Letter to the Editor, BJOG Title:Prophylactic negative wound pressure dressing (NWPD) after caesarean – an extended debate to include surgical aspectsRe: Hyldig N, Joergensen JS, Lamont RF, Moller S, Vinter CA. Prophylactic negative pressure wound therapy in obese women undergoing caesarean section: a commentary on new evidence that fuels the debate. BJOG 2021; https://doi.org/10.1111/1471-0528.16750.Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKEmail: email@example.comTel: 07906620662Word count: 500Corresponding Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKStatement of interest: The author has no conflict of interest or funding to declare.
In our writing, we voice stories of two Australian rivers to convey Indigenous ways of knowing and being. Interweaving academic literature, nature writing and creativity, we craft a story of reconnection that is transformative, action-oriented and potentially political. An open mind, place-intuition and the process of attending can deepen our river relationships, creating a sense of love and communicative connectedness. Paying deep attention, we notice meanings embedded in plain sight, within hearing range of rivers and watery places. Our relationships may be ‘in our faces’ such as the wind, or the air, water or bushes nearby. We communicate across binaries to experience the dissolution of imagined barriers. Feeling, hearing, writing and storytelling can support verbalising of experience, helping to bring to mind place-wisdom. It offers an everyday possibility for people now estranged from their riverine kin. The process uses a post human-centred, common worlds frame to consider the Anthropocene in regenerative ways. It is creative and liberating, and rivers are dying for people to take action by speaking out for and with our greater selves. In this learning journey, we synthesise learnings, hoping to inspire people everywhere to hear the call of rivers, to respond, take action and learn to love their rivers again.
Background & Aim Cardiogenic shock (CS) withholds a significantly high mortality rate between 40-60% despite advances in diagnosis and medical/surgical intervention. To-date, machine learning(ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROC) accuracy for the early prediction of CS. Methods A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards early detection of CS. Results A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N=21) evaluated patient outcomes, of which 14.3% (N=3) were assessed. The collective patient cohort (N=698) consisted of 314(45.0%) females, with an average age and body mass index (BMI) of 64.1years and 28.1kg/m2, respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (alfa=0.05), deeming it of superb sensitivity and specificity. Conclusions From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions prior to standardizing use of these technologies.
The present perspective is a synthesis of 80 published investigations in the setting of a retroaortic left brachiocephalic vein, described in 250 patients. Clinical presentation, radiographic findings, ultrasonographic findings, saline contrast echocardiography, computed-tomographic angiocardiography, magnetic resonance imaging, and angiocardiography provided the diagnostic information used to define the disease entity prior to considering the surgical approach to the associated cardiac anomalies. We have also addressed several issues concerning the influence of isomerism, the establishment of diagnosis, and its importance in various surgical and interventional procedures. Although the retroaortic left brachiocephalic vein is asymptomatic, its recognition during clinical investigation should raise the possibility of an association with other malformations, especially right aortic arch, ventricular septal defect, and anomalies of the outflow tracts. We submit that an increased appreciation of this venous anomaly may facilitate surgical planning, endovascular procedures, placement of central venous lines, and transvenous pacemakers.
Background: This study evaluated the utilization and outcomes of postcardiotomy mechanical circulatory support (MCS). Methods: This was a retrospective, single institution analysis of adult cardiac surgery cases that required de novo MCS following surgery from 2011-2018. Patients that were bridged with MCS to surgery were excluded. The primary outcomes were early operative mortality and longitudinal survival. Secondary outcomes included postoperative complications, and five-year all-cause readmission. Results: 533 patients required de novo postcardiotomy MCS, with the most commonly performed procedure being isolated coronary artery bypass grafting (29.8%). Median cardiopulmonary bypass and cross clamp times were 185 (IQR 123-260) minutes and 122 (IQR 81-179) minutes, respectively. A total of 442 (82.9%) of patients were supported with intra-aortic balloon pump counterpulsation, 23 (4.3%) with an Impella device, and 115 (21.6%) with extracorporeal membrane oxygenation. Three (0.6%) patients had an unplanned ventricular assist device placed. Operative mortality was 29.8%. Longitudinal survival was 56.1% and 43.0% at 1- and 5-years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (P<0.001). Freedom from readmission was 61.4% at 5-years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0-12.9, P<0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment. Conclusions: Postcardiotomy MCS is associated with high operative mortality. Even patients that survive to discharge have compromised longitudinal survival, with nearly only half surviving to 1-year. Close follow-up and early referral to advanced heart failure specialists may be prudent in improving these outcomes.
