Use of the flat panel detector fluoroscope reduces radiation exposure during periacetabular osteotomy.

The Periacetabular Osteotomy is a technically demanding procedure that requires precise intraoperative evaluation of pelvic anatomy. Fluoroscopic images pose a radiation risk to operating room staff, scrubbed personnel, and the patient. Most commonly, a Standard Fluoroscope with an Image Intensifier is used. Our institution recently implemented the novel Fluoroscope with a Flat Panel Detector. The purpose of this study was to compare radiation dosage and accuracy between the two fluoroscopes. A retrospective review of a consecutive series of patients who underwent Periacetabular Osteotomy for symptomatic hip dysplasia was completed. The total radiation exposure dose (mGy) was recorded and compared for each case from the standard fluoroscope (n = 27) and the flat panel detector (n = 26) cohorts. Lateral center edge angle was measured and compared intraoperatively and at the six-week postoperative visit. A total of 53 patients (96% female) with a mean age and BMI of 17.84 (± 6.84) years and 22.66 (± 4.49) kg/m2 (standard fluoroscope) and 18.23 (± 4.21) years and 21.99 (± 4.00) kg/m2 (flat panel detector) were included. The standard fluoroscope averaged total radiation exposure to be 410.61(± 193.02) mGy, while the flat panel detector averaged 91.12 (± 49.64) mGy (p < 0.0001). The average difference (bias) between intraoperative and 6-week postoperative lateral center edge angle measurement was 0.36° (limits of agreement: - 3.19 to 2.47°) for the standard fluoroscope and 0.27° (limits of agreement: - 2.05 to 2.59°) for the flat panel detector cohort. Use of fluoroscopy with flat panel detector technology decreased the total radiation dose exposure intraoperatively and produced an equivalent assessment of intraoperative lateral center edge angle. Decreasing radiation exposure to young patients is imperative to reduce the risk of future comorbidities.

Impact of pulsed field ablation on intraluminal esophageal temperature.

INTRODUCTION: Atrio-esophageal fistula after esophageal thermal injury (ETI) is one of the most devastating complications of available energy sources for atrial fibrillation (AF) ablation. Pulsed field ablation (PFA) uses electroporation as a new energy source for catheter ablation with promising periprocedural safety advantages over existing methods due to its unique myocardial tissue sensitivity. In preclinical animal studies, a dose-dependent esophageal temperature rise has been reported. In the TESO-PFA registry intraluminal esophageal temperature (TESO) changes in a clinical setting are evaluated. METHODS: Consecutive symptomatic AF patients (62 years, 67% male, 61% paroxysmal AF, CHA2 DS2 Vasc Score 2) underwent first-time PFA and were prospectively enrolled into our registry. Eight pulse trains (2 kV/2.5 s, bipolar, biphasic, x4 basket/flower configuration each) were delivered to each pulmonary vein (PV). Two extra pulse trains per PV in flower configuration were added for wide antral circumferential ablation. Continuous intraluminal esophageal temperature (TESO) was monitored with a 12-pole temperature probe. RESULTS: Median TESO change was statistically significant and increased by 0.8 ± 0.6°C, p < .001. A TESO increase ≥ 1°C was observed in 10/43 (23%) patients. The highest TESO measured was 40.3°C. The largest TESO difference (∆TESO) was 3.7°C. All patients remained asymptomatic considering possible ETI. No atrio-esophageal fistula was reported on follow-up. CONCLUSION: A small but significant intraluminal esophageal temperature rise can be observed in most patients during PFA. TESO rise over 40°C is rare. The clinical implications of the observed findings need to be further evaluated.

Safety and Feasibility of Catheter Ablation Procedures in Patients with Bleeding Disorders.

