Facility-based approach for the management of acute ST segment elevation myocardial infarction with cardiogenic shock in a rural medical centre: the Durango model.

INTRODUCTION: Cardiogenic shock (CS) complicates 5%-15% of cases of acute myocardial infarction (AMI) with inpatient mortality greater than 40%. The implementation of standardised protocols may improve clinical outcomes in patients with AMI-CS. METHODS AND ANALYSIS: The Durango model is a prospective single-centre registry designed to enable early identification of patients with STEMI-CS to facilitate primary reperfusion therapy with a shock team management algorithm in a rural level II heart attack centre. This prospective registry includes all patients >18 years of age presenting with STEMI with or without CS beginning on 1 February 2023. The primary outcome measures are adherence to model-based documentation of SCAI shock Classification prehospital and in the ED with appropriate STEMI shock alert for AMI and stages C, D, E shock; use of mechanical circulatory support Pre-PCI and door to support time <90 min. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board with a waiver of informed consent. The findings will be submitted for publication in a peer-review open access journal on completion of the study. CONCLUSIONS: The Durango model will demonstrate that the implementation of a STEMI shock team can be feasible in a rural medical centre through comprehensive education of a diverse group providers with different levels of experience, continuous model/device proficiency training and performance feedback.

Additions and emendations to the annotated checklist of anthiadine fishes (Percoidei: Serranidae).

Anderson (2018) published an annotated checklist of anthiadine fishes with information on the 29 genera and 226 species then considered valid. Since then there have been a number of publications on the systematics of anthiadines, including descriptions of 23 new species and one new genus. Herein, data on those new taxa and emended accounts of others are presented.

Development of a Wireless Telemetry Sensor Device to Measure Load and Deformation in Orthopaedic Applications.

Due to sensor size and supporting circuitry, in-vivo load and deformation measurements are currently restricted to applications within larger orthopaedic implants. The objective of this study is to repurpose a commercially available low-power, miniature, wireless, telemetric, tire-pressure sensor (FXTH87) to measure load and deformation for future use in orthopaedic and biomedical applications. The capacitive transducer membrane was modified, and compressive deformation was applied to the transducer to determine the sensor signal value and the internal resistive force. The sensor package was embedded within a deformable enclosure to illustrate potential applications of the sensor for monitoring load. To reach the maximum output signal value, sensors required compressive deformation of 350 ± 24 µm. The output signal value of the sensor was an effective predictor of the applied load on a calibrated plastic strain member, over a range of 35 N. The FXTH87 sensor can effectively sense and transmit load-induced deformations. The sensor does not have a limit on loads it can measure, as long as deformation resulting from the applied load does not exceed 350 µm. The proposed device presents a sensitive and precise means to monitor deformation and load within small-scale, deformable enclosures.

Anthias albofasciatus Fowler and Bean, 1930, a junior synonym of Tosana niwae Smith and Pope, 1906 (Teleostei: Serranidae: Anthiadinae).

Anthias albofasciatus Fowler Bean, known only from the holotype collected east of Hong Kong in the South China Sea, has been considered a valid species of either Anthias or Pseudanthias. The holotype is compared with the holotype of Tosana niwae Smith Pope from Urado Bay, Shikoku, Japan, as well as non-type specimens from the South China Sea and south-eastern Japan, and shown to be conspecific. Anthias albofasciatus is therefore considered a junior subjective synonym of Tosana niwae.

Annotated checklist of anthiadine fishes (Percoidei: Serranidae).

This checklist includes information on the 29 genera and 226 species of anthiadine serranid fishes currently considered valid. For each genus the type species and number of species are given. For each species the valid name (and name under which it was originally described, if different), primary type(s), type locality, reference(s) to illustration(s), counts, and distribution are presented.

Two new species of callanthiid fishes of the genus Grammatonotus (Percoidei: Callanthiidae) from Pohnpei, western Pacific.

In late July/early August 2015, ichthyologists from the Bishop Museum collecting fishes off Pohnpei in the Caroline Islands group, western Pacific Ocean, obtained specimens of two undescribed species of Grammatonotus. One of the new species, G. xanthostigma, closely resembles the recently described G. brianne, differing most strikingly in the shape of the caudal fin. The other, G. pelipel, is distinctive in having the following combination of characters: disjunct lateral line, barred pattern of coloration (most distinctive in small individuals), and caudal fin truncate to slightly emarginate in small specimens, but with upper and lower lobes produced in largest example known. Herein we provide characters that distinguish callanthiids from other percoids and that distinguish Grammatonotus from Callanthias, the other genus in the family Callanthiidae, along with descriptions of the new species.

