Avanafil mediated dual inhibition of IKKβ and TNFR1 in an experimental paradigm of Alzheimer's disease: in silico and in vivo approach

In Alzheimer's disease pathology, inhibitors of nuclear factor kappa-β kinase subunit β (IKKB) and Tumor necrosis factor receptor 1 (TNFR1) signaling are linked to neuroinflammation-mediated cognitive decline. We explored the role of a phosphodiesterase 5 inhibitor (PDE5I) with dual antagonistic action on IKKB and TNFR1 to inhibit nuclear factor kappa B (NF-kB) and curb neuroinflammation. In the in silico approach, the FDA-approved Zinc 15 library was docked with IKKB and TNFR1. The top compound with dual antagonistic action on IKKB and TNFR1 was selected based on bonding and non-bonding interactions. Further, induced fit docking (IFD), molecular mechanics-generalized Born and surface area (MMGBSA), and molecular dynamic studies were carried out and evaluated. Lipopolysaccharide (LPS) administration caused a neuroinflammation-mediated cognitive decline in mice. Two doses of avanafil were administered for 28 days while LPS was administered for 10 days. Morris water maze (MWM) along with the passive avoidance test (PAT) were carried out. Concurrently brain levels of inflammatory markers, oxidative parameters, amyloid beta (Aβ), IKKB and NF-kB levels were estimated. Avanafil produced good IKKB and TNFR1 binding ability. It interacted with crucial inhibitory amino acids of IKKB and TNFR1. MD analysis predicted good stability of avanafil with TNFR1 and IKKB. Avanafil 6 mg/kg could significantly improve performance in MWM, PAT and oxidative parameters and reduce Aβ levels and inflammatory markers. As compared to avanafil 3 mg/kg, 6 mg/kg dose was found to exert better efficacy against elevated Aβ , neuroinflammatory cytokines and oxidative markers while improving behavioural parameters.Communicated by Ramaswamy H. Sarma.

Large Chorioangioma in Triplets: An Uncommon Occurrence

A 25-year-old primigravida presented at 26 weeks of gestation by dates, the first time for the routine antenatal checkup. No histories were suggestive of pregnancy-induced hypertension (PIH) and edema. On physical examination, pallor was present with microcytic hypochromic anemia. Raised beta-human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were present. Ultrasonography revealed triples with two thin echogenic intertwining membranes. Anomaly scan did not reveal any abnormality in fetuses. The placenta showed a large oval hypoechoic mass arising from its edge and bulge into the amniotic fluid. A central feeding vessel with a branching pattern and pulsatile color flow like that of the umbilical artery is noted on the color Doppler. She was spontaneously preterm delivered vaginally at 28 weeks of gestation. All three fetuses were stillborn. Histopathological diagnosis of angiomatous chorioangioma was confirmed. This case classically represents a grave complication of the large chorioangioma.

Matrix Metalloproteinase Enzyme Responsive Delivery of 5-Fluorouracil Using Collagen-I Peptide Functionalized Dendrimer-Gold Nanocarrier

ObjectiveThe aim was to develop matrix metalloproteinase 1 (MMP1) responsive nanoparticle system for the delivery of 5-fluorouracil (5Fu) anticancer drug.SignificanceThe MMP1 in the cancer microenvironment induced drug release have advantage of targeted drug release and reduce the distribution of drug to the healthy tissuesMethodG5 polyamidoamine PAMAM dendrimer (G5) coated gold nanoparticles were synthesized and loaded with 5Fu. The drug loaded nanoparticles were further coated with collagen I (Col-I) peptide which is a substrate for MMP1 enzyme (Col-I 5Fu@G5AuNP).ResultThe nanoparticles were highly monodispersed with a particle size of 30 nm and showed high drug encapsulation efficiency. The release of drug from the nanoparticles in HEPES buffer pH 7.4 was faster, higher and better controlled when incubated with MMP1 enzyme. The half-maximum inhibitory concentration for Col-I 5Fu@G5AuNP was eight times lower than the 5Fu against MCF-7, suggesting the improved delivery and anticancer activity of 5Fu after encapsulation in the developed enzyme-responsive nanocarrier system. The computed tomography (CT) x-ray attenuation of Col-I@G5AuNP showed a good contrasting property.ConclusionThe formulation Col-I 5Fu@G5AuNP has improved anticancer activity than free drug and the CT imaging results are promising for its theranostic applications for breast cancer.

