Impact of routine surveillance duplex ultrasound and subsequent reintervention after superficial femoral artery stenting.

OBJECTIVE: Superficial femoral artery (SFA) stenting is a common treatment for peripheral artery disease. It is effective in the short term; however, in-stent restenosis (ISR) limits long-term success. Surveillance with duplex ultrasound (DUS) can identify patients who develop ISR leading to early reintervention, but data to support this practice is sparce. The purpose of this study was to evaluate whether surveillance and subsequent reintervention improves outcomes in patients with SFA stents. METHODS: A single-center, retrospective study was performed with patients undergoing SFA stenting between 2005 and 2020 who had a follow-up with DUS. Five groups were identified based on the presence of ISR on DUS (ISR vs no ISR [NISR]), recurrence of symptoms (symptomatic [SX] vs asymptomatic [ASX]), and if any reintervention was performed (reintervention [R] vs no reintervention [NR]): (1) ISR+SX+R; (2) ISR+SX+NR; (3) ISR+ASX+R; (4) ISR+ASX+NR; and (5) NISR+NR. The primary endpoint was amputation-free survival, and the secondary endpoint was patency. Predictors of mortality and surveillance were identified by multivariable logistic regressions and Cox multivariate regression models. Survival curves were presented as Kaplan-Meier plots using log-rank test for subgroup comparison. RESULTS: Two hundred fifty-seven patients were included in the analysis. The indication for intervention was claudication in 28% and chronic limb-threatening ischemia in 72%. A total of 161 patients (63%) underwent reintervention for ISR. Of patients who had restenosis on DUS, those who were symptomatic and did not undergo reintervention (ISR+SX+NR) did the worst, with 50% amputation rate. In contrast, those who were asymptomatic but did undergo reintervention (ISR+ASX+R) had the lowest amputation rate of 13%. Active smoking was a predictor of both loss of patency and amputation (1.72; 95% confidence interval [CI], 1.00-2.98; P = .050; 3.55; 95% CI, 1.53-8.25; P = .003). Post procedure dual antiplatelet therapy had a positive association with limb salvage (hazard ratio [HR], 0.23; 95% CI, 0.09-0.58; P = .001), whereas diabetes (HR, 2.61; 95% CI, 1.21-6.01; P = .019), stent occlusion (HR, 17.0; 95% CI, 5.93-63.1; P < .001), and chronic limb-threatening ischemia presentations (HR, 4.31; 95% CI, 1.86-11.7; P=.002) were negatively associated with limb salvage. CONCLUSIONS: Routine surveillance DUS and subsequent reintervention on ISR after SFA stenting is associated with improved patency and amputation-free survival. Surveillance DUS should be routine for patients after stenting, with reintervention strongly considered if ISR is identified for both symptomatic and asymptomatic.

Long-term outcomes of staged iliofemoral endoconduits prior to complex endovascular aortic aneurysm repair.

OBJECTIVE: Adverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (ECs) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral ECs prior to complex EVAR. METHODS: Between 2012 and 2023, 59 patients (44% male; median age, 75 ± 6 years) underwent ECs before complex EVAR using self-expanding covered stents (Viabahn). For common femoral artery (CFA) disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency. RESULTS: Unilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac, external iliac, and CFA were 7 mm (interquartile range [IQR], 6-8 mm), 6 mm (IQR, 5-7 mm), and 6 mm (IQR, 6-7 mm), respectively. Internal iliac artery was inadvertently excluded in 10 patients (17%). Six patients (10%) had an intraoperative vascular injury during the EC procedure, and six patients (10%) had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. In 23 patients (39%), 22 Fr OD devices were used; 20 Fr were used in 22 patients (37%), and 18 Fr in 14 patients (24%). Technical success for accessing EC was 89%. There was no difference in major adverse events at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82%, respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six secondary interventions (10%) were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up. CONCLUSIONS: ECs improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the EC directly under ultrasound guidance and using sequential dilation to avoid EC disruption.

Mid-term Outcomes of the Viabahn VBX® Balloon-Expandable Covered Stent for Fenestrations During Complex Endovascular Aortic Aneurysm Repair (EVAR).

