bluuebunny/crossref_metadata_2025 huggingface dataset:
Salt and cardiovascular disease: insufficient evidence to recommend low sodium intake
Authors: O’Donnell Martin , Mente Andrew , Alderman Michael H , Brady Adrian J B , Diaz Rafael , Gupta Rajeev , López-Jaramillo Patricio , Luft Friedrich C , Lüscher Thomas F , Mancia Giuseppe , Mann Johannes F E , McCarron David , McKee Martin , Messerli Franz H , Moore Lynn L , Narula Jagat , Oparil Suzanne , Packer Milton , Prabhakaran Dorairaj , Schutte Alta , Sliwa Karen , Staessen Jan A , Yancy Clyde , Yusuf Salim
Published: July 2020

Several blood pressure guidelines recommend low sodium intake (<2.3 g/day, 100 mmol, 5.8 g/day of salt) for the entire population, on the premise that reductions in sodium intake, irrespective of the levels, will lower blood pressure, and, in turn, reduce cardiovascular disease occurrence. These guidelines have been developed without effective interventions to achieve sustained low sodium intake in free-living individuals, without a feasible method to estimate sodium intake reliably in individuals, and without high-quality evidence that low sodium intake reduces cardiovascular events (compared with moderate intake). In this review, we examine whether the recommendation for low sodium intake, reached by current guideline panels, is supported by robust evidence. Our review provides a counterpoint to the current recommendation for low sodium intake and suggests that a specific low sodium intake target (e.g. <2.3 g/day) for individuals may be unfeasible, of uncertain effect on other dietary factors and of unproven effectiveness in reducing cardiovascular disease. We contend that current evidence, despite methodological limitations, suggests that most of the world’s population consume a moderate range of dietary sodium (2.3–4.6g/day; 1–2 teaspoons of salt) that is not associated with increased cardiovascular risk, and that the risk of cardiovascular disease increases when sodium intakes exceed 5 g/day. While current evidence has limitations, and there are differences of opinion in interpretation of existing evidence, it is reasonable, based upon observational studies, to suggest a population-level mean target of <5 g/day in populations with mean sodium intake of >5 g/day, while awaiting the results of large randomized controlled trials of sodium reduction on incidence of cardiovascular events and mortality.
Prognostic impact of multiple fragmented QRS on cardiac events in idiopathic dilated cardiomyopathy
Authors: Marume Kyohei , Noguchi Teruo , Kamakura Tsukasa , Tateishi Emi , Morita Yoshiaki , Miura Hiroyuki , Nakaoku Yuriko , Nishimura Kunihiro , Yamada Naoaki , Tsujita Kenichi , Izumi Chisato , Kusano Kengo , Ogawa Hisao , Yasuda Satoshi
Published: July 2020

Aims 

To evaluate the prognostic impact of fragmented QRS (fQRS) on idiopathic dilated cardiomyopathy (DCM).

Methods and results 

We conducted a prospective observational study of 290 consecutive patients with DCM (left ventricular ejection fraction ≤ 40%) and narrow QRS who underwent cardiac magnetic resonance. We defined fQRS as the presence of various RSR′ patterns in ≥2 contiguous leads representing the anterior (V1–V5), inferior (II, III, and aVF), or lateral (I, aVL, and V6) myocardial segments. Multiple fQRS was defined as the presence of fQRS in ≥2 myocardial segments. Patients were divided into three groups: no fQRS, single fQRS, or multiple fQRS. The primary endpoint was a composite of hard cardiac events consisting of heart failure death, sudden cardiac death (SCD), or aborted SCD. The secondary endpoints were all-cause death and arrhythmic event. During a median follow-up of 3.8 years (interquartile range, 1.8–6.2), 31 (11%) patients experienced hard cardiac events. Kaplan–Meier analysis showed that the rates of hard cardiac events and all-cause death were similar in the single-fQRS and no-fQRS groups and higher in the multiple-fQRS group (P = 0.004 and P = 0.017, respectively). Multivariable Cox regression identified that multiple fQRS is a significant predictor of hard cardiac events (hazard ratio, 2.23; 95% confidence interval, 1.07–4.62; P = 0.032). The multiple-fQRS group had the highest prevalence of a diffuse late gadolinium enhancement pattern (no fQRS, 21%; single fQRS, 22%; multiple fQRS, 39%; P < 0.001).

Conclusion 

Multiple fQRS, but not single fQRS, is associated with future hard cardiac events in patients with DCM.
Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation
Authors: Aksu Tolga , Guler Tumer Erdem , Bozyel Serdar , Yalin Kivanc , Gopinathannair Rakesh
Published: July 2020

Aims

Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT).

Methods and results

This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3–27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses.