Prospecting for Cressa cretica to treat COVID-19 via in silico molecular docking models of the SARS-CoV-2

The severe acute respiratory syndrome COVID-19 declared as a global pandemic by the World Health Organization has become the present wellbeing worry to the whole world. There is an emergent need to search for possible medications. Cressa cretica is reported to show antitubercular, antibacterial and expectorant property. In this research, we aim to prospect the COVID-19 main protease crystal structure (Mpro; PDB ID: 6LU7) and the active chemical constituents from Cressa cretica in order to understand the structural basis of their interactions. We examined the binding potential of active constituents of Cressa cretica plant to immensely conserved protein Mpro of SARS-CoV-2 followed by exploration of the vast conformational space of protein-ligand complexes by molecular dynamics (MD) simulations. The results suggest the effectiveness of 3,5-Dicaffeoylquinic acid and Quercetin against standard drug Remdesivir. The active chemical constituents exhibited good docking scores, and interacts with binding site residues of Mpro by forming hydrogen bond and hydrophobic interactions. 3,5-Dicaffeoylquinic acid showed the best affinity towards Mpro receptor which is one of the target enzymes required by SARS CoV-2 virus for replication suggesting it to be a novel research molecule. The potential of the active chemical constituents from Cressa cretica against the SARS-CoV-2 virus has best been highlighted through this study. Therefore, these chemical entities can be further scrutinized and provides direction for further consideration for in-vivo and in-vitro validations for the treatment of covid-19. Communicated by Ramaswamy H. Sarma.

Anomalous coronary artery in Tetralogy of Fallot-Feasibility of right ventricular outflow tract stenting as initial palliation

This study addresses the outcome of right ventricle outflow tract (RVOT) stenting in Tetralogy of Fallot (ToF) with anomalous coronaries crossing the RVOT. RVOT stenting in ToF patients has emerged as an alternative to Blalock Taussig shunting. This is a single center study of patients who underwent RVOT stenting for symptomatic ToF at Birmingham Children's Hospital between 2005 and 2020. A total of 122 patients underwent RVOT stenting as initial palliation over a 15-year period, 10 patients had anomalous coronaries crossing the RVOT (study group) and 112 not (comparative group). Median age of the study group was 72.5 days (interquartile range [IQR]: 28-103) with a weight of 4.7 kg (IQR: 3.5-4.9). No significant differences were found between the two groups regarding the patients' weights and ages, procedure and screening times, or hospital stay. Four had valve sparing stenting. Oxygen saturations increased from a median of 75.5% (IQR: 70-82) to 94.5% (IQR: 90-95), p < 0.002. Postprocedure median hospital stay was 3 days (IQR: 2-6). Six patients underwent interstage catheterization reintervention and one needed early surgical palliation due to stent suboptimal position. Complete repair could be delayed for a median of 11.1 months (IQR: 5.6-19.2). At surgical repair, the patients had a median age of 12.3 months (IQR: 7.5-25.6) and weight of 7.7 kg (IQR: 6.8-10.8). There were no deaths. RVOT stenting in ToF with anomalous coronaries is safe and effective. Dilatable stents should be used when two-stage delayed conduit repair is the default approach.

Supravalvular pulmonary stenosis: A risk factor for reintervention in Noonan syndrome with pulmonary valve stenosis

To assess the short- and long-term outcomes of balloon pulmonary valvuloplasty (BPV) in children with Noonan syndrome (NS). Pulmonary stenosis (PS) is the most common congenital heart lesion in NS. BPV is the accepted first line treatment in PS. However, BPV in NS patients has been reported to be less effective, without specific factors for the need for reintervention being identified. Retrospective case-note review of all patients with NS who underwent BPV between 1985 and 2020. Patients were divided into 2 groups: those with supravalvular pulmonary stenosis (SPS) in addition to valvar PS, and those with isolated valvar PS. A cohort of 54 patients with NS underwent BPV at a median of 275 (interquartile range [IQR]: 108-575) days of age. SPS was present in 32 (59%) patients whereas 22 had (41) isolated PS. The preprocedural invasive gradient was 47 (IQR: 35-69) mmHg, and 44 (IQR: 35-48) mmHg in those with SPS and those without respectively (p = 0.88). Reintervention was required in 22 patients (41%): 17 (77%) -with SPS and 5 (23%) without (p = 0.017). Fourteen patients (11 with SPS) required surgical reintervention and 8 (6 with SPS) required further BPV. There was no significant difference in the age at initial BPV, pre- and postprocedural gradients and interval until reintervention between groups. This is the largest reported cohort of patients with NS undergoing BPV. Although BPV is often successful, the reintervention rates are high. SPS was a risk factor for reintervention.

