 12 hours without hypotensive episodes or obvious signs of neurological deficits. Computed tomographic myelography was performed by instillation of a nonionic iodinated contrast medium via the epidural catheter on postpartum day 2 for imaging confirmation of catheter placement in the extradural space.

LESSONS

Early recognition that epidural catheters for neuraxial analgesia have been inserted into the subdural space is important for the prevention of high spinal blocks. Subdural analgesia could still be achieved by careful clinical assessment and titration of low analgesic doses. This report also presents important and clear serial computed tomographic images of catheter placement in the thoracic-lumbar subdural spaces and the extent of volume spread in the subdural space following administration of contrast medium.

Rare presentation of pneumothorax in a young woman with underlying congenital pulmonary airway malformation

Congenital pulmonary airway malformation (CPAM) is the most common among a rare group of congenital anomalies of the lower respiratory tract. It has variable presentation depending on its subtype and the patient's age. It may lead to respiratory distress in neonates. It can be a particularly challenging diagnosis in children born asymptomatic but present with complications later in life such as haemoptysis, recurrent chest infections, breathlessness and pneumothorax. Prenatal ultrasound, chest X-ray, CT scan and MRI are helpful in making a radiological diagnosis.A woman in her late teens presented with shortness of breath and right pleuritic chest pain. CT's chest showed a number of bullae of varying sizes on the right, including one huge bulla compressing all three lobes. She underwent lung volume reduction surgery via video-assisted thoracoscopy, and the histology specimen confirmed the diagnosis of CPAM type 1.

Feasibility of Free-Breathing, Non-ECG-Gated, Black-Blood Cine Magnetic Resonance Images With Multitasking in Measuring Left Ventricular Function Indices

OBJECTIVE

To clinically validate the feasibility and accuracy of cine images acquired through the multitasking method, with no electrocardiogram gating and free-breathing, in measuring left ventricular (LV) function indices by comparing them with those acquired through the balanced steady-state free precession (bSSFP) method, with multiple breath-holds and electrocardiogram gating.

MATERIALS AND METHODS

Forty-three healthy volunteers (female:male, 30:13; mean age, 23.1 ± 2.3 years) and 36 patients requiring an assessment of LV function for various clinical indications (female:male, 22:14; 57.8 ± 11.3 years) were enrolled in this prospective study. Each participant underwent cardiac magnetic resonance imaging (MRI) using the multiple breath-hold bSSFP method and free-breathing multitasking method. LV function parameters were measured for both MRI methods. Image quality was assessed through subjective image quality scores (1 to 5) and calculation of the contrast-to-noise ratio (CNR) between the myocardium and blood pool. Differences between the two MRI methods were analyzed using the Bland-Altman plot, paired t-test, or Wilcoxon signed-rank test, as appropriate.

RESULTS

LV ejection fraction (LVEF) was not significantly different between the two MRI methods (P = 0.222 in healthy volunteers and P = 0.343 in patients). LV end-diastolic mass was slightly overestimated with multitasking in both healthy volunteers (multitasking vs. bSSFP, 60.5 ± 10.7 g vs. 58.0 ± 10.4 g, respectively; P < 0.001) and patients (69.4 ± 18.1 g vs. 66.8 ± 18.0 g, respectively; P = 0.003). Acceptable and comparable image quality was achieved for both MRI methods (multitasking vs. bSSFP, 4.5 ± 0.7 vs. 4.6 ± 0.6, respectively; P = 0.203). The CNR between the myocardium and blood pool showed no significant differences between the two MRI methods (18.89 ± 6.65 vs. 18.19 ± 5.83, respectively; P = 0.480).

CONCLUSION

Multitasking-derived cine images obtained without electrocardiogram gating and breath-holding achieved similar image quality and accurate quantification of LVEF in healthy volunteers and patients.