Conclusion

This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.
Emergent Viral Infections of the CNS
Authors: Wiley Clayton A
Published: July 2020

Biological evolution of the microbiome continually drives the emergence of human viral pathogens, a subset of which attack the nervous system. The sheer number of pathogens that have appeared, along with their abundance in the environment, demand our attention. For the most part, our innate and adaptive immune systems have successfully protected us from infection; however, in the past 5 decades, through pathogen mutation and ecosystem disruption, a dozen viruses emerged to cause significant neurologic disease. Most of these pathogens have come from sylvatic reservoirs having made the energetically difficult, and fortuitously rare, jump into humans. But the human microbiome is also replete with agents already adapted to the host that need only minor mutations to create neurotropic/toxic agents. While each host/virus symbiosis is unique, this review examines virologic and immunologic principles that govern the pathogenesis of different viral CNS infections that were described in the past 50 years (Influenza, West Nile Virus, Zika, Rift Valley Fever Virus, Hendra/Nipah, Enterovirus-A71/-D68, Human parechovirus, HIV, and SARS-CoV). Knowledge of these pathogens provides us the opportunity to respond and mitigate infection while at the same time prepare for inevitable arrival of unknown agents.
Late-time decaying dark matter: constraints and implications for the H0-tension
Authors: Haridasu Balakrishna S , Viel Matteo
Published: July 2020

We constrain and update the bounds on the lifetime of a decaying dark matter model with a warm massive daughter particle using the most recent low-redshift probes. We use Supernovae Type-Ia, Baryon Acoustic Oscillations and the time delay measurements of gravitationally lensed quasars. These data sets are complemented by the early universe priors taken from the Cosmic Microwave background. For the maximum allowed fraction of the relativistic daughter particle, the updated bounds on the lifetime are found to be $\tau \gt 9\, \rm {Gyr}$ and $\tau \gt 11\, \rm {Gyr}$ at $95{{\ \rm per\ cent}}$ C.L., for the two-body and many-body decay scenarios, respectively. We also comment on the recent proposal that the current two-body decaying dark matter model can provide resolution for the H0-tension, by contrasting against the standard ΛCDM model. We infer that the current dark matter decaying scenario is unlikely to alleviate the H0-tension. We find that the decaying dark matter is able to reduce the trend of the decreasing H0 values with increasing lens redshifts observed in the strong lensing data set.
The nature of kink MHD waves in the solar corona: magnetic twist and phase mixing
Authors: Bahari K , Ebrahimi Z
Published: July 2020

To study the nature of magnetohydrodynamic (MHD) kink waves, the temporal behaviour of an initial kink perturbation of a typical coronal flux tube has been investigated in this paper. The flux tube has a transitional layer that separates the core region of the tube from the surrounding environment. In the transitional layer, the background density and magnetic field varies continuously from the internal to the external values. The magnetic field is straight and aligned with the tube axis in the internal and external regions of the flux tube, but is assumed to be twisted in the transitional layer. Hence, in the transitional layer the background Alfvén speed is inhomogeneous and perturbations become out of phase due to the process of phase mixing. Our result shows that as the energy of the wave transfers to the local Alfvén waves in the inhomogeneous region, the magnetic tension force becomes the dominant restoring force of the wave. The numerical results show that the nature of the small-scale oscillations in the transitional layer is determined by the ratio of the azimuthal components of the restoring forces.
The dual origin of the Galactic thick disc and halo from the gas-rich Gaia–Enceladus Sausage merger
Authors: Grand Robert J J , Kawata Daisuke , Belokurov Vasily , Deason Alis J , Fattahi Azadeh , Fragkoudi Francesca , Gómez Facundo A , Marinacci Federico , Pakmor Rüdiger
Published: July 2020

We analyse a set of cosmological magnetohydrodynamic simulations of the formation of Milky Way-mass galaxies identified to have a prominent radially anisotropic stellar halo component similar to the so-called ‘Gaia Sausage’ found in the Gaia data. We examine the effects of the progenitor of the Sausage (the Gaia–Enceladus Sausage, GES) on the formation of major galactic components analogous to the Galactic thick disc and inner stellar halo. We find that the GES merger is likely to have been gas-rich and contribute 10–50 ${{\ \rm per\ cent}}$ of gas to a merger-induced centrally concentrated starburst that results in the rapid formation of a compact, rotationally supported thick disc that occupies the typical chemical thick disc region of chemical abundance space. We find evidence that gas-rich mergers heated the proto-disc of the Galaxy, scattering stars on to less-circular orbits such that their rotation velocity and metallicity positively correlate, thus contributing an additional component that connects the Galactic thick disc to the inner stellar halo. We demonstrate that the level of kinematic heating of the proto-galaxy correlates with the kinematic state of the population before the merger, the progenitor mass, and orbital eccentricity of the merger. Furthermore, we show that the mass and time of the merger can be accurately inferred from local stars on counter-rotating orbits.
Dynamic zoom simulations: A fast, adaptive algorithm for simulating light-cones
Authors: Garaldi Enrico , Nori Matteo , Baldi Marco
Published: July 2020