Key Points : • Interventional therapies directed at fenestration closure in the Fontan patient must rely on good hemodynamic data • The Large Optimus-CVSTM stent is an additional armamentarium for fenestration closure however, longer term follow up is needed • Multi institutional studies defining the long-term benefits of fenestration closure and outlining fenestration management guidelines may help improve the long-term morbidity and mortality in this group of patients.
The paper discusses various partial solutions used for estimating fatigue life under variable amplitude multiaxial loading in the high-cycle fatigue domain. The concurring effects are treated, and their proposed solutions are commented upon. The major focus is on the categories of the phase shift effect and of cycle counting, and on the scope and quality of data, which support discussed theories. Results of own new experimental data set on specimens from S355 steel are provided. Fatigue life estimates for McDiarmid and Findley multiaxial methods and for two different methods of load path decomposition to cycles are shown to highlight some of the points open for discussion. It is concluded that the available experimental data are not sufficient to substantiate a clear decision to follow a definite algorithm.
Electrogram-guided Endomyocardial Biopsy Yield in Patients with Suspected Cardiac SarcoidosisAbbas Hoteit MD, Marwan M. Refaat, MDDivision of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, LebanonRunning Title: Electrogram-guided Biopsy in Cardiac SarcoidosisWords: 819 (excluding the title page and references)Keywords: Cardiac Sarcoidosis, Heart Diseases, Cardiovascular Diseases, Cardiac ArrhythmiasFunding: NoneDisclosures: NoneCorresponding Author:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FAAMAAssociate Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonUS Address: 3 Dag Hammarskjold Plaza, 8th Floor, New York, NY 10017, USAOffice: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Sarcoidosis is a multisystem disease that is characterized by T-cell mediated formation of noncaseating granulomas in affected organs. The disease commonly might involve hilar lymphadenopathy, lungs, liver, spleen, heart, and other organs. The natural course and prognosis of the disease generally depends on the extent of the disease and the organs affected where spontaneous remission occurs in around two-thirds of patient.1 Involvement of the heart is recognized in around 30% of patients and is associated with poor prognosis.2 The presentation of patients with cardiac sarcoidosis varies significantly; it can range from mild to severe disease such as heart failure and fatal arrhythmias. Patients with cardiomyopathies might require implantable cardiac defibrillators or cardiac resynchronization therapy for sudden death prevention.3,4 Cardiac sarcoidosis can either present alongside extracardiac manifestations or isolated.5Diagnosis of cardiac sarcoidosis presents a particular challenge since there is no gold standard diagnostic tool and the presentation is variable.6 There are no disease-specific biomarkers that can reliably be used for diagnosis. Clinicians typically rely on current published guidelines for diagnostic criteria of cardiac sarcoidosis such as those of Heart Rhythm Society (HRS) and the Japanese Ministry of Health and Welfare (JMHW). The revised JMHW criteria provide a diagnosis either through histological evidence on biopsy or through the fulfillment of major and minor criteria that do not include cardiac PET whereas the HRS criteria provide either a definite pathway for diagnosis through histology or a clinical pathway for diagnosis of probable cardiac sarcoidosis that includes both cardiac PET and CMR as criteria.7,8 A definitive diagnosis of cardiac sarcoidosis can be obtained if endomyocardial biopsy can show noncaseating granulomas in the context of suspected cardiac sarcoidosis and other granulomatous diseases are excluded. However, endomyocardial biopsy has a low sensitivity of 20-30% since it is limited by several factors such as technique, sampling, patchy