Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism

PURPOSE OF REVIEW

Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies.

RECENT FINDINGS

Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.

Angiographic Coronary Slow Flow Is Not a Valid Surrogate for Invasively Diagnosed Coronary Microvascular Dysfunction

BACKGROUND

Ischemia with no obstructive coronary arteries is frequently caused by coronary microvascular dysfunction (CMD). Consensus diagnostic criteria for CMD include baseline angiographic slow flow by corrected TIMI (Thrombolysis In Myocardial Infarction) frame count (cTFC), but correlations between slow flow and CMD measured by invasive coronary function testing (CFT) are uncertain.

OBJECTIVES

The aim of this study was to investigate relationships between cTFC and invasive CFT for CMD.

METHODS

Adults with ischemia with no obstructive coronary arteries underwent invasive CFT with thermodilution-derived baseline coronary blood flow, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). CMD was defined as abnormal CFR (<2.5) and/or abnormal IMR (≥25). cTFC was measured from baseline angiography; slow flow was defined as cTFC >25. Correlations between cTFC and baseline coronary flow and between CFR and IMR and associations between slow flow and invasive measures of CMD were evaluated, adjusted for covariates. All patients provided consent.

RESULTS

Among 508 adults, 49% had coronary slow flow. Patients with slow flow were more likely to have abnormal IMR (36% vs 26%; P = 0.019) but less likely to have abnormal CFR (28% vs 42%; P = 0.001), with no difference in CMD (46% vs 51%). cTFC was weakly correlated with baseline coronary blood flow (r = -0.35; 95% CI: -0.42 to -0.27), CFR (r = 0.20; 95% CI: 0.12 to 0.28), and IMR (r = 0.16; 95% CI: 0.07-0.24). In multivariable models, slow flow was associated with lower odds of abnormal CFR (adjusted OR: 0.53; 95% CI: 0.35 to 0.80).

CONCLUSIONS

Coronary slow flow was weakly associated with results of invasive CFT and should not be used as a surrogate for the invasive diagnosis of CMD.

Cardiogenic Shock Intravascular Cooling Trial (CHILL-SHOCK)

BACKGROUND

Cardiogenic shock (CS) is complicated by high mortality rates. Targeted temperature control (TTC) has been proposed as an adjunct therapy in CS. This study aims to examine the safety of TTC in patients presenting with CS.

METHODS AND RESULTS

In this open-label, randomized controlled pilot trial, 20 patients with hemodynamic criteria for CS were assigned to standard of care plus TTC vs standard of care alone. The primary outcome was a composite safety outcome, including well-described complications of TTC. Secondary outcomes included mortality at 90 days, invasive hemodynamic and echocardiographic parameters, electrocardiographic measurements, and inotrope dosing. There were no significant differences in the composite analysis of prespecified safety outcomes (3 events in the TTC group vs 0 events in the control group; P = 0.24). Patients randomized to TTC demonstrated a statistically significant increase in cardiac index and cardiac power index compared to the control group at 48-96 hours after randomization (3.6 [3.1, 3.9] L/min/m2 vs 2.6 [2.5, 3.15] L/min/m2; P = 0.029 and 0.61 [0.55, 0.7] W/m2 vs 0.53 [0.435, 0.565] W/m2; P = 0.029, respectively).

CONCLUSION

TTC may be a safe adjunct therapy for patients presenting with CS and may yield improvement in specific hemodynamic parameters.

Use of Intravascular Ultrasound and Coronary Angiography to Measure the Prevalence of Myocardial Bridge in Heart Transplant Patients

Myocardial bridge (MB) detection rates vary across methods and most studies that have assessed MB include symptomatic patients. Intravascular ultrasound (IVUS) is a sensitive tool for MB detection and donor hearts may serve as a surrogate measure of asymptomatic patients. We used IVUS and coronary angiography to measure MB prevalence in heart transplant patients during routine follow-up invasive coronary assessments. This was a retrospective, single-center study of heart transplant patients who received follow-up coronary assessments at the University of Chicago Heart and Vascular Center between December 2014 and December 2021. A single experienced interventional cardiologist assessed incidental findings of MB in IVUS and coronary angiography. Detection rates were compared with meta-analysis-reported prevalence. Of 129 patients, IVUS-detected MB in 87 patients (67.4%), whereas coronary angiography detected 41 (31.8%). All MB found by coronary angiography were detected by IVUS. Some level of cardiac allograft vasculopathy was found in 92 patients (71.3%). Our IVUS-detected MB prevalence was greater than meta-analysis-reported pooled prevalence across all methods: autopsy, computed tomography angiography, and coronary angiography (67.4% [95% confidence interval [CI] 59.4 to 75.5] vs 42% [95% CI 30 to 55]; 22% [95% CI 18 to 25]; 6% [95% CI 5 to 8], p ≤0.005). The difference between our observed IVUS-detected MB prevalence and meta-analysis autopsy reported MB prevalence was 1.25 (95% CI 1.11 to 1.40). In conclusion, the high prevalence of MB recorded in donor hearts emphasizes the need to further investigate the causes of chest pain in patients who are found to have MB.

Increases in adolescent firearm injuries were associated with school closures during COVID-19

BACKGROUND

Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic.

METHODS

Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes.

RESULTS

There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city.