The advent of a new generation of large-scale galaxy surveys is pushing cosmological numerical simulations in an uncharted territory. The simultaneous requirements of high resolution and very large volume pose serious technical challenges, due to their computational and data storage demand. In this paper, we present a novel approach dubbed dynamic zoom simulations – or dzs – developed to tackle these issues. Our method is tailored to the production of light-cone outputs from N-body numerical simulations, which allow for a more efficient storage and post-processing compared to standard comoving snapshots, and more directly mimic the format of survey data. In dzs, the resolution of the simulation is dynamically decreased outside the light-cone surface, reducing the computational work load, while simultaneously preserving the accuracy inside the light-cone and the large-scale gravitational field. We show that our approach can achieve virtually identical results to traditional simulations at half of the computational cost for our largest box. We also forecast this speedup to increase up to a factor of 5 for larger and/or higher resolution simulations. We assess the accuracy of the numerical integration by comparing pairs of identical simulations run with and without dzs. Deviations in the light-cone halo mass function, in the sky-projected light-cone, and in the 3D matter light-cone always remain below 0.1 per cent. In summary, our results indicate that the dzs technique may provide a highly valuable tool to address the technical challenges that will characterize the next generation of large-scale cosmological simulations.
Escape Room: Innovative Teaching Strategy to Stimulate Critical Thinking/Judgment in Nursing Students
Authors: Smith Veronica Rakaczky , Paul Patricia Ann
Published: July 2020

The Escape Room, an innovative teaching strategy, can be customized to various nursing scenarios. Student teams complete puzzles and tasks to reach designated goals and objectives within a limited time frame. Escape Rooms were designed as a clinical make-up day for 10 first-year, second-semester associate degree nursing students. Using activity theory to create a constructivist learning environment, scenarios were designed to focus on diabetic ketoacidosis and safety/environmental factors associated with aspiration pneumonia and wound dehiscence. This student sample evaluated the Escape Room experiences as an effective method for content retention and clinical thinking/judgment.
Resuscitating the Socratic Method: Student and Faculty Perspectives on Posing Probing Questions During Clinical Teaching
Authors: Abou-Hanna Jacob J. , Owens Sonal T. , Kinnucan Jami A. , Mian Shahzad I. , Kolars Joseph C.
Published: July 2020

Purpose

Teaching by way of asking questions is a time-honored practice that has taken on the negative connotation of “pimping” among medical students and has made some faculty hesitant to ask students questions during clerkship rotations. Yet, quantitative studies exploring student perspectives on this practice are limited. This study aimed to solicit student and faculty views and investigate faculty perceptions of students’ preferences.

Method

Students who completed their internal medicine clerkship during the 2017–2018 academic year (n = 165) and were from the 2020 graduating class and their supervising faculty (n = 144) at the University of Michigan Medical School were asked to complete a Likert response survey in April 2019. The survey solicited perspectives on questions probing medical knowledge posed to students by faculty. Surveys were constructed using an iterative process, and data were analyzed using t tests and linear regressions.

Results

A total of 140 (85%) students and 112 (78%) faculty participated. Of those, 125 (89%) students and 109 (97%) faculty agreed that probing questions are valuable for student education, but only 73 (65%) faculty perceived that students agreed with this statement (P < .001). In addition, 115 (82%) students preferred to be asked too many questions than none at all. Fifty-five (39%) students agreed that they feel humiliated when they answer a question incorrectly. However, only 7 (5%) students agreed that faculty ask questions to humiliate them, and only 20 (14%) preferred that faculty stop asking questions if they answer a question incorrectly.

Conclusions

Students valued probing questions more than faculty perceived, which argues against a withdrawal from the Socratic teaching method in the clinical arena. The students’ experience of humiliation when answering incorrectly requires further study and perhaps can be tempered by more explicit framing of the role of the questioning process.
Recent advances of miRNAs in the development and clinical application of gastric cancer
Authors: Wu Si-Ran , Wu Qiong , Shi Yong-Quan
Published: July 2020

Gastric cancer (GC) is one of the most common malignant tumors. The mechanism of how GC develops is vague, and therapies are inefficient. The function of microRNAs (miRNAs) in tumorigenesis has attracted the attention from many scientists. During the development of GC, miRNAs function in the regulation of different phenotypes, such as proliferation, apoptosis, invasion and metastasis, drug sensitivity and resistance, and stem-cell-like properties. MiRNAs were evaluated for use in diagnostic and prognostic predictions and exhibited considerable accuracy. Although many problems exist for the application of therapy, current studies showed the antitumor effects of miRNAs. This paper reviews recent advances in miRNA mechanisms in the development of GC and the potential use of miRNAs in the diagnosis and treatment of GC.
Social Determinants of Health and the Role of Routine Pediatric Care in a Medically Complex Toddler
Authors: Cuttin Karen , Neri Caitlin , Tang Margot , Kuhn Jocelyn , Pearl Kerry , Augustyn Marilyn
Published: July 2020

CASE:

Late on a Friday afternoon, a new family presents to your practice for urgent care. They come with their youngest child Mai, a 2-year-old girl, who, although born in the United States at 36 weeks gestation, has resided in Laos with her grandparents for the past 16 months. Your triage nurse tells you that she has a fever and was found to have profound anemia while at the WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) office earlier today.

