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PurposeTo provide insight into the current use and results of ultrasound-facilitated catheter-directed thrombolysis (USAT) in patients with high-risk pulmonary embolism (PE).
IntroductionSystemic thrombolysis is an effective treatment for hemodynamically unstable, high-risk PE, but is associated with bleeding complications. USAT is thought to reduce bleeding and is therefore advocated in patients with high-risk PE and contraindications for systemic thrombolysis.
MethodsWe conducted a retrospective cohort study of all patients who underwent USAT for high-risk PE in the Netherlands from 2010 to 2017. Characteristics and outcomes were analyzed. Primary outcomes were major (including intracranial and fatal) bleeding and all-cause mortality after 1 month. Secondary outcomes were all-cause mortality and recurrent venous thromboembolism within 3 months.
Results33 patients underwent USAT for high-risk PE. Major bleeding occurred in 12 patients (36%, 95% CI 22–53), including 1 intracranial and 3 fatal bleeding. All-cause mortality after 1 month was 48% (16/33, 95% CI 31–66). All-cause mortality after 3 months was 50% (16/32, 95% CI 34–66), recurrent venous thromboembolism occurred in 1 patient (1/32, 3%, 95% CI 1–16).
ConclusionsThis study was the first to describe characteristics and outcomes after USAT in a study population of patients with high-risk PE only, an understudied population. Although USAT is considered a relatively safe treatment option, our results illustrate that at least caution is needed in critically ill patients with high-risk PE. Further research in patients with high-risk PE is warranted to guide patient selection.
[en] Efficacy of Metarhizium anisopliae strain (IMI330189) and Mad1 protein alone or in combination by feeding method to overcome immune-related enzymes and Toll-like pathway genes was investigated in migratory locust. M. anisopliae (IMI330189) is a potent and entomopathogenic fungal strain could be effectively used against insect pests. Similarly, Mad1 protein adheres to insect cuticle, causing virulence to insects. We confirmed maximum 55% of mortality when M. anisopliae (IMI330189) and Mad1 was applied in combination. Similarly, increased PO activity was observed in locust with combined dose of Mad1 + IMI330189 whereas PO, POD, and SOD activities reduced using Mad1 independently. Four Toll-like signaling pathway genes (MyD88, Cactus, Pelle, and CaN) were investigated from midgut and body of the migratory locust after 72 h of treatments. Subsequently, the expression of MyD88 in the midgut and body significantly decreased with the application of Mad1 and Mad1 + IMI330189. Performance of these treatments was absolutely non-consistent in both parts of insects. Meanwhile, IMI330189 significantly raised the expression of Cactus in both midgut and body. However, the combined treatment (Mad1 + IMI330189) significantly reduced the Cactus expression in both body parts. Pelle expression was significantly increased in the midgut with the application of independent treatment of Mad1 and IMI330189 whereas the combined treatment (Mad1 + IMI330189) suppressed the Pelle expression in midgut. Its expression level was absolutely higher in body with the application of IMI330189 and Mad1 + IMI330189 only. On the other hand, Mad1 significantly increased the expression of CaN in midgut. However, all three treatments significantly affected and suppressed the expression of CaN gene in body of locust. This shows that the applications of M. anisopliae and Mad1 protein significantly affected Toll signaling pathway genes, which ultimately increased level of susceptibility of locust. However, their effect was significantly different in both parts of locust which recommends that the Toll-related genes are conserved in midgut instead of locust body.
[en] Ischemic heart disease (IHD) also known as coronary artery disease (CAD) is one of the major causes of morbidity and mortality. Two-dimensional echocardiography (2D echo) is a non-invasive diagnostic technique that provides information regarding the cardiac function and hemodynamics. This paper was designed to update the reader on the fundamental principles and current applications of 2D echo imaging recommended in patients with known or suspected IHD. Also the recent advances on the prognostic and diagnostic value and the future directions of 2D echo in the evaluation of IHD will be addressed. Although the noninvasive imaging modalities for the evaluation of IHD have expanded over the last decade, 2D echo remains the most cost-effective and risk-effective imaging choice in most settings. The main drawback of echocardiography remains in the limited echogenicity of many patients and its undeniable operator dependence. However, improvement of existing well-established echocardiographic methods (2D echo, stress echocardiography, contrast echocardiography) in conjunction with the development of new emerging echocardiography methods (3D echo, tissue Doppler imaging (TDI), speckle tracking imaging) are anticipated to increase the clinical utility of echocardiography in IHD
[en] 5-Hydroxymethylcytosine (5hmC) is an important, yet poorly understood epigenetic DNA modification, especially in invertebrates. Aberrant genome-wide 5hmC levels have been associated with cadmium (Cd) exposure in humans, but such information is lacking for invertebrate bioindicators. Here, we aimed to determine whether this epigenetic mark is present in DNA of the hepatopancreas of the land snail Cantareus aspersus and is responsive to Cd exposure. Adult snails were reared under laboratory conditions and exposed to graded amounts of dietary cadmium for 14 days. Weight gain was used as a sublethal endpoint, whereas survival as a lethal endpoint. Our results are the first to provide evidence for the presence of 5hmC in DNA of terrestrial mollusks; 5hmC levels are generally low with the measured values falling below 0.03%. This is also the first study to investigate the interplay of Cd with DNA hydroxymethylation levels in a non-human animal study system. Cadmium retention in the hepatopancreas of C. aspersus increased from a dietary Cd dose of 1 milligram per kilogram dry weight (mg/kg d. wt). For the same treatment, we identified the only significant elevation in percentage of samples with detectable 5hmC levels despite the lack of significant mortalities and changes in weight gain among treatment groups. These findings indicate that 5hmC is an epigenetic mark that may be responsive to Cd exposure, thereby opening a new aspect to invertebrate environmental epigenetics.
