ABSTRACT
OBJECTIVES: To assess coronary artery calcification (CAC) on non-contrast non-ECG-gated CT thorax (NC-NECG-CTT) and to evaluate its correlation with short-term risk of cardiovascular disease (CVD) events and death. METHODS: Single-institution retrospective study including all patients 40-70 years old who underwent NC-NECG-CTT over a period of 6 months. Individuals with known CVD were excluded. The presence of CAC was assessed and quantified by the Agatston score (CACS). CAC severity was defined as mild (< 100), moderate (100-400), or severe (> 400). CVD events (including CVD death, myocardial infarction, revascularisation procedures, ischaemic stroke, acute peripheral atherosclerotic ischaemia), and all-cause mortality over a median of 3.5 years were recorded. Cox proportional-hazards regression modelling was performed including CACS, age, gender and CVD risk factors (smoking, hypertension, diabetes mellitus, dyslipidaemia, and family history of CVD). RESULTS: Of the total 717 eligible cases, 325 (45%) had CAC. In patients without CAC, there was only one CVD event, compared to 26 CVD events including 5 deaths in patients with CAC. The presence and severity of CAC correlated with CVD events (p < 0.001). A CACS > 100 was significantly associated with both CVD events, hazard ratio (HR) 5.74, 95% confidence interval: 2.19-15.02; p < 0.001, and all-cause mortality, HR 1.7, 95% CI: 1.08-2.66; p = 0.02. Ever-smokers with CAC had a significantly higher risk for all-cause mortality compared to never-smokers (p = 0.03), but smoking status was not an independent predictor for CVD events in any subgroup category of CAC severity. CONCLUSIONS: The presence and severity of CAC assessed on NC-NECG-CTT correlates with short-term cardiovascular events and death. KEY POINTS: ⢠Patients aged 40-70 years old without known CVD but with CAC on NC-NECG-CTT have a higher risk of CVD events compared to those without CAC. ⢠CAC (Agatston) score above 100 confers a 5.7-fold increase in the risk of short-term CVD events in these patients. ⢠The presence and severity of CAC on NC-NECG-CTT may have prognostic and therapeutic implications.
Subject(s)
Brain Ischemia , Coronary Artery Disease , Stroke , Vascular Calcification , Humans , Adult , Middle Aged , Aged , Retrospective Studies , Coronary Vessels , Coronary Angiography/methods , Risk Factors , Risk Assessment , Coronary Artery Disease/diagnostic imaging , Tomography, X-Ray Computed , Thorax , Vascular Calcification/diagnostic imaging , PrognosisABSTRACT
INTRODUCTION: Atrial fibrillation (AF) is frequent after any cardiac surgery, but evidence suggests it may have no significant impact on survival if sinus rhythm (SR) is effectively restored early after the onset of the arrhythmia. In contrast, management of preoperative AF is often overlooked during or after cardiac surgery despite several proposed protocols. This study sought to evaluate the impact of preoperative AF on mortality in patients undergoing isolated surgical aortic valve replacement (AVR). METHODS: We performed a retrospective, single-center study involving 2628 consecutive patients undergoing elective, primary isolated surgical AVR from 2008 to 2018. A total of 268/2628 patients (10.1%) exhibited AF before surgery. The effect of preoperative AF on mortality was evaluated with univariate and multivariate analyses. RESULTS: Short-term mortality was 0.8% and was not different between preoperative AF and SR cohorts. Preoperative AF was highly predictive of long-term mortality (median follow-up of 4 years [Q1-Q3 2-7]; hazard ratio [HR]: 2.24, 95% confidence interval [CI]: 1.79-2.79, p < .001), and remained strongly and independently predictive after adjustment for other risk factors (HR: 1.54, 95% CI: 1.21-1.96, p < .001) compared with preoperative SR. In propensity score-matched analysis, the adjusted mortality risk was higher in the AF cohort (OR: 1.47, 95% CI: 1.04-1.99, p = .03) compared with the SR cohort. CONCLUSIONS: Preoperative AF was independently predictive of long-term mortality in patients undergoing isolated surgical AVR. It remains to be seen whether concomitant surgery or other preoperative measures to correct AF may impact long-term survival.
