Ultrasound-Assisted Lumbar Punctures in Children: An Updated Systematic Review With Meta-Analysis.

CONTEXT: Lumbar puncture (LP) is a common procedure in children, but the rates of unsuccessful and traumatic LPs remain high. Point-of-care ultrasound (POCUS) has been proposed as a tool for improvement. OBJECTIVES: Our aim was to systematically review current evidence on the usefulness of POCUS assisted LP in children. DATA SOURCES: PubMed, Embase, and the CENTRAL were searched up to November 2022. STUDY SELECTION: We searched for randomized control trials assessing the effectiveness of POCUS assisted LP in children. DATA EXTRACTION: Data were extracted by 2 reviewers independently. RESULTS: Seven randomized control trials involving 618 participants were included. Overall, the first attempt POCUS assisted LP was successful in 72% compared with 59.6% in the standard group, regardless of the definition used. The calculated risk difference was 13.0% (95% confidence interval [CI]: 3% to 23%) I2:53%, odds ratio: 2.00 (95% CI: 1.13 to 3.53), I2: 45% and risk ratio:1.21 (95% CI: 1.01 to 1.44) I2:64%. Additionally, fewer traumatic LPs occurred in the US-assisted group, with a risk difference of -12% (95% CI: -0.22 to -0.03), odds ratio: 0.45 (95% CI: 0.26 to 0.78) and risk ratio: 0.53 (95% CI: 0.35 to 0.79). POCUS did not extend the duration of LP procedure with mean difference: -1.11 (95% CI: -2.88 to 0.66). CONCLUSIONS: POCUS improved the first attempt success rate and reduced the incidence of traumatic LPs compared with standard LP procedure in children. Therefore, if it is available, POCUS should be used routinely before every LP, especially when performed by less experienced physicians.

Health-related Quality of Life Increases After First-time Acute Myocardial Infarction: a Population-based Study.

INTRODUCTION: Acute myocardial infarction (AMI) affects patients' health-related quality of life (HRQOL). AMI may decrease HRQOL, thus negatively affecting QOL. However, the improvements in interventional treatment and early rehabilitation after AMI may have a positive effect on HRQOL. AIM: We evaluated HRQOL in patients after the first AMI treated in a reference cardiology centre in Poland and assessed which clinical variables affect HRQOL after AMI. MATERIAL AND METHODS: We prospectively evaluated HRQOL in 60 consecutive patients suffering after their first AMI during the index hospitalisation and again after 6 months, using: (i) MacNew, (ii) World Health Organization Quality of Life (WHOQOL) BREF, and (iii) Short Form (SF) 36. RESULTS: As measured by the MacNew questionnaire, global, social, and physical functioning did not change (p≥0.063), whereas emotional functioning improved 6 months after AMI, compared to index hospitalisation (p=0.002). As measured by WHOQOL BREF, physical health, psychological health, and environmental functioning did not change (p≥0.321), whereas social relationships improved 6 months after AMI (p=0.042). As assessed by SF-36, the global HRQOL improved after AMI (p=0.044). Patients with improved HRQOL in SF-36 often had a higher baseline body mass index (p=0.046), dyslipidaemia (p=0.046), and lower left ventricle ejection fraction (LVEF; p=0.013). LVEF<50% was the only variable associated with improved HRQOL in multivariate analysis (OR 4.463, 95% CI 1.045 - 19.059, p=0.043). CONCLUSIONS: HRQOL increased 6 months after the first AMI, especially in terms of emotional functioning and social relationships. Patients with LVEF<50% were likely to have improved HRQOL.

P2Y12 antagonist ticagrelor inhibits the release of procoagulant extracellular vesicles from activated platelets.