distribution of granulomas, location of lesions, and stage of the disease at the time of biopsy.5 Areas of inflammation and scarring typically show abnormal electrogram morphology, hence, it is thought that electrogram guidance may help in increasing the yield of endomyocardial biopsies. Electrogram guidance would potentially help avoiding normal myocardium during biopsy leading to increased yield and sensitivity.9In their study, Ezzedine et al. assessed the diagnostic yield of electrogram-guided endomyocardial biopsy and investigated association between positive endomyocardial biopsy and prognosis in patients with suspected cardiac sarcoidosis.10 This retrospective observational study included seventy-nine patients between 2011 and 2019 who had suspected cardiac sarcoidosis based on clinical presentation and findings on late gadolinium-enhancement cardiac magnetic resonance and/or cardiac positron emission tomography-computed tomography with N-13 NH3 perfusion imaging and F-18 fluorodeoxyglucose. Biopsy was done in patients suspicious of cardiac sarcoidosis in patients without extracardiac sarcoidosis or those with extracardiac disease but atypical/equivocal findings of cardiac sarcoidosis on imaging and meeting criteria in HRS guidelines as per the routine practice in Mayo Clinic. Mapping of the heart was performed prior to biopsy with partial guidance based on pre-procedural cardiac imaging. In patients with no identifiable abnormalities on electrogram, biopsies were taken from areas corresponding to those with abnormalities on pre-procedural imaging. Collected specimens were processed according to protocol and assessed by a blinded specialist. These specimens were considered positive if there was a combination of non-necrotizing granulomas, interstitial fibrosis, and scatted eosinophils. The study showed that electrogram-guided endomyocardial biopsy was associated with an adequate negative predictive value but low positive predictive value. A diagnosis of probable cardiac sarcoidosis can be made in patients with extracardiac manifestations according to established guidelines whereas in patients with suspected isolated cardiac sarcoidosis this is more difficult and as such biopsies play a more major role here. This study showed that, when guided by electrograms, endomyocardial biopsies had a higher diagnostic yield (41%) than that established in literature around 20-25%. Utilizing both abnormalities seen on both electrograms and on CMR or PET showed the highest diagnostic yield in endomyocardial biopsies. This acts as an important point of consideration for further research because accurate and timely diagnosis is paramount due to the diagnostics challenges and poor prognosis seen in cardiac sarcoidosis.10Previous evidence had shown that a positive endomyocardial biopsy for sarcoidosis was associated with poor prognosis.11However, LVAD and transplantation-free survival was found to be similar regardless of status of endomyocardial biopsy in this study.10 The authors explained that this could be explained by earlier detection of disease, differences in treatment, or more subtle detection of areas of involvement through electrograms. This study was well conducted but has been limited by its nature of being a retrospective observational study. Also, mapping was mostly limited to the right ventricle which may have underestimated the diagnostic yield of biopsies. This study represents the management done in a single tertiary care center which may not represent the same practice in other institutions with different facilities. Further multicenter and prospective studies are warranted to corroborate the data here and assess diagnostic and therapeutic modalities and long-term outcomes in patients.ReferencesStatement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med Aug 1999 ;160(2):736-55.Sekhri V, Sanal S, Delorenzo LJ, Aronow WS, Maguire GP. Cardiac sarcoidosis: a comprehensive review. Arch Med Sci Aug 2011; 7(4):546-54.AlJaroudi WA, Refaat MM, Habib RH, Al-Shaar L, Singh M, Gutmann R, Bloom HL, Dudley SC, Ellinor PT, Saba SF, Shalaby