Subject(s)
Atrial Fibrillation , Heart Valve Prosthesis Implantation , Aortic Valve/surgery , Atrial Fibrillation/complications , Atrial Fibrillation/surgery , Humans , Retrospective Studies , Risk Factors , Treatment OutcomeABSTRACT
The chromosome 16p13 region has been associated with several autoimmune diseases, including type 1 diabetes (T1D) and multiple sclerosis (MS). CLEC16A has been reported as the most likely candidate gene in the region, since it contains the most disease-associated single-nucleotide polymorphisms (SNPs), as well as an imunoreceptor tyrosine-based activation motif. However, here we report that intron 19 of CLEC16A, containing the most autoimmune disease-associated SNPs, appears to behave as a regulatory sequence, affecting the expression of a neighbouring gene, DEXI. The CLEC16A alleles that are protective from T1D and MS are associated with increased expression of DEXI, and no other genes in the region, in two independent monocyte gene expression data sets. Critically, using chromosome conformation capture (3C), we identified physical proximity between the DEXI promoter region and intron 19 of CLEC16A, separated by a loop of >150 kb. In reciprocal experiments, a 20 kb fragment of intron 19 of CLEC16A, containing SNPs associated with T1D and MS, as well as with DEXI expression, interacted with the promotor region of DEXI but not with candidate DNA fragments containing other potential causal genes in the region, including CLEC16A. Intron 19 of CLEC16A is highly enriched for transcription-factor-binding events and markers associated with enhancer activity. Taken together, these data indicate that although the causal variants in the 16p13 region lie within CLEC16A, DEXI is an unappreciated autoimmune disease candidate gene, and illustrate the power of the 3C approach in progressing from genome-wide association studies results to candidate causal genes.
Subject(s)
Autoimmune Diseases/genetics , DNA-Binding Proteins/genetics , DNA/genetics , Membrane Proteins/genetics , Chromosomes, Human, Pair 16 , Humans , Monocytes/metabolism , Polymerase Chain Reaction , Polymorphism, Single Nucleotide , Quantitative Trait LociABSTRACT
The scope of artificial intelligence (AI) in healthcare is promising, and AI has the potential to revolutionise the field of palliative care services also. Consumer satisfaction in palliative care is a critical aspect of providing high-quality end-of-life support. It encompasses various elements that contribute to a positive experience for both patients and their families. AI-based tools and technologies can help in early identification of the beneficiaries, reduce the cost, improve the quality of care and satisfaction to the patients with chronic life-limiting illnesses. However, it is essential to ensure that AI is used ethically and in a way that complements, rather than replaces, the human touch and compassionate care, which are the core components of palliative care. This article tries to analyse the scope and challenges of improving consumer satisfaction through AI-based technology in palliative care services.
Subject(s)
Artificial Intelligence , Palliative Care , Humans , Patient Satisfaction , Consumer BehaviorABSTRACT
BACKGROUND: Palliative care is gaining global attention and is endorsed in high level policy commitments,but progress towards universal palliative care coverage is constrained in many countries. The WHO released a new conceptual model for the assessment of palliative care development in 2021, comprising 18 indicators to measure a country's palliative care situation. Of these 10 core indicators to be used to monitor the progressof palliative care in countries at more mature stage of development. The coreindicators would then facilitate both in country and global comparativeanalysis and will also inform decision makers about the gaps and challenges in palliative care provision. AIM: This article tries to analyse the position of the development of palliative care in India on the 10 coreindicators and uses information from various relevant secondary resources. RESULTS: National programme forpalliative care (2017) has been included in the National Health Mission and policies on palliative care have been framed by four states: Kerala, Maharashtra, Karnataka and Tamilnadu. While significant improvement in the availability of palliative care services across India have been observed, regional and state- wise disparities remain high. CONCLUSION: Our analysis indicates that the prosed set of indicators by WHO can be a valuable means to monitor the progress of palliative care development in the country on a year- on -year basis.
Subject(s)
Hospice and Palliative Care Nursing , Palliative Care , Humans , India , Policy , World Health OrganizationABSTRACT
INTRODUCTION: This study aimed to investigate whether the direction of force applied to the occlusal surface influenced the pattern of tensile stresses in roots of sound and root canal-prepared mandibular molar teeth. The effect of obturation forces on the development of apical stress was also investigated. To this end, models were constructed using micro-computed tomographic imaging and investigated using finite element analysis. METHODS: Micro-computed tomographic data established boundaries of internal and external model surfaces to allow finite element analysis. Individually segmented components were modeled based on mechanical properties in precedent literature. The following conditions were considered: axial force directed over the mesial marginal ridge, a mesial or a distal tipping force, a combination of both a torquing force and axial loading, and hydrostatic pressure. The maximum principal stresses were determined. RESULTS: The highest root stress occurred in the cervical third of root surfaces (ie, not apically) under all loading conditions. Importantly, mesial tipping forces resulted in tension on distal roots, whereas distal tipping resulted in tension in the mesial roots. Intracanal pressures produced tensile stress on the internal root canal walls in the cervical third of the root. Stresses were calculated to be less than the fatigue tensile strength of dentin. CONCLUSIONS: Static loading, under the conditions modeled, does not result in stress concentration at the root apices that would cause root fracture under normal masticatory loads. Stress patterns developing from mesial and distal tipping forces help to explain the appearance of vertical root fractures reported in sound nonrestored molar teeth.
