Returning to work with long covid in the UK during lockdown and other COVID-19 restrictions: A qualitative study.

Few previous studies have considered the experiences of people with long covid returning to work beyond symptoms in terms of employer and other support factors. The aim of this research was to understand the experience of returning to work for those with long covid symptoms in contrast to the non-long covid group who had not experienced COVID-19 during the time restrictions were imposed to limit the spread of COVID-19 infection. Twenty-one participants with long covid and 13 participants who had not had COVID-19 were interviewed. Themes were identified from transcripts using framework analysis. Participants with long covid experienced difficulties returning to work, particularly from fatigue, cognitive symptoms and breathlessness. Symptoms were heterogeneous and fluctuated in severity over time. A lack of understanding from colleagues and managers sometimes led to a premature return to work without adequate support, associated with further long covid relapse. Outside-of-work, support was salient for a successful return to work. The standard phased return offered by employers may be too short and rigid for some people with long covid. They may benefit from a tailored intervention to support a return to work that targets symptom management, and engages with work colleagues, managers, and family members.

Feasibility, tolerability, and first experience of intracystic treatment with peginterferon alfa-2a in patients with cystic craniopharyngioma.

Background: Children with craniopharyngiomas (CPs) typically suffer from a life-long chronic disease. The younger the child, the more vulnerable the maturing brain is to invasive therapies such as surgery or radiotherapy. Therefore, treatment modalities facilitating avoidance or delay of invasive therapies are beneficial for these patients. In the last decade, intracystic injection of interferon alfa-2a or alfa-2b evolved as a treatment of choice based on efficacy and minor toxicity. However, the drug is no longer available internationally. After an extensive pharmacological review, peginterferon alfa-2a was identified as the agent with closest similarity. Methods: A retrospective case series is described, including five patients treated with intracystic peginterferon alfa-2a for cystic CP according to an innovative care protocol. After initial CP cyst aspiration, peginterferon alfa-2a was injected once per week via an Ommaya reservoir for 6 weeks followed by response assessment with MRI. Results: Patients' age ranged from 4 to 54 years (four patients <12 years, one adult patient). Intracystic therapy with peginterferon alfa-2a was tolerated well by all five individuals without any major toxicities and resulted in cyst shrinkage in all of the five patients. The importance of a permeability study prior to commencing intracystic therapy became apparent in one patient who suffered from cyst leakage. Conclusions: Intracystic treatment with peginterferon alfa-2a was found to be a tolerable and efficacious treatment modality in patients with cystic CP. This experience warrants further research with a larger number of patients with measurement of long-term efficacy and safety outcomes.

Role of Occupational Therapy Cognitive Assessment in Mild Traumatic Brain Injury: Is Universal Consultation Required?

INTRODUCTION: Mild traumatic brain injury (mTBI) or concussion is prevalent among trauma patients, but symptoms vary. Assessing discharge safety is not standardized. At our institution, occupational therapy (OT) performs cognitive assessments for mTBI to determine discharge readiness, potentially increasing resource utilization. We aimed to describe characteristics and outcomes in mTBI trauma patients and hypothesized that OT consultation was associated with increased length of stay (LOS). METHODS: This is a retrospective study at a level 1 trauma center over 17 mo. All patients with mTBI, without significant concomitant injuries, were included. We collected data regarding OT assessment, LOS, mechanism of injury, Glasgow coma score, injury severity score (ISS), concussion symptoms, and patient disposition. Statistical analysis was performed, and significance was determined when P < 0.05. RESULTS: Two hundred thirty three patients were included. Median LOS was 1 d and ISS 5. Ninety percent were discharged home. The most common presenting symptom was loss of consciousness (85%). No symptoms were associated with differences in LOS or discharge disposition (P > 0.05). OT consult (n = 114, 49%) was associated with longer LOS and higher ISS (P < 0.01). Representation with concussive symptoms, discharge disposition, mechanism of injury, and patient demographics were no different regardless of OT consultation (P > 0.05). CONCLUSIONS: mTBI is common and assessment for discharge safety is not standardized. OT cognitive assessment was associated with longer LOS and higher injury severity. Despite institutional culture, OT consultation was variable and not associated with improved concussion-related outcomes. Our data suggest that OT is not required for mTBI discharge readiness assessment. To improve resource utilization, more selective OT consultation should be considered. Further prospective data are needed to identify which patients would most benefit.