AA, Weiss R, McNamara DM, Halder I, London B; for the Genetic Risk Assessment of Defibrillator Events (GRADE) Investigators. Effect of Angiotensin Converting Enzyme Inhibitors and Receptor Blockers on Appropriate Implantable Cardiac Defibrillator Shock: Insights from the GRADE Multicenter Registry. Am J Cardiol Apr 2015; 115 (7): 115(7):924-31.Refaat M, Mansour M, Singh JP, Ruskin JN, Heist EK: Electrocardiographic Characteristics in Right Ventricular Versus Biventricular Pacing in Patients With Paced Right Bundle Branch Block QRS Pattern. J Electrocardiol Mar-Apr 2011; 44 (2): 289-95.Isobe M, Tezuka D. Isolated cardiac sarcoidosis: Clinical characteristics, diagnosis and treatment. Int J Cardiol Mar 2015; 182:132-40.Ahmed AI, Abebe AT, Han Y, Alnabelsi T, Agrawal T, Kassi M, Aljizeeri A, Taylor A, Tleyjeh IM, Al-Mallah MH. The prognostic role of cardiac positron emission tomography imaging in patients with sarcoidosis: A systematic review. J Nucl Cardiol Jul 2021; doi: 10.1007/s12350-021-02681-z. Online ahead of print.Sharma A, Okada DR, Yacoub H, Chrispin J, Bokhari S. Diagnosis of cardiac sarcoidosis: an era of paradigm shift. Ann Nucl Med Feb 2020;34(2):87-93.Ha FJ, Agarwal S, Tweed K, Palmer SC, Adams HS, Thillai M, Williams L. Imaging in Suspected Cardiac Sarcoidosis: A Diagnostic Challenge. Curr Cardiol Rev 2020;16(2):90-97.Liang JJ, Hebl VB, DeSimone CV, Madhavan M, Nanda S, Kapa S, Maleszewski JJ, Edwards WD, Reeder G, Cooper LT , Asirvatham SJ. Electrogram guidance: a method to increase the precision and diagnostic yield of endomyocardial biopsy for suspected cardiac sarcoidosis and myocarditis. JACC Heart Fail Oct 2014;2(5):466-73.Ezzedine FM, Kapa S, Rosenbaum A, Blauwet L, Deshmukh AJ, AbouEzzeddine OF, Maleszewski JJ, Asirvatham SJ, Bois JP, Schirger JA, Chareonthaitawee P, Siontis KC. Electrogram-guided Endomyocardial Biopsy Yield in Patients with Suspected Cardiac Sarcoidosis and Relation to Outcome. J Cardiovasc Electrophysiol Jul 2021; In Press.Ardehali H , Howard DL, Hariri A, Qasim A, Hare JM, Baughman KL, Kasper EK. A positive endomyocardial biopsy result for sarcoid is associated with poor prognosis in patients with initially unexplained cardiomyopathy. Am Heart J Sep 2005 ;150(3):459-63.
Vascular access for percutaneous coronary intervention (PCI) is usually obtained through the radial or femoral, and to lesser extent the brachial or ulnar artery. We describe the transcarotid approach for PCI in a patient with severe peripheral artery disease. No adverse neurological or cardiac events were observed.
The transcription machinery of archaea can be roughly classified as a simplified version of eukaryotic organisms. The basal transcription factor machinery binds to the TATA-box found around 28 nucleotides upstream of the transcription start site; however, some transcription units lack a clear TATA-box and still have TBP/TFB binding over them. This apparent absence of conserved sequences could be a consequence of sequence divergence associated with the upstream region, operonic and gene organization. Furthermore, earlier studies have found that a structural analysis gains more information compared to a simple sequence inspection. In this work, we evaluated and coded 3630 archaeal promoter sequences of three organisms, Haloferax volcanii, Thermococcus kodakarensis, and Sulfolobus solfataricus into DNA duplex stability, enthalpy, curvature, and bendability parameters. We also split our dataset into conserved TATA and degenerated TATA promoters in order to identify differences among these two classes of promoters. The structural analysis reveals variations in archaeal promoters’ architecture, i.e., a distinctive signal is observed in the TFB, TBP, and TFE binding sites independently of these being TATA-conserved or TATA-degenerated. In addition, the promoter encountering method was validated with upstream regions of 13 other archaea, suggesting that there might be promoter sequences among them. Therefore, we suggest a novel method for locating promoters within the genome of archaea based on energetic/structural features.