Subject(s)
Molar , Root Canal Preparation , Dental Stress Analysis/methods , Finite Element Analysis , Root Canal Therapy , Stress, Mechanical , Tooth Root/diagnostic imagingABSTRACT
OBJECTIVE: To identify a plasma biomarker of atheromatous disease. METHODS AND RESULTS: Surface-enhanced laser desorption ionization-time-of-flight mass spectrometry was used to identify possible plasma protein biomarkers of atheromatous disease in patients presenting with chronic stable angina pectoris by comparing those with 3-vessel disease with those without any evidence of coronary artery disease. The level of a 14.7-kDa protein was elevated; this protein was isolated and identified as a lysozyme. Arterial plasma lysozyme levels, measured by immunoassay, confirmed this observation in separate cohorts of patients. The application of arterial plasma lysozyme levels to 197 patients with varying degrees of coronary artery disease, using a cutoff value of 1.5 microg/mL, was able to distinguish patients with 1 or more occluded coronary arteries, with 86% sensitivity and 93% specificity. Of 20 patients with carotid atheroma, 19 had increased arterial plasma levels. In contrast, C-reactive protein levels showed no association with disease severity. Venous lysozyme levels in patients with carotid atheroma were shown to decrease after intensive atorvastatin treatment. CONCLUSION: Raised plasma lysozyme levels may be a useful biomarker of atherosclerotic cardiovascular disease and response to therapy. Additional studies to investigate this are warranted.
Subject(s)
Carotid Artery Diseases/enzymology , Coronary Artery Disease/enzymology , Muramidase/blood , Aged , Angina Pectoris/enzymology , Angina Pectoris/etiology , Atorvastatin , Biomarkers/blood , C-Reactive Protein/metabolism , Carotid Artery Diseases/drug therapy , Coronary Angiography , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Female , Heptanoic Acids/therapeutic use , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Immunoassay , Male , Middle Aged , Predictive Value of Tests , Pyrroles/therapeutic use , Sensitivity and Specificity , Severity of Illness Index , Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization , Treatment Outcome , Up-RegulationABSTRACT
The concept of prosthesis-patient mismatch (PPM) has gained much attention since first described 40 years ago. Previous studies have shown conflicting evidence regarding increased early and late morbidity and mortality with PPM after aortic valve replacement (AVR). The aim of this study was to evaluate the effects of PPM on short- and long-term mortality in low-risk patients after isolated AVR. A retrospective, single-center study involving 1707 consecutive patients ≤80 years of age with preserved left ventricular systolic function who underwent elective, primary isolated AVR operations from 2008 to 2018. Patients were stratified into 2 groups according to the presence of PPM (nâ¯=â¯96), defined as effective orifice area index <0.85 cm2/m2 body surface area, and no-PPM (nâ¯=â¯1611). The effect of PPM on mortality was evaluated with univariate and multivariate analyses. 30-day mortality was 0.8% (4.2% in PPM group vs 0.6 in no-PPM group; Pâ¯=â¯0.005). PPM occurred more in female gender, obese and older patients. PPM was highly associated with long-term all-cause mortality (median 4 years [Q1-Q3 2-7]; HR: 1.79, 95% CI: 1.27-2.55, Pâ¯=â¯0.002), and remained strongly and independently associated after adjustment for other risk factors (HR: 1.60, 95% CI: 1.10-2.34, Pâ¯=â¯0.014). In propensity score-matched analysis, the adjusted mortality risk was higher in PPM group (HR: 2.03, 95% CI: 1.22-3.39, Pâ¯=â¯0.006) compared to no-PPM group. In a single-centre observational study, PPM increased early mortality and was independently associated with long-term all-cause mortality after low-risk, primary isolated AVR operations. Strategies to avoid PPM should be explored and implemented.
Subject(s)
Aortic Valve Stenosis , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Female , Heart Valve Prosthesis Implantation/adverse effects , Humans , Prosthesis Design , Retrospective Studies , Treatment OutcomeABSTRACT
Variant angina is caused by focal spasm of the epicardial coronary arteries and is variably associated with atherosclerotic coronary disease. We present the clinical course of profound coronary spasm in a woman which resulted in life-threatening symptoms. Although not previously reported, administration of the endothelin antagonist bosentan resulted in complete resolution of her symptoms which were refractory to commonly used anti-anginals, and these symptoms recurred when the drug was inadvertently withdrawn, confirming efficacy of the agent. The details of her clinical outcome and a review of the role of endothelin and its antagonists in coronary vasospasm are discussed.