Adaptive design with bayesian informed interim decisions: application to a randomized trial of mechanical circulatory support

Background

Cardiovascular trials increasingly require large sample sizes and long follow-up periods. Several approaches have been developed to optimize sample size such as adaptive group sequential trials, samples size re-estimation based on the promising zone, and the win ratio. Traditionally, the log-rank or the Cox proportional hazards model is used to test for treatment effects, based on a constant hazard rate and proportional hazards alternatives, which however, may not always hold. Large sample sizes and/or long follow up periods are especially challenging for trials evaluating the efficacy of acute care interventions.

Purpose

We propose an adaptive design wherein using interim data, Bayesian computation of predictive power guides the increase in sample size and/or the minimum follow-up duration. These computations do not depend on the constant hazard rate and proportional hazards assumptions, thus yielding more robust interim decision making for the future course of the trial.

Methods

PROTECT IV is designed to evaluate mechanical circulatory support with the Impella CP device vs. standard of care during high-risk PCI. The primary endpoint is a composite of all-cause death, stroke, MI or hospitalization for cardiovascular causes with initial minimum follow-up of 12 months and initial enrolment of 1252 patients with expected recruitment in 24 months.

The study will employ an adaptive increase in sample size and/or minimum follow-up at the Interim analysis when ∼80% of patients have been enrolled. The adaptations utilize extensive simulations to choose a new sample size up to 2500 and new minimal follow-up time up to 36 months that provides a Bayesian predictive power of 85%.

Bayesian calculations are based on patient-level information rather than summary statistics therefore enabling more reliable interim decisions. Constant or proportional hazard assumptions are not required for this approach because two separate Piece-wise Constant Hazard Models with Gamma-priors are fitted to the interim data. Bayesian predictive power is then calculated using Monte-Carlo methodology. Via extensive simulations, we have examined the utility of the proposed design for situations with time varying hazards and non-proportional hazards ratio such as situations of delayed treatment effect (Figure) and crossing of survival curves. The heat map of Bayesian predictive power obtained when the interim Kaplan-Meier curves reflected delayed response shows that for this scenario an optimal combination of increased sample size and increased follow-up time would be needed to attain 85% predictive power.

Conclusion

A proposed adaptive design with sample size and minimum follow-up period adaptation based on Bayesian predictive power at interim looks allows for de-risking the trial of uncertainties regarding effect size in terms of control arm outcome rate, hazard ratio, and recruitment rate.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abiomed, Inc Figure 1

GnRH agonist and hCG (dual trigger) versus hCG trigger for final follicular maturation: a double-blinded, randomized controlled study

STUDY QUESTION

Does co-administration of GnRH agonist and Human chorionic gonadotropin (hCG; dual trigger) in IVF cycles improve the number of mature oocytes and pregnancy outcome compared to hCG alone?

SUMMARY ANSWER

Using the dual trigger for final follicular maturation increases the number of oocytes, mature oocytes and number of blastocysts (total and top-quality) compared to triggering with hCG alone.

WHAT IS KNOWN ALREADY

hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, based on retrospective studies, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome and pregnancy rates.

STUDY DESIGN, SIZE, DURATION

A single center, randomized controlled, double-blinded clinical trial between May 2016 and June 2018 analyzed by intention to treat (ITT).

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

One hundred and fifty-five normal responder patients were randomized either to receive hCG or dual trigger for final oocyte maturation. Data on patients age, BMI, AMH, number of oocytes retrieved, number of metaphase 2 (MII) oocytes, zygotes and blastocysts, clinical pregnancy rate and live birth rate were assessed and compared between the dual trigger group and the hCG group. We performed a planned interim analysis after the recruitment of 50% of the patients. Based on the totality of outcomes at the interim analysis we decided to discontinue further recruitment.