Grammatonotus brianne, a new callanthiid fish from Philippine waters, with short accounts of two other Grammatonotus from the Coral Triangle.

In May 2014, a group of ichthyologists from the California Academy of Sciences and the Bishop Museum collecting fishes off the coast of Batangas, Luzon, Philippine Islands, obtained, in a depth of ca. 150 meters, four specimens of a species of Grammatonotus previously unknown to science. This new species, Grammatonotus brianne, is distinguishable from its described congeners by the following combination of characters: short anal-fin spines, rhomboid shaped caudal fin, lateral line usually disjunct, and live coloration. Herein we provide characters that distinguish callanthiids from other percoids and that distinguish Grammatonotus from Callanthias, the other genus in the family Callanthiidae, along with the description of the new species and short accounts of two other Grammatonotus, G. crosnieri and G. roseus, from the Coral Triangle.

Redescription of the percoid fish Symphysanodon andersoni Kotthaus (Symphysanodontidae) from the northwestern Indian Ocean, based on the holotype and the second known specimen.

Symphysanodon andersoni was described in 1974 from a single specimen collected southwest of Socotra Island, near the entrance to the Gulf of Aden. A more recent report (2003) of its capture in the Gulf of Kutch, Arabian Sea, was based on a misidentification. The second known specimen of the Bucktoothed Slopefish, S. andersoni, (at 204 mm SL the largest known specimen of the genus Symphysanodon) was collected off the south coast of Oman, Arabian Sea, in April 2014. Symphysanodon andersoni is distinguishable from its congeners by number of tubed scales in the lateral line, 60 to 65 versus 42 to 59 in the other species of the genus. In view of the fact that S. andersoni is poorly known, we redescribe it based on the holotype and the new specimen collected off Oman and provide the first color photograph of the species.

Oral lesions you can't afford to miss.

Being able to promptly recognize and diagnose oral lesions is critical to heading off several potentially serious conditions. This article and photo guide can help.

Common questions about the management of gastroesophageal reflux disease.

Common questions that arise regarding treatment of gastroesophageal reflux disease (GERD) include which medications are most effective, when surgery may be indicated, which patients should be screened for Barrett esophagus and Helicobacter pylori infection, and which adverse effects occur with these medications. Proton pump inhibitors (PPIs) are the most effective medical therapy, and all PPIs provide similar relief of GERD symptoms. There is insufficient evidence to recommend testing for H. pylori in patients with GERD. In the absence of alarm symptoms, endoscopy is not necessary to make an initial diagnosis of GERD. Patients with alarm symptoms require endoscopy. Screening for Barrett esophagus is not routinely recommended, but may be considered in white men 50 years or older who have had GERD symptoms for at least five years. Symptom remission rates in patients with chronic GERD are similar in those who undergo surgery vs. medical management. PPI therapy has been associated with an increased risk of hip fracture, hypomagnesemia, community-acquired pneumonia, vitamin B12 deficiency, and Clostridium difficile infection.

Evaluation of nausea and vomiting: a case-based approach.

In the absence of acute abdominal pain, significant headache, or recent initiation of certain medications, acute nausea and vomiting is usually the result of self-limited gastrointestinal infections. Nausea and vomiting is also a common adverse effect of radiation therapy, chemotherapy, and surgical anesthesia. Other potential diagnoses include endocrine conditions (including pregnancy), central nervous system disorders, psychiatric causes, toxin exposure, metabolic abnormalities, and obstructive or functional gastrointestinal causes. The likely cause of acute nausea and vomiting can usually be determined by history and physical examination. Alarm signs such as dehydration, acidosis caused by an underlying metabolic disorder, or an acute abdomen warrant additional evaluation. Based on the suspected diagnosis, basic laboratory testing may include urinalysis, urine pregnancy testing, complete blood count, comprehensive metabolic panel, amylase and lipase levels, thyroid-stimulating hormone level, and stool studies with cultures. Imaging studies include abdominal radiography, ultrasonography, and computed tomography. Computed tomography of the head should be performed if an acute intracranial process is suspected. Chronic nausea and vomiting is defined by symptoms that persist for at least one month. Patients with risk factors for gastric malignancies or alarm symptoms should be evaluated with esophagogastroduodenoscopy. If gastroparesis is suspected, a gastric emptying study is recommended. In addition to functional causes, it is also important to consider psychiatric causes when evaluating patients with chronic nausea and vomiting.