Aims/Objectives: Patients with bleeding disorders are a rare and complex population in catheter ablation (CA) procedures. The most common types of bleeding disorders are von Willebrand disease (VWD) and hemophilia A (HA). Patients with VWD or HA tend to have a higher risk of bleeding complications compared to other patients. There is a lack of data concerning peri- and postinterventional coagulation treatment. We sought to assess the optimal management of patients with VWD and HA referred for catheter ablation procedures. Methods and Results: In this study, we analyzed patients with VWD or HA undergoing CA procedures at two centers in Germany and Switzerland between 2016 and 2021. Clotting factors were administered in conjunction with hemostaseological recommendations. CA was performed as per the institutional standard. During the procedure, unfractionated heparin (UFH) was given intravenously with respect to the activated clotting time (ACT). Primary endpoints included the feasibility of the procedure, bleeding complications, and thromboembolic events during the procedure. Secondary endpoints included bleeding complications and thromboembolic events up to one year after catheter ablation. A total of seven patients (three VWD Type I, one VWD Type IIa, three HA) underwent 10 catheter ablation procedures (pulmonary vein isolation (PVI): two × radiofrequency (RF), one × laser balloon (LB), one × cryoballoon (CB); PVI + cavotricuspid isthmus (CTI): one × RF; PVI + left atrial appendage isolation (LAAI): one × RF; Premature ventricular contraction (PVC): three × RF; Atrioventricular nodal reentrant tachycardia (AVNRT): one × RF). VWD patients received 2000−3000 IE Wilate i.v. 30 to 45 min prior to ablation. Patients with HA received 2000−3000 IE factor VIII before the procedure. All patients undergoing PVI received UFH (cumulative dose 9000−18,000 IE) with a target ACT of >300 s. All patients after PVI were started on oral anticoagulation (OAC) 12 h after ablation. Two patients received aspirin (acetylsalicylic acid; ASA) for 4 weeks after the ablation of left-sided PVCs. No anticoagulation was prescribed after slow pathway modulation in a case with AVNRT. No bleeding complications or thromboembolic events were reported. During a follow-up of one year, one case of gastrointestinal bleeding occurred following OAC withdrawal after LAA occlusion. Conclusions: After the substitution of clotting factors, catheter ablation in patients with VWD and HA seems to be safe and feasible.

Proinflammatory cytokines levels in sepsis and healthy volunteers, and tumor necrosis factor-alpha associated sepsis mortality: A systematic review and meta-analysis.

BACKGROUND: Sepsis is a global health challenge associated with significant morbidity and mortality. Detrimental sepsis effects are attributed to excessive inflammation or a "cytokine storm." However, anti-inflammation therapies have failed to lower sepsis mortality. We aim to characterize levels of key inflammatory cytokines in patients with sepsis and compare levels with those in healthy individuals and relate tumor necrosis factor (TNF) α levels to patient characteristics and outcomes. METHODS: We performed a systematic review and meta-analysis. Medline, Embase, Cochrane Library, and Web of Science Core Collection databases were searched between 1985 and May 2020. Analysis was restricted to studies in English. We included randomized controlled trials (RCTs), controlled trials, cohort studies, case series, and cross-sectional studies that reported mean levels of cytokines in the circulation thought to be relevant for sepsis pathogenesis. We also evaluated concentrations of these cytokines in healthy individuals. The Quality in Prognosis Studies tool was used to assess the methodological quality of included studies. We extracted summary data from published reports. Data analyses were performed using a random-effects model to estimate pooled odds ratios (OR) with 95% confidence intervals for cytokine levels and mortality. This systematic review is registered in PROSPERO (CRD42020179800). FINDINGS: We identified 3654 records, and 104 studies were included with a total of 3250 participants. The pooled estimated mean TNFα concentration in sepsis patients was 58.4 pg/ml (95% Confidence Interval or CI 39.8-85.8 pg/ml), and in healthy individuals was 5.5 pg/ml (95% CI 3.8-8.0 pg/ml). Pooled estimate means for IL-1ß and IFN-γ in sepsis patients were 21.8 pg/ml and 63.3 pg/ml, respectively. Elevated TNFα concentrations associated with increased 28-day sepsis mortality (p = 0.001). In subgroup analyses, we did not detect an association between TNFα levels and sepsis source, sepsis severity, or sequential organ failure assessment (SOFA) score. A TNF-α cutoff level ≥14.7 pg/ml separated sepsis patients from healthy individuals with a sensitivity of 82.6%, a specificity of 91.7%, and a likelihood ratio of 9.9. INTERPRETATION: Sepsis mean TNFα concentration is increased approximately 10-fold compared to mean concentration in healthy individuals, and TNFα associated with sepsis mortality but not sepsis severity. The concept that elevated cytokines cause sepsis should be revisited in the context of these data. FUNDING: None.

Incarcerated umbilical hernia in a 22-month-old child.

Incarceration of an umbilical hernia (UH) rarely occurs in the pediatric population. They usually resolve spontaneously or are treated after the child turns 4-5 years old [1, 2]. Risk factors for incarceration have been identified, but little is understood about how incarceration of an UH occurs.

Individualized or fixed approach to pulmonary vein isolation utilizing the fourth-generation cryoballoon in patients with paroxysmal atrial fibrillation: the randomized INDI-FREEZE trial.