MAIN RESULTS AND THE ROLE OF CHANCE

One hundred and fifty-five patients were included in the study. The age (36 years versus 35.3 years P = NS), BMI (24 kg/m2 versus 23.7 kg/m2) and the AMH (20.1 pmol/l versus 22.4 pmol/l) were comparable between the two groups. Based on ITT analysis, the number of eggs retrieved (11.1 versus 13.4, P = 0.002), the MII oocytes (8.6 versus 10.3, P = 0.009), total number of blastocysts (2.9 versus 3.9, P = 0.01) and top-quality blastocysts transferred (44.7% versus 64.9%; P = 0.003) were significantly higher in the dual trigger group compared to the hCG group. The clinical pregnancy rate (24.3% versus 46.1%, OR 2.65 (1.43-1.93), P = 0.009) and the live birth rate per transfer (22% versus 36.2%, OR= 1.98 (1.05-3.75), P = 0.03) were significantly higher in the dual trigger group compared to the hCG group.

LIMITATIONS, REASONS FOR CAUTION

None.

WIDER IMPLICATIONS OF THE FINDINGS

The enhanced response observed with the dual trigger might lead to better IVF outcomes were it used more widely.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by TRIO Fertility. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02703584.

DATE OF TRIAL REGISTRATION

March 2016.

DATE OF FIRST PATIENT'S ENROLLMENT

May 2016.

Four right ventricle to pulmonary artery conduit types

OBJECTIVE

The most durable valved right ventricle to pulmonary artery conduit for the repair of congenital heart defects in patients of different ages, sizes, and anatomic substrate remains uncertain.

METHODS

We performed a retrospective analysis of 4 common right ventricle to pulmonary artery conduits used in a single institution over 30 years, using univariable and multivariable models of time-to-failure to analyse freedom from conduit dysfunction, reintervention, and replacement.

RESULTS

Between 1988 and 2018, 959 right ventricle to pulmonary artery conduits were implanted: 333 aortic homografts, 227 pulmonary homografts, 227 composite porcine valve conduits, and 172 bovine jugular vein conduits. Patients weighed 1.6 to 98.3 kg (median 15.3 kg), and median duration of follow-up was 11.4 years, with 505 (52.2%) conduits developing dysfunction, 165 (17.2%) requiring catheter intervention, and 415 (43.2%) being replaced. Greater patient weight, conduit z-score, type and position, as well as catheter intervention were predictors of freedom from replacement. Multivariable analysis demonstrated inferior durability for smaller composite porcine valve conduits, with excellent durability for larger diameter conduits of the same type. Bovine jugular vein conduit longevity was inferior to that of homografts in all but the smallest patients. Freedom from dysfunction at 8 years was 60.7% for aortic homografts, 72% for pulmonary homografts, 51.2% for composite porcine valve conduits, and 41.3% for bovine jugular vein conduits. Judicious oversizing of the conduit improved conduit durability in all patients, but to the greatest extent in patients weighing 5 to 20 kg.

CONCLUSIONS

Pulmonary and aortic homografts had greater durability than xenograft conduits, particularly in patients weighing 5 to 20 kg. Judicious oversizing was the most significant surgeon-modifiable factor affecting conduit longevity.

REDUCE-IT: accumulation of data across prespecified interim analyses to final results

Background

REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), an event-driven trial, randomized 8,179 statin-treated patients with elevated triglycerides (TGs) and increased cardiovascular (CV) risk to icosapent ethyl (IPE); pure, stable prescription eicosapentaenoic acid, 4g/day or placebo. 1,612 primary endpoint events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) projected 90% power to detect 15% relative risk reduction (5% 2-sided alpha). The key secondary composite endpoint was CV death, nonfatal MI, or nonfatal stroke. An independent data and safety monitoring committee (DMC) performed prespecified interim analyses (IAs) at ∼60% (IA1 31 May 2016 data cutoff; 2.9 y median primary endpoint follow-up) and ∼80% (IA2 01 May 2017; 3.7 y) of events; final analysis included 1,606 events (06 Sep 2018; 4.9 y median study follow-up).

Purpose

Explore REDUCE-IT efficacy and safety across prespecified IAs for insight into progression of robustness and consistency of conclusions.

Methods

The interim statistical analysis plan guided study continuation decisions by a prespecified decision-making process, including assessment of safety, treatment arm performance, primary composite endpoint formal analyses, and informal robustness analyses, with no futility or efficacy stopping requirements. Prior to DMC IA study continuation decisions, the need for a mature dataset to support the robustness of final efficacy and safety findings was discussed. Sponsor, Steering Committee, and Clinical Endpoint Committee were blinded throughout.

