Causes and Clinical Outcomes of Patients Who Failed Screening for Transcatheter Tricuspid Valve Interventions

Transcatheter tricuspid valve intervention (TTVI) has recently emerged as a promising alternative to surgery for tricuspid regurgitation (TR). However, a significant proportion of patients fail screening for TTVI, and little is known about their characteristics and natural history. This study sought to investigate causes of screen failure and outcomes of patients declined for TTVI. This was a retrospective single-center study of 32 patients who were ineligible for participation in transcatheter tricuspid valve replacement and tricuspid transcatheter edge-to-edge repair trials. Patients were classified into 2 groups according to the therapy they received: optimized medical therapy (OMT) group or intervention group. The mean age was 82 ± 7.8 years and 68.8% were women. The most common reasons for TTVI exclusion were anatomic/procedural impediment (53.1%), inclusion criteria not met (40.6%), and multivalvular disease (6.3%). Overall, 19 patients (59.4%) did not undergo subsequent tricuspid intervention. The clinical outcomes of these patients who received OMT alone were poor, with a 1-year composite of cardiac death or heart failure readmission of 47.4%. These rates were worse than in patients who subsequently underwent an intervention, albeit not statistically significant (OMT: 47.7% vs 23.1% interventions, p = 0.3), and were significantly more pronounced in the subgroup of patients who were excluded for anatomic/procedural limitations (OMT: 70% vs 14.3% interventions, p = 0.05). In conclusion, patients ineligible for TTVI, particularly, those with anatomic/procedural limitations, and treated medically have poor outcomes. These data underscore the importance of earlier referral and support the need for further transcatheter therapy iterations.

Compact terahertz harmonic generation in the Reststrahlenband using a graphene-embedded metallic split ring resonator array

Harmonic generation is a result of a strong non-linear interaction between light and matter. It is a key technology for optics, as it allows the conversion of optical signals to higher frequencies. Owing to its intrinsically large and electrically tunable non-linear optical response, graphene has been used for high harmonic generation but, until now, only at frequencies < 2 THz, and with high-power ultrafast table-top lasers or accelerator-based structures. Here, we demonstrate third harmonic generation at 9.63 THz by optically pumping single-layer graphene, coupled to a circular split ring resonator (CSRR) array, with a 3.21 THz frequency quantum cascade laser (QCL). Combined with the high graphene nonlinearity, the mode confinement provided by the optically-pumped CSRR enhances the pump power density as well as that at the third harmonic, permitting harmonic generation. This approach enables potential access to a frequency range (6-12 THz) where compact sources remain difficult to obtain, owing to the Reststrahlenband of typical III-V semiconductors.

Terahertz microscopy using laser feedback interferometry based on a generalised phase-stepping algorithm

In this paper we report an improved method of coherent sensing through the use of a generalized phase-stepping algorithm to extract magnitude and phase information from interferometric fringes acquired by laser feedback interferometry (LFI). Our approach allows for significantly reduced optical sampling and acquisition times whilst also avoiding the need for fitting to complex models of lasers under optical feedback in post-processing. We investigate theoretically the applicability of this method under different levels of optical feedback, different laser parameters, and for different sampling conditions. We furthermore validate its use experimentally for LFI-based sensing using a terahertz (THz)-frequency laser in both far-field and near-field sensing configurations. Finally we demonstrate our approach for two-dimensional nanoscale imaging of the out-of-plane field supported by individual micro-resonators at THz frequencies. Our results show that fully coherent sensing can be achieved reliably with as little as 4 sampling points per imaging pixel, opening up opportunities for fast coherent sensing not only at THz frequencies but across the visible and infra-red spectrum.

UPDATE ON THE USE OF METHOTREXATE IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is an auto-immune disorder described by permanent inflammation of the articular synovial membrane. Non-treated RA can cause gradual joint damage, ending in complaint, poor lifestyle, and an upright ratio of death. Approximately one percent of the people are involved, and the disorder begins, in general, appears during the third and fifth decades of age, with more occurrences in females. The treatment is complicated as well as involves various stages of medications with variable methods of application as well as non-pharmacologic methods. The extra prevalent are disease person's culture, then, sports and mechanical and behavioral therapy. Due to more chance of ischemic heart disease, trials should be increased to lessen the assisting behaviors such as cigarette smoking, high lipid profile, elevation of blood pressure, and high body mass index.