CONCLUSION

AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Relaparotomy after Cesarean Section: Experience in a Tertiary Referral Hospital

This study was aimed at exploring the causes of relaparotomy following caesarean section. The surgical procedures performed during relaparotomy were also discussed. This was a prospective study conducted in the Department of Obstetrics and Gynaecology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from November 2020 to May 2021. MMCH is the largest referral Hospital in Mymensingh. During this study period 48 puerpera needed relaparotomy after caesarean section within 6 weeks of caesarean section. The frequency of relaparotomy was 2.6%. Of the 48 cases, 28(58.33%) cases needed relaparotomy due to post partum haemorrhage (PPH). Among them 9(18.75%) had primary PPH, 19(39.58%) patients had secondary PPH. Here 7(14.58%) patients suffered from sub rectus hematoma, 5(10.42%) patients had puerperal sepsis, 3(6.23%) had internal haemorrhage and 4(8.33%) women had wound dehiscence. Foreign body was removed in 1 case (2.08%). Main procedure performed was subtotal (45.83%) and total hysterectomy (25%). Coagulation failure and septicaemia were causes of maternal death. Case fatality rate was 4.17%. Obstetric patients who need relaparotomy face potential death. This study will help us to identify the causes for relaparotomy. Due precautions should be taken as far as possible to avoid this complications following caesarean section and thereby reduce maternal mortality and morbidity.

Intratympanic Dexamethasone in Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss can be a frightening experience for the sufferer and needs immediate treatment. Systemic steroid therapy has been the mainstay of treatment of this condition but concerns about their side effects has led to their use by intratympanic injection. We studied the results of intratympanic dexamethasone (IT-Dexa) both as a primary therapy and as salvage treatment after failure of oral steroids. A total of 39 patients of SSNHL were studied prospectively. Of these 23 were given oral steroids. Ten of these showed no response and were treated with IT-Dexa 4 mg/ml twice a week for two weeks. In addition, 16 patients who reported later than two weeks or had concomitant medical disorders like diabetes and/or hypertension were treated with IT-Dexa. While oral steroids showed hearing improvement (≥ 10 dB) in 56.5% patients, the recovery rate was 62.5% and 80% in those treated primarily with IT-Dexa and as salvage therapy respectively. There was a negative correlation of delay in institution of treatment with hearing recovery. Conclusion: intratympanic dexamethasone is a safe and effective treatment and should be offered to patients as a primary treatment modality and also as salvage therapy after failure of oral steroids. For best results the treatment should be started at the earliest.

Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients

Background

The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs.

Purpose

To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients.

Methods

Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs.

Results

30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15–12.27, P<0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15–1.58, P<0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P<0.001). Of note, readmitted and non-readmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%).

Conclusion

Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge.

Funding Acknowledgement

Type of funding sources: None.

Multiple Intracardiac Masses Involving 3 Chambers of the Heart

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A 42-year-old man presented with multiple cardiac masses.

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Metastatic disease is far more prevalent than primary cardiac tumors.

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Multimodality imaging aids in the diagnostic and management strategy.

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Optimal treatment of large, chronic intracardiac thrombi needs to be refined.

The Transulnar Approach to Coronary Angiography and Intervention: Assessing the Anatomy of the Ulnar Artery Using Angiography

BACKGROUND

The transulnar approach (TUA) has been proposed as a safe alternative to the more established transradial approach (TRA) for cardiac catheterization. However, no study has assessed the anatomy and variability of the ulnar artery using angiography.

METHODS

A retrospective analysis of patients who underwent transradial cardiac catheterization during routine clinical care was conducted. Both quantitative and qualitative measurements of artery diameter were collected.

RESULTS

Among 700 consecutive patients, mean distal ulnar artery diameter (UAD) was larger in men (3.2 ± 0.9 mm) compared with women (2.7 ± 0.7 mm; P<.001). UAD was larger than radial artery diameter (RAD) at all measured sites (distal ulnar, 3.0 ± 0.8 mm; distal radial, 2.9 ± 0.7 mm; P=.046). Compared with the radial artery, the ulnar artery had more atresia (4.3% ulnar vs 0% radial; P<.001), fewer loops (0.6% ulnar vs 2.4% radial; P<.01), and less spasm (2.7% ulnar vs 23.4% radial; P<.001). UAD had more variability (distal variance, 0.68) as compared with the RAD (distal variance, 0.53; P<.001).

CONCLUSION

We found that the ulnar artery has a larger diameter, fewer loops, and less spasm, but more variance than the radial artery. Additionally, males have larger ulnar arteries than women. These findings have implications on the application of TUA either as an alternative to TRA or as the primary point of access.

Trauma-informed Approaches to Substance Use Interventions with Indigenous Peoples: A Scoping Review

Indigenous Peoples experience disproportionately higher rates of problematic substance use. These problems are situated in a context of individual and intergenerational trauma from colonization, residential schools, and racist and discriminatory practices, policies, and services. Therefore, substance use interventions need to adopt a trauma-informed approach. We aimed to synthesize and report the current literature exploring the intersection of trauma and substance use interventions for Indigenous Peoples. Fourteen databases were searched using keywords for Indigenous Peoples, trauma, and substance use. Of the 1373 sources identified, 117 met inclusion criteria. Literature on trauma and substance use with Indigenous Peoples has increased in the last 5 years (2012-2016, n = 29; 2017-2021, n = 48), with most literature coming from the United States and Canada and focusing on historical or intergenerational trauma. Few articles focused on intersectional identities such as 2SLGBTQIA+ (n = 4), and none focused on veterans. There were limited sources (n = 25) that reported specific interventions at the intersection of trauma and substance use. These sources advocate for multi-faceted, trauma-informed, and culturally safe interventions for use with Indigenous Peoples. This scoping review illuminates gaps in the literature and highlights a need for research reporting on trauma-informed interventions for substance use with Indigenous Peoples.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Multidimensional spectroscopy of magneto-excitons at high magnetic fields

We perform two-dimensional Fourier transform spectroscopy on magneto-excitons in GaAs at magnetic fields and observe Zeeman splitting of the excitons. The Zeeman components are clearly resolved as separate peaks due to the two-dimensional nature of the spectra, leading to a more accurate measurement of the Zeeman splitting and the Landé g factors. Quantum coherent coupling between Zeeman components is observed using polarization dependent one-quantum two-dimensional spectroscopy. We use two-quantum two-dimensional spectroscopy to investigate higher four-particle correlations at high magnetic fields and reveal the role of the Zeeman splitting on the two-quantum transitions. The experimental two-dimensional spectra are simulated using the optical Bloch equations, where many-body effects are included phenomenologically.