In vitro catheter and sorbent-based method for clearance of radiocontrast material during cerebral interventions.

BACKGROUND: Contrast-induced acute kidney injury is a severe condition resulting from the use of radiology contrast in patients with predisposing factors. HYPOTHESIS: We hypothesized that a novel system including a device containing polymer resin sorbent beads and a custom-made suctioning catheter could efficiently remove contrast from an in vitro novel model of circulatory system (MOCS) mimicking the cerebral circulation. METHODS: A custom-made catheter was built and optimized for cerebral venous approach. The efficiency of a system made of a polymer resin sorbent beads column (CST 401, Cytosorbents) and this particular catheter was tested in the MOCS running a solution composed of 0.9% saline and radio-contrast. During two series of 18 cycles of first-pass experiments we assessed the catheter's suctioning efficiency and the system's ability to clear radio-contrast injected into the MOCS's cerebral arterial segment. We also assessed the functioning and reliability of the MOCS. RESULTS: Mean suctioning efficiency of the catheter was 84% ± 24%. The polymer sorbent column contrast removal rate was initially 96% and gradually decreased with subsequent cycles in a linear fashion during an experiment lasting approximately 90 minutes. The MOCS had a reliability of 0.9946×min(-1) where 1 × min(-1) was the optimum value. CONCLUSION: A system including a polymer resin sorbent beads column and a custom-made suctioning catheter had an excellent initial efficiency in quickly removing contrast from an artificial MOCS mimicking the cerebral circulation. MOCS is an inexpensive and relatively reliable custom-made system that can be used for training or testing purposes.

Experimental first-pass method for testing and comparing sorbent polymers used in the clearance of iodine contrast materials.

BACKGROUND: Sorbents have been shown to adsorb iodinated radiocontrast media. OBJECTIVE: In this study we describe a simple method to compare various sorbents in terms of capacity to adsorb radiocontrast media. METHODS: Iodixanol solution was injected into columns filled with three types of sorbent at filtration velocities of increasing magnitude. Two variables of interest - contrast removal rate and matched iodine retention (MIR) - were calculated to measure the adsorption efficiency and the mass of contrast iodine adsorbed versus sorbent used, respectively. RESULTS: The highest contrast removal and MIR for Porapak Q, CST 401 and Amberlite XAD4 were 41, 38 and 16% (p = 0.22 and 0.0005 for comparisons between Porapak Q-CST 401 and CST 401-Amberlite XAD4) and 0.060, 0.055 and 0.024, respectively (p = 0.18 and 0.0008). Extrapolation to a clinical scenario may suggest that removal of 8 ml iodixanol could be achieved by masses of sorbents of 43, 47 and 107 g, respectively. CONCLUSION: In this study we set a benchmark for comparing the radiocontrast-adsorbing efficiency of polymer sorbents during first-pass experiments, using a readily available methodology.

Endovascular therapy for cardiac catheterization associated strokes.

BACKGROUND: Stroke is one of the most feared complications after cardiac catheterization. Endovascular treatment combining mechanical and pharmacological therapy has been reported as an effective treatment option in selected patients with acute stroke due to large-vessel occlusion. Little is known about safety and clinical outcome when this approach is utilized in cardiac catheterization associated strokes. METHODS AND RESULTS: We analyzed clinical and radiological characteristics and outcomes in the endovascular acute stroke treatment databases from two University Hospitals from July 2006 to December 2008 (Cleveland Clinic Foundation) and September 1999 and December 2008 (UPMC Presbyterian hospital), respectively. Of a total of 419 acute stroke interventions, 14 (3.34%) were identified as strokes during or immediately after cardiac catheterization. The mean age was 71 ± 7 years; eight were women (57.1%). Mean National Institute of Health Stroke Scale was 17 (±7.6). Four patients underwent intravenous thrombolysis followed by intraarterial intervention. Median time to treatment was 240 minutes from last time seen normal (range 66-1,365 minutes). Seven patients (50%) had a favorable outcome (modified Rankin Scale [mRS]≤ 2). In-patient mortality was 42%. CONCLUSION: In acute strokes following cardiac catheterization, multimodal endovascular therapy is safe and feasible and despite a high mortality is associated with a higher than expected rate of favorable outcomes compared to the natural history of the disease. Despite a significant proportion of patients developing symptoms in hospitals where neurointerventions are available, the median time to treatment was longer than expected. Future efforts should focus on faster implementation of recanalization therapies for this form of acute stroke.