County-level variation in healthcare coverage and ischemic heart disease mortality

BACKGROUND

Healthcare coverage has been shown to have implications in the prevalence of coronary artery disease. We explore the impact of lack of healthcare coverage on ischemic heart disease (IHD) mortality in the US.

METHODS

We obtained county-level IHD mortality and healthcare coverage data from the CDC databases for a total of 3,119 US counties. The age-adjusted prevalence of current lack of health insurance among individuals aged 18 to 64 years were obtained for the years 2018 and 2019 and were placed into four quartiles. First (Q1) and fourth quartile (Q4) had the least and highest age-adjusted prevalence of adults without health insurance, respectively. IHD mortality rates, adjusted for age through the direct method, were obtained for the same years and compared among quartiles. Ordinary least squares (OLS) regression for each demographic variable was conducted with the quartiles as an ordinal predictor variable and the age-adjusted mortality rate as the outcome variable.

RESULTS

We identified a total of 172,942 deaths related to ischemic heart disease between 2018 and 2019. Overall AAMR was higher in Q4 (92.79 [95% CI, 92.35-93.23]) compared to Q1 (83.14 [95% CI, 82.74-83.54]), accounting for 9.65 excess deaths per 100,000 person-years (slope = 3.47, p = 0.09). Mortality rates in Q4 for males (126.20 [95% CI, 125.42-126.98] and females (65.57 [95% CI, 65.08-66.05]) were higher compared to Q1 (115.72 [95% CI, 114.99-116.44] and 57.48 [95% CI, 57.04-57.91], respectively), accounting for 10.48 and 8.09 excess deaths per 100,000 person-years for males and females, respectively. Similar trends were seen among Hispanic and non-Hispanic populations. Northeastern, Southern, and Western regions had higher AAMR within Q4 compared to Q1, with higher prevalence of current lack of health insurance accounting for 49.2, 8.15, and 29.04 excess deaths per 100,000 person-years, respectively.

CONCLUSION

A higher prevalence of adults without healthcare coverage may be associated with increased IHD mortality rates. Our results serve as a hypothesis-generating platform for future research in this area.

Drug-Coated Balloon Venoplasty to Treat Iatrogenic Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is a condition that has seen a decrease in incidence in recent years. Whereas balloon angioplasty and stenting are both acceptable treatment options for PVS, they are limited by the high rate of restenosis. This research paper presents 4 cases of severe symptomatic PVS that were successfully treated with the use of drug-coated balloons, resulting in positive outcomes. (Level of Difficulty: Advanced.).

Embryo selection through artificial intelligence versus embryologists: a systematic review

STUDY QUESTION

What is the present performance of artificial intelligence (AI) decision support during embryo selection compared to the standard embryo selection by embryologists?

SUMMARY ANSWER

AI consistently outperformed the clinical teams in all the studies focused on embryo morphology and clinical outcome prediction during embryo selection assessment.

WHAT IS KNOWN ALREADY

The ART success rate is ∼30%, with a worrying trend of increasing female age correlating with considerably worse results. As such, there have been ongoing efforts to address this low success rate through the development of new technologies. With the advent of AI, there is potential for machine learning to be applied in such a manner that areas limited by human subjectivity, such as embryo selection, can be enhanced through increased objectivity. Given the potential of AI to improve IVF success rates, it remains crucial to review the performance between AI and embryologists during embryo selection.

STUDY DESIGN SIZE DURATION

The search was done across PubMed, EMBASE, Ovid Medline, and IEEE Xplore from 1 June 2005 up to and including 7 January 2022. Included articles were also restricted to those written in English. Search terms utilized across all databases for the study were: ('Artificial intelligence' OR 'Machine Learning' OR 'Deep learning' OR 'Neural network') AND ('IVF' OR 'in vitro fertili*' OR 'assisted reproductive techn*' OR 'embryo'), where the character '*' refers the search engine to include any auto completion of the search term.