Analysis of complex multidimensional optical spectra by linear prediction

We apply Linear Prediction from Singular Value Decomposition (LPSVD) to two-dimensional complex optical data in the time-domain to generate spectra with advantages over discrete Fourier transformation (DFT). LPSVD is a non-iterative procedure that fits time-domain complex data to the sum of damped sinusoids, or Lorentzian peaks in the spectral domain. Because the fitting is linear, it is not necessary to give initial guess parameters as in nonlinear fits. Although LPSVD is a one-dimensional algorithm, it can be performed column-wise on two-dimensional data. The method has been extensively used in 2D NMR spectroscopy, where spectral peaks are typically nearly ideal Lorentzians, but to our knowledge has not been applied in the analogous optical technique, where peaks can be far from Lorentzian. We apply LPSVD to the analysis of zero, one, and two quantum electronic two-dimensional spectra from a semiconductor microcavity. The spectra consist of non-ideal, often overlapping peaks. We find that LPSVD achieves a very good fit even on non-ideal data. It reduces noise and eliminates discrete distortions inherent in the DFT. We also use it to isolate and analyze weak features of interest.

Concomitant Lower-Extremity Deep Vein Thrombosis in Patients With Pulmonary Embolism Undergoing Catheter-Directed Therapy

Deep vein thrombosis (DVT) is often seen in patients with acute pulmonary embolism (PE). Risk stratification of PE patients is useful in predicting mortality risk and hospital course. However, rates or predictors of DVT or proximal DVT (popliteal, femoral, common femoral, or iliac thrombosis) have not been studied in the highest-risk patients who receive catheter-directed therapy (CDT) for their PE. A single-center retrospective analysis of patients referred for CDT for confirmed PE was conducted to evaluate rates and predictors of DVT or proximal DVT and the impact on short-term outcomes. In 137 consecutive patients undergoing CDT for PE with available lower-extremity ultrasound, the rates of DVT and proximal DVT in PE patients receiving CDT were 76.6% and 65.0%, respectively. Rates of DVT (P=.68) and proximal DVT (P=.72) did not differ between high-risk or non-high risk PE patients. The only significant factor associated with presence of concomitant DVT was previous DVT (P=.045). The presence of a concomitant DVT or proximal DVT was not associated with an increase in all-cause mortality or hospitalization at 30 days or 1 year compared with an absence of concomitant DVT or proximal DVT. The results of this study suggest that patients with PE clinically requiring CDT have high rates of concomitant DVT and proximal DVT, prior DVT predicts concomitant DVT, and the presence of DVT is not associated with additional risk in this already high-risk population of patients.

Retrospective comparison of percutaneous balloon pericardiotomy with pericardiocentesis versus pericardiocentesis alone for management of symptomatic pericardial effusions

Background

Cardiac tamponade is a potentially life-threatening complication of pericardial effusion. Pericardiocentesis with drainage is the mainstay of treatment for patients with pericardial effusion and cardiac tamponade. Percutaneous balloon pericardiotomy (PBP) is an adjunct to pericardiocentesis that may alleviate the risk for recurrent effusion and repeat procedures. However, the efficacy of PBP plus pericardiocentesis compared to pericardiocentesis alone is not clear.

Purpose

We sought to determine whether PBP plus pericardiocentesis was associated with less recurrence of pericardial effusion than pericardiocentesis alone.

Methods

We conducted a single-centre retrospective analysis of patients ≥18 years old with non-iatrogenic pericardial effusion undergoing either pericardiocentesis alone or PBP plus pericardiocentesis for the first time. For PBP, a balloon was advanced over a guidewire until it crossed the pericardium and was then inflated until the balloon profile was fully expanded. Type of balloon used, and single or double balloon technique were left up to the operator. Recurrent pericardial effusion was defined as a large pericardial effusion on echocardiogram, pericardial effusion that caused hemodynamic compromise, or pericardial effusion that necessitated another intervention to drain at any time after initial procedure. Risk factors for recurrent pericardial effusion were also assessed.

Results

There were 208 patients who underwent pericardiocentesis, with 33 patients receiving PBP plus pericardiocentesis. In all patients, the rate of recurrent pericardial effusion was 15.9% and 15.2%, respectively (p=0.92). In patients with a cancer diagnosis at time of procedure, the rate of recurrent pericardial effusion was 17.8% and 16.7%, respectively (p=0.89). In patients with malignant pericardial effusion as confirmed by cytology, the rate of recurrent pericardial effusion was 20.4% and 13.3%, respectively (p=0.72). Patients with a connective tissue disease (CTD) had an increased odds ratio (OR) of recurrent pericardial effusion when compared to patients without a CTD (OR 3.19, 95% CI 1.31–7.77).

Conclusions

The results of this study suggest that PBP plus pericardiocentesis offers no significant benefit over pericardiocentesis alone at preventing recurrent pericardial effusion. This finding was true in all sub-groups, including patients with cancer and patients with malignant pericardial effusion. Patients with a CTD were three times more likely than patients without a CTD of having a recurrent pericardial effusion, independent of treatment strategy.

Funding Acknowledgement

Type of funding sources: None.

Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India

This study from southern India showed that the trabecular microarchitecture and proximal hip geometry were significantly impaired in postmenopausal women with diabetes as compared to age and BMI matched non-diabetic controls. This is despite there being no significant difference in bone mineral density at the femoral neck and hip not between both groups. One-third of the study subjects with type 2 diabetes had prevalent vertebral fractures. Bone mineral density assessment as a standalone tool may not adequately reflect bone health in subjects with diabetes.