On walking into the room, you describe Mai as “listless” and “sickly.” Her vitals were notable for fever (102°F), tachycardia (140 beats per minute), and tachypnea (35 breaths per minute). On physical examination, she was grunting with a systolic ejection murmur and without hepatosplenomegaly. Laboratory test results revealed hemoglobin of 2.2 g/dL, hematocrit of 12%, mean corpuscular volume of 50 fL, red cell distribution width of 27%, reticulocyte count of 3%, ferritin of <2 ng/mL, iron of 15 μg/dL, total iron binding count of 420 μg/dL, white blood cell count of 13.5 K/μL, and platelets of 605 K/μL. Her evaluation was consistent with severe iron deficiency anemia (IDA), which was further supported by reported restrictive diet and excessive cow milk intake of 35 ounces daily. She was admitted to the Pediatric Intensive Care Unit in high-output cardiac failure and was slowly transfused with 15 mL/kg of packed red blood cells over 2 days with careful monitoring. Once stabilized, she was transferred to the inpatient floor for further nutritional evaluation and supplementation. Additional workup, including hemoglobin electrophoresis, fecal occult blood test, celiac studies, and stool parasite testing were normal. The clinical picture was consistent with a viral infection in the setting of profound IDA and malnutrition.

Although her clinical status had improved, she remained inpatient for nutritional optimization. Her height was at the 54th percentile (z-score: 0.11), weight was at the first percentile (z-score: −2.25), and body mass index was below the first percentile (z-score: −3.18), diagnostic of severe protein-calorie malnutrition.1 She was evaluated by an interdisciplinary growth and nutrition team, received multivitamin and mineral supplements, and was monitored for refeeding syndrome. She was noted to be “difficult to engage,” “resistant to new faces,” and made little progress on expanding her dietary choices. Concerns about a possible diagnosis of autism spectrum disorder were raised by her treating team. What would you do next?

REFERENCE

1. Bouma S. Diagnosing pediatric malnutrition: paradigm shifts of etiology-related definitions and appraisal of the indicators. Nutr Clin Pract. 2017;32:52–67.
Patient insights on features of an effective pharmacogenomics patient portal
Authors: Truong Tien M. , Lipschultz Elizabeth , Schierer Emily , Danahey Keith , Ratain Mark J. , O’Donnell Peter H.
Published: July 2020

Objectives

We built a novel mock pharmacogenomics web portal to deliver pharmacogenomic information and results to patients. Utilizing a patient focus group, we then sought to understand patient insights on desired features of an effective pharmacogenomics patient portal.

Methods

The mock YourPGx Portal delivered four sample pharmacogenomic results (omeprazole, simvastatin, clopidogrel, and codeine). Patients from our existing institutional, prospective pharmacogenomics implementation study were recruited to pilot the mock portal and then asked to participate in a focus group discussion led by two facilitators. All patients had been previously genotyped, but none had been directly provided access to their own genotyping results and none had previously used the YourPGx portal. The focus group discussion explored nine domains: (1) factors influencing drug response, (2) concerns about drug effects, (3) understanding of genomics and pharmacogenomics, (4) reasons to undergo pharmacogenomic testing, (5) sources of pharmacogenomic information for patient education, (6) attributes of pharmacogenomic sources of information, (7) considerations about privacy and personal pharmacogenomic information, (8) sharing of pharmacogenomic information, and (9) features of an effective patient portal.

Results

The median age of patients (n = 10) was 65.5 years old (range 38–72), 70% female, 50% Caucasian/30% Black, and 60% held a bachelor/advanced degree. When asked about resources for seeking pharmacogenomic information, patients preferred consulting their providers first, followed by self-education, then using information provided by university research organizations. A theme emerged regarding attributes of these sources, namely a desire for understandability and trust. Patients said that the effectiveness of a pharmacogenomics patient portal is improved with use of symbolisms/graphics and clear and concise content. Effective use of colors, quantifying information, consistency, and use of layperson’s language were additional important facets. Patients communicated the appeal of secured phone/app-enabled access and said that they would desire linking to their electronic medical records to allow sharing of information with different members of their healthcare team.

Conclusions

Patients named providers as their primary source of pharmacogenomic information, but a pharmacogenomics patient portal that is carefully constructed to incorporate desired features may be a favorable tool to effectively deliver pharmacogenomic information and results to patients.
Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement
Authors: Prabhakar Manu , Liu Shuangbo , Bagai Akshay , Yanagawa Bobby , Verma Subodh , Cheema Asim N.
Published: July 2020

Purpose of review

Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors.

Recent findings

Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason.

Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.
Degenerative mitral regurgitation
Authors: Soulat-Dufour Laurie , Addetia Karima
Published: July 2020

Purpose of review

Degenerative mitral regurgitation (DMR) continues to be an important cause of morbidity and mortality with surgical mitral valve repair remaining the gold standard for the treatment of severe disease. The purpose of this review is to summarize recent advances in the understanding of DMR as well as the progress made in its assessment with a focus on imaging techniques.

Recent findings

Recent insights into the anatomy and physiology of DMR challenge the assumption that fibroelastic deficiency and Barlow disease are part of a single DMR spectrum. Advances in echocardiography and cardiovascular MRI have the potential to improve quantification of mitral regurgitation, provide unique information on prognosis and impact of DMR, further the association between DMR and arrhythmic risk and aide in decision-making for DMR treatment.