PARTICIPANTS/MATERIALS SETTING METHODS

A literature search was conducted for literature relating to AI applications to IVF. Primary outcomes of interest were accuracy, sensitivity, and specificity of the embryo morphology grade assessments and the likelihood of clinical outcomes, such as clinical pregnancy after IVF treatments. Risk of bias was assessed using the Modified Down and Black Checklist.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty articles were included in this review. There was no specific embryo assessment day across the studies-Day 1 until Day 5/6 of embryo development was investigated. The types of input for training AI algorithms were images and time-lapse (10/20), clinical information (6/20), and both images and clinical information (4/20). Each AI model demonstrated promise when compared to an embryologist's visual assessment. On average, the models predicted the likelihood of successful clinical pregnancy with greater accuracy than clinical embryologists, signifying greater reliability when compared to human prediction. The AI models performed at a median accuracy of 75.5% (range 59-94%) on predicting embryo morphology grade. The correct prediction (Ground Truth) was defined through the use of embryo images according to post embryologists' assessment following local respective guidelines. Using blind test datasets, the embryologists' accuracy prediction was 65.4% (range 47-75%) with the same ground truth provided by the original local respective assessment. Similarly, AI models had a median accuracy of 77.8% (range 68-90%) in predicting clinical pregnancy through the use of patient clinical treatment information compared to 64% (range 58-76%) when performed by embryologists. When both images/time-lapse and clinical information inputs were combined, the median accuracy by the AI models was higher at 81.5% (range 67-98%), while clinical embryologists had a median accuracy of 51% (range 43-59%).

LIMITATIONS REASONS FOR CAUTION

The findings of this review are based on studies that have not been prospectively evaluated in a clinical setting. Additionally, a fair comparison of all the studies were deemed unfeasible owing to the heterogeneity of the studies, development of the AI models, database employed and the study design and quality.

WIDER IMPLICATIONS OF THE FINDINGS

AI provides considerable promise to the IVF field and embryo selection. However, there needs to be a shift in developers' perception of the clinical outcome from successful implantation towards ongoing pregnancy or live birth. Additionally, existing models focus on locally generated databases and many lack external validation.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Monash Data Future Institute. All authors have no conflicts of interest to declare.

REGISTRATION NUMBER

CRD42021256333.

Successful Revascularization of Critical Limb Ischemia: A Challenging Case of a Unilateral Tibial-to-Tibial Intervention

Critical limb ischemia requires urgent diagnosis and intervention. Limitations to percutaneous revascularization therapy stem from multilevel diseased vasculature. Retrograde revascularization utilizing anterior tibial artery access in complex and proximal lesions is an alternative route for intervention that can lead to limb salvage and symptom resolution.

Abstract P568: Osteoporosis and Cardiovascular Disease-Related Mortality Trends in the United States, 1999 - 2020

Background: Cardiovascular disease (CVD) and osteoporosis share common risk factors and often co-exist. In this study, we quantify CVD-related mortality trends in individuals with osteoporosis.

Hypothesis: Among gender, racial, and geographic subgroups, disproportionate mortality rates related to CVD and osteoporosis are observed.

Methods: We performed cross-sectional analyses using the CDC Wide-Ranging Online Data for Epidemiologic Research database to identify mortality rates from 1999 to 2020 with CVD as the underlying cause of death and osteoporosis within the multiple causes of death. Quantified measures included age-adjusted mortality rate (AAMR), average annual percentage change (AAPC), and 95% confidence intervals. Joinpoint regression (National Cancer Institute) was used for AAPC calculation. Stata (StataCorp LLC) was used for data visualization.

Results: There was a total of 70,930 deaths from 1999 to 2020. The AAMR decreased from 1.76 in 1999 to 0.40 in 2020 [p <0.05] with an AAPC of -6.8%. There were a higher AAMR among females (1.34) compared to males (0.27) [p <0.05], with a similar AAPC (-6.6% and -7.2%, respectively [p >0.05]). White populations had the highest AAMR, followed by Asian populations (0.63), then Black populations (0.28) [p <0.05]. AAPC was similar among the three racial subgroups (-6.9%, -6.8%, -4.7%, respectively [p >0.05]). Non-Hispanic (0.98) subgroups had higher AAMR than Hispanic subgroups (0.45) [p <0.05], with a similar AAPC (-6.8% and -6.6%, respectively [p >0.05]). Non-metro regions (1.17) had higher AAMR compared to metro regions (0.9) [p <0.05], with a similar AAPC (-5.8% and -7.2%, respectively [p >0.05]). The Midwest (1.19) had the highest AAMR, followed by the West (1.13), South (0.80), and the Northeast (0.74) [p <0.05]. AAPC was similar among all US regions (-6.4%, -6.6%, -8.3%, and -6.4%, respectively [p >0.05]).

Conclusion: Disparities related to CVD and osteoporosis related mortality exist among gender, racial, and geographic subgroups within the United States.