INTRODUCTION

There is limited information with regard to bone health in Indian postmenopausal women with type 2 diabetes. We studied the bone mineral density (BMD), trabecular bone score (TBS), prevalent vertebral fractures (VF), proximal hip geometry, and bone mineral biochemistry in ambulatory postmenopausal women with and without type 2 diabetes mellitus (T2DM).

METHODS

This was a cross-sectional study conducted at a tertiary care center. BMD, TBS, prevalent vertebral fractures, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied.

RESULTS

A total of 202 ambulatory postmenopausal women known to have type 2 diabetes mellitus with mean (SD) age of 65.6 (5.2) years and 200 age and BMI matched non-diabetic controls with mean (SD) age of 64.9 (4.7) years were recruited from the local community. Although the prevalence of lumbar spine osteoporosis was significantly lower among cases (30.7%) as compared to controls (42.9%), the prevalence of degraded bone microarchitecture (TBS < 1.200) was significantly higher among cases (51%) than in controls (23.5%); P < 0.001. Prevalent vertebral fractures were not significantly different in cases and controls. The various geometric indices of the proximal hip were significantly impaired in subjects with diabetes as compared to controls.

CONCLUSION

This study may highlight the utility of the trabecular bone score and hip structural analysis in subjects with diabetes, where the bone mineral density tends to be paradoxically high, and may not adequately predict fracture risk.

Left Ventricular Pressure Ratio Predicts In-Hospital Outcomes in Hospitalized Heart Failure With Reduced Ejection Fraction

BACKGROUND

Given the risk of hemodynamic compromise in heart failure with reduced ejection fraction (HFrEF) patients undergoing left heart catheterization (LHC), there is a need for a simple parameter that can predict clinical outcomes. We hypothesize that left ventricular pressure ratio (LVPR), calculated as left ventricle systolic/left ventricle end-diastolic pressure, is a strong predictor of hemodynamic collapse in these patients.

METHODS

Retrospective analysis of consecutive hospitalized HFrEF patients undergoing combined LHC and right heart catheterization (RHC) at a single institution from 2015-2017 was performed. LVPR was compared with standard RHC hemodynamic variables. The primary outcome was in-hospital escalation of therapy, defined as ≥40 mm Hg drop in systolic blood pressure (SBP), SBP ≤90 mm Hg for ≥15 minutes, start or escalation of vasoactive medications, cardiopulmonary resuscitation, or in-hospital death. Receiver-operating characteristic (ROC) analysis and Kaplan-Meier survival analysis were performed for prediction of the primary outcome.

RESULTS

A total of 176 patients were included in this study. ROC analysis determined an optimal cut-off value of ≤3.96, which correlated with an area under the curve (AUC) of 0.65 (sensitivity, 45.9%; specificity, 83.2%; correctly classified, 64.9%). AUC was similar to other variables obtained using RHC. In-hospital survival free of escalation of therapy was lower in the low LVPR group vs the high LVPR group (0% vs 33%, respectively; P<.01).

CONCLUSION

LVPR is an easily measured index obtained during LHC that can risk stratify hospitalized patients with HFrEF at the time of LHC.

Effect of Postoperative Analgesic Exposure to the Cannabinoid Receptor Agonist WIN55 on Osteogenic Differentiation and Spinal Fusion in Rats

BACKGROUND

After spinal surgery and other orthopaedic procedures, most patients receive opioids for pain, leading to potential complications such as pseudarthrosis and opioid abuse associated with long-term use. As an alternative, the endocannabinoid system has been shown to have antinociceptive activity, while contributing to bone homeostasis via the CB1 and CB2 cannabinoid receptors. This study evaluates the impact of the cannabinoid receptor agonist WIN55,212-2 (WIN55) on osteogenic differentiation in vitro as well as bone regeneration and spinal fusion in a preclinical rat model.

METHODS

Primary rat bone marrow stromal cells were cultured in standard or osteogenic media and exposed to vehicle alone or WIN55. Runx2 and Alkaline phosphatase (Alpl) were quantified via qPCR (quantitative real-time polymerase chain reaction), followed by assessment of ALP activity and matrix mineralization. For in vivo evaluation, 45 female Sprague Dawley rats (n = 15 per group) underwent L4-L5 posterolateral spinal fusion with bilateral placement of collagen scaffolds preloaded with low-dose rhBMP-2 (recombinant human bone morphogenetic protein-2; 0.5 μg/implant). Postoperatively, rats received the vehicle alone or 0.5 or 2.5 mg/kg WIN55 via daily intraperitoneal injections for 5 days. Bone regeneration and spinal fusion were assessed using radiography, manual palpation-based fusion scoring, microcomputed tomography imaging, and histology.

RESULTS

mRNA expression levels of Runx2 and Alp were similar among cells treated with vehicle alone and WIN55. Likewise, exposure to WIN55 did not inhibit ALP activity or bone matrix mineralization. In this animal model, no significant differences were found among groups with regard to mean fusion score, fusion rate, or new bone volume.

CONCLUSIONS

WIN55 showed no adverse impact on osteogenic differentiation, bone regeneration, and spinal fusion. This supports that cannabinoid receptor agonists should be further investigated as a potential alternative approach for postoperative analgesia following spinal fusion and other orthopaedic procedures requiring bone-healing.

CLINICAL RELEVANCE

The identification of alternative treatments for postoperative pain following orthopaedic surgical procedures is crucial in combating the ongoing opioid abuse crisis. The endocannabinoid system may represent a viable alternative target for addressing orthopaedic postoperative pain.