Results

Primary and key secondary endpoints achieved statistical significance at IA1 and IA2 that persisted at final analyses (p-value below final adjusted 2-sided alpha of 0.0437); hazard ratios also remained consistent and similar robustness was observed across individual endpoint components; clarity of findings across endpoints and subgroups improved with more events. Stopping for overwhelming efficacy was discussed at each IA; prior to IA study continuation recommendations, the DMC considered historical examples of failed CV outcome studies for TG-lowering and mixed omega-3 therapies, reflected on the potential for overestimating final demonstrated benefit using incomplete data, and weighed societal impacts of fuller datasets relative to patient therapy access.

Conclusions

Consistent, potent efficacy emerged early and persisted across the two prespecified interim and final analyses. The mature dataset demonstrated highly statistically significant reductions in the primary (25%; p=0.00000001) and key secondary (26%; p=0.0000006) endpoints and allowed robust analyses to support overall efficacy and safety conclusions. Allowing the REDUCE-IT dataset to fully mature provided clinicians with robust, consistent, and reliable data upon which to base clinical decisions for IPE in CV risk reduction.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.

Impact of timing of randomization after an acute coronary syndrome and subsequent events in patients with type 2 diabetes mellitus: an analysis of the EXAMINE trial

Background

The timing of enrolment following an acute coronary syndrome (ACS) may influence cardiovascular (CV) outcomes and potentially treatment effect in clinical trials. Using a large contemporary trial in patients with type 2 diabetes mellitus (T2DM) post-ACS, we examined the impact of timing of enrolment on subsequent CV outcomes.

Methods

EXAMINE was a randomized trial of alogliptin versus placebo in 5380 patients with T2DM and a recent ACS. The primary outcome was a composite of CV death, non-fatal myocardial infarction [MI], or non-fatal stroke. The median follow-up was 18 months. In this post hoc analysis, we examined the occurrence of subsequent CV events by timing of enrollment divided by tertiles of time from ACS to randomization: 8–34, 35–56, and 57–141 days.

Results

Patients randomized early (compared to the latest times) had less comorbidities at baseline including a history of heart failure (HF; 24.7% vs. 33.0%), prior coronary artery bypass graft (9.6% vs. 15.9%), or atrial fibrillation (5.9% vs. 9.4%). Despite the reduced comorbidity burden, the risk of the primary outcome was highest in patients randomized early compared to the latest time (adjusted hazard ratio [aHR] 1.47; 95% CI 1.21–1.74) (Figure 1). Similarly, patients randomized early had an increased risk of recurrent MI (aHR 1.51; 95% CI 1.17–1.96) and HF hospitalization (1.49; 95% CI 1.05–2.10).

Conclusion

In a contemporary cohort of T2DM with a recent ACS, early randomization following the ACS increases the risk of CV events including recurrent MI and HF hospitalization. This should be taken into account when designing future clinical trials.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Takeda Pharmaceutical

Short to medium term outcomes of right ventricular outflow tract stenting as initial palliation for symptomatic infants with complete atrioventricular septal defect with associated tetralogy of Fallot

OBJECTIVES

To assess the impact of right ventricular outflow tract (RVOT) stenting as the primary palliation in infants with complete atrioventricular septal defect with associated tetralogy of Fallot (cAVSD/TOF).

BACKGROUND

Historically, palliation of symptomatic patients with cAVSD/TOF has been achieved through surgical systemic to pulmonary artery shunting. More recently RVOT stenting has evolved as an acceptable alternative in patients with tetralogy of Fallot.

METHODS

Retrospective review of all patients with cAVSD/TOF who underwent RVOT stenting as palliation over a 13-year period from two large tertiary referral centers.

RESULTS

Twenty-six patients underwent RVOT stenting at a median age of 57 days (interquartile range [IQR] 25.5-106.5). Median weight for stent deployment was 3.7 kg (IQR 2.91-5.5 kg). RVOT stenting improved oxygen saturations from a median of 72% (IQR 70-76%) to 90% (IQR 84-92%), p < .001. There was a significant increase in the median Z-score for both branch pulmonary arteries at median follow-up of 255 days (IQR 60-455). Eight patients required RVOT stent balloon dilatations and 8 patients required re-stenting for progressive desaturation. The median duration between reinterventions was 122 days (IQR 53-294 days). Four patients died during the follow-up period. No deaths resulted from the initial intervention. To date, definitive surgical intervention was achieved in 19 patients (biventricular repair n = 15) at a median age of 369 days (IQR 223-546 days).