Abstract P354: Trends in Malignancy and Cardiovascular Disease Related Mortality in the United States

Introduction: In the United States (US), malignancy and cardiovascular disease (CVD) make up the majority of the burden of chronic diseases, leading to greater morbidity and mortality. As the general population grows older, the prevalence of these two disease entities are likely to increase. Efforts in cardio-oncology have been focused on disease prevention and treatment, however, little is known about existing disparities in this population.

Hypothesis: Unequivocal burden of CVD-related mortality exists among certain gender, racial, and geographic subgroups.

Methods: Data was obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database using death certificate information from the National Vital Statistics system. All CVD-related death (I00 - I78) as the underlying cause of death in individuals with malignancy (C00 - C97) as the multiple causes of death were queried from 1999 - 2020. Underlying cause of death was defined as the disease that directly led to death and the multiple causes of death were defined as the diseases that contributed to death. Quantified measures included age-adjusted mortality rate (AAMR) per 100,000 population, 95% confidence intervals, and average annual percentage change (AAPC). Joinpoint regression (National Cancer Institute) was utilized for trend analysis and AAPC calculation.

Results: There was a total of 595,446 deaths between 1999 and 2020. The AAMR in 1999 was 24.85 which decreased to 12.811 by 2020 (p <0.05), with an AAPC of -3.1%. Males (23.14) had a higher AAMR compared to females (11.05) (p <0.05), and AAPC for both males and females were -3.4%. AAMR was disproportionately higher in non-Hispanic populations (16.26) compared to Hispanic populations (9.17) (p <0.05), with similar AAPC (-3.1% and -3.0%, respectively [p >0.05]). Black individuals (18.87) had the highest AAMR, followed by White individuals (15.81), American Indian/Alaska Native individuals (9.40), and Asian/Pacific Islander individuals (8.26) (p <0.05). All AAPC for the racial subgroups were similar (-3.3%, -3.1%, -2.7%, and -4.1%, respectively [p >0.05]). Non-metro regions (17.20) had higher AAMR compared to metro regions (15.54) (p <0.05) with an AAPC of -2.4 and -3.3%, respectively (p >0.05). The Northeast (17.93) had the highest AAMR, followed by similar AAMR in the Midwest (16.44) and West (16.30) regions, and then South regions (13.98) (p <0.05). AAPC was similar among all US census regions (-3.6%, -3.3%, -3.4%, and -2.8%, respectively [p >0.05]).

Conclusion: Even with decreasing rates of AAMR from 1999 to 2020, there remains a disproportionate burden of AAMR among gender, racial, and geographic subgroups. Continued efforts targeted at mitigating CVD-related mortality in patients with underlying malignancy is warranted.

Assessment of Lower Limb Deep Vein Thrombosis: Characterization and Associated Risk Factors Using Triplex Doppler Imaging

Background

Deep vein thrombosis (DVT) is a common health problem. Accurate diagnosis of DVT is essential to avoid potentially fatal acute consequences of pulmonary embolism.

Aim

The study aims to assess deep venous thrombosis (DVT) of the lower limbs and to analyze the related risk factors.

Methods

This is a retrospective study including 60 patients who were examined using Triplex Doppler imaging. The patients were referred to the imaging departments with symptoms of lower limb DVT. The risk of DVT was expressed as an odds ratio (OR) with 95% confidence interval. Multiple logistic regression analysis was used to detect the independent risk factors. P value <0.05 was considered a significant statistic.

Results

Among the Saudi patients in Najran, acute DVT was more prevalent than chronic one (56.7% vs 38.3%), while subacute is less frequent (5%). DVTs are more prevalent in females than males (60% vs 40%) and most commonly affect patients older than 40. DVTs affect the left lower limb veins more than the right limb (75% vs 15%) and are less frequent on both sides (10%). The left popliteal vein (PV) and left common femoral vein (CFV) were the most common sites for acute DVTs. Binary logistic analysis revealed the independent risk factors for developing lower extremity DVT; malignancy (OR = 2.84, 95% CI = 0.518-15.513), surgery (OR = 2.66, 95% CI = 0.411-17.281), trauma (OR = 2.30, 95% CI = 0.452-11.658), and diabetes and hypertension (OR = 1.53, 95% CI = 0.335-6.969).

Conclusion

Acute lower limb DVT was more prevalent than chronic one. Malignancy, surgery, trauma, diabetes mellitus, and hypertension were the most common risk factors for lower limb DVTs. Left popliteal and left common femoral veins were the most common sites of acute DVTs.