OBJECTIVES: The optimal bridging stent for fenestrations during complex endovascular aortic aneurysm repair (EVAR) has not been defined. At our institution, the Viabahn VBX® is frequently used given its availability and mechanical and heparin-bonding characteristics. This study aims to assess the performance of the Viabahn VBX® versus the iCast® balloon-expandable covered stents as bridging stents for fenestrations during complex EVAR. METHODS: A retrospective study of consecutive patients undergoing complex EVAR between 2015 and 2021 was performed. Celiac arteries (CAs), superior mesenteric arteries (SMAs), left renal arteries (LRAs), and right renal arteries (RRAs) stented with fenestrations were grouped according to the type of bridging stent, VBX® versus iCast®. Target vessels (TV) stented with a branch or scallop were excluded. The primary endpoints included primary patency and freedom from target vessel instability (TVI). RESULTS: A total of 292 patients undergoing complex EVAR were treated using VBX® or iCast® with a mean follow-up of 190 days (interquartile range [IQR], 36-384) for the VBX® cohort and 804 days (IQR, 384-1507) for the iCast® cohort. A total of 677 TVs were stented, including 134 (20%) CAs, 175 (26%) SMAs, 182 (27%) LRAs, 186 (27%) RRAs, and 12 (2%) additional vessels. Proximal reinforcement was more frequent with VBX than with iCast® stent (23% vs. 2.4%, P <.0001). There was no difference in primary patency rates at 2-year between VBX® and iCast® stent for CA (100% vs. 96.4%; P=.32), SMA (97.8% vs. 100%; P=.14) and renal arteries (96.7% vs. 99.4%; P=.11). There was no difference between VBX® and iCast® in the cumulative incidence of type Ic and type IIIc endoleaks (3.2% vs. 5.6%; P=.69) or freedom from TVI at 2 years. CONCLUSION: Viabahn VBX® stents are a safe and effective option as bridging stents in fenestrations during complex EVAR with comparable mid-term outcomes to iCast® stents. However, proximal stent reinforcement may be required with VBX stent to ensure adequate sealing at the fenestrations. Longer follow-ups and larger series are required to assess long-term outcomes and durability.

Early experience with patient-specific unibody bifurcated fenestrated-branched devices for complex endovascular aortic aneurysm repair.

OBJECTIVE: Short distances between the lowest visceral/renal artery and the aortic bifurcation are technically challenging during complex endovascular aortic aneurysm repair (EVAR), particularly after previous infrarenal repair. Traditionally, inverted limb bifurcated devices have been used in addition to fenestrated-branched (FB) endografts, but short overlap, difficult cannulation, and potential crushing of bridging stents are limitations for their use. This study reviews the early experience of patient-specific company manufactured devices (PS-CMDs) with a unibody bifurcated FB design for complex EVAR. METHODS: Consecutive complex EVAR procedures over a 34-month period with unibody bifurcated FB-devices as part of physician-sponsored investigational device exemption studies at two institutions were reviewed. Unibody bifurcated FB designs included FB bifurcated or fenestrated inverted limb devices. End points included technical success, survival, frequency of type I or III endoleaks, limb occlusion, and secondary interventions. RESULTS: Among 168 patients undergoing complex EVAR, 33 patients (19.6%; 78.7% male; mean age, 77 years) received unibody bifurcated FB PS-CMDs. FB bifurcated and fenestrated inverted limb devices were used in 31 (93.9%) and 2 (6.06%) patients, respectively. The median maximum aneurysm diameter was 61 mm (interquartile range [IQR], 55-69 mm). Prior EVAR was reported by 29 patients (87.9%), of whom 2 (6.06%) had suprarenal stents. A short distance between the lowest renal artery and aortic bifurcation was demonstrated in 30 patients (90.9%), with median distance of 47 mm (IQR, 38-54 mm). Preloaded devices were used in 23 patients (69.7%). A total of 128 fenestrations were planned; 22 (17.2%) were preloaded with guidewires and 5 (3.9%) with catheters. The median operative time was 238 minutes (226-300 minutes), with a median fluoroscopy time of 65.5 minutes (IQR, 56.0-77.7 minutes) and a median dose area product of 147 mGy∗cm2 (IQR, 105-194 mGy∗cm2). Exclusive femoral access was used in 14 procedures (42.4%). Technical success was 100%. Target vessel primary patency was 100% at a median follow-up time of 11.7 months (IQR, 3.5-18.6 months). Two patients (6.06%) required reintervention for iliac occlusion; one patient required stenting and the other a femoral-femoral bypass. No aortic-related deaths occurred after the procedure. During follow-up, 11 type II endoleaks (33.3%) and 1 type Ib endoleak (3.03%) were detected; the latter was treated with leg extension. No type Ia or III endoleaks occurred. CONCLUSIONS: Complex EVAR using unibody bifurcated FB-PS-CMDs is a simple, safe, and cost-effective alternative for the treatment of patients with short distances between the renal arteries and the aortic bifurcation. Further studies are required to assess benefits and durability of unibody bifurcated FB devices.

Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections.

OBJECTIVE: Endovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. METHODS: We reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). RESULTS: Among 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. CONCLUSIONS: TES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.

Inpatient outcomes of NSTEMI among patients with immune thrombocytopenia: a propensity matched national study.

Patients with immune thrombocytopenia (ITP) admitted for non-ST elevation myocardial infarction (NSTEMI) present a unique therapeutic challenge due to the increased risk of bleeding with antiplatelet and anticoagulation therapies. There is limited evidence studying hospital mortality and complications in this population. The study included a patient cohort from the 2018-2021 National Inpatient Sample database. Propensity score matched NSTEMI patients with and without ITP using a 1:1 matching ratio. Outcomes analyzed were in-hospital mortality, rates of diagnostic angiogram, percutaneous coronary intervention (PCI), acute kidney injury (AKI), congestive heart failure (CHF), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, ventricular tachycardia (VT), ventricular fibrillation (VF), major bleeding, need for blood and platelet transfusion, length of stay (LOS), and total hospitalization charges. A total of 1,699,020 patients met inclusion criteria (660,490 females [39%], predominantly Caucasian 1,198,415 (70.5%); mean [SD] age 67, [3.1], including 2,615 (0.1%) patients with ITP. Following the propensity matching, 1,020 NSTEMI patients with and without ITP were matched. ITP patients had higher rates of inpatient mortality (aOR 1.98, 95% CI 1.11-3.50, p 0.02), cardiogenic shock, AKI, mechanical ventilation, tracheal intubation, red blood cells and platelet transfusions, longer LOS, and higher total hospitalization charges. The rates of diagnostic angiogram, PCI, CHF, VT, VF, and major bleeding were not different between the two groups. Patients with ITP demonstrated higher odds of in-hospital mortality for NSTEMI and need for platelet transfusion with no difference in rates of diagnostic angiogram or PCI.

Flavonoids and Alzheimer's disease: reviewing the evidence for neuroprotective potential.

Neurodegeneration, which manifests as several chronic and incurable diseases, is an age-related condition that affects the central nervous system (CNS) and poses a significant threat to the public's health for the elderly. Recent decades have experienced an alarming increase in the incidence of neurodegenerative disorders (NDDs), a severe public health issue due to the ongoing development of people living in modern civilizations. Alzheimer's disease (AD) is a leading trigger of age-related dementia. Currently, there are no efficient therapeutics to delay, stop, or reverse the disease's course development. Several studies found that dietary bioactive phytochemicals, primarily flavonoids, influence the pathophysiological processes underlying AD. Flavonoids work well as a supplement to manufactured therapies for NDDs. Flavonoids are effective in complementing synthetic approaches to treat NDDs. They are biologically active phytochemicals with promising pharmacological activities, for instance, antiviral, anti-allergic, antiplatelet, anti-inflammatory, antitumor, anti-apoptotic, and antioxidant effects. The production of nitric oxide (NO), tumor necrosis factor (TNF-α), and oxidative stress (OS) are downregulated by flavonoids, which slow the course of AD. Hence, this research turned from preclinical evidence to feasible clinical applications to develop newer therapeutics, focusing on the therapeutic potential of flavonoids against AD.