Morning light treatment for inflammatory bowel disease: a clinical trial.

BACKGROUND: Inflammatory bowel disease (IBD) affects over 3 million Americans and has a relapsing and remitting course with up to 30% of patients experiencing exacerbations each year despite the availability of immune targeted therapies. An urgent need exists to develop adjunctive treatment approaches to better manage IBD symptoms and disease activity. Circadian disruption is associated with increased disease activity and may be an important modifiable treatment target for IBD. Morning light treatment, which advances and stabilizes circadian timing, may have the potential to improve IBD symptoms and disease activity, but no studies have explored these potential therapeutic benefits in IBD. Therefore, in this study, we aim to test the effectiveness of morning light treatment for patients with IBD. METHODS: We will recruit sixty-eight individuals with biopsy-proven IBD and clinical symptoms and randomize them to 4-weeks of morning light treatment or 4-weeks of treatment as usual (TAU), with equivalent study contact. Patient-reported outcomes (IBD-related quality of life, mood, sleep), clinician-rated disease severity, and a biomarker of gastrointestinal inflammation (fecal calprotectin) will be assessed before and after treatment. Our primary objective will be to test the effect of morning light treatment versus TAU on IBD-related quality of life and our secondary objectives will be to test the effects on clinician-rated disease activity, depression, and sleep quality. We will also explore the effect of morning light treatment versus TAU on a biomarker of gastrointestinal inflammation (fecal calprotectin), and the potential moderating effects of steroid use, restless leg syndrome, and biological sex. DISCUSSION: Morning light treatment may be an acceptable, feasible, and effective adjunctive treatment for individuals with active IBD suffering from impaired health-related quality of life. TRIAL REGISTRATION: The study protocol was registered on ClinicalTrials.gov as NCT06094608 on October 23, 2023, before recruitment began on February 1, 2024.

The Assessment of Social Isolation and Loneliness in Cancer Patients and Survivors in the Pre-COVID-19 Period: A Systematic Review.

BACKGROUND: In the context of cancer research, identifying social isolation and loneliness is a priority given how both exacerbate poor outcomes and lead to increased mortality in oncological populations. The purpose of this systematic review is to identify all quantitative instruments that have been used to assess either social isolation or loneliness in patients previously or currently diagnosed with cancer in the pre-COVID-19 period. METHOD: PubMed (Web), Scopus, CINAHL, and PsycINFO were searched on August 22, 2019. All databases were searched from inception with no filters applied. The search strategies included terms that captured the following concepts: instruments/tools, social isolation or loneliness, and cancer. RESULTS: A total of 289 titles/abstracts were returned. Upon review, 114 titles/abstracts were deemed to be potentially eligible and the full text was retrieved. Of the 114 full texts, 69 articles met inclusion criteria and comprised the final sample. Publications span years 1980 through 2019, with the majority (71%) occurring in the last decade prior to this review, between 2009 and 2019. Average age of the study samples, with few exceptions, was often over 50 years old. Many studies used all-female samples, while only one study used an all-male sample. The most common cancer diagnosis of participants was breast cancer. The most common measure was the UCLA Loneliness Scale, used in 22 studies. Most measures we identified were used only once, and 11 measures were used 2-3 times. When the information was given, response ranges were always Likert-type scales most often ranging from 1-4 or 1-5, and sometimes from 1-10 possible response options. In terms of psychometrics, test-retest reliability and validity were rarely reported; by contrast, internal consistency (Cronbach's alpha) was reported more than half of the time (60.9%). CONCLUSION: When selecting a measure to assess loneliness in cancer populations, the UCLA Loneliness Scale is both psychometrically strong and versatile across patients with different cancers, ages, and racial backgrounds. When selecting a measure to assess social isolation in cancer populations, both the PROMIS-SF V 2.0 social isolation and the Berkman-Syme Network Index are brief and have been used in patients with non-White racial backgrounds.

Exploring the association between income inequality and sleep in Canadian adolescents: A path analysis approach.