Implementation and comparison of different taste masking techniques to design and assess dispersible tablet formulations

The objective of this study was to assess the efficacy of several taste-masking techniques and to study the impact of different formulation variables on the physicochemical properties of dispersible tablets containing Ranitidine as a model drug. Ranitidine powder was taste masked using various techniques. Factorial design (24) was applied to design the set of tablet formulations. The four factors implemented were the manufacturing method, filler type, superdisintegrant type and superdisintegrant concentration. Levels selected were direct compression and wet granulation for the manufacturing method, microcrystalline cellulose and mannitol for the diluent type, sodium starch glycolate and croscarmellose sodium for superdisintegrant type, and 2% and 10% for superdisintegrant concentration. Granulation with calcium carbonate (ratio of 1:8) was the taste-masking method of choice to be implemented. The formulated tablets results revealed that the manufacturing method has a significant influence on all the tested physicochemical properties (p-values < 0.05) such as tablet’s weight variation, hardness, friability, and disintegration time. Croscarmellose sodium obtained better results than sodium starch glycolate. Both fillers obtained good properties when implementing direct compression method with croscarmellose sodium concentration of 2%, or wet granulation method with croscarmellose sodium concentration of 10%. Drug release was also increased by increasing concentration of croscarmellose sodium. These findings represent an easy manufacturing procedure with relatively low-cost materials that can be implemented to formulate dispersible tablets of bitter tasting drugs that will enhance patient compliance and lead to faster onset of action.

Directed delivery of terahertz frequency radiation from quantum cascade lasers within a dry 3He dilution refrigerator

We present a scheme for the full integration of terahertz (THz) frequency quantum cascade lasers (QCLs) within a dilution refrigerator in order to provide a directed delivery of THz power into the sample space. We describe a successful operation of a 2.68 THz QCL located on the pulse tube cooler stage of the refrigerator, with its output coupled onto a two-dimensional electron gas (2DEG) located on a milli-kelvin sample stage via hollow metal waveguides and Hysol thermal isolators, achieving a total loss from QCL to the sample of ∼-9 dB. The thermal isolators limit heat leaks to the sample space, with a base temperature of ∼210 mK being achieved. We observe cyclotron resonance (CR) induced in the 2DEG by the QCL and explore the heating impact of the QCL on all stages of the refrigerator. The CR effect induced by the THz QCL is observable at electron temperatures as low as ∼430 mK. The results show a viable route for the exploitation of THz QCLs within the environment of a dilution refrigerator and for the THz power delivery in very low-temperature (<0.5 K) condensed matter experiments.

Dual acting acid-cleavable self-assembling prodrug from hyaluronic acid and ciprofloxacin: A potential system for simultaneously targeting bacterial infections and cancer

The incidence and of bacterial infections, and resulting mortality, among cancer patients is growing dramatically, worldwide. Several therapeutics have been reported to have dual anticancer and antibacterial activity. However, there is still an urgent need to develop new drug delivery strategies to improve their clinical efficacy. Therefore, this study aimed to develop a novel acid cleavable prodrug (HA-Cip) from ciprofloxacin and hyaluronic acid to simultaneously enhance the anticancer and antibacterial properties of Cip as a superior drug delivery system. HA-Cip was synthesised and characterised (FT-IR, HR-MS, and H1 NMR). HA-Cip generated stable micelles with an average particle size, poly dispersion index (PDI) and zeta potential (ZP) of 237.89 ± 25.74 nm, 0.265 ± 0.013, and -17.82 ± 1.53 mV, respectively. HA-Cip showed ≥80 % cell viability against human embryonic kidney 293 cells (non-cancerous cells), ˂0.3 % haemolysis; and a faster pH-responsive ciprofloxacin release at pH 6.0. HA-Cip showed a 5.4-fold improvement in ciprofloxacin in vitro anticancer activity against hepatocellular cancer (HepG2) cells; and enhanced in vitro antibacterial activity against Escherichia coli and Klebsiella pneumoniae at pH 6.0. Our findings show HA-Cip as a promising prodrug for targeted delivery of ciprofloxacin to efficiently treat bacterial infections associated, and/or co-existing, with cancer.

Accuracy of Magnetic Resonance Spectroscopy in Discrimination of Neoplastic and Non-Neoplastic Brain Lesions

Background

Differentiation of brain lesions by conventional MRI alone is not enough. The introduction of sophisticated imaging methods, such as MR Spectroscopy (MRS), will contribute to accurate differentiation.

