Kidney outcomes and prognostic factors of myeloma associated acute kidney injury in the contemporary era.

Myeloma cast nephropathy (MCN) has historically been associated with poor kidney outcomes. We aimed to evaluate the kidney outcomes and identify prognostic factors of myeloma-associated acute kidney injury (M-AKI) in the contemporary era of anti-plasma cell therapy. Patients who received anti-myeloma therapy with M-AKI (January 2012 to June 2020) from a single centre were identified from electronic medical records. Diagnosis of MCN was either biopsy confirmed (BC) or clinically suspected (CS), the latter defined as acute kidney injury with reduced estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 and involved serum free light chains (iSFLC) >500 mg/L at diagnosis. Twenty-six patients with M-AKI were identified (BC: n = 13, CS: n = 13). Median eGFR at diagnosis was 12 (interquartile range 6-20) mL/min/1.73 m2 . All six dialysis-requiring patients achieved dialysis independence after 71 (43-208) days. The best-achieved eGFR was 47 (32-67) mL/min/1.73 m2 after 120 (63-167) days post-treatment, which was maintained at 47 (33-66) mL/min/1.73 m2 12 months post-treatment. Patients with best-achieved eGFR above the median were more likely to have achieved an iSFLC of <20 mg/L (above median group 62% versus below median group 0%; p < .001) and lower best post-treatment iSFLC (20 (12-90) versus 67 (29-146) mg/L; p < .05). Best-achieved iSFLC was a prognostic factor for superior eGFR following treatment for M-AKI. Despite low eGFR at diagnosis, contemporary anti-myeloma therapy can achieve significant recovery of kidney function.

Co-leadership to co-design in mental health-care ecosystems: what does it mean to us?

PURPOSE: This study aims to demonstrate how service providers, service users and their families should be able to share the co-leadership, co-auspicing, co-ownership, and co-governance, of a the mental health-care ecosystem, at every level, as it develops upwards and wider, in a process of inclusivity, conviviality and polyphonic discourse, via the overlapping phases of co-creativity, codesign, co-production, co-delivery, co-evaluation, co-research and co-replication, to achieve outcomes of co-communal or organisational well-being. DESIGN/METHODOLOGY/APPROACH: "Co-design" is shorthand code for encouraging multiple pathways and trajectories toward forming and sustaining a sparkling web or vibrant network of inclusive opportunities for stakeholder participation and a collaborative partnership in organizational development, in these circumstances, for more effective mental health services (MHSs). FINDINGS: In a co-design framework, all partners should be entitled to expect and "to have and to hold" an ongoing equal stake, voice and power in the discourse from start to finish, in a bottom-up process which is fostered by an interdisciplinary leadership group, providing the strong foundation or nutrient-rich and well-watered soil and support from which a shared endeavor can grow, blossom and generate the desired fruit in ample quality and quantity. ORIGINALITY/VALUE: The authors should be working toward co-design and co-production of contemporary MHSs in a mental health-care ecosystem.

Functional coronary angiography in symptomatic patients with no obstructive coronary artery disease.

BACKGROUND: Patients without obstructive coronary artery disease (CAD) may have epicardial or microvascular dysfunction. The purpose of this study was to characterize patterns of epicardial and microvascular dysfunction in men and women with stable and unstable angina undergoing functional coronary angiography to inform medical therapy. METHODS: 163 symptomatic patients with ≤50% diameter stenosis and fractional flow reserve (FFR) > 0.8 underwent endothelium-dependent epicardial and microvascular function after intracoronary acetylcholine (10-4  M, 81 mcg over 3 minutes). Endothelium-independent function was assessed using coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) after intravenous adenosine (140 ug/kg/min). Coronary microvascular dysfunction (CMD) was defined as CFR < 2.5, HMR ≥2, or ≤50% change in coronary blood flow with acetylcholine (CBFACH ). RESULTS: Seventy-two percent had endothelial-dependent epicardial dysfunction (response to ACH: % ∆ in coronary artery diameter and ∆%CBFACH ) and 92% had CMD. Among CMD patients, 65% had CFR < 2.5, 35% had HMR ≥2, and 60% had CBFACH change ≤50%. CFR modestly correlated with HMR (r = -0.38, p < .0001). Among patients with normal CFR, 26% had abnormal epicardial and 20% had abnormal microvascular endothelial dysfunction. Women had a lower CFR (p = .02), higher FFR (p = .03) compared to men. There were no differences in epicardial and microvascular function between patients with stable and unstable angina. CONCLUSION: In patients with no obstructive CAD: CMD is prevalent, abnormal CFR does not correlate with epicardial or microvascular endothelial dysfunction, women have lower CFR, higher FFR but similar endothelial function compared to men.

