Efficacy and safety of high-power short-duration ablation for atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

High-power short-duration (HPSD) ablation has emerged as an alternative to conventional standard-power long-duration (SPLD) ablation. We aim to assess the efficacy and safety of HPSD versus SPLD for atrial fibrillation (AF) ablation.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL were performed through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI).

PROSPERO ID

CRD42023471797.

RESULTS

We included six RCTs with a total of 694 patients. HPSD was significantly associated with a decreased total procedure time (MD: -22.88 with 95% CI [-36.13, -9.63], P = 0.0007), pulmonary vein isolation (PVI) time (MD: -19.73 with 95% CI [-23.93, -15.53], P < 0.00001), radiofrequency time (MD: -10.53 with 95% CI [-12.87, -8.19], P < 0.00001). However, there was no significant difference between HPSD and SPLD ablation with respect to the fluoroscopy time (MD: -0.69 with 95% CI [-2.00, 0.62], P = 0.30), the incidence of esophageal lesions (RR: 1.15 with 95% CI [0.43, 3.07], P = 0.77), and the incidence of first pass isolation (RR: 0.98 with 95% CI [0.88, 1.08], P = 0.65).

CONCLUSION

HPSD ablation was significantly associated with decreased total procedure time, PVI time, and radiofrequency time compared with SPLD ablation. On the contrary, SPLD ablation was significantly associated with low maximum temperature.

Management of Severe Anemia in a Jehovah's Witness Patient With Lung Abscess Secondary to Malpositioned Laparoscopic Adjustable Gastric Band: A Case Report

Jehovah's Witnesses is a Christian denomination widely recognized for their steadfast refusal of blood transfusions, even when facing severe anemia. We describe a unique case of a 42-year-old Jehovah's Witness woman with severe iron deficiency anemia. She necessitated surgical correction of a malpositioned gastric band within the context of a complex necrotizing aspiration pneumonia secondary to esophageal obstruction. Medical management of this severe anemia has been a challenge as traditional approaches, like a blood transfusion, are not possible. Instead, a multifaceted approach has been described with intravenous iron infusions, recombinant human erythropoietin, vitamin B12, folate, and vitamin C administration. We emphasize the lack of consensus on guideline protocols regarding management of severe anemia for Jehovah's Witness patients and the subsequent need for more investigation into that matter. It also underscores the significance of respecting patient autonomy through close collaboration between patients and their health care providers to ensure effective patient-centered care.

Lymphodepleting chemotherapy practices and effect on safety and efficacy outcomes in patients with solid tumours undergoing T cell receptor-engineered T cell (TCR-T) Therapy: a systematic review and meta-analysis

BACKGROUND

T cell receptor-engineered T cell (TCR-T) therapy has shown promising efficacy in advanced solid tumours. Lymphodepleting (LD) chemotherapy improves TCR-T cell therapy efficacy but is associated with significant toxicities. Evidence is sparse regarding the optimum LD regimen for TCR-T cell therapy in solid tumours.

METHODS

A systematic review was conducted of interventional, prospective clinical trials describing LD practices prior to TCR-T cell therapy in patients with advanced solid tumours. The objective was to define LD regimens administered prior to TCR-T cell therapy and their effects on specific safety and efficacy outcomes in this patient population.

RESULTS

Searches returned 484 studies, 19 (231 patients) met the eligibility criteria. Cyclophosphamide (cyclo) 60 mg/kg daily (2 days), plus fludarabine (fludara) 25 mg/m2 daily (5 days) was the most common LD regimen (38% of studies). Higher dose LD regimens were associated with increased pooled incidence rates of febrile neutropaenia compared to low dose (0.64, [95% Confidence interval (CI): 0.50-0.78], vs. 0.39 [95% CI: 0.25-0.53], respectively) but were not significantly associated with higher objective responses (odds ratio: 1.05, 95%CI: 0.60-1.82, p = 0.86). A major shortfall in safety data reporting was identified; determination of LD regimen effects on many safety outcomes was not possible.