Objective

To determine the diagnostic accuracy of MRS in differentiating neoplasm and non-neoplastic brain lesion.

Methodology

This is a cross-sectional descriptive study conducted at Khartoum State from the period of 2015 to 2017. Thirty cases with brain lesions were included in the study investigated with MRS (Single-voxel spectroscopy) and conventional MRI. A comparison of MRS findings and histopathologic analysis was performed. The ratios of Cho/Cr and Cho/NAA were analyzed and compared between neoplastic and non-neoplastic brain masses. Data were analyzed using SPSS version 23.

Results

Out of the 30 patients affected with brain lesions, there were 16 females and 14 males with a mean age of 44 +- 18 years. The ratios of Cho/Cr and Cho/NAA were higher in gliomas, astrocytoma, and meningioma than non-neoplastic lesions. Kappa statistical value (K) showed a good agreement between MRS and histopathological analysis (K= 0.60). The diagnostic accuracy of MRS was 100%, with 82.60% sensitivity, 85.71% specificity, 95% PPV, and 60% NPV.

Conclusion

MRS has high diagnostic accuracy in differentiating neoplasm from non-neoplastic brain tumors. The elevation ratios of Choline-to- N-acetyl aspartate and choline-to- creatine can help neurosurgeons and clinicians differentiate benign from malignant masses.

Atrial fibrillation in the elderly population: Challenges and management considerations

IMPORTANCE

Atrial fibrillation is the most clinically significant arrhythmia in humans when viewed both from a global and also a national perspective. In the United States, approximately 2.7-6.1 million people are estimated to have atrial fibrillation. With the aging of the population, this prevalence is on an increasing trend and remains an obstacle to cardiovascular health despite significant advancements specific to cardiovascular disease management.

OBSERVATION

In this specific group of patients, healthcare utilization is a concern from the public health perspective. Unfortunately, misconceptions dominate clinical decision making; for instance, the avoidance of safe and effective anticoagulation strategies in patients at the highest risk for embolic strokes continues to be widespread in clinical practice and is often based on a skewed assessment of risk versus benefit. Also, when there are contraindications to standard interventions for atrial fibrillation, a clear and nuanced understanding of second- and third-line interventions with proven benefit is often lacking.

CONCLUSIONS AND RELEVANCE

An individualized approach should be followed by physicians when managing atrial fibrillation in the elderly patient, taking into consideration the risk of complications, particularly the embolic stroke and the availability of treatment options for stroke prevention whether through pharmacological anticoagulation or left atrial appendage occluding devices. The following review sets out to clarify these issues.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P&lt;0.0001). Levels of ADVS-1 was &gt;3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 &gt;15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (&lt;0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

Effective Management of High-Grade Left Common Carotid and Brachiocephalic Arterial Stenosis With Endovascular Stenting

Multi-vessel disease including the brachiocephalic artery remains a relatively rare finding in atherosclerotic disease when compared to stenosis of other major vasculature. Its management presents many difficulties. Endovascular intervention is a highly preferred choice of therapy in these patients although it is dependent on operator experience. We present a case of left common carotid and brachiocephalic arterial stenosis in a patient who presented with neurological alterations that was treated with endovascular stenting. Technical difficulty was encountered during intervention but was successful.

Review of ultrasound contrast agents in current clinical practice with special focus on DEFINITY® in cardiac imaging

Echocardiography is the most widely used noninvasive modality to evaluate the structure and function of the cardiac muscle in daily practice. However, up to 15-20% of echocardiograms are considered suboptimal. To enable accurate assessment of cardiac function and wall motion abnormality, the use of ultrasound microbubble contrast has shown substantial benefits in cases of salvaging nondiagnostic studies and enhancing the diagnostic accuracy in daily practice. DEFINITY^® is a perflutren based, lipid shelled microbubble contrast agent, which is US FDA approved for left ventricular opacification. The basis of ultrasound microbubbles, its development, and the clinical role of DEFINITY (characteristics, indications and case examples, side effect profile and existing evidence) is the subject of discussion in this review.