Pharmacological targeting of adaptor proteins in chronic inflammation.

BACKGROUND: Inflammation, a biological response of the immune system, can be triggered by various factors such as pathogens, damaged cells, and toxic compounds. These factors can lead to chronic inflammatory responses, potentially causing tissue damage or disease. Both infectious and non-infectious agents, as well as cell damage, activate inflammatory cells and trigger common inflammatory signalling pathways, including NF-κB, MAPK, and JAK-STAT pathways. These pathways are activated through adaptor proteins, which possess distinct protein binding domains that connect corresponding interacting molecules to facilitate downstream signalling. Adaptor molecules have gained widespread attention in recent years due to their key role in chronic inflammatory diseases. METHODS: In this review, we explore potential pharmacological agents that can be used to target adaptor molecules in chronic inflammatory responses. A comprehensive analysis of published studies was performed to obtain information on pharmacological agents. CONCLUSION: This review highlights the therapeutic strategies involving small molecule inhibitors, antisense oligonucleotide therapy, and traditional medicinal compounds that have been found to inhibit the inflammatory response and pro-inflammatory cytokine production. These strategies primarily block the protein-protein interactions in the inflammatory signaling cascade. Nevertheless, extensive preclinical studies and risk assessment methodologies are necessary to ensure their safety.

Relationship of neutrophil lymphocyte ratio, monocyte lymphocyte ratio and neutrophil monocyte ratio with treatment response in pulmonary tuberculosis patients during intensive phase treatment.

OBJECTIVE: To determine the relationship of Neutrophil Lymphocyte Ratio (NLR), Monocyte Lymphocyte Ratio (MLR), and Neutrophil Monocyte Ratio (NMR) with treatment response in Pulmonary Tuberculosis (PTB) patients during intensive phase treatment (IPT). METHODS: This analytical cross-sectional study was conducted at Ojha Institute of Chest Diseases (OICD), Dow University of Health Sciences, from February to December 2021. 100 patients were enrolled using purposive sampling technique. Both male and female of age 18 and above, rifampicin sensitive newly diagnosed cases of PTB by Acid Fast Bacilli (AFB) microscopy and Gene Xpert MTB/RIF were included. SPSS version 26 was used to analyze data. Numerical data was expressed in median and interquartile range and categorical data was expressed in frequencies and percentages. RESULTS: Out of total 100 patients, 81% (n = 81) showed treatment response with negative AFB Sputum Smear Microscopy (SSM) after 2nd month. Out of 81% (n = 81) of the patients who achieved treatment response, 83.9% (n = 68) also had decreased NLR, 85.2% (n = 69) had decreased MLR and 83.9% (n = 68) had decreased NMR from baseline. However 19% (n = 19) did not achieved treatment response with positive AFB SSM after 2nd month of ATT (Anti tuberculosis treatment), among them 10.52% (n = 2) were INH resistant with no decrease in all the ratios after 2nd month. CONCLUSION: Leukocyte ratios decreased significantly from baseline as PTB was treated in patients who achieved treatment response with negative AFB SSM after two months of ATT and hence these ratios could be used as markers to monitor the treatment response.

Letter to editor : optimizing surgical approaches for anterior communicating artery aneurysms: development and internal validation of a novel surgical scoring system.

The recent publication titled "Optimizing Surgical Approaches for Anterior Communicating Artery Aneurysms: Development and Internal Validation of a Novel Surgical Scoring System" presents a groundbreaking study in neurosurgery. This critique examines both the positive and negative impacts of the research. Positive aspects include the potential to improve patient outcomes through personalized surgical approaches guided by a standardized scoring system. Internal validation enhances the credibility of the scoring system. However, challenges such as the need for external validation and additional surgeon training are acknowledged. Overall, while the study offers promising advancements, further research and validation are essential for widespread implementation in clinical practice.

Letter to the editor: "A nomogram based on radiomics and clinical information to predict prognosis in percutaneous balloon compression for the treatment of trigeminal neuralgia: a retrospective cohort study of published cases".