CONCLUSION

RVOT stenting in cAVSD/TOF is a safe and effective palliative procedure in symptomatic infants, promoting pulmonary artery growth and improving oxygen saturations.

Localized In Situ Nanoemulgel Drug Delivery System of Quercetin for Periodontitis: Development and Computational Simulations

This study was aimed at formulating a bioabsorbable, controlled-release, nanoemulgel of Quercetin, a potent antimicrobial and anti-inflammatory agent for the treatment of periodontitis that could improve its solubility and bioavailability. Screening of components was carried out based on the solubility studies. Nanoemulsion containing cinnamon oil as the oil phase, tween 80 and Carbitol® as the surfactant-cosurfactant mixture (Smix) and water as the aqueous phase containing 125 µg/200 µL of Quercetin was prepared by using spontaneous emulsification method. Nanoemulgel was prepared using 23% w/v poloxamer 407 as gel base. Comprehensive evaluation of the formulated nanoemulgel was carried out, and the optimized formulation was studied for drug release using Franz vertical diffusion cells. The formulated nanoemulgelexhibited a remarkable release of 92.4% of Quercetin at the end of 6 h, as compared to that of pure Quercetin-loaded gel (<3% release). The viscosity of the prepared nanoemulgel was found to be 30,647 ± 0.32 cPs at 37 °C. Also, molecular dynamics (MD) simulation was utilized to understand the gelation process and role of each component in the formulation. The present study revealed that the developed nanoemulgel of Quercetin could be a potential delivery system for clinical testing in periodontitis.

Right ventricular outflow tract stent versus BT shunt palliation in Tetralogy of Fallot

OBJECTIVE

This study sets out to compare morbidity, mortality and reintervention rates after stenting of the right ventricular outflow tract (RVOT) versus modified Blalock-Taussig shunt (mBTS) for palliation in patients with tetralogy of Fallot (ToF)-type lesions.

METHODS

Retrospective case review study evaluating 101 patients (64 males) with ToF lesions who underwent palliation with either mBTS (n=41) or RVOT stent (n=60) to augment pulmonary blood flow over a 10-year period. Procedure-related morbidity, mortality and reintervention rates were assessed and compared.

RESULTS

Admission rate to paediatric intensive care unit (PICU) was lower in the RVOT stent group (22% vs 100%; p<0.001). Thirty-day mortality in the RVOT stent group was (1/60 (1.7%)) compared with (2/41 (4.9%)) in the mBTS group (p=0.565). Mortality until surgical repair was comparable in both groups (5/60, 8.4%, including three non-cardiac death in the RVOT stent group vs 2/41, 4.9% (p=0.698)). Total hospital length of stay was shorter for the RVOT stent group (median 7 days vs 14 days; p<0.003). Time to surgical repair was shorter in the RVOT stent group (median 232 days, IQR 113-360) compared with the mBTS group (median 428 days, IQR 370-529; p<0.001) due to improved pulmonary arterial growth.

CONCLUSION

RVOT stenting in Fallot-type lesions can be accomplished safely, with lower PICU admission rate, a shorter hospital length of stay and shorter duration of palliation until complete repair compared with mBTS palliation.

Outcome after transcatheter occlusion of patent ductus arteriosus in infants less than 6 kg: A national study from United Kingdom and Ireland

OBJECTIVES

This study aimed to report our national experience with transcatheter patent ductus arteriosus (PDA) occlusion in infants weighing <6 kg.

BACKGROUND

The technique of transcatheter PDA closure has evolved in the past two decades and is increasingly used in smaller patients but data on safety and efficacy are limited.

METHODS

Patients weighing < 6 kg in whom transcatheter PDA occlusion was attempted in 13 tertiary paediatric cardiology units in the United Kingdom and Ireland were retrospectively analyzed to review the outcome and complications.

RESULTS

A total of 408 patients underwent attempted transcatheter PDA closure between January 2004 and December 2014. The mean weight at catheterization was 4.9 ± 1.0 kg and mean age was 5.7 ± 3.0 months. Successful device implantation was achieved in 374 (92%) patients without major complication and of these, complete occlusion was achieved in 356 (95%) patients at last available follow-up. Device embolization occurred in 20 cases (5%). The incidence of device related obstruction to the left pulmonary artery or aorta and access related peripheral vascular injury were low. There were no deaths related to the procedure.