AIMS: Cryoballoon (CB) based pulmonary vein isolation (PVI) is a widely used technique for treatment of atrial fibrillation (AF); however the ideal energy dosing has not yet been standardized. This was a single-centre randomized clinical trial aiming at assessing the safety, acute efficacy, and clinical outcome of an individualized vs. a fixed CB ablation protocol using the fourth-generation CB (CB4) guided by pulmonary vein (PV) potential recordings and CB temperature. METHODS AND RESULTS: Patients were randomized in a 1:1 fashion to two different dosing protocols: INDI-FREEZE group (individualized protocol): freeze-cycle duration of time to effect plus 90 s or interruption of the freeze-cycle and repositioning CB if a CB temperature of -30°C was not within 40 s. Control group (fixed protocol): freeze-cycle duration of 180 s. No-bonus freeze-cycle was applied in either patient group. The primary endpoint was freedom from atrial tachyarrhythmia at 12 months. Secondary end points included procedural parameters and complications. A total of 100 patients with paroxysmal AF were prospectively enrolled. No difference was seen in the primary endpoint [INDI-FREEZE group: 38/47 (81%) vs. control group: 40/47, (85%), P = 0.583]. The total freezing time was significantly shorter in the INDI-FREEZE group (157 ± 56 s vs. 212 ± 83 s, P < 0.001), while procedure duration (57.9 ± 17.9 min vs. 63.2 ± 20.2 min, P = 0.172) was similar. No differences were seen in the minimum CB and oesophageal temperatures as well as in periprocedural complications. CONCLUSION: Compared to the fixed protocol, the individualized approach provides a similar safety profile and clinical outcome, while reducing the total freezing time.

Mortality risk in chronic Chagas cardiomyopathy: a systematic review and meta-analysis.

AIMS: This study aimed to estimate the annual mortality risk and its determinants in chronic Chagas cardiomyopathy. METHODS AND RESULTS: We conducted a systematic search in MEDLINE, Web of Science Core Collection, Embase, Cochrane Library, and LILACS. Longitudinal studies published between 1 January 1946 and 24 October 2018 were included. A random-effects meta-analysis using the death rate over the mean follow-up period in years was used to obtain pooled estimated annual mortality rates. Main outcomes were defined as all-cause mortality, including cardiovascular, non-cardiovascular, heart failure, stroke, and sudden cardiac deaths. A total of 5005 studies were screened for eligibility. A total of 52 longitudinal studies for chronic Chagas cardiomyopathy including 9569 patients and 2250 deaths were selected. The meta-analysis revealed an annual all-cause mortality rate of 7.9% [95% confidence interval (CI): 6.3-10.1; I2  = 97.74%; T2  = 0.70] among patients with chronic Chagas cardiomyopathy. The pooled estimated annual cardiovascular death rate was 6.3% (95% CI: 4.9-8.0; I2  = 96.32%; T2  = 0.52). The annual mortality rates for heart failure, sudden death, and stroke were 3.5%, 2.6%, and 0.4%, respectively. Meta-regression showed that low left ventricular ejection fraction (coefficient = -0.04; 95% CI: -0.07, -0.02; P = 0.001) was associated with an increased mortality risk. Subgroup analysis based on American Heart Association (AHA) classification revealed pooled estimate rates of 4.8%, 8.7%, 13.9%, and 22.4% (P < 0.001) for B1/B2, B2/C, C, and C/D stages of cardiomyopathy, respectively. CONCLUSIONS: The annual mortality risk in chronic Chagas cardiomyopathy is substantial and primarily attributable to cardiovascular causes. This risk significantly increases in patients with low left ventricular ejection fraction and those classified as AHA stages C and C/D.

Association between cytokine levels, sepsis severity and clinical outcomes in sepsis: a quantitative systematic review protocol.

INTRODUCTION: It is widely assumed that sepsis is a life-threatening systemic inflammation caused by a dysregulated host response to infection mediated by an increase in multiple proinflammatory cytokines. The levels of key proinflammatory cytokines tumour necrosis factor, interleukin-1ß and interferon γ are poorly characterised during sepsis. We believe this project will produce a 'gold-standard' document to which other reports on cytokine levels will be compared. The objective of this systematic review will be to identify key cytokine circulating levels in patients with sepsis and assess the association between these levels and morbidity and mortality outcomes related to sepsis. METHODS AND ANALYSIS: We would include reports of any design except for case reports. Sepsis patients will comprise those with a diagnosis of sepsis, severe sepsis or septic shock. The primary exposure is levels of three proinflammatory cytokines. The primary outcome is mortality at 28 or 30 days. Study subjects can be of any age, sex or ethnicity. Studies will be restricted to the English language. Medline, Embase, Cochrane Library and Web of Science Core Collection will be searched for eligible studies. A database search will include studies from 1985 to May 2020. Two reviewers will independently screen and select studies, assess methodological quality and extract data. A meta-analysis will be performed, if possible, and the Grading of Recommendations Assessment Development and Evaluation Summary of Findings presented. ETHICS AND DISSEMINATION: Formal ethical approval is not required as data will be extracted from existing literature. This systematic review will be disseminated through a peer-reviewed publication and at conference meetings. PROSPERO REGISTRATION NUMBER: CRD42020179800.

Neurodevelopmental and Mental Health Screening for Patients with Turner Syndrome in Pediatric Endocrine Clinics: Results of a Pediatric Endocrine Society Survey.