This critique evaluates a recent study on a nomogram based on radiomics and clinical data to predict the prognosis of percutaneous balloon compression (PBC) for trigeminal neuralgia (TN), focusing on its strengths, weaknesses, and suggestions for future research. It acknowledges the innovative approach's potential to personalize treatment and improve outcomes, but raises concerns about the study's retrospective nature, sample size limitations, and challenges in implementing radiomics in clinical practice. Overall, although the nomogram offers promise, further validation in larger cohorts is essential to confirm its utility and reliability. Future research should prioritize prospective multicenter studies with standardized protocols, collaborative efforts among institutions, and innovative techniques to advance our understanding and management.

Effect of connector height and retainer occlusal thickness on the fracture resistance of posterior 4-unit monolithic 5Y-TZP fixed partial dentures after thermomechanical aging.

STATEMENT OF PROBLEM: The connector height and retainer occlusal thickness of fixed partial dentures (FPDs) may affect restoration longevity. PURPOSE: The purpose of this in vitro study was to determine and compare the fracture resistance of 4-unit monolithic 5% yttria tetragonal zirconia polycrystal (5Y-TZP) FPDs made with different connector heights and retainer occlusal thicknesses after thermomechanical aging. MATERIAL AND METHODS: Forty test metal dies were duplicated from a master metal die containing 2 anatomic abutment preparations of the mandibular right first premolar and second molar for a 4-unit FPD. The dies were divided into 2 groups of 20 each for the fabrication of 4-unit FPDs, with 2-mm and 4-mm uniform connector heights at all 3 connectors, resulting in 6.3-mm2 and 12.6-mm2 connector areas. Each of these groups was further divided into 2 subgroups based on the occlusal thickness of the 2 retainers of 1 mm and 2 mm (n=10). Polyvinyl siloxane impressions of the test metal dies were made and poured in Type V dental stone. Laboratory scans were performed on all the stone dies, and 40 5Y-TZP FPDs (Ceramill Zolid FX) were designed and fabricated. Subsequently, all the FPDs were luted on to the metal dies with a self-adhesive resin cement. The FPDs were preloaded (400 000 mechanical cycles; 4000 thermocycles) using a mastication simulator and tested for axial compressive strength. Two-way analysis of variance (ANOVA) was used to examine the effect of connector and occlusal thicknesses on the fracture load (α=.05). The data were further assessed using the post hoc Tukey HSD multiple comparison test (α=.05). RESULTS: The mean fracture load values were between 737 N and 1563 N. Significant differences in the mean fracture load were found between the connector heights (601 N; P<.001) and occlusal thicknesses (225 N; P=.002), but the interaction of the 2 factors was not significant (P=.132) The Tukey post hoc analysis showed significant differences between the connector thicknesses groups (P<.01), but the occlusal thicknesses were found to be similar for the same connector height (P=.609) CONCLUSIONS: Connector height and occlusal retainer thickness influenced the fracture load of 4-unit monolithic 5Y-TZP FPDs after thermomechanical aging.

Synthesis and characterizations of conocarpus- and azadirachta-derived activated carbons as wastewater recycling material.

Water being the most important fluid supporting the life as well as industry is getting sparse and polluted day by day. Activated carbon (AC) can be utilized in various applications of significant environmental impact and sustainable living such as carbon dioxide sensing and capturing, air purification, and water recycling. However, in the wake of the recent corona pandemic which resulted in global lockdown and took the entire world by shock, a cost-effective and simple synthesis of such a useful material remains dire need of time. Therefore, this paper describes a simple and cost-effective synthesis of activated carbon (AC) of high porosity and surface area derived from the pruning of conocarpus and azadirachta trees. In reference to the study under consideration, alongside numerous others, a furnace was employed to synthesize activated carbon. However, our approach utilized a more conventional methodology wherein the environmental parameters were not optimized. In furnace-based procedures, factors such as temperature, pressure, and humidity are meticulously regulated, contrasting with the conventional methodologies where such parameters lack optimal control. Consequently, employing a furnace does not constitute a cost-effective approach for the physical activation of organic samples thus proving a furnace is not imperative for physical activation. The synthesis was carried out by physical activation in the form of carbonization followed by chemical activation with potassium hydroxide (KOH). The influence of activated carbon from each pruning over filtration of water containing industrial dye was investigated. Activation temperature and impregnation ratio of 600-800 °C and 1:5 were selected respectively. X-ray diffraction patterns (XRD) for all AC samples indicted the appearance of broad peaks at 2θ value of 20-30° which confirms the presence of carbon in the sample. The physical morphology arrangement by SEM analysis showed uneven arrangement of pores of conocarpus which indicated higher iodine number and hence higher adsorption capacity of 442.13 mg/g.