CONCLUSIONS

Transcatheter closure of PDA can be accomplished in selected infants weighing <6 kg despite the manufacturer's recommended weight limit of 6 kg for most ductal occluders. The embolization rate is higher than previously reported in larger patients. Retrievability of the occluder and duct morphology needs careful consideration before deciding whether surgical ligation or transcatheter therapy is the better treatment option.

MRI evaluation of lumbar disc degenerative disease

INTRODUCTION

Lower back pain secondary to degenerative disc disease is a condition that affects young to middle-aged persons with peak incidence at approximately 40 y. MRI is the standard imaging modality for detecting disc pathology due to its advantage of lack of radiation, multiplanar imaging capability, excellent spinal soft-tissue contrast and precise localization of intervertebral discs changes.

AIMS AND OBJECTIVE

To evaluate the characterization, extent, and changes associated with the degenerative lumbar disc disease by Magnetic Resonance Imaging.

STUDY DESIGN

Cross-sectional and observational study.

MATERIALS AND METHODS

A total 109 patients of the lumbar disc degeneration with age group between 17 to 80 y were diagnosed & studied on 1.5 Tesla Magnetic Resonance Imaging machine. MRI findings like lumbar lordosis, Schmorl's nodes, decreased disc height, disc annular tear, disc herniation, disc bulge, disc protrusion and disc extrusion were observed. Narrowing of the spinal canal, lateral recess and neural foramen with compression of nerve roots observed. Ligamentum flavum thickening and facetal arthropathy was observed.

RESULT

Males were more commonly affected in Degenerative Spinal Disease & most of the patients show loss of lumbar lordosis. Decreased disc height was common at L5-S1 level. More than one disc involvement was seen per person. L4 - L5 disc was the most commonly involved. Annular disc tear, disc herniation, disc extrusion, narrowing of spinal canal, narrowing of lateral recess, compression of neural foramen, ligamentum flavum thickening and facetal arthropathy was common at the L4 -L5 disc level. Disc buldge was common at L3 - L4 & L4 - L5 disc level. Posterior osteophytes are common at L3 - L4 & L5 -S1 disc level. L1- L2 disc involvement and spondylolisthesis are less common.

CONCLUSION

Lumbar disc degeneration is the most common cause of low back pain. Plain radiograph can be helpful in visualizing gross anatomic changes in the intervertebral disc. But, MRI is the standard imaging modality for detecting disc pathology due to its advantage of lack of radiation, multiplanar imaging capability, excellent spinal soft-tissue contrast and precise localization of intervertebral discs changes.

Incidental detection of ascariasis worms on USG in a protein energy malnourished (PEM) child with abdominal pain

A 10-year-old child presented with dull aching periumbilical abdominal pain for 15 days. The child was not gaining weight despite a good appetite. Physical examination of the child revealed grade-I protein energy malnourishment (PEM) according to IAP (Indian Academic of Paediatrics) classification. The rest of the systemic examination was normal. Routine blood investigation revealed anaemia with eosinophilia. Abdominal ultrasonography did not show any abnormality with curvilinear transducer (3.5-5 MHz), however, linear ultrasound transducer (7.5-12 MHz) with harmonic tissue imaging showed worms in the lumen of the small intestine with curling movement on real time scanning. Stool examination for the eggs of ascariasis was positive. The patient was treated with antihelminthic drugs. Dietary modification for the PEM was advised. After 3 months of treatment, the patient improved and stool examination for Ascaris was negative on follow-up.

Intraocular metallic foreign body: role of computed tomography

Orbital foreign bodies remain a serious diagnostic problem, despite development of diagnostic imaging techniques. Non-metallic orbital foreign body will not be detected in routine x-ray. Here we are presenting a case of 32-year-old male presented with acute pain in left eye immediately after he had been pounding a metal object with a metal chisel. Following this event patient develop blurring of vision in left eye with tearing. Patient's vision in left eye was found to be hand motion with conjunctiva mildly injected, left corneal central 1 mm Seidel-negative full-thickness laceration and dense traumatic cataract was seen on ocular examination. Dilated fundus examination of left eye was not possible due to traumatic cataract. Vitreous hemorrhage, vitreous detachment and a echogenic foreign body present in posterior segment in B-Scan sonography. Well-defied hyperdense foreign body producing streak artifacts with vitreous hemorrhage was seen in the posterior chamber of left eyeball in CT orbit. The patient was diagnosed with a corneal laceration, traumatic cataract, vitreous hemorrhage and a metallic intraocular foreign body. He was brought to the operating room urgently for corneal laceration repair, pars plana vitrectomy, lensectomy, and removal of the metallic intraocular foreign body done.