Intrinsic stimuli-responsive nanocarriers for smart drug delivery of antibacterial agents-An in-depth review of the last two decades

Antibiotic resistance due to suboptimal targeting and inconsistent antibiotic release at bacterial infection sites has driven the formulation of stimuli-responsive nanocarriers for antibacterial therapy. Unlike conventional nanocarriers, stimuli-responsive nanocarriers have the ability to specifically enhance targeting and drug release profiles. There has been a significant escalation in the design and development of novel nanomaterials worldwide; in particular, intrinsic stimuli-responsive antibiotic nanocarriers, due to their enhanced activity, improved targeted delivery, and superior potential for bacterial penetration and eradication. Herein, we provide an extensive and critical review of pH-, enzyme-, redox-, and ionic microenvironment-responsive nanocarriers that have been reported in literature to date, with an emphasis on the mechanisms of drug release, the nanomaterials used, the nanosystems constructed and the antibacterial efficacy of the nanocarriers. The review also highlights further avenues of research for optimizing their potential and commercialization. This review confirms the potential of intrinsic stimuli-responsive nanocarriers for enhanced drug delivery and antibacterial killing. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Nanotechnology Approaches to Biology > Nanoscale Systems in Biology.

A Single Coronary Artery Anomaly: Right Coronary Artery as a Branch From the Left Anterior Descending Artery

An anomalous origin of the right coronary artery (RCA) from the left anterior descending artery (LAD), also known as a single coronary artery, is an extremely rare finding in clinical practice. It is usually a benign anomaly; however, symptoms are highly dependent on the course that the anomalous RCA takes after branching off of the LAD. We present a case of a patient who had decompensated heart failure and was detected to have a single coronary artery. The patient was treated with guideline-directed medical therapy with notable improvement in clinical status in the following days. Enhanced awareness of congenital cardiac anomalies may help guide management.

A self-assembled polymer therapeutic for simultaneously enhancing solubility and antimicrobial activity and lowering serum albumin binding of fusidic acid

The global antimicrobial resistance crisis has prompted worldwide efforts to develop new and more efficient antimicrobial compounds, as well as to develop new drug delivery strategies and targeting mechanisms. This study aimed to synthesize a novel polyethylene glycol-fusidic acid (PEG-FA) conjugate for self-assembly into nano-sized structures and explore its potential for simultaneously enhancing aqueous solubility and antibacterial activity of FA. In addition, the ability of PEG-FA to bind to HSA with lower affinity than FA is also investigated. Haemolysis and in vitro cytotoxicity studies confirmed superior biosafety of the novel PEG-FA compared to FA. The water solubility of FA after PEG conjugation was increased by 25-fold compared to the bare drug. PEG-FA nanoparticles displayed particle size, polydispersity index and zeta potential of 149.3 ± 0.21 nm, 0.267 ± 0.01 and 5.97 ± 1.03 mV, respectively. Morphology studies using high-resolution transmission electron microscope revealed a homogenous spherical shape of the PEG-FA nanoparticles. In silico studies showed that Van der Waals forces facilitated PEG-FA self-assembly. HSA binding studies showed that PEG-FA had very weak or no interaction with HSA using in silico molecular docking (-2.93 kcal/mol) and microscale thermophoresis (K_d=14999 ± 1.36 µM), which may prevent bilirubin displacement. Conjugation with PEG did not inhibit the antibacterial activity of FA but rather enhanced it by 2.5-fold against Staphylococcus aureus and methicillin-resistant Staphylococcus aureus, compared to the bare FA. These results show that PEG-FA can simultaneously enhance solubility and antibacterial activity of FA, whilst also reducing binding of HSA to decrease its side effects.

Supramolecular self-assembled drug delivery system (SADDs) of vancomycin and tocopherol succinate as an antibacterial agent: in vitro, in silico and in vivo evaluations

In this study self-assembled drug delivery system (SADDs) composed of a hydrophobic d-α-tocopherol succinate (TS) and a hydrophilic vancomycin (VCM) were formulated, and its potential for enhancing the antibacterial activity of VCM against Staphylococcus aureus (SA) and Methicillin-resistant Staphylococcus aureus (MRSA) were explored. The SADDs were synthesized via supramolecular complexation, then characterized for in silico, in vitro and in vivo studies. In silico studies confirmed the self-assembly of VCM/TS into NPs. The size, surface charge and drug loading of the SADDs was ˂100 nm, -27 mV and 68%, respectively. The SADDs were non-hemolytic and biosafe. A sustained release of VCM from SADDs was noted, with 52.2% release after 48 hr. The in vitro antibacterial test showed a twofold decrease in Minimum inhibitory concentration (MIC) against SA and MRSA, and a significantly higher reduction in MRSA biofilms compared to bare VCM. Further, in silico studies confirmed strong and stable binding of TS to MRSA efflux pumps. The in vivo study using mice skin infection models showed a 9.5-fold reduction in bacterial load after treatment with SADDs, in comparison with bare VCM. These findings affirmed that VCM/TS NPs as a promising novel nano-delivery for treating bacterial infections.