Safety and efficacy of catheter-directed therapy versus anticoagulation alone in a higher-risk acute pulmonary embolism population

There is little data comparing safety and efficacy outcomes in patients with pulmonary embolism (PE) receiving catheter directed therapies (CDT) compared to a similar-risk cohort of PE patients receiving anticoagulation alone. 1094 patients with acute PE were studied. CDT and conservatively-managed patients were compared using propensity score matching to assess safety outcomes, which included bleeding and acute kidney injury at 2 and 7 days after PE diagnosis. Efficacy outcomes included change in vital signs over 72 h and in-hospital mortality. PE patients with RV strain who underwent CDT (n = 76) had more bleeding at 2 days (additional 1.04 g/dL loss, 95% CI − 1.48 to − 0.60, p < 0.001) and 7 days (additional 1.36 g/dL loss, 95% CI − 1.88 to − 0.84, p < 0.001) compared to those receiving anticoagulation alone (n = 303). There was a significant increase in creatinine at 2 days (additional 0.22 mg/dL elevation, 95% CI 0.02 to 0.42, p = 0.03), but not at 7 days (additional 0.12 mg/dL elevation, 95% CI − 0.11 to 0.35, p = 0.30). In-hospital mortality for patients receiving CDT versus anticoagulation alone was similar (OR 1.21, 95% CI 0.53 to 2.77; p = 0.65). In patients with baseline abnormal vital signs who received CDT versus anticoagulation alone, heart rate, respiratory rate and oxygen requirement improved significantly faster and to levels closer to normal (p ≤ 0.001). CDT was associated with a small but increased risk of bleeding, but no significant worsening of renal function. CDT may be associated with more rapid improvements in heart rate, respiratory rate, and oxygen requirement.

Phosphorus cycling from a coastal upwelling zone in the Southeastern Arabian Sea

The present study examined the seasonal cycling of phosphorous (P) along the southwest coast of India (SWCI) based on two cruises during the southwest monsoon (SWM) and northeast monsoon (NEM) of 2018. During SWM, the entire SWCI experienced intense upwelling manifested by the incursion of cold, nutrient-rich, and hypoxic waters. During NEM, the region was transformed into a warm, well-oxygenated and nutrient-deplete environment. Dissolved inorganic phosphorus (DIP) was significantly high in the subsurface during SWM due to its release from sediments. The sediment P was high and showed an increasing trend towards the south, principally dependent on the sediment texture, organic carbon, and Fe concentrations. Bioavailable P, the sum of exchangeable (P_Ex) and reducible (P_Fe) fractions, was almost consistent (5-20%) over seasons, though P_Fe showed a marked reduction during SWM. Authigenic fraction (P_Aut) was the most dominant (46%), followed by detrital (P_Det 41%) and residual (P_Res 8%) fractions. Principal component analysis (PCA) of geochemical parameters for SWM was indicative of the high dissolution of Fe (oxy)hydroxides under hypoxia releasing P and its complexation with organic matter and Fe. PCA results for the NEM were different, as it indicated increased preservation of P-associated organic matter and Fe, alternately favouring the formation of P_Aut in sediments. The study's significance is the observation that the bottom water oxygen concentration can significantly influence sedimentary P cycling in tropical coastal upwelling zones.

Safe and rapid radial hemostasis achieved using a novel topical hemostatic patch: Results of a first-in-human pilot study using hydrophobically modified polysaccharide-chitosan

BACKGROUND

The transradial approach (TRA) for catheter interventions decreases vascular complications and bleeding versus transfemoral approach. Reducing time to hemostasis and preventing radial artery occlusion (RAO) following TRA are important and incompletely realized aspirations.

OBJECTIVES

This first-in-human study sought to evaluate the efficacy of a novel, topically applied compound (hydrophobically modified polysaccharide-chitosan, hm-P) plus minimal required pneumatic compression, to achieve rapid radial arterial hemostasis in post-TRA procedures compared with de facto standards.

MATERIALS AND METHODS

About 50 adult patients undergoing 6 French diagnostic TRA procedures were prospectively enrolled. At procedure completion, a topical hm-P impregnated patch was placed over the dermotomy and TR Band (TRB) compression was applied to the access site. This patch was used as part of a novel rapid deflation protocol with a primary outcome of time to hemostasis. Photographic and vascular ultrasound evaluation of the radial artery was performed to evaluate the procedural site.

RESULTS

Time to hemostasis was 40.5 min (IQR: 38-50 min) with the majority of patients (n = 39, 78%) not requiring reinflation. Patients with bleeding requiring TRB reinflation were more likely to have low body weight and liver dysfunction, with absence of hypertension and LV dysfunction. The rate of RAO was 0% with predischarge radial artery patency documented in all patients using vascular ultrasound. One superficial hematoma was noted. No late bleeding events or cutaneous reactions were reported in the study follow-up.

CONCLUSIONS

Topical application of hm-P in conjunction with pneumatic compression was safe and resulted in rapid and predictable hemostasis at the arterial puncture site.

Injury Prevention Programs for Throwing Injuries in Softball Players: A Systematic Review

CONTEXT

Throwing-related injuries occur commonly in softball players. Preventative programs can be implemented to assist in identifying and correcting risk factors that could potentially lead to injury and therefore time missed from both practice and games.

OBJECTIVE

The purpose of this study was to determine if position-specific injury prevention programs have been developed to decrease the risk of throwing-related injuries in softball players.

DATA SOURCES

A systematic review was performed using the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) guidelines. PubMed, PMC, and EBSCO were searched for articles on injury prevention programs using the following key terms: softball, injury prevention, throwing injuries, pitcher, and shoulder.

STUDY SELECTION

Studies that involved fast-pitch softball and included female participants as well as rehabilitation programs were included. Articles that highlighted slow-pitch softball or did not include female participants were excluded.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

The initial search identified 1605 articles. After implementing a filter, 131 articles remained. Thirteen articles were screened out as duplicates. After screening for inclusion criteria, 7 articles remained and were included in the systematic review.

RESULTS

Decreased range of motion (ROM) in both the upper and the lower extremities, unbalanced muscular strength, and fatigue were identified as risk factors for throwing injuries in softball players. Within the upper extremity, strength and ROM of the rotator cuff muscles, biceps, and extensors of the forearm were emphasized. The main focus of the lower extremity was the strength of the gluteal muscles and ROM of the lumbopelvic-hip complex. Only 1 study detailed an injury prevention program for softball players. The prevention program outlined was generalized for all softball players and was not position specific.