OBJECTIVES: An estimated 30% of Canadian adolescents do not get the recommended 8-10hours of sleep. No prior study has examined the role of income inequality, the gap between rich and poor within a society, in adolescent sleep. The aim of this study is to examine the association between income inequality and sleep duration among Canadian adolescents, how this association differs by gender, and whether depressive symptoms, anxiety, and social cohesion mediate this relationship. METHODS: Multilevel path models were conducted using cross-sectional survey data from 74,501 adolescents who participated in the Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study in 2018-2019. Income inequality was measured at the census division level and sleep duration, gender, depressive symptoms, anxiety, and social cohesion were measured at the individual level. RESULTS: A 1% increase in income inequality was associated with a 3.67-minute decrease in sleep duration (95% CI=-5.64 to -1.70). The cross-level interactions between income inequality and gender were significant, suggesting that income inequality has more adverse associations with sleep among females than males. Both depressive symptoms and anxiety were significant mediators, wherein greater income inequality was associated with higher levels of depressive symptoms and anxiety, which were in turn, associated with a shorter sleep duration. CONCLUSION: Interventions that reduce income inequality may prevent depressive symptoms and anxiety and improve sleep in adolescents. Reducing societal income gaps may improve adolescent sleep especially in those attending school in high income inequality areas, females, and those experiencing depressive symptoms and anxiety.

HealthyPlan.City: A Web Tool to Support Urban Environmental Equity and Public Health in Canadian Communities.

Urban environmental factors such as air quality, heat islands, and access to greenspaces and community amenities impact public health. Some vulnerable populations such as low-income groups, children, older adults, new immigrants, and visible minorities live in areas with fewer beneficial conditions, and therefore, face greater health risks. Planning and advocating for equitable healthy urban environments requires systematic analysis of reliable spatial data to identify where vulnerable populations intersect with positive or negative urban/environmental characteristics. To facilitate this effort in Canada, we developed HealthyPlan.City ( https://healthyplan.city/ ), a freely available web mapping platform for users to visualize the spatial patterns of built environment indicators, vulnerable populations, and environmental inequity within over 125 Canadian cities. This tool helps users identify areas within Canadian cities where relatively higher proportions of vulnerable populations experience lower than average levels of beneficial environmental conditions, which we refer to as Equity priority areas. Using nationally standardized environmental data from satellite imagery and other large geospatial databases and demographic data from the Canadian Census, HealthyPlan.City provides a block-by-block snapshot of environmental inequities in Canadian cities. The tool aims to support urban planners, public health professionals, policy makers, and community organizers to identify neighborhoods where targeted investments and improvements to the local environment would simultaneously help communities address environmental inequities, promote public health, and adapt to climate change. In this paper, we report on the key considerations that informed our approach to developing this tool and describe the current web-based application.

Guideline for the management of Clostridioides difficile infection in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2024 update.

Our objective was to update a clinical practice guideline for the prevention and treatment of Clostridioides difficile infection (CDI) in pediatric patients with cancer and hematopoietic cell transplantation recipients. We reconvened an international multi-disciplinary panel. A systematic review of randomized controlled trials (RCTs) for the prevention or treatment of CDI in any population was updated and identified 31 new RCTs. Strong recommendations were made to use either oral metronidazole or oral vancomycin for non-severe CDI treatment, and to use either oral vancomycin or oral fidaxomicin for severe CDI. A strong recommendation that fecal microbiota transplantation should not be routinely used to treat CDI was also made. The panel made two new good practice statements to follow infection control practices including isolation in patients experiencing CDI, and to minimize systemic antibacterial administration where feasible, especially in patients who have experienced CDI.

Lipid-Based Nanoparticles in Delivering Bioactive Compounds for Improving Therapeutic Efficacy.

In recent years, due to their distinctive and adaptable therapeutic effects, many natural bioactive compounds have been commonly used to treat diseases. Their limited solubility, low bioavailability, inadequate gastrointestinal tract stability, high metabolic rate, and shorter duration of action limited their pharmaceutical applications. However, those can be improved using nanotechnology to create various drug delivery systems, including lipid-based nanoparticles, to adjust the compounds' physicochemical properties and pharmacokinetic profile. Because of the enormous technical advancements made in the fundamental sciences and the physical and chemical manipulation of individual atoms and molecules, the subject of nanotechnology has experienced revolutionary growth. By fabricating certain functionalized particles, nanotechnology opens an innovative horizon in research and development for overcoming restrictions, including traditional medication administration systems. Nanotechnology-driven bioactive compounds are certain to have a high impact and clinical value for current and future uses. Lipid-based nanotechnologies were shown to deliver a range of naturally occurring bioactive compounds with decent entrapment potential and stability, a successfully controlled release, increased bioavailability, and intriguing therapeutic activity. This review outlines bioactive compounds such as paclitaxel, curcumin, rhodomyrtone, quercetin, kaempferol, resveratrol, epigallocatechin-3-gallate, silymarin, and oridonin, fortified within either a natural or synthetic lipid-based drug delivery system based on nanotechnology and their evaluation and clinical considerations.