With growing interest in the use of noninvasive transcatheter therapies in the mitral valve space, comprehensive assessment of the mitral valve is critical to instruct decision-making and guide therapeutic strategy.
Functional mitral regurgitation
Authors: Asch Federico M. , Medvedofsky Diego
Published: July 2020

Purpose of review

Functional mitral regurgitation (FMR) is a complex condition in which significant mitral regurgitation coexist with cardiomyopathy and heart failure and carries an increased risk for associated morbidity and mortality. In addition to guideline-directed medical therapy and cardiac resynchronization therapy, percutaneous transcatheter mitral valve repair (TMVr) is a new therapeutic option but requires careful selection of the proper candidates. We describe the different mechanisms of functional mitral regurgitation, review echocardiographic parameters to assess its severity, and discuss recently published relevant studies including TMVr.

Recent findings

Two randomized controlled trials assessing the efficacy and safety of TMVr using the MitraClip in patients with heart failure and severe functional mitral regurgitation were published: MITRA-FR (Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation) and COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation). The results of these trials were opposite: although MITRA-FR failed to show clinical benefit, COAPT showed a dramatic clinical and echocardiographic benefit from transcatheter mitral valve repair using the MitraClip device. We discuss these two important trials and how differences in patient enrollment could explain the discrepant results and the manner they may influence future studies and clinical practice.

Patients with FMR receiving optimal guideline-directed medical therapy and cardiac resynchronization therapy who meet specific clinical and echocardiographic criteria can benefit from transcatheter mitral valve repair.
Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population
Authors: Cauwenberghs Nicholas , Haddad Francois , Sabovčik František , Kobayashi Yukari , Amsallem Myriam , Morris Daniel Armando , Voigt Jens-Uwe , Kuznetsova Tatiana
Published: July 2020

Objective:

Echocardiographic definitions of subclinical left atrial dysfunction based on epidemiological data remain scarce. In this population study, we derived outcome-driven thresholds for echocardiographic left atrial function parameters discriminating between normal and abnormal values.

Methods:

In 1306 individuals (mean age, 50.7 years; 51.6% women), we echocardiographically assessed left atrial function and LV global longitudinal strain. We derived cut-off values for left atrial emptying fraction (LAEF), left atrial function index (LAFI) and left atrial reservoir strain (LARS) to define left atrial dysfunction using receiver-operating curve threshold analysis. Main outcome was the incidence of cardiac events and atrial fibrillation (AFib) on average 8.5 years later.

Results:

For prediction of new-onset AFib, left atrial cut-offs yielding the best balance between sensitivity and specificity (highest Youden index) were: LAEF less than 55%, LAFI less than 40.5 and LARS less than 23%. Applying these cut-offs, abnormal LAEF, LAFI and LARS were, respectively, present in 27, 37.1 and 18.1% of the cohort. Abnormal LARS (<23%) was independently associated with higher risk for cardiac events and new-onset AFib (P ≤ 0.012). Participants with both abnormal LAEF and LARS presented a significantly higher risk to develop cardiac events (hazard ratio: 2.10; P = 0.014) and AFib (hazard ratio: 6.45; P = 0.0036) than normal counterparts. The concomitant presence of an impaired LARS and LV global longitudinal strain improved prognostic accuracy beyond a clinical risk model for cardiac events and the CHARGE-AF Risk Score for AFib.

Conclusion:

Left atrial dysfunction based on outcome-driven thresholds predicted cardiac events and AFib independent of conventional risk factors. Screening for subclinical left atrial and LV systolic dysfunction may enhance cardiac disease prediction in the community.
Efficacy of Azithromycin Eyedrops for Individuals With Meibomian Gland Dysfunction–Associated Posterior Blepharitis
Authors: Arita Reiko , Fukuoka Shima
Published: July 2020

Purpose:

To examine the safety and efficacy of azithromycin eyedrops in Japanese individuals with meibomian gland dysfunction (MGD)-associated posterior blepharitis.

Methods:

Individuals with MGD-associated posterior blepharitis who visited the Itoh Clinic, Saitama, Japan, were randomly assigned to receive azithromycin (1%) eyedrops (AZM group, 16 eyes of 16 patients) or preservative-free artificial tears (control group, 20 eyes of 20 patients) for 2 weeks. All subjects also applied a warming eyelid compress twice per day. Subjective symptoms (Standardized Patient Evaluation of Eye Dryness [SPEED] score), lipid layer thickness (LLT) and interferometric pattern of the tear film, plugging and vascularity of the lid margin, noninvasive break-up time of the tear film (NIBUT) and fluorescein-based break-up time of the tear film (TBUT), corneal–conjunctival fluorescein staining score, tear meniscus height, meibum grade, meiboscore, tear osmolarity, and Schirmer test value were determined before and after treatment. Side effects of treatment were also recorded.