Subject(s)
Angina Pectoris, Variant/drug therapy , Antihypertensive Agents/therapeutic use , Coronary Vasospasm/drug therapy , Endothelins/antagonists & inhibitors , Sulfonamides/therapeutic use , Angina Pectoris, Variant/etiology , Angina Pectoris, Variant/metabolism , Bosentan , Coronary Vasospasm/complications , Coronary Vasospasm/metabolism , Endothelins/metabolism , Female , Humans , Middle Aged , Treatment OutcomeABSTRACT
Wegener's granulomatosis (WG) is a systemic necrotising vasculitis involving the respiratory and renal tracts. Dual valvular involvement in WG is uncommon. We describe a 52-year-old patient with aortic regurgitation and mitral stenosis due to WG requiring replacement of both valves. We also discuss a strategy for follow-up of asymptomatic WG patients with suspected heart valve involvement.
Subject(s)
Aortic Valve Insufficiency/etiology , Granulomatosis with Polyangiitis/complications , Mitral Valve Stenosis/etiology , Aortic Valve Insufficiency/diagnostic imaging , Aortic Valve Insufficiency/pathology , Biopsy , Echocardiography, Transesophageal , Eosinophils/pathology , Granulomatosis with Polyangiitis/pathology , Humans , Male , Middle Aged , Mitral Valve Stenosis/diagnostic imaging , Mitral Valve Stenosis/pathologyABSTRACT
Patients with high spinal cord injury may present with significant cardiac dysautonomia. There is a dearth of data regarding electromechanical interference to cardiac pacemakers from phrenic nerve stimulators which are used in such patients for respiratory support. We report an instance of bipolar lead permanent pacemaker insertion for ventricular standstill in a man with quadriplegia following C2 fracture and the measures we adopted to minimise electromagnetic interference with phrenic nerve stimulators. To the best of our knowledge, this is the first reported instance of successful pacemaker insertion in a quadriplegic patient on long-term diaphragmatic pacing.
Subject(s)
Bradycardia/therapy , Cardiac Pacing, Artificial/methods , Electric Stimulation Therapy/methods , Phrenic Nerve/physiology , Quadriplegia/complications , Respiratory Insufficiency/therapy , Aged , Diaphragm/innervation , Electrodes, Implanted , Humans , Male , Pacemaker, Artificial , Phrenic Nerve/diagnostic imaging , Radiography , Respiratory Insufficiency/diagnostic imaging , Respiratory Insufficiency/etiology , Spinal Cord Injuries/complicationsABSTRACT
A radicular variant of dens invaginatus (DI) is a rare form of dens invaginatus which develops in the root of the tooth after the crown development is completed. This report involves successful management of a case with guided tissue regeneration and describes the cone beam computed tomography (CBCT) characteristics of true radicular DI. A 20-year-old woman reported with recurrent swelling and pus discharge associated with her maxillary left central incisor (#21). Cone beam computed tomography (CBCT) of the region revealed #21 had an invagination in the mesial aspect of the coronal third of the root with a para radicular low-density region perforating both the cortices. A diagnosis of true radicular variant of DI was made by exclusion. The case was managed with Biodentine® , platelet-rich fibrin and freeze-dried demineralised bone graft. A 2-year review showed that the tooth was functional with normal periodontal parameters and normal response to electric pulp sensibility test.
Subject(s)
Dens in Dente , Guided Tissue Regeneration , Platelet-Rich Fibrin , Adult , Female , Humans , Incisor , Root Canal Therapy , Young AdultABSTRACT
BACKGROUND: COVID-19 can present with cardiovascular complications. CASE SUMMARY: We present a case report of a 43-year-old previously fit patient who suffered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with thrombosis of the coronary arteries causing acute myocardial infarction. These were treated with coronary stenting during which the patient suffered cardiac arrest. He was supported with automated chest compressions followed by peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). No immediate recovery of the myocardial function was observed and, after insufficient venting of the left ventricle was diagnosed, an Impella 5 pump was implanted. The cardiovascular function recovered sufficiently and ECMO was explanted and inotropic infusions discontinued. Due to SARS-CoV-2 pulmonary infection, hypoxia became resistant to conventional mechanical ventilation and the patient was nursed prone overnight. After initial recovery of respiratory function, the patient received a tracheostomy and was allowed to wake up. Following a short period of agitation his neurological function recovered completely. During the third week of recovery, progressive multisystem dysfunction, possibly related to COVID-19, developed into multiorgan failure, and the patient died. DISCUSSION: We believe that this is the first case report of coronary thrombosis related to COVID-19. Despite the negative outcome in this patient, we suggest that complex patients may in the future benefit from advanced cardiovascular support, and may even be nursed safely in the prone position with Impella devices.