Inhibitory effect of telocyte-induced M1 macrophages on endometriosis: Targeting angiogenesis and invasion

PURPOSE

Telocytes (TCs), a novel type of stromal cells found in tissues, induce macrophage differentiation into classically activated macrophages (M1) types and enhance their phagocytic function. The purpose of this study was to investigate the inhibitory effects of TC-induced M1 macrophages on endometriosis (EMs).

METHODS

mouse uterine primary TCs and endometrial stromal cells (ESCs) were isolated and identified using double immunofluorescence staining. For the in vitro study, ESCs were treated with TC-induced M1 macrophages, and the vascular endothelial growth factor (VEGF), matrix metalloproteinase 9 (MMP9), and nuclear factor kappa B (NF-κb) genes were identified by quantitative real-time PCR (qRT-PCR) or western blotting (WB). For the in vivo study, an EMs mouse model received TC-conditioned medium (TCM) via abdominal administration, and characterized the inhibitory effects on growth (lesion weight, volume, and pathology), tissue-resident macrophages differentiation by immunostaining, angiogenic capacity (CD31 and VEGF), invasive capacity (MMP9), and NF-κb expression within EMs lesions.

RESULTS

immunofluorescent staining showed that uterine TCs expressed CD34+ and vimentin+, whereas ESCs expressed vimentin+ and cytokeratin-. At the cellular level, TC-induced M1 macrophages can significantly inhibit the expression of VEGF and MMP9 in ESCs through WB or qRT-PCR, possibly by suppressing the NF-κb pathway. The in vivo study showed that macrophages switch from the alternatively activated macrophages (M2) in untreated EMs lesions to the M1 subtype after TCM exposure. Thereby, TC-induced M1 macrophages contributed to the inhibition of EMs lesions. More importantly, this effect may be achieved by suppressing the expression of NF-κb to inhibit angiogenesis (CD31 and VEGF) and invasion (MMP9) in the tissue.

CONCLUSION

TC-induced M1 macrophages play a prevailing role in suppressing EMs by inhibiting angiogenic and invasive capacity through the NF-κb pathway, which provides a promising therapeutic approach for EMs.

Torque changes of anchorage units in preadolescent patients treated with a digitally designed tooth-borne expander anchored to deciduous vs. permanent molars

AIM

To compare the effects on permanent or deciduous anchorage dental units in patients treated with a digitally designed palatal expander.

METHODS

Inclusion criteria were the following: presence of maxillary transverse deficiency, no previous orthodontic treatment, no extractions, absence of agenesis, congenital pathologies and cranio-maxillofacial malformations. Twenty patients (11 males, 9 females, 11 ± 1.8 years) received a digitally designed and metal printed palatal expander anchored on first permanent molars and 1 activation per day for 30 days (Group 1). Twenty-one patients (12 males, 9 females, 8.6 ± 1.4 years) received a digitally designed and metal printed palatal expander anchored on second deciduous molars and 2 activations per day for 14 days (Group 2). Digital intraoral scans were taken before expansion and after device removal, and torque and the palatal transverse diameter were digitally measured. The FDI notation was used to indicate each tooth CONCLUSION: Less dental torque augmentation was produced in Group 2.

RESULTS

Significant intragroup differences over time were found in Group 1 considering the torque of teeth 1.6, 1.4, 1.3, 2.1, 2.4, 2.5, 2.6. Significant differences between groups were found regarding the longitudinal change in torque of teeth 1.5, 2.4 and 2.5. Significant intragroup differences over time were found in both groups considering all transverse diameter parameters. No significant differences were found between groups in the transverse diameter modifications over time.

CONCLUSION

Less dental torque augmentation was produced in Group 2.