Results:

In the AZM group, SPEED score, LLT, interferometric pattern, plugging and vascularity of the lid margin, NIBUT, TBUT, meibum grade, and tear osmolarity were significantly improved after treatment compared with baseline. The SPEED score, interferometric pattern, plugging, vascularity, meibum grade, and tear osmolarity were also significantly improved after treatment in the AZM group compared with the control group. Common side effects in the AZM group were transient eye irritation and blurred vision.

Conclusion:

Azithromycin eyedrops improved eyelid inflammation, the quality and quantity of the lipid layer of the tear film, and tear film stability. Such eyedrops thus seem to be a safe and effective treatment for MGD-associated posterior blepharitis.
Intraoperative performance and long-term postoperative outcomes after scleral fixation of IOLs with polytetrafluoroethylene suture
Authors: Bhojwani Deepak , Vasavada Abhay R. , Vasavada Vaishali , Vasavada Shail , Praveen Mamidipudi R. , Srivastava Samaresh
Published: July 2020

Purpose:

To report intraoperative performance and long-term postoperative outcomes after scleral fixation of intraocular lenses (IOLs) with polytetrafluoroethylene suture (PTFE).

Setting:

Raghudeep Eye Hospital, Ahmedabad, India.

Design:

Prospective, interventional case series.

Methods:

One hundred eyes undergoing scleral fixation of IOLs using PTFE suture (Gore-Tex) with 12 months or more postoperative follow-up were included. The primary outcome measures were occurrence of intraoperative and postoperative complications such as glaucoma, suture-related complications, and inflammation within the follow-up period. The secondary outcome measure was improvement in visual acuity (VA).

Results:

Of the 100 eyes, posteriorly dislocated IOLs (53 eyes) followed by dropped nuclei (33 eyes) were the most common surgical indications. Mean follow-up was 23 months (range 12 months to 5 years). Seventy-one patients (77.17%) had 18 months or more follow-up; 21 eyes had a rise in intraocular pressure in the early postoperative period; 12 of them required glaucoma surgery. Early complications were vitreous hemorrhage in 13 eyes, retinal detachment in 6 eyes, and transient hyphema in 1 eye. Late postoperative complications were cystoid macular edema (9 eyes), epiretinal membrane (3 eyes), and bullous keratopathy (3 eyes). Mean VA improved from 0.92 ± 0.16 (SD) logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.41 ± 0.27 logMAR. LogMAR at final follow-up was 0.41 ± 0.28 (P < .01). There were no cases of suture-related complications (erosion/breakage/granuloma) or IOL decentration throughout the follow-up period.

Conclusions:

Scleral fixation of IOLs with PTFE suture was found to be safe and well tolerated. All eyes had well-centered IOLs, with no suture-related complications during long-term follow-up. VA improved significantly with acceptable postoperative complications.
Liver fibrosis regression correlates with downregulation in liver angiogenesis in chronic hepatitis C through viral eradication
Authors: Chen Sheng-Hung , Huang Chia-Lin , Chiang I-Ping , Chang Tzu-Ching , Wang Hung-Wei , Hsu Wei-Fan , Tsai Tsung-Yu , Peng Cheng-Yuan
Published: July 2020

Objectives

The impact of viral eradication on hepatic angiogenesis is unknown. This study aimed to analyze the correlations of liver angiogenesis with liver fibrosis progression or regression in chronic hepatitis C (CHC) after viral eradication.

Methods

From 2003 to 2020, a cohort of 130 eligible participants underwent paired percutaneous liver biopsies (median = 48 months apart; range = 46–62) at the treatment baseline and after sustained virological response to CHC treatment at the tertiary referral center. The collagen proportionate area (CPA) of liver tissue sections was determined using picrosirius red staining through digital image analysis. CD34 and α-smooth muscle actin (α-SMA) phenotypically quantitated liver angiogenesis and myofibroblasts, respectively, through immunohistochemistry staining, to correlate the total, portal, and extraportal liver angiogenesis with fibrogenesis.

Results

Paired histology manifested significant regressions in fibrosis stages, and necroinflammatory grades (both P 
< 0.001). The median of changes in CPAs (follow-up minus baseline) was −6.12% (interquartile range = −12.35 to −2.05%). The median of CPA changes per year was −1.38%/year (interquartile range = −2.98 to −0.51%/year). The significance of declines in total CD34 [coefficient (95% confidence interval), 5.577 (3.286–7.868); P 
< 0.001] outweighed α-SMA declines, when explaining (R
2 = 0.522; adjusted R
2 = 0.502) the CPA declines through multiple regression analysis adjusting for other histological variables.