Subject(s)
Cardiac Pacing, Artificial/methods , Echocardiography, Transesophageal/methods , Aged , Humans , MaleABSTRACT
UNLABELLED: Familial nonsyndromal multiple supernumerary teeth is a rare condition. The prevalence, unique distribution, potential complications, associated conditions, aetiology and treatment options of this condition are discussed in this case report. This paper also comments on the potential of genetic studies on the defects affecting tooth number. CLINICAL RELEVANCE: This paper describes the considerations dental practitioners have to take when they encounter a case of multiple supernumerary teeth.
Subject(s)
Tooth, Impacted/diagnostic imaging , Tooth, Supernumerary/genetics , Female , Humans , Male , Radiography , Siblings , Tooth, Supernumerary/diagnostic imaging , Young AdultABSTRACT
Incomplete endodontic treatment is potentially a public health issue. The aim of this retrospective study was to evaluate the endodontic treatment completion rate at a University student clinic and to identify the factors associated with completion rates. The records of all patients who commenced an endodontic treatment (code 415) from January 2015 to December 2015 were extracted. A total of 783 records were available for analysis of which 86% received complete endodontic treatment. Maxillary first molars were significantly associated with incomplete endodontic treatment (IET). Patients requiring an additional visit (code 455) were 1.5 times more likely to have an IET. The endodontic treatment completion rate at the School of Dentistry at the University of Queensland is higher than those reported in other international university-based student clinics. Focus group surveys of students and supervisors are required to identify the reasons for higher IET with maxillary first molars and code 455.
Subject(s)
Root Canal Therapy , Universities , Humans , Molar , Retrospective Studies , StudentsABSTRACT
A 51-year-old woman with known primary antiphospholipid syndrome presented with a 4-day history of chest and abdominal pain, inferior ST-segment elevation on a 12-lead ECG and a subtherapeutic international normalised ratio. In view of a significantly raised high-sensitivity troponin I assay, inferior wall hypokinesis on transthoracic echocardiography and despite unobstructed epicardial vessels on emergency coronary angiography, a diagnosis of myocardial infarction was made. Furthermore, the patient also developed both bilateral adrenal haemorrhages leading to acute adrenal insufficiency and microvascular thrombotic renal disease concurrently. The patient therefore fulfilled the diagnostic criteria for catastrophic antiphospholipid syndrome presenting with cardiac, endocrine and renal involvement. Early diagnosis permitted appropriate treatment with anticoagulation, dual antiplatelet therapy, secondary prevention and corticosteroid replacement therapy and led to a full recovery. This case highlights first the importance of adequate anticoagulation in antiphospholipid syndrome and, second, the potentially fatal, multiorgan complication of failure to do so.
Subject(s)
Antiphospholipid Syndrome/complications , Coronary Vessels/diagnostic imaging , Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/physiopathology , Adrenal Cortex Hormones/administration & dosage , Adrenal Cortex Hormones/therapeutic use , Adrenal Insufficiency/complications , Antiphospholipid Syndrome/diagnosis , Antiphospholipid Syndrome/drug therapy , Chest Pain/diagnosis , Chest Pain/etiology , Coronary Angiography/methods , Coronary Vessels/anatomy & histology , Early Diagnosis , Echocardiography/methods , Electrocardiography , Female , Humans , Kidney Diseases/pathology , Middle Aged , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/pathology , Platelet Aggregation Inhibitors/administration & dosage , Platelet Aggregation Inhibitors/therapeutic use , Thrombosis , Treatment Outcome , Troponin I/metabolismABSTRACT
Ventricular free wall rupture is a catastrophic complication of acute myocardial infarction accounting for a significant proportion of in-patient deaths. Various imaging modalities including two-dimensional and contrast echocardiography have been applied for the early diagnosis of free wall rupture. Cardiac magnetic resonance imaging has recently gained favor as a tool providing accurate diagnosis and visualization of the site of rupture to enable planned surgery. We present a case of subacute free wall rupture where contrast enhanced myocardial resonance imaging helped to delineate the location and extent of the myocardial tear, thereby prompting appropriate surgical intervention.