CONCLUSION

Standard consensus guidelines for the design and reporting of adoptive cell therapy (ACT) studies would facilitate accurate risk-benefit analysis for optimising LD regimens in patients with advanced solid tumours.

Retention Loss of Locator Attachment System Different Retention Caps for Two Implant Retained Mandibular OverdentureMedhat

Purpose. The objective of this invitro study was to evaluate gradual loss of retention at different time intervals between four different colour coded retentive caps of locator R-TX attachment system through 3000 cycles resembling 3years of attachment usage. Material and Methods. According to prosthetically driven implant placement, two implants were digitally planned and placed by 3D printed surgical stent in an epoxy model. Forty-eight mandibular complete dentures divided into four groups (12 dentures for each group) were constructed to compare Loss of retention between (12 pairs of locator R-TX each retention cap: zero retention, low retention, medium retention and regular retention), each was subjected to insertion and removal cycles resembling 3years of patient usage. Retention values at zero, one, two, three years were recorded using universal testing machine. Results: Locator R-TX medium &low retention showed no statistically significant retention values through three years while locator R-TX regular retention cap showed better retention values at zero, first, second year of use. Conclusion. Locator R-TX attachment systems low, medium, regular retention cap had no statistically significant different retention values at the end of third year of use while there were only statistically significant primary retention values. Clinical Implications. The importance of difference retention caps appears only in the start of over denture treatment until complete patient adaptation to over denture treatment10

The Emerging Treatment Options of Plasmablastic Lymphoma: Analysis of 173 Individual Patient Outcomes

Plasmablastic lymphoma (PBL) is a newly recognized aggressive subtype of non-Hodgkin lymphoma. Its rarity hinders testing effective treatment options in clinical trials. We conducted a systematic review of PubMed and our internal records to retrieve patients with a PBL diagnosis with evaluable treatment outcomes. Aggressive chemotherapy was defined as more intense regimens than CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone). We compiled a meta-dataset of 173 patients. The median age at diagnosis was 48.5 years, 75% of patients were male, and stages III/IV accounted for 47% of the cohort. Of 138 patients with known response status after first-line chemotherapy, 63 (45%) achieved a complete response with a 2-year relapse-free survival of 71.6%. Sixty-nine (50%) patients received first-line CHOP. There was no significant difference in the objective response rate among the 2 most commonly used regimens, CHOP and DA-EPOCH (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) (69% vs. 79%; P = .4). The median follow-up was 9 months, and the 2-year overall survival (OS) was 47.4%. A univariate analysis identified factors associated with worse OS, including stage III/IV (hazard ratio [HR], 2.82; P < .001), human herpes virus-8-positive (HR, 3.30; P = .01), bone marrow (HR, 1.07; P = .035), and cardiorespiratory involvement (HR, 2.26; P = .015). Meanwhile, Epstein-Varr virus-encoded small RNA-positivity (HR, 0.31; P < .001) and involvement of head and neck (HR, 0.44; P = .009) were associated with better OS. Multivariate analysis showed that aggressive chemotherapy was significantly associated with better OS (HR, 0.22; P = .016). Patients with PBL with high-risk features, such as advanced stage, human herpes virus-8-positivity, bone marrow, and cardiorespiratory involvement, require more aggressive chemotherapy. Bortezomib and lenalidomide are promising add-on agents.

Obese communities among the best predictors of COVID-19-related deaths

Coronavirus disease 2019 (COVID-19) is the largest outbreak to strike the world since the Spanish flu in 1918. Visual examination of the world map shows a wide variation of death tolls between countries. The main goal of our series is to determine the best predictors of such discrepancy.

METHODS

This is a retrospective study in which the rate of COVID-19 deaths was correlated with each of the following independent variables: total tests per 1 million population, gross domestic product (GDP), average temperatures per country, ultraviolet index, median age, average BMI per country, food supply, Bacille Calmette-Guerin compulsory status, and passenger traffic.

RESULTS

BMI per country proved to be the second best predictor of death rate with an R value of 0.43, and GDP being the best predictor with R = 0.65.