Palonosetron in pediatric patients: A single-center, retrospective evaluation of policy and clinical practice guideline discordance.

INTRODUCTION: Clinical practice guidelines (CPGs) recommending palonosetron for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) were adapted for use at our institution. Palonosetron was restricted for use in patients experiencing breakthrough CINV and receiving highly emetogenic chemotherapy (HEC) or undergoing stem cell transplant conditioning and in patients with refractory CINV receiving HEC. Given the significant cost of palonosetron, we aimed to determine the proportion of chemotherapy blocks where palonosetron use was discordant with the institutional policy or source CPG. METHODS: A retrospective review of the health records of patients who received palonosetron between 1 July 2019 and 30 June 2020 was undertaken. Details of palonosetron use, antiemetic regimen and the date and time of each vomit during the acute and delayed phases were collected for each chemotherapy block where palonosetron was given. Discordance with the institutional policy and the source CPG was determined by assessing the indication for palonosetron and the dose. In the subset of chemotherapy blocks where information regarding vomiting episodes was available, the extent of acute phase chemotherapy-induced vomiting (CIV) control was reported. RESULTS: Four hundred thirty-eight chemotherapy blocks, representing 122 patients (mean age 9 years), receiving 595 palonosetron doses were included. Palonosetron use was discordant with institutional policy during most (72%; 314/438) of the chemotherapy blocks analyzed. However, palonosetron use was concordant with the source CPG during most chemotherapy blocks (74%; 326/438). Complete CIV control during the acute phase was observed in 66% (195/295) of chemotherapy blocks where palonosetron was given, irrespective of concomitant antiemetics administered. CONCLUSION: The majority of palonosetron use at our institution was discordant with institutional policy, but concordant with the source CPG. Our institutional policy has since been updated to be more aligned with the source CPG.

Formulation of Folate Receptor-Targeted Silibinin-Loaded Inhalable Chitosan Nanoparticles by the QbD Approach for Lung Cancer Targeted Delivery.

Aim: Targeted delivery of chemotherapeutics by functionalized nanoparticles exhibits a wonderful prospect for cancer treatment. The main objective of this research was to develop folate receptor-targeted silibinin (SB)-loaded inhalable polymeric nanoparticles (FA-CS-SB-NPs) for the treatment of lung cancer. Method: The qbD approach was implemented to prepare SB-loaded nanoparticles. Folic acid was conjugated by electrostatic conjugation in an optimized batch. The therapeutic potentials of formulations were determined using a lung cancer cell-bearing rat model. Result: Optimized formulation exhibited a spherical surface with a mean particle size of 275 ± 1.20 nm, a PDI of 0.234 ± 0.07, a ζ-potential of 32.50 ± 0.21, an entrapment efficiency of 75.52 ± 0.87%, and a CDR of 63.25 ± 1.21% at 48 h. Aerodynamic behaviors such as the mass median aerodynamic diameter (MMAD) and geometric size distribution (GSD) were found to be 2.75 ± 1.02 and 3.15 ± 0.88 µm, respectively. After 24 h of incubation with FA-CS-SB-NPs, the IC50 value was found to be 24.5 g/mL. FA-SB-CS-NPs maintained a significantly higher deposition of SB in lung tissues. Conclusions: Thus, the noninvasive nature and target specificity of FA-CS-SB-NPs pave the way for pulmonary delivery for treating lung cancer.

Evaluating a promising methylcellulose hydrogel for enhanced diabetic foot ulcer therapy through comprehensive preclinical studies.

The present research focuses on formulating and evaluating hydrogels modified with crosslinking agents using methylcellulose to treat diabetic foot ulcers (DFU). Methylcellulose hydrogels are prepared and characterized for their crosslinking capacity through FTIR and degradation studies. The optimized hydrogel is further assessed for viscosity, gel strength, contact angle, in-vitro biodegradation, water-vapor transmission rate, anti-bacterial activity, and in-vivo efficacy. The results demonstrate that the developed hydrogel exhibits promising properties for DFU treatment, including increased wound healing percentage, improved ulcer morphology, reduced levels of proinflammatory cytokines, and enhanced tissue characteristics. These findings suggest that the novel hydrogel composition could serve as a viable alternative to existing dressings for DFU management.