CONCLUSION

There is a paucity of information about injury prevention programs for softball players. Of the evidence analyzed, balanced strengthening of the upper and lower extremities while maintaining dynamic range of motion was frequently utilized in developing an injury prevention program.

Two-beam coupling by a hot electron nonlinearity

Transparent conductive oxides such as indium tin oxide (ITO) bear the potential to deliver efficient all-optical functionality due to their record-breaking optical nonlinearity at epsilon near zero (ENZ) wavelengths. All-optical applications generally involve more than one beam, but, to our knowledge, the coherent interaction between beams has not previously been discussed in these materials, which have a hot electron nonlinearity. Here we study the optical nonlinearity at ENZ in ITO and show that spatial and temporal interference has important consequences in a two-beam geometry. Our pump-probe results reveal a polarization-dependent transient that is explained by diffraction of pump light into the probe direction by a temperature grating produced by pump-probe interference. We further show that this effect allows tailoring the nonlinearity by tuning the frequency or chirp. Having fine control over the strong and ultrafast ENZ nonlinearity may enable applications in all-optical neural networks, nanophotonics, and spectroscopy.

Spectrum of Clinical Presentation and Surgical Outcome in Patients with Chronic Subdural Haemorrhage: A Retrospective Study

Introduction: Chronic subdural haematomas are one among common neurosurgical emergencies especially affecting elderly male. Usually, presents with subacute Cerebro Vascular Accident (CVA), impaired higher mental function and sometimes with reversible dementia. Rarely, it presents with end stage herniation. Burr Hole Drainage (BHD) is the most popular and worldwide procedure of choice and it successfully address the problem in majority of cases. However, in a small group of patients it needs a wider craniotomy to deal with the subdural membrane which is mainly associated with recurrence of the entity. Aim: To evaluate the comparative incidence of various clinical presentation and analysing the outcome of different treatment modalities in different subgroups of patients with chronic subdural haemorrhage with respect to complication and survivality. Materials and Methods: This retrospective study enrolled data of 100 consecutive patients of subacute (n=30) and chronic subdural haematoma (n=70) who were admitted and undergone neurosurgical management of Veer Surendra Sai Institute of Medical Science and Research (VIMSAR), Burla, Odisha between September 2018 to September 2020. Variables were collected from patient’s records at discharge and analysed with respect to spectrum of clinical presentation and surgical outcome of different treatment modalities and problems associated with it. Results: The mean age group was 57.39 years and headache was the most common clinical presentation in the present study (86%) followed by hemiparasis (74%). BHD was carried out in 94 patients (94%). Primary craniotomy and membrane excision was carried out in 5 patients. Secondary craniotomy was performed in 1 patient after early re-accumulation and clinical deterioration. The outcome was assessed utilising Glasgow outcome scale with total five deaths in the series. Conclusion: Chronic Subdural Haemorrhage (CSDH) a problem of late adulthood (5th to 6th decade) which mostly follows two to three weeks after trauma. It needs proper preoperative assessment and requires timely intervention with skilled nursing care for early recovery. Post-traumatic subacute subdural haematoma in young subject and alcoholics needs special attention during course of their treatment. Bilateral puppilary failure, low Glasgow Coma Scale (GCS) and seizure association are risk factors for poor outcome.

Measurement of Placental Index in Different Gestational Age Groups in Bangladeshi Women

Placenta is the mirror of maternal and fetal status; it reflects the changes due to complications in pregnancy of mother. The growth and survival of the fetus in utero is directly related to formation, development and maturation of the placenta. Placental index was correlated to poor pregnancy outcomes. Placental index can help to identify fetal growth restriction which is result of placental insufficiency and is characterized by insufficient trasnsplacental transport of nutrients and oxygen. This cross sectional descriptive study would provide information about the ratio of placental index in different gestational age group in Bangladeshi women. To achieve this aim the study was performed on 60 human placenta and corresponding fetuses and gestational age (in weeks) categorized as Group A (28-32), Group B (33-37), Group C (38-40). These sample and information were collected from normal pregnancy in Gynecology and Obstetrics Department of Mymensingh Medical College Hospital from July 2009 to June 2010. After preservation in 10% formal saline, study was done in Department of Anatomy in Mymensingh Medical College. In this study, the mean±SD placental index was in Group A (0.187±0.113), Group B (0.153±0.025) and Group C (0.166±0.025) and also observed that mean placental index decreased with age up to certain level then increase in Group C. The mean placental index was maximum in Group A (0.187±0.113) and was minimum in Group B (0.153±0.025). The mean difference of placental index between Groups A&B, A&C and B&C was statistically not significant. Observed findings of this study were compared with those of Western and Bangladeshi researches.

Relationship between pre- and post-operative isokinetic strength after ACL reconstruction using hamstring autograft

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are of major concern in sports. As mostly young and active individuals are affected there is an emphasis on the rapid and safe return to sports (RTS). Strengthening the ventral and dorsal thigh muscles is a prerequisite for a successful RTS after ACL reconstruction (ACLR), as persistent muscle weakness may increase the incidence for secondary injuries and impair performance. Aiming to increase evidence on the importance of preoperative muscle strength and the coaching of patients, the purpose of this study is to compare thigh muscle strength pre- and post-operatively after ACLR.

METHODS

We performed a retrospective analysis of 80 patients with primary, isolated ACLR using a four-stranded hamstring autograft. We performed bilateral isokinetic concentric strength measurement (60°/s) before and six months after ACLR. Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q ratio) and the corresponding limb symmetry indices (LSI). Pearson correlations were calculated for pre- and post-surgical values.