Alcohol Ablation of Extracardiac Thoracic Tumor.

This case illustrates a novel percutaneous treatment of a highly vascular thoracic tumor impinging on the left atrium and right pulmonary artery by delivery of coils and alcohol ablation via a circumflex coronary artery feeder branch. (Level of Difficulty: Advanced.).

UK trial of the Osseointegrated Prosthesis for the Rehabilitation for Amputees: 1995-2018.

BACKGROUND:: Amputation of a limb impacts on patients' self-perception and quality of life. Prostheses directly anchored to the skeleton are being investigated, aiming to avoid soft tissue complications. OBJECTIVES:: We report outcome data for the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees Implant System with a minimum of 9-year follow-up. METHODS:: Eighteen transfemoral amputees received unilateral implants between 1997 and 2008. Five were implanted before a formalised protocol, called Osseointegrated Prosthesis for the Rehabilitation of Amputees, was developed. Mean follow-up of the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group is 11.4 years (1.8-18.6 years), while for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group it is 12.3 years (2.9-15.9). RESULTS:: The Kaplan-Meier cumulative survivorship is 40% for the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group and 80.21% for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group. Five implants (28%) have been removed, three (17%) for deep infection, one (5.6%) for chronic pain, later proven to be infected and one (5.6%) due to implant fracture secondary to loosening due to infection. Two patients (11%) have peri-implant infections suppressed with oral antibiotics. Eleven cases (61%) of superficial infection were successfully treated with antibiotics. 36-Item short-form health survey and Questionnaire for persons with a Transfemoral Amputation showed significant improvements in quality of life up to 5 years after implantation. CONCLUSION:: This small cohort of patients demonstrates osseointegrated prosthesis allows prolonged usage and improves patients' quality of life compared to conventional prostheses. CLINICAL RELEVANCE: These prostheses may provide a future gold standard for amputees and this study provides the first outcome data over such a time period to be reported from outside of the developers group.

Coronary Artery Straightening Causing Acute Severe Mitral Regurgitation.

A 79-year-old woman had an atretic LIMA to LAD but without significant LAD stenosis, patent SVG to OM1, patent SVG to RCA, and severe tandem lesions in a very tortuous LCX for which she underwent PCI. Placement of a BMW coronary guidewire into the LCX resulted in the straightening of the vessel.

Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: A meta-analysis.