[en] The use of inferior vena cava (IVC) filters is recommended in patients with acute pulmonary embolism (PE) who have absolute contraindications to anticoagulant drugs and/or in those subjects with recurrent PE despite treated with an adequate anticoagulant regimen. During the last 2 decades, some investigations have demonstrated that the use of IVC filters in high-risk PE patients, treated or not with systemic thrombolysis, was able to reduce the short-term mortality rate if inserted early after the acute event. The aim of the present review is to analyze the use of IVC filters in high-risk PE patients enrolled in prospective multicenter registries between 1990 and 2018. After screening 3542 article in PubMed, Scopus, Cochrane library and Goggle Scholar databases, we identified four registry studies meeting the inclusion criteria. In a prospective cohort of 39,056 patients, 1387 (3.5%) were hemodynamically unstable at admission. Among them, IVC filters were used only in 2.7% of cases. Conversely, IVC filters were inserted in 3.8% of hemodynamically stable patients. Over the years, a fluctuating trend in the use of IVC filters was observed. In the absence of randomized controlled trial on this issue, which would be difficult, if not impossible to realize, data obtained from the medical literature seem to suggest that IVC filters could represent a valid adjunctive therapy in hemodynamically unstable PE patients, able to prevent further hemodynamic deterioration. Further and larger subgroup analyses, obtained both by prospective and retrospective studies, are necessary to clarify this therapeutic approach.
[en] In their recently published pooled analysis of four drug-coated balloon (DCB) studies, which focused on the impact of patient and lesion characteristics on LLL at 6 months (Albrecht T et al. Cardiovasc Intervent Radiol. 2018 Dec 11. https://doi.org/10.1007/s00270-018-2137-3 ), the authors reported slightly inaccurate 2-year mortality rates.
[en] Numerous studies have investigated the impacts of ambient fine particulate matter (PM2.5) on human health. In this study, we examined the association of daily PM2.5 concentrations with the number of deaths for the cerebrovascular disease on the same day, using the generalized additive model (GAM) controlling for temporal trend and meteorological variables. We used the data between 2012 and 2014 from Shanghai, China, where the adverse health effects of PM2.5 have been of particular concern. Three different approaches (principal component analysis, shrinkage smoothers, and the least absolute shrinkage and selection operator regularization) were used in GAM to handle multicollinear meteorological variables. Our results indicate that the average daily concentration of PM2.5 in Shanghai was high, 55 μg/m3, with an average daily death for cerebrovascular disease (CVD) of 62. There was 1.7% raised cerebrovascular disease deaths per 10 μg/m3 increase in PM2.5 concentration in the unadjusted model. However, PM2.5 concentration was no longer associated with CVD deaths after controlling for meteorological variables. The results were consistent in the three modelling techniques that we used. As a large number of people are exposed to air pollution, further investigation with longer time period including individual-level information is needed to examine the association.
[en] The increase in cancer incidence has led to an alarming increase in mortality rate worldwide, Africa and Cameroon especially as such necessitates the assessment and establishment of improved radiotherapy facilities for a better well-being and increase life expectancy. Wecarried out a retrospective, transversal, and quality study of facilities during a period of 29years in the General Hospital of Yaoundé (GHY) using questionnaires and data sheets related to External Beam Radiotherapy and Brachytherapy. We used Epi Info software to analyze the data. Our results show that no radiotherapy facility from the creation of the GHY until 2017ever attained the normative score of 100%. The indicator related to the staff had 15 anormative score of 80.84%, equipment 18.18% and infrastructure 75%. The most represented staff specialty was radiotherapy technicians (RTTs) with 42.86%, each of the following werejust 14.29%, radiation oncologists (RO), medical physicists (MP), and engineer. The staff was fairly knowledge able on the major types of cancer, main causes and treatment methods. 28.58% of them had a mastery of radiotherapy, 28.57% knew the essential equipment needed for a brachytherapy unit and 46.67% for an external beam therapy. This calls for great need to improve radiotherapy facilities
[en] To assess if adherence to international guidelines for pregnant cardiac patients’ mode of delivery is achievable with available local resources. Study Design: Prospective quasi experimental descriptive study. Place and Duration of Study: All Pregnant patients with cardiac disease reporting to Armed Forces Institute of Cardiac Disease/National Institute of Heart Disease (AFIC/NIHD) who were admitted for and were delivered from Oct 2009 to Sep 2011 were included in the study. Methodology: International guidelines and recommendations for mode of delivery for cardiac patients with pregnancy were followed for patients. Caesarean sections were reserved only for obstetrical reasons and absolute cardiac indications. The patients with first trimester miscarriage were not included. Data was collected on a personal computer Microsoft excel sheet. Frequency was calculated from the data entered. The reduction in caesarean section rate and increase in vaginal delivery rate as per guidelines without an increase in maternal mortality, was the main outcome. Results: Total of 221 patients were delivered in the 2 year period between October 2009 to September 2011 at AFIC/NIHD. The caesarean section rate the year before 2008-2009 had been 48.6%. After the change in practice by concurring to international guidelines, the caesarean section rate for the 2 year period dropped to 26.7%. The hospital maternal deaths were 5. This was slightly better to the year 2008-2009 which had 3 maternal deaths. Conclusion: It’s possible to adhere to international recommendations and protocols for pregnant cardiac patients and achieve internationally comparable outcome in terms of mode of delivery without increasing current institutional maternal mortality rate with local hospital resources. (author)
PurposeTo compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.
Materials and MethodsIn this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23–89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.
ResultsIn the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).
ConclusionHigher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores Level of Evidence: Level 4, case series.