Conclusion

Through viral eradication in CHC, the downregulated liver angiogenesis significantly explains the CPA regression.
Isolated Right Atrial Rupture From Blunt Chest Trauma in Motor Vehicle Collisions
Authors: Feola Alessandro , Mastroianni Valerio , Scamardella Irene Adelaide , Zangani Pierluca , Della Pietra Bruno , Campobasso Carlo Pietro
Published: July 2020

Isolated right atrial rupture after nonpenetrating blunt chest trauma is rare, and very few cases have been reported in the literature. Isolated right atrial rupture is a diagnostic challenge in these patients, who are mostly victims of motor vehicle collisions. The clinical presentation is heterogeneous and can vary depending on rupture location and size. The anatomical sites mostly involved are the appendage and the free wall followed by the superior and inferior vena cava junctions. The present case study shows a fatal isolated rupture of the right atrial appendage in a victim of a motor vehicle collision. At the emergency room, a computed tomography scan revealed a severe pericardial blood effusion, and pericardiocentesis was promptly performed. Unfortunately, the patient suddenly worsened just before cardiac surgery. Autopsy findings showed a cardiac tamponade due to a linear laceration 1.8 cm in length on the right atrial appendage. No other relevant injuries were observed. A prompt diagnosis of isolated right atrial rupture can be crucial for victims of blunt chest trauma with unexplained hypotension or hemodynamic instability to improve their chances of survival. Medicolegal issues can be raised mainly related to delayed diagnosis. Once a cardiac rupture is suspected, the injury repair is essential to achieve the best outcome.
Split Calvarial Bone Graft for Reconstruction of Skull Defect in Langerhans Cell Histiocytosis
Authors: Baek Sang Oon , Kim Jaewon , Lee Jun Yong
Published: July 2020

Langerhans cell histiocytosis (LCH) is a rare disease in which histiocytes proliferates in several tissues. It mainly occurs in children between 1 and 15 years of age, and affects bone especially the skull being the most common site of invasion. It is desirable to reconstruct the skull defect after surgical removal of the lesion with autologous bone considering the fact that this disease affects children who continuously experience the deformation and growth of the frontal head. We introduce a case report who reconstructs the skull defect using split calvarial bone graft in LCH. A 3-year-old male visited the hospital with a painful, palpable protruding mass in the frontal area lasting 1 month. Craniectomy with skull tumor removal was performed by neurosurgeon, after that we harvested a calvarial bone graft and carefully separated the outer cortex from the inner cortex. Then, we covered the donor site with the inner cortex while covered the bone defect with the outer cortex and fixed with absorbable plates. The patient showed palpable mass at 1-year follow-up but it disappeared. After 5 years, there was no recurrence, the lytic lesion of the skull was resolved, and showed cosmetically good result. We conclude that the palpable lesion was more likely to be the result of postoperative swelling of the plate. We propose split calvarial bone graft as a good treatment option for reconstruction of the skull defect in LCH.
Flow Chart for Reconstructive Head and Neck Surgery in Composite Soft and Hard Tissue Defects
Authors: Lethaus Bernd , Kamal Mohammad , Kettner Franziska , Kloss-Brandstätter Anita , Halama Dirk , Hölzle Frank , Bartella Alexander K.
Published: July 2020

Introduction:

Virtual planning of reconstructive surgical procedures in patients with osseous and composite defects in the head and neck region is becoming increasingly a state of the art modality. However, computational algorithms lack the capability of planning the involved soft tissue and vascular pedicle position. The authors present a flow-chart to solve this problem in the reconstruction of defects of the upper and lower jaw.

Material and Methods:

Clinical records from 2013 to 2018 from a tertiary care center were screened for patients undergoing osseous reconstruction in the head and neck region. A flow-chart considering soft tissue positioning and the anatomical course of the vascular pedicle was assessed in consideration of the defect and donor-site.

Results:

A total of 81 osseous and composite microvascular reconstructive procedures have been conducted. Defects of the lower jaw were the most common (n = 61). The free fibula flap was the most common reconstructive measure and showed a wide versatility of surgical options to reconstruct these defects. The flow charts were assessed accordingly in these procedures.

Conclusion:

Soft tissue and vascular pedicle positioning can be planned pre-operatively by the use of virtual planning and should be considered as an enhancement tool to the already existing computational algorithms of planning hard tissue reconstruction.
Intradiploic Hematoma Associated With Synostosis in an Infant
Authors: Solaja Ogi , McAuley David , Peters Daniel A.
Published: July 2020

Intradiploic hematomas are extremely rare, particularly in newborns. Caused by bleeding between the inner and outer tables of the calvarium, they manifest with bony swelling of the skull. The authors present the first case of an intraosseous hematoma associated with synostosis, and the first report in a female patient. The clinical, radiological, surgical, and pathological characteristics of this lesion are discussed.
Modulation of Brain Transcriptome by Combined Histone Deacetylase Inhibition and Plasma Treatment Following Traumatic Brain Injury and Hemorrhagic Shock
Authors: Dekker Simone E. , Biesterveld Ben E. , Bambakidis Ted , Williams Aaron M. , Tagett Rebecca , Johnson Craig N. , Sillesen Martin , Liu Baoling , Li Yongqing , Alam Hasan B.
Published: July 2020

Introduction:

We previously showed that the addition of valproic acid (VPA), a histone deacetylase inhibitor, to fresh frozen plasma (FFP) resuscitation attenuates brain lesion size and swelling following traumatic brain injury (TBI) and hemorrhagic shock (HS). The goal of this study was to use computational biology tools to investigate the effects of FFP+VPA on the brain transcriptome following TBI+HS.