Diabetic Ketoacidosis, Very Severe Hypertriglyceridemia, and Pseudohyponatremia Successfully Managed With Insulin Infusion

Hypertriglyceridemia is a common lipid abnormality that has serious consequences, such as acute pancreatitis and premature atherosclerosis. The consensus for first-line treatment to lower the triglyceride levels has not been fully evaluated. We present a case of very severe hypertriglyceridemia with diabetic ketoacidosis and an artifactual pseudohyponatremia. The patient was effectively and safely treated with guideline-directed medical therapy; however, it needed a longer duration of intravenous insulin. Therefore, our case has been in agreement with literature by concluding that insulin is in fact an effective and minimally invasive form to lower a high triglyceride level, especially in patients who have concurrent uncontrolled diabetes mellitus.

Intravascular ultrasound-guided mechanical thrombectomy using the INARI ClotTriever device of an iatrogenic deep venous thrombosis

Deep vein thrombosis (DVT) is a common disorder affecting 1 to 2 per 1000 Americans annually, resulting in significant morbidity and mortality. Anticoagulation is the mainstay management strategy for DVT. However, this could prove insufficient in cases where a mechanical obstruction is responsible for the DVT. We are presenting an interesting case of iatrogenic DVT incurred after Prolene suturing of lacerated iliac vein and the management employed for this challenging case with a successful and significant improvement in the clinical outcome.

Phase Fitted And Amplification Fitted Of Runge-Kutta-Fehlberg Method Of Order 4(5) For Solving Oscillatory Problems

In this paper, the proposed phase fitted and amplification fitted of the Runge-Kutta-Fehlberg method were derived on the basis of existing method of 4(5) order to solve ordinary differential equations with oscillatory solutions. The recent method has null phase-lag and zero dissipation properties. The phase-lag or dispersion error is the angle between the real solution and the approximate solution. While the dissipation is the distance of the numerical solution from the basic periodic solution. Many of problems are tested over a long interval, and the numerical results have shown that the present method is more precise than the 4(5) Runge-Kutta-Fehlberg method.

Anticoagulants for the treatment of venous thromboembolism in patients with cancer: A comprehensive systematic review, pairwise and network meta-analysis

Cancer-associated venous thromboembolism (VTE) is associated with high VTE recurrence and bleeding. We included all randomized clinical trials that evaluated the efficacy and safety of various anticoagulants in cancer-associated VTE. Trial-level data were extracted from 13 trials. Aggregate odds ratios (ORs) were calculated using direct and network meta-analysis. The primary outcome was VTE (pulmonary embolism and/or deep vein thrombosis) recurrence. Secondary outcomes were major bleeding and all-cause mortality. We identified 13 trials with 4869 patient-years of follow-up (6595 total patients; mean age 62.4 ± 12.2; 50.4 % female; 17.7 % hematological malignancies). The most common cancer type was colorectal and 48 % had metastatic cancer at baseline. Compared to vitamin-K-antagonists (VKAs), non-vitamin-K-antagonist-oral-anticoagulants (NOACs) were associated with significantly reduced VTE recurrence (OR, 0.58; 95 % CI, 0.40-0.83) and reduced major bleeding risks (OR, 0.56; 95 % CI, 0.35-0.91). However, no differences were observed in the subgroup analysis of patients with active cancer. Although NOACs were associated with reduced VTE recurrence compared with low-molecular-weight-heparin (LMWHs) (OR, 0.46; 95 % CI, 0.25- 0.85), there was a significant increased major bleeding in high-quality trials. LMWHs were associated with significantly reduced VTE recurrence compared with VKAs (OR, 0.52; 95 % CI, 0.39-0.71) and similar bleeding risks. Conclusions: Among patients with cancer-associated VTE, NOACs were associated with significantly reduced VTE recurrence and bleeding compared with VKAs, however, with similar outcomes in the active cancer population. NOACs were associated with reduced VTE recurrence but higher bleeding risks compared with LMWHs. LMWHs were associated with significantly reduced VTE recurrence and similar bleeding compared with VKAs.