Using a Novel Gameplay Intervention to Target Intrusive Memories After Work-Related Trauma: Iterative Qualitative Analysis of Intensive Care Unit Staff Experiences.

BACKGROUND: Many intensive care unit (ICU) staff experience intrusive memories following work-related traumatic events, which can lead to long-term mental health outcomes and impact work functioning. There is a need for interventions that target intrusive memories in this population; however, factors such as mental health stigma and difficulty in fitting interventions into busy schedules can pose barriers. The Brief Gameplay Intervention For National Health Service Intensive Care Unit Staff Affected By COVID-19 Trauma (GAINS) study tested a brief, digital imagery-competing task intervention (including computer gameplay) with the aim of reducing the recurrence of intrusive memories, which holds promise for overcoming some of these barriers. OBJECTIVE: This substudy aims to explore barriers and facilitators to the uptake and practical use of the intervention by ICU staff, along with its acceptability, and iteratively explore the impact of intervention optimizations to further refine the intervention. METHODS: The GAINS study is a randomized controlled trial comparing access to a brief digital imagery-competing task intervention for 4 weeks with usual care followed by delayed access to the intervention. The participants were ICU staff who worked during the COVID-19 pandemic and experienced intrusive memories. All participants were sent a questionnaire at 4 weeks to gather data about intervention acceptability. Nested within the randomized controlled trial, a subset of 16 participants was interviewed, and data were analyzed using thematic analysis drawing from a framework approach. RESULTS: Both quantitative and qualitative data indicated high acceptability of the intervention. Intervention use data show that, on average, staff were able to target approximately 73% (3.64/4.88) of their intrusive memories and engaged with the Tetris component for the full 20 minutes per session. Overall, on the acceptability questionnaire, staff found the intervention easy to use, helpful, and highly acceptable. The interviews generated four themes: approach to the intervention, positives of the intervention, negatives of the intervention, and improvements and optimizations. Findings highlighted barriers that ICU staff experienced: stigma, feeling weak for seeking help, not wanting colleagues to know they were struggling, and skepticism. However, they provided suggestions on how barriers could be overcome and discussed the advantages of the intervention when compared with other treatments. Although participants described many positive aspects of the intervention, such as being easy to use, enjoyable, and leading to a reduction in the frequency or intensity of intrusive memories, they also raised practical issues for implementation. CONCLUSIONS: The intervention has the potential to overcome stigma and reduce the frequency of intrusive memories after traumatic events among ICU staff. Further refinement is needed to improve the adoption and reach of this intervention. A limitation is that we could not interview the National Health Service staff who were unable or unwilling to take part in the trial.

Clinical and Treatment History of Patients with Partial DiGeorge Syndrome and Autoimmune Cytopenia at Multiple Centers.

BACKGROUND: Patients with partial DiGeorge syndrome (pDGS) can present with immune dysregulation, the most common being autoimmune cytopenia (AIC). There is a lack of consensus on the approach to type, combination, and timing of therapies for AIC in pDGS. Recognition of immune dysregulation early in pDGS clinical course may help individualize treatment and prevent adverse outcomes from chronic immune dysregulation. OBJECTIVES: Objectives of this study were to characterize the natural history, immune phenotype, and biomarkers in pDGS with AIC. METHODS: Data on clinical presentation, disease severity, immunological phenotype, treatment selection, and response for patients with pDGS with AIC were collected via retrospective chart review. Flow cytometric analysis was done to assess T and B cell subsets, including biomarkers of immune dysregulation. RESULTS: Twenty-nine patients with the diagnosis of pDGS and AIC were identified from 5 international institutions. Nineteen (62%) patients developed Evan's syndrome (ES) during their clinical course and twenty (69%) had antibody deficiency syndrome. These patients demonstrated expansion in T follicular helper cells, CD19hiCD21lo B cells, and double negative cells and reduction in CD4 naïve T cells and regulatory T cells. First-line treatment for 17/29 (59%) included corticosteroids and/or high-dose immunoglobulin replacement therapy. Other overlapping therapies included eltrombopag, rituximab, and T cell immunomodulators. CONCLUSIONS: AIC in pDGS is often refractory to conventional AIC treatment paradigms. Biomarkers may have utility for correlation with disease state and potentially even response to therapy. Immunomodulating therapies could be initiated early based on early immune phenotyping and biomarkers before the disease develops or significantly worsens.