Methods:

Swine underwent TBI+HS, kept in shock for 2 h, and resuscitated with FFP or FFP + VPA (n = 5/group). After 6 h of observation, brain RNA was isolated and gene expression was analyzed using a microarray. iPathwayGuide, Gene Ontology (GO), Gene-Set Enrichment Analysis, and Enrichment Mapping were used to identify significantly impacted genes and transcriptomic networks.

Results:

Eight hundred differentially expressed (DE) genes were identified out of a total of 9,118 genes. Upregulated genes were involved in promotion of cell division, proliferation, and survival, while downregulated genes were involved in autophagy, cell motility, neurodegenerative diseases, tumor suppression, and cell cycle arrest. Seven hundred ninety-one GO terms were significantly enriched. A few major transcription factors, such as TP53, NFKB3, and NEUROD1, were responsible for modulating hundreds of other DE genes. Network analysis revealed attenuation of interconnected genes involved in inflammation and tumor suppression, and an upregulation of those involved in cell proliferation and differentiation.

Conclusion:

Overall, these results suggest that VPA treatment creates an environment that favors production of new neurons, removal of damaged cells, and attenuation of inflammation, which could explain its previously observed neuroprotective effects.
Transferability of Liver Transplantation Experience to Complex Liver Resection for Locally Advanced Hepatobiliary Malignancy-Lessons Learnt From 3 Decades of Single Center Experience
Authors: Chan Albert C. Y. , Chok Kenneth S. H. , Dai Jeff , Tsang Simon H. Y. , Cheung Tan To , Poon Ronnie , Fan S. T. , Lo C. M.
Published: July 2020

Objective:

To study the impact of LT experience on the outcome of CLR for locally advanced hepatobiliary malignancy

Summary of Background data:

Despite evolution in LT knowledge and surgical techniques in the past decades, there is yet data to evaluate the significance of LT experience in performing CLR.

Methods:

Postoperative outcome after CLR between 1995 and 2019 were reviewed and correlated with LT experience in a single center with both LT and CLR service. CLR was defined as hepatectomy with vasculobiliary reconstruction, or multivisceral resection, central bisectionectomy (S4/5/8), or associating liver partition and portal vein ligation for staged hepatectomy. Spearman rank correlation and receiver operating characteristic analysis were used to define the association between CLR-related outcomes and LT experience.

Results:

With cumulative single-center experience of 1452 LT, 222 CLR were performed during the study period [hepatectomy with biliary (27.0%), or vascular (21.2%) reconstruction, with multivisceral resections (9.9%), with associating liver partition and portal vein ligation for staged hepatectomy (18.5%)] mainly for hepatocellular carcinoma (53.2%), and hilar cholangiocarcinoma (14%). Median tumor size was 7.0 cm. Other features include macrovascular invasion (23.4%), and juxta-visceral invasion (14%). Major postoperative complication rate was 25.2% and mortality rate was 6.3%. CLR-complication rate was inversely associated with LT experience (R = −0.88, P < 0.005). Receiver operator characteristic analysis revealed the cutoff for LT experience to have the greatest influence on CLR was 95 with a sensitivity of 100% and Youden index of 1. Multivariable analysis showed that blood transfusion, prolonged operating time, LT experience < /=95 were associated with major postoperative complications.

Conclusion:

LT experience was complimentary to CLR for locally advanced hepatobiliary malignancy with improved postoperative outcome.
Natural killer cell activation related to clinical outcome of COVID-19
Authors: Maucourant Christopher , Filipovic Iva , Ponzetta Andrea , Aleman Soo , Cornillet Martin , Hertwig Laura , Strunz Benedikt , Lentini Antonio , Reinius Björn , Brownlie Demi , Gomez Angelica Cuapio , Ask Eivind Heggernes , Hull Ryan M. , Haroun-Izquierdo Alvaro , Schaffer Marie , Klingström Jonas , Folkesson Elin , Buggert Marcus , Sandberg Johan K. , Eriksson Lars I. , Rooyackers Olav , Ljunggren Hans-Gustaf , Malmberg Karl-Johan , Michaëlsson Jakob , Marquardt Nicole , Hammer Quirin , Strålin Kristoffer , Björkström Niklas K. ,   Karolinska COVID-19 Study Group
Published: July 2020

Understanding innate immune responses in COVID-19 is important for deciphering mechanisms of host responses and interpreting disease pathogenesis. Natural killer (NK) cells are innate effector lymphocytes that respond to acute viral infections, but might also contribute to immune pathology. Here, using 28-color flow cytometry, we describe a state of strong NK cell activation across distinct subsets in peripheral blood of COVID-19 patients, a pattern mirrored in scRNA-seq signatures of lung NK cells. Unsupervised high-dimensional analysis identified distinct immunophenotypes that were linked to disease severity. Hallmarks of these immunophenotypes were high expression of perforin, NKG2C, and Ksp37, reflecting a high presence of adaptive NK cell expansions in circulation of patients with severe disease. Finally, arming of CD56bright NK cells was observed in course of COVID-19 disease states, driven by a defined protein-protein interaction network of inflammatory soluble factors. This provides a detailed map of the NK cell activation-landscape in COVID-19 disease.