The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis' circle is incomplete is difficult to judge during emergency surgery, and the authors' judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.
The filamentous fungus Magnaporthe oryzae has the potential to be developed as an alternative platform organism for the heterologous production of industrially important enzymes. M. oryzae is easy to handle, fast-growing and unlike yeast, posttranslational modifications like N-glycosylations are similar to the human organism. Here, we established M. oryzae as a host for the expression of the unspecific peroxygenase from the basidiomycete Agrocybe aegerita (AaeUPO). UPOs are attractive biocatalysts for selective oxyfunctionalization of non-activated carbon-hydrogen bonds. To improve and simplify the isolation of AaeUPO in M. oryzae, we fused a Magnaporthe signal peptide for protein secretion and set it under control of the strong EF1-promotor. The success of the heterologous production of full-length AaeUPO in M. oryzae and the secretion of the functional enzyme was confirmed by a peroxygenase-specific enzyme assay. These results offer the possibility to establish the filamentous ascomycete M. oryzae as a broad applicable alternative expression system. This is in particular valid for proteins that cannot or not in sufficient yields produced in established systems.
Background: The administration of L-glutamine (Gln) suppresses allergic airway inflammation via the rapid upregulation of MAPK phosphatase (MKP)-1, which functions as a negative regulator of inflammation by deactivating p38 and JNK mitogen-activated protein kinases (MAPKs). However, the role of endogenous Gln remains to be elucidated. Therefore, we investigated the mechanism by which endogenous Gln regulates MKP-1 induction and allergic airway inflammation in an ovalbumin-based murine asthma model. Methods: We depleted endogenous Gln levels using l-γ-glutamyl- p-nitroanilide (GPNA), an inhibitor of the Gln transporter ASCT2, and glutamine synthetase small interfering (si)RNA. Lentivirus expressing MKP-1 was injected to achieve overexpression of MKP-1. Asthmatic phenotypes were assessed using our previously developed ovalbumin-based murine model, which is suitable for examining sequential asthmatic events, including neutrophil infiltration. Gln levels were analyzed using a Gln assay kit. Results: GPNA or glutamine synthetase siRNA successfully depleted endogenous Gln levels. Importantly, homeostatic MKP-1 induction did not occur at all, which resulted in prolonged p38 MAPK and cytosolic phospholipase A 2 (cPLA 2) phosphorylation in Gln-deficient mice. Gln deficiency augmented all examined asthmatic reactions, but it exhibited a strong bias toward increasing the neutrophil count, which was not observed in MKP-1-overexpressing lungs. This neutrophilia was inhibited by a cPLA 2 inhibitor and a leukotriene B4 inhibitor, but not by dexamethasone. Conclusion: Gln deficiency leads to the impairment of MKP-1 induction and activation of p38 MAPK and cPLA 2, resulting in the augmentation of neutrophilic, more so than eosinophilic, airway inflammation.
In this paper a collaborative writing group explores how we, two rivers, express ourselves over time, place and space, our energies long interpreted as veins and arteries carrying the Country’s life affirming blood. Voiced as River: I, River, this position reflects a worldview in which interrelationship with living river is normal, and River Spirit is ever-present. It is a position underpinned by Indigenous narratives as riverine expressions of place-based love. At times the paper is also voiced as writing group or individuals, with voices being interchanged where required for smooth reading. We see this as part of the decolonising process, which feels liberating and healing amongst the writers. Each writer is equally valued as co-creator, contributor, narrator and story teller. The two Rivers, being Martuwarra Fitzroy River (Kimberley, Western Australia), and Unamen Shipu Romaine River (North Shore, Québec, Canada) illustrate a common condition of being, through heritage, life, change and possibility. Through stories and voices, the socio-scientific implications of colonisation and lost connections become clear, considering the interaction, the dialogue and the cultural synthesis of living water systems that have always incorporated all life forms into rivers of life. As a way of navigating towards wholeness, Aboriginal knowledge systems and narratives for healing are used to bring together findings of this intercultural river learning journey.