Detection and quantification of TIMP1 and miR-141 through RT-LAMP and TT-LAMP in serum samples during estrous cycle in buffalo

Estrus identification is a common problem in the reproductive management of farm animals. Hence, several studies have been conducted to explore biomarkers for estrus detection. One of our previous studies identified the abundance of RNA biomarkers such as TIMP1 and miR-141 in buffalo saliva during the estrus stage. However, the level of these RNA biomarkers in buffalo serum during estrous cycle is undetected. Therefore, the present study was designed to quantify TIMP1 and miR-141 in serum during buffalo estrous cycle. Blood samples were collected in different stages of estrous cycle from four healthy cyclic buffaloes. The quantification of TIMP1 and miR-141 was performed with direct serum using RT-LAMP and TT-LAMP technologies, respectively. The LAMP amplification was confirmed by agarose gel electrophoresis and the color change was quantified in comparison to a non-template control using ImageJ software. A decreased abundance of TIMP1 at the diestrus stage and a decreasing trend of miR-141 from proestrus to diestrus stages were observed, which was further reinforced by simulated random populations generated with R programming. Specifically, TIMP1 was found significantly (P < 0.0001) abundant at estrus and metestrus stages as compared to the diestrus stage, whereas miR-141 was significantly (P < 0.001) higher during the proestrus stage as compared to the other stages of estrous cycle. The ROC curve analysis showed miR-141 to be a better biomarker than TIMP1 as it distinguished the proestrus stage from diestrus with a sensitivity and specificity of 83 % and 98 %. This study also marked the first use of TT-LAMP technology for rapid miRNA detection in livestock.

Differences in the reproductive output and larval survival of Rocky Mountain wood ticks (Dermacentor andersoni) and American dog ticks (Dermacentor variabilis) from prairie populations near their northern distributional limits in western Canada

The effects of temperature and relative humidity (RH) on female reproductive output, egg development and larval survival were determined for Rocky Mountain wood ticks (Dermacentor andersoni) from a prairie population (Chin Lakes, Alberta, Canada) near the northern distribution limit of this species. The responses of D. andersoni eggs and unfed larvae to different temperature (25 or 32 °C) and RH (35, 55, 75, 85 or 95%) regimes were compared to our previously published data (Diyes et al. 2021) for a northern prairie population of American dog ticks (Dermacentor variabilis). Oviposition by D. andersoni females took 21-30 days at 25 °C and 95% RH compared to 10-21 days for D. variabilis. The number of eggs laid by female ticks was strongly dependent on their engorgement weight, and D. andersoni females produced more eggs than D. variabilis females of an equivalent body weight. Eggs of D. andersoni took less time to develop at 32 °C than 25 °C with ≥ 85% RH, and hatched faster than those of D. variabilis. Larval survival times declined as temperature increased and RH decreased, but D. andersoni survived longer at 32 °C and ≤ 75% RH than D. variabilis. The interspecific differences in responses to the same temperature and humidity regimes indicate that D. andersoni is xerophilic, whereas D. variabilis is hydrophilic. Hence, 'prairie' populations of the Rocky Mountain wood tick occur in the drier grassland ecoregions but are absent in Aspen Parklands Ecoregion which is located to the north and east of the distributional range of D. andersoni.

The impact of photodynamic therapy on skin homeostasis in patients with actinic keratosis: A prospective observational study

BACKGROUND

Photodynamic therapy (PDT) is an effective treatment for actinic keratosis (AKs), but there is little information on how PDT affects skin barrier function. The objectives of this study are: To compare skin barrier function between skin with AKs and healthy skin and to evaluate the impact of PDT on skin homeostasis in patients with AKs.

METHODS

A prospective observational study was conducted in patients with AKs to evaluate epidermal barrier function and skin homeostasis before and 1 ek after receiving PDT.

RESULTS

A total of 21 subjects were included in the study, male/female ratio was 17:4, mean age was 75.86 years. The number of AKS observed before starting treatment was reduced with respect to those diagnosed 1 month after starting PDT (14.83 vs. 1.91, p < 0.0001). Application of PDT for treating AKs modifies epidermal barrier function. Immediately after the first session temperature, transepidermal water loss (TEWL), stratum corneum hydration (SCH) and total antioxidant capacity (TAC) increased while pH decreased on lesional skin. After 1-month follow-up, the only remained change was the increased in SCH. Higher increases in temperature were observed when using occlusive PDT compared to mixed modality. 5-ALA and M-ALA seem to have a similar impact on skin barrier.