INTRODUCTION: International Turner syndrome (TS) Clinical Practice Guidelines recommend screening for neurodevelopmental (ND) and mental health (MH) concerns in girls with TS; however, it remains unclear whether this is implemented in current practice. The objective of this mixed methods study was to assess screening practices for ND and MH in girls with TS from the perspective of pediatric endocrinologists. METHODS: Pediatric Endocrine Society members who provide care for girls with TS were invited to complete an electronic survey on screening practices. Descriptive statistics were used to summarize quantitative results concurrently with thematic analysis of free-text survey responses. RESULTS: A total of 124 surveys were completed (86% attending pediatric endocrinologists, 81% at academic institutions). Overall, 25% of providers reported their patients with TS received both ND and MH screenings. Only 9 (9%) respondents endorsed screening for ND concerns themselves, while more providers (26%) reported they screen for MH concerns. Multiple barriers to screening for ND and MH concerns within the clinical setting were endorsed. Nearly all providers (>93%) reported they would consider using a short, validated screening tool for ND and MH concerns if such tools were available. DISCUSSION: A minority of pediatric endocrinologists currently perform ND or MH screening for patients with TS, however, many would be interested in implementing a brief screening tool into their clinical practice. Given almost all girls with a TS diagnosis receive care from pediatric endocrinologists at least annually, this may be an effective method to increase the proportion of girls with TS who receive recommended screenings.

Plasma DNA and RNA differentially impact coagulation during abdominal sepsis-an explorative study.

BACKGROUND: Cell-free DNA (cfDNA) and extracellular RNA (exRNA) are both suspected to activate coagulation cascades in sepsis. Therefore, our study investigated the influence of plasmatic nucleic acids on coagulation in septic patients in comparison to patients after major abdominal surgery. MATERIALS AND METHODS: A total of 15 patients with sepsis, 10 postoperative patients, and 10 healthy volunteers were included in this longitudinal study. Blood was collected at sepsis onset and after surgery respectively, as well as after 24, 72 and 168 h. Levels of cfDNA and exRNA were measured by quantitative probe-based polymerase chain reaction. In addition, thromboelastography for coagulation as well as thromboaggregometry for platelet function was conducted. RESULTS: Both cfDNA and exRNA were elevated in patients with sepsis compared with postoperative patients and healthy volunteers. While higher exRNA levels correlated with a faster clotting time and more stable clots, cfDNA correlated with a shorter clotting time but also less fibrinolysis. In addition, higher cfDNA seems to be associated with kidney dysfunction as well as with general markers of cell damage (lactate dehydrogenase and lactate). CONCLUSIONS: Both nucleic acid species might be associated with different effects on coagulation during sepsis, with an overall procoagulatory influence. For this reason, individualized therapeutic approaches in patients suffering from coagulation-associated organ dysfunction might be feasible.

Mushroom poisoning: a case report from Jordan.

An eight years male child with his family ate fresh mushroom at lunch time from back garden at their home in a village in the North of Jordan. By the evening approximately six hours later all started feeling nausea, abdominal cramps and vomiting they rushed to nearest primary health care center. After getting general medical medication they were transfer to a referral hospital at city of Irbid. The boy got deteriorated with diarrhea in addition to the previous gastrointestinal complains and died on third day. The message from this case is to ascertain in the public opinion that unknown type of mushroom even eaten previously could be poisonous and fetal.

Hypolipidaemic effects of Citrullus colocynthis L. in rabbits.

Aim of this research to study the effect of Citrullus colocynthis (70% EtOH) extract on lipid profile on Rabbits. The plant extract was orally administered to the atherogenic rabbits (atherogenic diet + cholesterol powder supplement 400 mg/kg/body weight/day dissolved in 5 mL coconut oil) at dose of 1.2 g kg(-1) body weight/day. During the hall period of the experiment blood was collected and serum was analyzed for lipid profile. Animals were sacrificed; the heart and the liver were collected and kept at -20 degrees C until assayed. Biochemical analysis of blood serum and tissue (liver and heart muscle) level were made for cholesterol, Phospholipids and triglycerides. In addition blood serum was analyzed further for HDL-Cholesterol. All the results were statistically analyzed using students t-test. Hypolipidaemic nature of Citrullus colocynthis (70% EtOH) extract was studied in hyperlipidaemic Rabbits. The increased cholesterol levels were brought to normal by administration of Citrullus colocynthis. Serum cholesterol levels dropped from 940.7 to 230.41 (75.55%) and further to 119.2 (87.32%) by the end of the experiment. Similarly, phospholipids and triglycerides levels were observed to be also reduced. The tissues lipids profiles of liver and heart muscle showed similar changes in those noticed in serum lipids. Citrullus colocynthis possesses active hypolipidaemic constituents.