CONCLUSION

This article shows a tight correlation between average BMI, food supply per country, and COVID-19-related deaths. Such predisposing factors might operate by upregulating the inflammation pathway in heavily struck countries, leading to easier triggering of the infamous cytokine storm syndrome. Obesity also increases cardiovascular and respiratory morbidities, which are coupled to increased ICU demand and deaths among infected cases.Video abstract: http://links.lww.com/CAEN/A25.

Skin to cervical epidural space distances as read from magnetic resonance imaging films: consideration of the "hump pad."

STUDY OBJECTIVE

To measure the distances from the skin to the epidural space (DSES) of the lower cervical and upper thoracic intervertebral spaces.

DESIGN

Retrospective review of films of the cervical spine as obtained by magnetic resonance imaging (MRI).

SETTING

Health care facility that provides diagnosis and treatment of patients with chronic pain.

MEASUREMENTS AND MAIN RESULTS

MRI sagittal films of 100 patients, who had diagnostic studies for chronic headaches and cervicobrachial radiculopathy, were reviewed. Measurements were made of DSES, the dural sac, and the spinal cord by centimeter ruler. Estimates were also made of the width of the epidural space by measuring the distance from the ligamentum flavum to the dural sac. The longest DSES were noted at C6-7 and C7-T1 levels, with a mean of 5.7 cm, but they decreased to a mean of 5.4 cm at the T1-2, and to 4. 7 cm at the T2-3 intervertebral spaces. One of the major factors in this variability was the presence of an accumulation of fatty tissue along the lower cervical and upper thoracic area, which the authors named the "hump pad." This accumulation appears to be thicker in obese patients, with a slight correlation coefficient with the patient's weight. The distances from ligamentum flavum to dural sac, representing the depth of the epidural space, averaged 0.3 cm, 0.4 cm, 0.5 cm, and 0.4 cm, respectively.

CONCLUSIONS

In the cervical spine, DSES varies from space to space. In obese individuals, the fat pad may increase DSES at the lower cervical intervertebral spaces. The longest mean distances from the ligamentum flavum to the dural sac and to the spinal cord were found at the T1-2 and T2-3 levels, precisely where DSES is shorter. All things being equal, the upper thoracic intervertebral spaces appeared to provide a greater margin of safety for insertion of epidural catheters to treat cervicobrachial radiculopathies.

Postlaminectomy pseudomeningocele. An unsuspected cause of low back pain

BACKGROUND AND OBJECTIVES

Patients with postlaminectomy pseudomeningoceles may present to pain management centers without having been diagnosed previously. Practitioners treating chronic low back pain need to be aware of this potential hazard.

METHODS

Retrospective analyses of six such cases was made including: clinical signs and symptoms, radiological findings, and possible therapeutic modalities.

RESULTS

In every case, there was a palpable fluctuating mass under the surgical scar, sensory loss in both lower extremities, and limited leg raising; moreover, heel tapping produced pain. Also, every patient had a history of long standing cigarette smoking and multiple spinal surgeries. Radiologically dural saccular or tubular structures were noted at myelograms, magnetic resonance imaging, or computed axial tomography scan, usually at the site of the surgery. In one patient with metallic devices, diagnosis was made by ultrasound.

CONCLUSIONS

The need for a complete examination by the pain specialist is emphasized since instrumentation in attempts to perform invasive procedures, i.e., inserting needles in the patients, may result in unintentional puncture of the pseudomeningocele and cerebrospinal fluid leaks. The clinical features accompanying the surgical complications ought to be recognized as a warning signal.

Delayed sympathetically maintained pain caused by electrical burn at the current's entry and exit sites

It is not uncommon for sympathetically maintained pain (SMP) to follow electric burns at the site of current entry. The occurrence of SMP at the exit point has not been reported. This report describes a patient who was exposed transiently to a 220W electrical current. After a delay of 3 months, the typical manifestations of SMP appeared on the right hand (entry point); symptoms appeared on the left foot (exit point) after 11 months. Ultrasonography was helpful in identifying the bony and soft tissue changes that occurred with SMP. Serial sympathetic blocks, oral phenytoin, and an intensive physical rehabilitation program were useful in treating this electrically induced SMP.