RESULTS

The operated as well as the unaffected leg increased maximal knee extension (+ 18% ± 7% p < 0.05; + 11% ± 5% p < 0.05) and flexion torque (+ 9% ± 5% p < 0.05, + 10% ± 6% p < 0.05) throughout the 6 months of rehabilitation. The H/Q ratio remained unaffected (- 2% ± 3% p = 0.93; - 4% ± 4% p = 0.27). LSI of knee extension strength increased significantly (6% ± 3% p < 0.05), while flexion strength remained unaffected (+ 2% ± 4% p = 0.27). Positive correlations underline the interrelationship between the strength pre- and post-surgery for the knee extension (r = 0.788 p < 0.05) and knee flexion strength (r = 0.637 p < 0.05) after ACLR.

CONCLUSIONS

Preoperative leg extension and flexion strength normalized to body mass are strongly correlated to postoperative strength performance after ACLR. Therefore, pre-operative quadriceps and hamstring muscle strength deficits may have a significant negative impact on functional performance following ACLR. This emphasizes the need for intensive preoperative screening and subsequent treatment to achieve the best possible preoperative leg strength before ACLR.

TRIAL REGISTRATION

DRKS00020210 .

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients

OBJECTIVES

. To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients.

METHODS

. This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used.

RESULTS

. The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r² = 0.04; dBP: p = 0.59; r² = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r² = 0.02; dBP: p = 0.82; r² = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes.

CONCLUSION

. No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

Two-year follow-up of bioresorbable vascular scaffolds in severe infra-popliteal arterial disease

OBJECTIVES

To assess the safety, efficacy, and durability of the Absorb bioresorbable vascular scaffold in predominantly complex, infra-popliteal lesions for the management of chronic limb ischemia at two-year clinical follow-up. Bioresorbable vascular scaffold are biodegradable scaffolds that provide short-term vascular support before undergoing intravascular degradation. A recent trial reported excellent 36-month vessel patency rates in simple infrapopliteal arterial lesions treated with Absorb bioresorbable vascular scaffold.

METHODS

This single-center, retrospective study evaluated the use of the Absorb bioresorbable vascular scaffold (everolimus impregnated poly-L-lactic scaffold) in patients with infra-popliteal peripheral arterial disease (PAD) with respect to safety (thrombosis and TIMI bleeding), technical success, and freedom from clinically driven target vessel failure at 24 months.

RESULTS

31 patients (51.6% male) with a median age of 67 years with predominantly advanced infra-popliteal disease were treated with 49 bioresorbable vascular scaffold in 41 vessels. The mean stenosis was 94% (80-100), with 49% of lesions being chronic thrombotic occlusions. No scaffold thrombosis or peri-procedural bleeding was observed. Procedural success was achieved in all patients; 93.5% of patients experienced freedom from clinically driven target vessel failure at 24 months, driven by one revascularization and one amputation. Primary patency was 96.7% at 12 months and 87.1% at 24 months. All patients were alive at 12 and 24 months.

CONCLUSIONS

At 24 months, our study found that patients with predominantly advanced infra-popliteal PAD who were treated with Absorb bioresorbable vascular scaffold reported improved clinical status and a low and durable rate of clinically driven target vessel failure extending out to 24 months.

Risk compensation in HIV PrEP adherence among Black men who have sex with men in HPTN 073 study

While HIV infections among men who have sex men (MSM) have started to decline in the United States, Black MSM continue to experience disproportionate rates of HIV infection. The purpose of this secondary analysis is to examine risk perception and its influence on PrEP adherence among Black MSM from HPTN 073. Risk perception was measured using the adapted Perceived Vulnerability to HIV Scale. The associations between risk perception and PrEP adherence were tested using generalized estimation equation model for time-variant repeated measures. Risk perception was not significantly associated with PrEP adherence. These findings suggest an there was no risk compensation among PrEP users, and inconsistency in perceived risk for HIV. Future studies should investigate the rationale for long term adherence to PrEP among Black MSM.

Hypophosphataemic osteomalacia due to cadmium exposure in the silver industry

Chronic heavy metal exposure and the health hazards that ensue are important public-health problems. We highlight the occurrence of hypophosphataemic osteomalacia due to chronic cadmium exposure in the silver industry in India. Three silversmiths presented similarly with clinical, biochemical and radiological evidence of hypophosphataemic osteomalacia. Considering their occupation, their blood samples were screened for heavy metals and were found to have toxic levels of cadmium. They were initiated on neutral phosphate and calcitriol. On follow-up, they reported significant reduction in severity of symptoms. It is essential to maintain a high index of suspicion in diagnosing this condition. A thorough knowledge of the occupational background of patients, as well as ambient conditions at the workplace is of utmost importance in contemplating the possibility of such rare occurrences. Moreover, regulatory agencies and policy makers ought to survey the silver industry and ensure that the metals used are within permissible safe limits of exposure.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

INTRODUCTION

The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.

MAIN BODY

The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.

CONCLUSION

The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Lipid Profile Status in Natural and Surgical Menopausal Women: A Comparative Study