Interaction with lipopolysaccharide is key to efficacy of tryptophan- and arginine-rich α-melanocyte-stimulating hormone analogs against Gram-negative bacteria.

Aim: In order to search for novel antibacterial therapeutics against Gram-negative bacteria, the antibacterial efficacies and mechanism of action of tryptophan- and arginine-rich α-melanocyte-stimulating hormone analogs were investigated. Materials & methods: We performed a killing assay to determine their efficacy; fluorescence, microscopic studies were used to understand their mechanism and peptide-lipopolysaccharide interaction. A checkerboard assay was used to find the effective combination of peptide and antibiotics. Results: Ana-peptides displayed good killing activity against Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Their strong interaction with lipopolysaccharide damaged the bacterial membranes and led to their subsequent death. Ana-5, the highest cationic and hydrophobic analog, emerged as the most potent peptide, showing synergistic action with rifampicin and erythromycin. Conclusion: Ana-5 can be presented as an important therapeutic candidate against bacterial infections.

Bacteria can cause infections. These infections are becoming harder to treat, because excessive use of antibiotics can cause these bacteria to become less susceptible to medicine. In hospitals, these bacteria can cause infections in the lungs, urinary tract, blood, or on the skin. Our bodies make small molecules called antimicrobial peptides (AMPs) to fight against bacteria. AMPs can weaken or quickly destroy bacteria by attaching to their surfaces and breaking them down. Our laboratory has made an AMP called Ana-5. Using Ana-5 with regular medicine is better at killing bacteria. Ana-5 is not only good at fighting these bacteria, but may also help to prevent future infections.

Effectiveness of Different Rotary Files Systems in Removal of Gutta-percha during Endodontic Retreatment with or without Solvents: A Comparative Study.

AIM: The purpose of the present study was to compare the efficacy of three different file systems in removing gutta-percha during endodontic retreatment with or without solvents. MATERIALS AND METHODS: The current study used 120 freshly extracted, single-rooted human mandibular premolars extracted for orthodontic procedures. The canal was prepared utilizing the step-back technique and obturation was done. The samples were allocated into three experimental groups at random, group I: Hedstrom Files, group II: D-RaCe rotary system, and group III: Mtwo retreatment files system. The three groups were again split into two subgroups of 20 samples each, i.e., with solvent and without solvent. Then, a stereomicroscope with a magnification of × 20 was used to examine the samples. The amount of GP and sealer left was measured in three sections: At apical third (1 mm above the apex), middle third (8 mm from the apex), and coronal third (2 mm below the cementoenamel junction). The obtained data were analyzed using parametric Analysis of Variance (ANOVA). p-values less than 0.05 were considered significant. RESULTS: The overall least debris on the dentinal surface was found in the middle third with/without solvent. The D-RaCe rotary system was 1.24 ± 0.11 and 1.44 ± 0.14, Mtwo retreatment files system was 1.38 ± 0.17 and 1.72 ± 0.09 and Hedstrom files was 2.08 ± 0.21 and 2.18 ± 0.16 respectively and A significant difference was found between the three different file system groups (p < 0.001). CONCLUSION: The current study concluded that, when combined with a solvent, the D-RaCe rotary retreatment system is more effective than the Mtwo rotary retreatment system and Hedstrom Files in removing gutta-percha and sealant from root canal walls. CLINICAL SIGNIFICANCE: When it comes to treating chronic infections, non-surgical retreatment is a more cautious method than periapical surgery. Retreatment should be performed efficiently and with appropriate instruments to ensure effective treatment.

A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction.

Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have increased mortality and increased risk of stroke. Due to the heterogeneous nature of both disease processes, it is difficult to ascertain whether the diagnosis and progression of AF is the cause of deterioration or if it is a symptom of worsening heart failure. This presents physicians with a clinical conundrum of whether optimizing their heart failure will decrease the overall AF burden or if restoration of sinus rhythm is necessary to optimize patients with HFpEF. In this paper, we will review the impact of AF in patients with HFpEF, the pathophysiology and heterogeneity of HFpEF and AF, and the management of these patients. As HFpEF and AF become more prevalent, managing these disease processes needs standardization to improve outcomes. Further research is needed to understand the complex interplay between AF and HFpEF to help determine the best management strategy.