BACKGROUND: Activated platelets release platelet extracellular vesicles (PEVs). Adenosine diphosphate (ADP) receptors P2Y1 and P2Y12 both play a role in platelet activation, The present hypothesis herein is that the inhibition of these receptors may affect the release of PEVs. METHODS: Platelet-rich plasma from 10 healthy subjects was incubated with saline, P2Y1 antagonist MRS2179 (100 µM), P2Y12 antagonist ticagrelor (1 µM), and a combination of both antagonists. Platelets were activated by ADP (10 µM) under stirring conditions at 37°C. Platelet reactivity was assessed by impedance aggregometry. Concentrations of PEVs- (positive for CD61 but negative for P-selectin and phosphatidylserine) and PEVs+ (positive for all) were determined by a state-of-the-art flow cytometer. Procoagulant activity of PEVs was measured by a fibrin generation test. RESULTS: ADP-induced aggregation (57 ± 13 area under curve {AUC] units) was inhibited 73% by the P2Y1 antagonist, 86% by the P2Y12 antagonist, and 95% when combined (p < 0.001 for all). The release of PEVs- (2.9 E ± 0.8 × 108/mL) was inhibited 48% in the presence of both antagonists (p = 0.015), whereas antagonists alone were ineffective. The release of PEVs+ (2.4 ± 1.6 × 107/mL) was unaffected by the P2Y1 antagonist, but was 62% inhibited by the P2Y12 antagonist (p = 0.035), and 72% by both antagonists (p = 0.022). PEVs promoted coagulation in presence of tissue factor. CONCLUSIONS: Inhibition of P2Y1 and P2Y12 receptors reduces platelet aggregation and affects the release of distinct subpopulations of PEVs. Ticagrelor decreases the release of procoagulant PEVs from activated platelets, which may contribute to the observed clinical benefits in patients treated with ticagrelor.

Paradoxical low-flow aortic stenosis - baseline characteristics, impact on mortality.

INTRODUCTION: Paradoxical low-flow, low-gradient aortic stenosis (pLF-LGAS) constitutes an important part of the population undergoing transcatheter aortic valve implantation (TAVI). However, it remains the least defined subtype of aortic stenosis (AS). AIM: To investigate baseline characteristics and impact on mortality of pLF-LGAS in patients treated with TAVI. MATERIAL AND METHODS: Two-hundred and thirty-one consecutive patients (mean aortic valve area: 0.76 ±0.41 cm2) who underwent TAVI in our centre during the period of 6 years were included in the study. Based on echocardiographic examination, patients with pLF-LGAS were identified, analysed and compared to a population with high-gradient AS (HGAS) and low-flow, low-gradient AS with reduced ejection fraction (classical, cLF-LGAS). The primary endpoints of the study were all-cause mortality after 30 days and 1 year. RESULTS: pLF-LGAS was diagnosed in 42 (18.2%) patients, whereas 40 (17.3%) had cLF-LGAS and 149 (64.5%) had HGAS. The pLF-LGAS population was younger, had higher prevalence of hypertension, and had higher ejection fraction (EF) than the HGAS population, and had a smaller proportion of heavily symptomatic patients than the cLF-LGAS population. Overall, 46 (19.9%) patients died within 12 months after TAVI. The 30-day and 1-year survival was comparable between AS subtypes. Multivariate analysis identified severe renal failure as an independent predictor of mortality among all patients. CONCLUSIONS: pLF-LGAS is common among subjects undergoing TAVI. Patients with paradoxical AS are younger, more often burdened with hypertension and have higher EF than the HGAS population, while being less symptomatic than the cLF-LGAS group. Presence of pLF-LGAS does not seem to affect short- and mid-term survival. Severe renal failure is an independent predictor of mortality after TAVI.

Left ventricular remodelling pattern and its relation to clinical outcomes in patients with severe aortic stenosis treated with transcatheter aortic valve implantation.

INTRODUCTION: Left ventricular hypertrophy (LVH) is a common compensating process in the pressure overload mechanism of aortic stenosis (AS). AIM: To identify a group of patients with a LVH pattern which may alter periprocedural and 1-year outcomes after transcatheter aortic valve implantation (TAVI). MATERIAL AND METHODS: Echocardiographic examinations of 226 patients with severe AS treated with TAVI between March 2010 and February 2016 were retrospectively analysed and correlated with echocardiographic parameters and clinical outcomes in the study group. Ultimately 208 patients were enrolled in the study. Based on left ventricular mass index (LVMI) and relative wall thickness (RWT) patients were divided into three categories: concentric remodelling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). Most of the patients with severe AS referred for TAVI were found to have CH (n = 150, 72.8%), then EH (n = 33, 16%) and CR (n = 16, 7.8%). RESULTS: There were no significant differences between groups in terms of periprocedural outcomes or complications. After a mean observation time of 561.8 ±239.0 days, the observed all-cause mortality rate was 19.9%. After multivariable adjustment, CR remained associated with a higher risk of mortality (HR = 4.31; 95% CI: 1.607-11.538; p = 0.004). CONCLUSIONS: Left ventricular hypertrophy is common in patients with severe AS prior to TAVI. The LVH pattern does not affect TAVI-related complications. In patients with severe AS referred for TAVI, CR seems to be the least favourable geometry of LVH, increasing the risk of 1-year all-cause death.