Assessing the quality and standards of operative notes in general surgery; A teaching institute's experience in Pakistan.

Objective: To evaluate the quality and standard of hand-written operative notes in a teaching institute. Methods: This prospective study was carried out in the department of surgery, Fatima Hospital, Baqai Medical University, from January 2023 till May 2023. One hundred fifty operative notes from general surgery domain were considered. These notes were evaluated according to the guidelines of Royal College of Surgeons, with added-on a few variables by the author. Results: All 150 notes were handwritten. Resident surgeon wrote the operative notes under the supervision of primary surgeon. There was a deficiency in mentioning medical record number, procedure starting time and duration of surgery. An important statement about the hemostasis is that it is secured-per-operatively was not documented. The residents were reluctant to explain the surgical procedures diagrammatically. The operative room number was missing in all notes. Post operative instructions lacked the information for nothing per oral, blood pressure, temperature, pulse rate, and input and output charting. Conclusion: It is observed that the operative surgical notes were however explainable about the procedure, but quality and standard was not matchable with that of Royal College of Surgeons notes. Hence, a lack of formal training for the resident surgeons in operative notes writing was observed. This study is a thought provoker to the surgeons and a guide to resident trainees, and hospital management to provide a handful operative notes writing theme in the form of performa provided in the department.

Frequency of neuro-imaging in the emergency room in patients with vertigo: A cross-sectional study at a tertiary care hospital in Karachi, Pakistan.

Objective: To determine the frequency of neuro-imaging and the prevalence of positive findings in patients with vertigo visiting an emergency room of a low-middle-income-country, Pakistan. Methods: This is a retrospective cross-sectional study conducted in the emergency room of the Aga Khan University Hospital, a 550 bedded tertiary care teaching facility located in Karachi, Pakistan. The frequency of neuro-imaging in patients visiting emergency room with vertigo during 20 years (2000-2020), their findings and disposition was calculated in percentages. A cost-analysis was performed in Pakistani Rupees & US Dollars to estimate the financial burden. Results: During the emergency room visits for vertigo, neuro-imaging (CT scans, MRIs, or both) was conducted for 159 patients, accounting for 70.98% of the cases. Out of these, 64 individuals (40.25%) received a positive diagnosis, which included acute infarcts, hemorrhages, metastases, space-occupying lesions, and meningeal enhancements. Interestingly, among those with negative findings, the 98 patients faced significantly higher costs, amounting to Rs.4,108,000 ($22,449), in contrast to the positive cases, which incurred Rs.2,496,600 ($13,642). Conclusion: The frequency of obtaining neuro-imaging tests in patients with vertigo were significantly high in our study. In addition, there was a significant financial burden associated with neuro-imaging especially for our low-middle-income country.

Base Editing Landscape Extends to Perform Transversion Mutation.

Base editors have drawn considerable academic and industrial attention in recent years because of their ability to alter single DNA bases with precision. However, the existing cytosine and adenine base editors can only install transition mutations. Three recent studies (Kurt et al.,Zhao et al., and Chen et al.) expand the base editing toolbox by developing cytosine transversion base editors.

Outcomes of Elective and Non-elective Fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms.

OBJECTIVE: To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). BACKGROUND: FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. METHODS: Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. RESULTS: A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001). CONCLUSIONS: Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.

Early Results and Feasibility of Total Endovascular Aortic Arch Repair Using 3-Vessel Company-Manufactured and Physician-Modified Stent-Grafts.