Transcatheter device closure of a traumatic ventricular septal defect

A traumatic ventricular septal defect (VSD) resulting from blunt chest injury is a very rare event in children. The clinical symptoms and timing of presentation are variable, so diagnosis and management of traumatic VSD may be challenging. Decision to close the traumatic VSD is usually based on a combination of severity of heart failure symptoms, hemodynamics, and defect size. We present a case of a 7-year-old boy who was run over by a truck and presented with head and liver injury initially. He was subsequently found to have a traumatic VSD. The VSD was closed percutaneously.

Flexible bronchoscopic removal of a three piece foreign body from a child's bronchus

Foreign body aspiration can be a life-threatening event especially in young children because they have smaller diameters of airway lumen, moreover, the delay in the diagnosis and subsequent therapeutic intervention can further increase the risk of morbidity.(1, 2) A retained foreign body can result in inflammatory response and granulation tissue formation around the object which make the foreign body removal difficult.(3) In such situations surgical intervention is usually needed but with interventional pulmonology modalities we can restrict the need for surgery.(4) Rigid bronchoscopy under general anaesthesia is the gold standard of diagnosis and management of foreign body aspiration.(1) However, nowadays flexible bronchoscopy is more widely available and most pulmonary physicians are trained in its use so it can be used to remove such foreign bodies. We hereby report a case of a neglected foreign body which remained in the bronchus of a child for 11 days, successfully removed by flexible bronchoscopy.

A novel technique for stenting pulmonary artery and conduit bifurcation stenosis

BACKGROUND

Distal conduit obstruction is a recognized complication after surgery for congenital heart disease requiring implantation of a conduit from the right ventricle to the pulmonary arteries. Endovascular stenting of distal conduit obstruction can be challenging due to the proximity to the pulmonary artery bifurcation.

OBJECTIVE

A technique is described, whereby a single stent is mounted onto two balloon angioplasty catheters in tandem. This ensemble was delivered to the distal conduit/pulmonary artery via a large Mullins sheath on two guidewires, one placed in each of the branch pulmonary arteries. The aim was to assess safety and efficacy of this novel technique.

MATERIALS AND RESULTS

Seven patients (mean age 13.4 (6.7-23.4) years, mean weight 44.2 (23-69) kg were treated with this method. The pressure gradient was reduced from 36 (26-52) mm Hg to 11 (8-15) mm Hg [P< 0.05]. RV/LV pressure ratio decreased from 0.85 (0.6-0.95) to 0.42 (0.35-0.5) [P < 0.05]. There were no significant complications. During follow-up over a median of 2.6 (0.3-6.7) years no patient required re-intervention or surgery.

CONCLUSION

This novel technique appears to be safe and effective for stenting stenoses just proximal to pulmonary artery bifurcation.

Rapid ventricular pacing for catheter interventions in congenital aortic stenosis and coarctation: effectiveness, safety, and rate titration for optimal results

INTRODUCTION

Infants and children with congenital aortic stenosis and coarctation of the aorta can be treated by catheter intervention. There are several pharmacological and mechanical techniques described to overcome the balloon movement; none, however, have proved entirely satisfactory. An alternative method to achieve balloon stability is the use of rapid ventricular pacing. We describe our experience with titrating the pacing rate and the use of this technique.

METHODS

A retrospective review of database was performed, to identify patients who underwent transcatheter intervention with rapid ventricular pacing. Invasive systemic pressures were documented with a catheter in the aorta. Rapid ventricular pacing was initiated at the rate of 180 per minute and increased by increments of 20 per minute to a rate required to achieve a drop in systemic pressure by 50% and a drop in pulse pressure by 25%. The balloon was inflated only after the desired pacing rate was reached. Pacing was continued until the balloon was completely deflated.

RESULTS

Thirty patients were identified, 29 of whom had interventions with rapid ventricular pacing. Balloon valvuloplasty of aortic valve was performed on 25 patients while 4 patients had stenting for coarctation by this technique. The rate of ventricular pacing required ranged from 200 to 260 per minute with a median rate of 240. Balloon stability at the time of intervention was achieved in 27 patients.

CONCLUSION

Rapid ventricular pacing is a safe and effective method to provide transient decrease in cardiac output at the time of transcatheter interventions to achieve balloon stability.