Paclitaxel-eluting versus sirolimus-eluting stents in diabetes mellitus: a report from the National Heart, Lung, and Blood Institute Dynamic Registry.

BACKGROUND: Diabetes is a powerful predictor of adverse events in patients undergoing percutaneous coronary intervention. Drug-eluting stents reduce restenosis rates compared with bare metal stents; however, controversy remains regarding which drug-eluting stents provides greater benefit in patients with diabetes. Accordingly, we compared the safety and efficacy of sirolimus-eluting stents (SES) with paclitaxel-eluting stents (PES) among diabetic patients in a contemporary registry. METHODS AND RESULTS: Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 2-year outcomes of diabetic patients undergoing percutaneous coronary interventions with SES (n=677) and PES (n=328). Clinical and demographic characteristics, including age, body mass index, insulin use, left ventricular function, and aspirin/clopidogrel use postprocedure, did not differ significantly between the groups except that PES-treated patients had a greater frequency of hypertension and hyperlipidemia. At the 2-year follow-up, no significant differences were observed between PES and SES with regard to safety or efficacy end points. PES- and SES-treated patients had similar rates of death (10.7% versus 8.2%, P=0.20), death and myocardial infarction (14.9% versus 13.6%, P=0.55), repeat revascularization (14.8% versus 17.8%, P=0.36), and stent thrombosis (1.3% versus 1.3%, P=0.95). After adjustment, no significant differences between the 2 stent types in any outcome were observed. CONCLUSIONS: PES and SES are equally efficacious and have similar safety profiles in diabetic patients undergoing percutaneous coronary interventions in clinical practice.

Late bacterial endocarditis of an amplatzer atrial septal defect occluder device.

A 66-year-old man with a large secundum atrial septal defect (ASD) that had been repaired percutaneously 30 months previously with an Amplatzer ASD occluder (ASO) presented with fevers and Staphylococcus aureus bacteremia. Transesophageal echocardiography revealed a 1.5 x 1.5 cm mobile mass on the left atrial side of his ASO consistent with a vegetation. When the ASO was explanted, the left atrial side of the device was poorly endothelialized. In conclusion, the present report is the first description of late infective endocarditis in an adult with an ASO.

Transapical off-pump removal of the native aortic valve: a proof-of-concept animal study.

OBJECTIVE: This study evaluates the feasibility of off-pump native aortic valve removal in preparation for transapical aortic valve replacement. Off-pump aortic valve replacement is performed by balloon predilatation of the native valve followed by insertion of a stented prosthesis. In patients with calcified annuli and cusps, particulate embolization, suboptimal prosthesis sizing, and perivalvular leaks may occur. Therefore, native valve removal may improve outcomes after transapical aortic valve replacement. METHODS: The aortic cusps were sequentially removed from 10 pigs in an off-pump procedure. A temporary valve was inserted percutaneously into the ascending aorta to prevent aortic regurgitation. The electrocardiogram, coronary blood flow, and arterial, left atrial, and ventricular pressures were continuously monitored. RESULTS: Removal of the aortic cusps caused a drop in diastolic arterial pressure and its equalization with left ventricular diastolic pressure. Systolic pressure decreased by 13.5%. Left atrial pressure increased by 86.0%. Coronary blood flow decreased by 39.9% and its pattern changed from mostly diastolic to mostly systolic. Electrocardiographic signs of ischemia appeared almost immediately. Percutaneous insertion of a temporary valve in the ascending aorta increased diastolic pressure and caused a tendency toward echocardiographic normalization. CONCLUSIONS: Aortic valve removal in a healthy beating heart causes acute massive aortic regurgitation, hemodynamic instability, and the rapid onset of myocardial ischemia. Reduction of left ventricular volume overload, by placement of a temporary valve in the ascending aorta, mitigates myocardial distress, helps stabilize hemodynamic parameters, and may be a useful tool to allow surgical manipulations of the aortic valve and annulus during transapical aortic valve replacement procedures.