This cross sectional, study was carried out in the department of Obstetrics and Gynaecology in Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from October 2015 to September 2016. The objective of the study was to evaluate dyslipidaemia between natural and surgical menopausal women. Patients who attended the menopausal clinic of Mymensingh Medical College Hospital, Mymensingh were included in the study. For this purpose 91 patient were divided into study (n=46) and comparison (n=45) groups. Serum total cholesterol (TC), serum triglyceride (TG), Serum high density lipoprotein cholesterol (HDL-cholesterol) were estimated by colorometric method and serum low density lipoprotein cholesterol (LDL-cholesterol) was calculated by using Friedwald's formula. Age range of menopausal women was 45 to 60 years. The mean age with SD was in study group 50.26±2.57 years and control group 49.02±3.13 years. It was observed that women with surgical menopause had higher mean plasma level of total cholesterol with standard deviation 192.84±52.43mg/dl while that of mean and standard deviation of natural menopause 192.26±27.56mg/dl i.e. Mean difference was statistically insignificant (p>0.05). Mean plasma levels of Triglyceride (TG) with standard deviation (215.87±67.73mg/dl) higher in surgical menopause as compared with natural menopause (147.33±65.17mg/dl) which was statistically significant (p<0.001). There was significant rise of mean with standard deviation of HDL cholesterol in natural menopause was (44.42±8.14mg/dl) as compared to surgical menopause (34.61±8.55mg/dl) and the mean difference was statistically highly significant (p<0.001). Mean with standard deviation of plasma LDL cholesterol (122.02±49.16mg/dl) rise in surgical menopause as compared to physiological menopause (118.06±20.56mg/dl) and was statistically insignificant (p>0.05). Serum total cholesterol, serum triglyceride (TG) and serum low density lipoprotein (LDL) was found significant higher level in surgical menopause. And only serum high density lipoprotein (HDL) was found significantly higher level in physiological menopause. So, surgical menopausal women were marked dyslipidaemia.

Biomarker-guided trials: Challenges in practice

Biomarker-guided trials have drawn considerable attention as they promise to lead to improvements in the benefit-risk ratio of treatments and enhanced opportunities for drug development. A variety of such designs have been proposed in the literature, many of which have been adopted in practice. Implementing such trial designs in practice can be challenging, and identifying those challenges was the main objective of a workshop organised by the MRC Hubs for Trials Methodology Research Network's Stratified Medicine Working Group in March 2017. Participants reflected on completed and ongoing biomarker-guided trials to identify the practical challenges encountered. Here, the key challenges identified during the workshop including those related to funding, ethical and regulatory issues, recruitment, monitoring of samples and laboratories, biomarker assessment, and data sharing and resources, are discussed. Despite the complexities often associated with biomarker-guided trials, the workshop concluded that they can play an important role in advancing the field of personalised medicine. Therefore, it is important that the practical challenges surrounding their implementation are acknowledged and addressed.

Automated polarization-dependent multidimensional coherent spectroscopy phased using transient absorption

An experimental apparatus is described for multidimensional optical spectroscopy with fully automated polarization control, based on liquid crystal variable retarders. Polarization dependence of rephasing two-dimensional coherent spectra are measured in a single scan, with absolute phasing performed for all polarization configurations through a single automated auxiliary measurement at the beginning of the scan. A factor of three improvement in acquisition time is demonstrated, compared to the apparatus without automated polarization control. Results are presented for a GaAs quantum well sample and an InGaAs quantum well embedded in a microcavity.

Percutaneous Transapical Left Ventricular Access to Treat Paravalvular Leak and Ventricular Septal Defect

BACKGROUND

Surgical transapical (TA) access is an established technique for structural heart (SH) procedures, but is associated with considerable morbidity. Percutaneous TA puncture provides direct access for SH procedures and may overcome the disadvantages of surgical access. This study sought to evaluate the safety of percutaneous TA left ventricular access for SH interventions.

METHODS

We performed a retrospective analysis at a university hospital. Thirteen percutaneous TA procedures were performed on consecutive patients between January 2013 and July 2017 to provide LV access for transcatheter therapies. All procedures were performed under general anesthesia with three-dimensional transesophageal echocardiography guidance.

RESULTS

All TA punctures were successful. Delivery sheath sizes ranged from 5 Fr to 7 Fr. Eleven of the 13 TA sites were closed with a device. Total median procedural and fluoroscopy times were 106 minutes (interquartile range, 39-117 minutes) and 26.5 minutes (interquartile range, 8.3-43.8 minutes), respectively. The planned procedure was completed successfully in all cases. One access-site complication occurred, involving embolism of a duct occluder into the pleural space and extravasation from the apical puncture site. Hemostasis of the apex site was achieved immediately with placement of three vascular plugs from a femoral approach. Two patients died prior to discharge and neither death was related to a procedural complication. There were no significant pericardial effusions.

CONCLUSION

Percutaneous TA access can be achieved safely in most cases to provide access for transcatheter procedures with short procedure times. Device closure of the TA access site is reliable, with a low complication rate and no procedure-related mortality.

Results of Locking Compression Plate (LCP) Fixation in Humeral Shaft Nonunion

Although nonoperative treatment is indicated & successful for the majority of diaphyseal humeral fractures, nonunion is not rare condition. The prevalence of nonunion as a complication of conservative treatment has been reported to be as high as 15%. Locking compression plate combined with autogenous cancellous bone grafting can result in reliable healing of these humeral nonunion with excellent functional outcome. This prospective observational study was conducted September, 2016 to October, 2018 at National Institute of Traumatulogy & Orthopaedic Rehablitation, Dhaka & Mymensingh Medical College, Mymensingh, Bangladesh. Fifteen (15) patients with non-united humeral shaft fractures were treated by open reduction and internal fixation by LCP with autogenous cancellous bone graft. Detailed clinical conditions of all patients, duration of injury, technical difficulty with the implant, hospital stay period were recorded. Follow up period was 6 months. The patients were evaluated clinically and radiologically for outcomes. The progresses of healing as well as occurrence of complications were recorded. The modified Constant and Murley score of functional assessment was used for shoulder & elbow function. Age of the study patients was ranged 20-50 years. Maximum patients were male 12. Mode of injury were found road traffic accident 8 cases, fall from height 5 cases. Right side was injured in 9 patients. Atrophic nonunion was found in 13 patients and hypertropic in 2 patients. The mean union time was 15 weeks. Only one patient had wound infection and 2 patients had shoulder stiffness. Functional outcome which constituted 90% satisfactory results in 13 cases according to modified Constant & Murley scoring system. Union rate was 100%. Therefore, LCP fixation with autogenous cancellous bone graft is a standard treatment method for nonunion of humeral shaft fracture.