OBJECTIVE: Total endovascular repair of aortic arch aneurysms is feasible in select patients. This study aims to evaluate the feasibility and early outcomes of total endovascular arch repair using 3-vessel company-manufactured devices (CMDs) and physician-modified endo grafts (PMEGs). METHODS: Patients unfit for open repair who underwent 3-vessel total arch repair at a single institution from 2018 to 2021 were reviewed. Patients received either 3-vessel inner-branch CMDs or PMEGs. Three-vessel designs were used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches in both devices were accessed via right brachial or carotid approach. The left carotid was accessed via carotid cutdown or femoral approach. The left subclavian artery was accessed via transfemoral approach. The study endpoints included procedural technical success, patient survival, neurologic events, cardiac complications, reinterventions, and target artery patency. RESULTS: Nine patients underwent treatment. Four patients were treated with PMEGs, and 5 with CMDs. Procedural technical success was 100%. There were no in-hospital deaths. There were no strokes, transient ischemic attacks, myocardial infarction, or spinal ischemia in the perioperative period. Major adverse events occurred in 3 patients (33%). Two (22%) vascular access complications and one (11%) acute kidney injury occurred. One (11%) patient required early reintervention for an access complication. The median follow-up period was 358 days (CMD, 392 days; PMEG, 198 days). There was a late reintervention and conversion to open repair at 142 days of follow-up in a patient with a PMEG that developed an aortic infection, leading to death on postoperative day 239. The mean length of stay was 7±4 days. Computed tomography imaging obtained during the immediate postoperative period revealed endoleak in 6 (66%) patients, out of which 5 resolved spontaneously and 1 required reintervention via left subclavian artery stenting. Target artery patency was 100% at the end of the follow-up period. CONCLUSIONS: Three-vessel total endovascular aortic arch repair using a CMD or PMEG is feasible with optimal early outcomes. Physician-modified stent-grafts are a feasible option for patients who do not meet anatomic criteria for CMDs. CLINICAL IMPACT: Management of aortic arch disease remains a significant challenge in vascular surgery. This study showcases the feasibility and safety of using a total endovascular approach to repair the aortic arch, which could potentially reduce morbidity and mortality associated with traditional surgical approaches. The results suggest that this minimally invasive technique could be an alternative treatment option for high-risk patients and could significantly improve outcomes for those requiring aortic arch repair. Overall, this study represents a promising development in the field of endovascular surgery and highlights the potential to improve patient outcomes.

Redo Fenestrated-Branched Endovascular Aortic Repair (F-BEVAR) for Failed F-BEVAR.

Failed fenestrated-branched endovascular aortic repair (F-BEVAR) requiring a redo F-BEVAR is a rare event. In this study, we report 2 cases of a failed F-BEVAR secondary to a type IIIb endoleak from tears on the fabric graft successfully treated with redo F-BEVAR. This is a technically challenging procedure that requires meticulous planning, advanced imaging technologies and experienced operators. Redo F-BEVAR appears to be a feasible and safe treatment option. However, larger series and long-term follow-up are needed to confirm effectiveness and durability.

Investigating theobromine as a potential anti-human coronaviral agent.

Coronaviruses (CoVs) have long been known to infect humans, mainly alpha-CoV and beta-CoV. The vaccines developed for SARS-CoV-2 are likely not effective against other coronavirus species, whereas the risk of the emergence of new strains that may cause the next epidemic/pandemic is high. The development of antiviral drugs that are effective across different CoVs represents a viable strategy for improving pandemic preparedness. In this study, we aim to identify pan-coronaviral agents by targeting the conserved main protease (Mpro). For drug screening, the catalytic dyad of four human CoVs (HCoVs: SARS-CoV-2, and seasonal CoV NL63, OC43, and 229E) was targeted by molecular docking. The identified leading candidate theobromine, a xanthine derivative, was further tested in cell culture models of coronavirus infection. Theobromine binds strongly with the catalytic dyad (His41 and Cys144/145) of SARS-CoV-2 and HCoV-NL63 Mpro, mildly with HCoV-OC43, but not with HCoV-229E. However, theobromine only shows dose-dependent inhibition in Calu3 cells inoculated with SARS-CoV-2, but not in cells inoculated with seasonal CoVs. Theobromine exerts antiviral activity against coronavirus infections potentially through targeting Mpro. However, the antiviral potency is distinct among different CoVs.