Effects of social value orientations on fairness judgments.

The authors assessed the impact that social value orientations--prosocial (i.e., concerned about outcomes for both oneself and others) versus proself (i.e., concerned about one's own outcome only)--had on fairness judgments in a non-negotiation setting. The results indicated that prosocials generally formed fairness judgments in a manner suggested by equity theory: Given the same input as a comparison other, they saw an equal outcome as fairer than a favorable or unfavorable outcome. The fairness determinations of proselfs, however, tended to follow the tenets of self-interest theory: Given the same input as a comparison other, they saw a favorable outcome as fairer than an unfavorable outcome. Contrary to self-interest theory, proselfs did not find a favorable outcome fairer than an equal outcome. These findings indicate that social value orientations differentially affect the evaluation of outcome information in the formation of fairness judgments.

A comparison of bare-metal and drug-eluting stents for off-label indications.

BACKGROUND: Recent reports suggest that off-label use of drug-eluting stents is associated with an increased incidence of adverse events. Whether the use of bare-metal stents would yield different results is unknown. METHODS: We analyzed data from 6551 patients in the National Heart, Lung, and Blood Institute Dynamic Registry according to whether they were treated with drug-eluting stents or bare-metal stents and whether use was standard or off-label. Patients were followed for 1 year for the occurrence of cardiovascular events and death. Off-label use was defined as use in restenotic lesions, lesions in a bypass graft, left main coronary artery disease, or ostial, bifurcated, or totally occluded lesions, as well as use in patients with a reference-vessel diameter of less than 2.5 mm or greater than 3.75 mm or a lesion length of more than 30 mm. RESULTS: Off-label use occurred in 54.7% of all patients with bare-metal stents and 48.7% of patients with drug-eluting stents. As compared with patients with bare-metal stents, patients with drug-eluting stents had a higher prevalence of diabetes, hypertension, renal disease, previous percutaneous coronary intervention and coronary-artery bypass grafting, and multivessel coronary artery disease. One year after intervention, however, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug-eluting stents as compared with those with bare-metal stents, whereas the risk of repeat revascularization was significantly lower among patients with drug-eluting stents. CONCLUSIONS: Among patients with off-label indications, the use of drug-eluting stents was not associated with an increased risk of death or myocardial infarction but was associated with a lower rate of repeat revascularization at 1 year, as compared with bare-metal stents. These findings support the use of drug-eluting stents for off-label indications.

Impact of drug-eluting stents among insulin-treated diabetic patients: a report from the National Heart, Lung, and Blood Institute Dynamic Registry.

OBJECTIVES: This study sought to evaluate the safety and efficacy of drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with insulin- and noninsulin-treated diabetes. BACKGROUND: Diabetes is a powerful predictor of adverse events after percutaneous coronary interventions (PCI), and insulin-treated diabetic patients have worse outcomes. The DES are efficacious among patients with diabetes; however, their safety and efficacy, compared with BMS, among insulin-treated versus noninsulin-treated diabetic patients is not well established. METHODS: Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 1-year outcomes of insulin-treated (n = 817) and noninsulin-treated (n = 1,749) patients with diabetes who underwent PCI with DES versus BMS. RESULTS: The use of DES, compared with BMS, was associated with a lower risk for repeat revascularization for both noninsulin-treated patients (adjusted hazard ratio [HR] = 0.59, 95% confidence interval [CI] 0.45 to 0.76) and insulin-treated subjects (adjusted HR = 0.63, 95% CI 0.44 to 0.90). With respect to safety in the overall diabetic population, DES use was associated with a reduction of death or myocardial infarction (adjusted HR = 0.75, 95% CI 0.58 to 0.96). However, this benefit was confined to the population of noninsulin-treated patients (adjusted HR = 0.57, 95% CI 0.41 to 0.81). Among insulin-treated patients, there was no difference in death or myocardial infarction risk between DES- and BMS-treated patients (adjusted HR = 0.95, 95% CI 0.65 to 1.39). CONCLUSIONS: Drug-eluting stents are associated with lower risk for repeat revascularization compared with BMS in treating coronary artery disease among patients with either insulin- or noninsulin-treated diabetes. In addition, DES use is not associated with any significant increased safety risk compared with BMS. These findings suggest that DES should be the preferred strategy for diabetic patients.