CONCLUSIONS

PDT can improve skin barrier function in patients with AKs. Skin homeostasis parameters can be used to assess efficacy and optimize dosing.

Participants' Underlying Beliefs of Using WIC Electronic Benefit Transfer (EBT) Cards in Stores in New Jersey

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an essential nutrition assistance program that has led to successful health outcomes and healthcare access. To alleviate discomfort associated with WIC shopping at stores, the Congress mandated the transition to electronic benefit transfer (EBT) card system from paper vouchers. This study aimed to explore the experiences of WIC recipients in using EBT cards in stores. WIC recipients from one WIC clinic in northern New Jersey (N = 220) participated in this study. An online survey was framed under the theory of planned behavior to probe their underlying behavioral, normative, and control beliefs of using EBT cards. Using content analyses, dominating themes of each belief were extracted. Participants composed of Hispanic (91.2%) with mean age of 31.68 (SD = 7.69). Most frequently mentioned advantages of using EBT cards were convenience and ease (34.3%) followed by fast and efficient (28.5%). Participants noted that most people would approve of using EBT cards (70%), especially those who receive the benefits and approve of the public assistance (16.7%). They stated that having improved store inventory and an increase in WIC-authorized stores (17.2%) would make the EBT cards use easy. The transition to EBT cars allowed purchase flexibility, alleviated stigma and the purchase process burdens, but the challenges associated with WIC app usage and store specific issues remained. These challenges should be addressed in future intervention to enable WIC recipients more engaged in using the EBT cards.

The absence of real-time pulmonary vein isolation during cryoballoon ablation is associated with atrial fibrillation recurrence and pulmonary vein reconnection : Insights from the Middelheim-PVI Registry 2

BACKGROUND

Absence of real-time pulmonary vein (PV) isolation (PVI) occurring in 15-40% of PVs during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI. Aim of the present study is to determine whether real-time PVI during CBA is predictive of long-term clinical outcome and durability of PVI.

METHODS

Eight hundred three AF patients (64 ± 10 years, 68% males) undergoing CBA were studied. The cohort was divided in 4 groups according to the number of PVs without real-time PVI: none (N = 252 [31.4%]), 1 (N = 255 [31.8%]), 2 (N = 159 [19.8%]), and 3-4 (N = 137 [17.1]).

RESULTS

At 3 years, 279 (34.7%) patients had recurrence of AF of which 188 underwent repeat ablation. A vein without real-time PVI was associated with AF recurrence (HR = 1.275; 95% CI 1.134-1.433; p < 0.01), independent of persistent AF type (HR = 2.075; 95% CI 1.584-2.738; p < 0.01), left atrial diameter (HR = 1.050; 95% CI 1.028-1.072; p < 0.01), and diagnosis-to-ablation time (HR = 1.002; 95% CI 1.000-1.005; p = 0.04). Highest success was achieved with present real-time PVI in all veins (77.4%), gradually decreasing per increasing number of absent real-time PVI: 66.3% for 1 vein, 58.5% for 2, and 48.9% for 3-4 veins (p < 0.001). At repeat ablation (N = 188), PV reconnection was seen in 99/430 (23.0%) versus 83/288 (28.8%) veins with and without real-time PVI, respectively (p = 0.08). Right inferior PVs (RIPVs) with real-time PVI were less reconnected than RIPVs without real-time PVI: 29.7% versus 43.7% (p = 0.047).

CONCLUSION

The absence of real-time PVI during CBA independently predicts AF recurrence with a 30% gradual decrease in outcome per increase in veins without real-time PVI. Real-time PVI is particularly important for the RIPV to achieve durable PVI.