OBJECTIVES: This meta-analysis evaluated the effectiveness of hybrid coronary revascularization (HCR) compared to coronary artery bypass grafting (CABG) for the treatment of multivessel coronary artery disease (MVCAD). BACKGROUND: HCR involves a combination of surgical and percutaneous techniques, which in selected patients may present an alternative to conventional CABG. METHODS: Databases were searched through June 30, 2016, and studies comparing HCR with CABG for treatment of MVCAD were selected. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The primary outcome of interest was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all cause mortality, myocardial infarction, and stroke. RESULTS: The analysis included 2,245 patients from 8 studies (1 randomized controlled trial and 7 observational studies). The risk of MACCE with HCR and CABG were 3.6% and 5.4%, respectively (OR, 0.53; 95% CI, 0.24-1.16). Compared to CABG group, patients in HCR group had similar risk of all cause mortality (OR, 0.85; 95% CI, 0.38-1.88), myocardial infarction (OR, 0.72; 95% CI, 0.31-1.64), stroke (OR, 0.53; 95% CI, 0.23-1.20), and repeat revascularization (OR, 1.28; 95% CI, 0.58-2.83). The need for postoperative blood transfusions (OR, 0.29; 95% CI, 0.14-0.59) and hospital stay (weighted mean difference -1.20 days; 95% CI -1.52 to -0.88 days) was significantly lower in the HCR group. CONCLUSION: HCR appears to be safe, and has similar outcomes when compared with conventional CABG. HCR can be a suitable alternative to conventional CABG in select patients with MVCAD. © 2017 Wiley Periodicals, Inc.

The Need to Promote Sexual Health in America: A New Vision for Public Health Action.

Sexual health is considered to be a state of wellness with physical, emotional, mental, and social dimensions. Sexual health can contribute to our overall well-being in each of these dimensions. However, despite the intrinsic importance and positive aspects of sexuality in our lives, the United States presently faces significant challenges related to the sexual health of its citizens, including human immunodeficiency virus, other sexually transmitted infections, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction, and cancers in reproductive tracts with serious disparities among the populations affected. In particular, high rates of poverty, income inequality, low educational attainment, stigma, racism, sexism, and homophobia can make it more difficult for some individuals and communities to protect their sexual health. Given that many pressing public health issues in the United States are related to sexual health and that sexual health has been increasingly recognized as an important national health priority, now is the time to energize and focus our efforts toward optimal sexual health of the population. In this paper, we outline the rationale for addressing sexual health as a means to better promote overall health and address sexuality related morbidities. In addition, we present a logic model outlining an approach for advancing sexual health in the United States, as well as a range of action steps for consideration by public health practitioners, researchers, and policymakers.

Clinical and angiographic results after hybrid coronary revascularization.

BACKGROUND: With hybrid coronary revascularization (HCR), minimally invasive left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting is combined with percutaneous coronary intervention (PCI) of non-LAD vessels. The purpose of this study was to examine the short-term clinical and angiographic results in one of the largest HCR series to date. METHODS: From 2003 to 2012, 300 consecutive patients (aged 64±12 years, female 31.7%, predicted risk of mortality 1.6%±2.1%) underwent HCR on an intent-to-treat basis at a single institution. After robotic or thoracoscopic LIMA harvest, off-pump LIMA to LAD grafting was performed through a 3- to 4-cm sternal-sparing, non-rib-spreading thoracotomy. PCI was utilized to treat non-LAD lesions either before, after, or concomitant with the surgical procedure. RESULTS: Of the 300 patients undergoing HCR on an intent-to-treat basis, HCR was performed with surgery first in 192 patients (64.0%), PCI first in 56 (18.7%), and as a concomitant procedure in 21 (7.0%). Of the 31 patients (10.1%) who did not undergo HCR, 24 patients (8.0%) did not have PCI and thus were incompletely revascularized. For all patients, 30-day mortality, stroke, and nonfatal myocardial infarction occurred in 4 (1.3%), 3 (1.0%), and 4 (1.3%), respectively. Angiographic LIMA evaluation was performed in 248 patients and revealed a FitzGibbon A LIMA patency rate of 97.6% (242 of 248 patients). Repeat revascularization was required in 13 of 300 patients (4.3%). CONCLUSIONS: Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term outcomes. It provides a minimally invasive alternative to traditional coronary artery bypass graft surgery and may prove more durable than multivessel PCI.

Long-term outcomes after percutaneous patent foramen ovale closure.

Percutaneous patent foramen ovale (PFO) closure is a treatment for cryptogenic stroke and migraine headache. The goal of this study was to assess long-term outcomes of patients treated with percutaneous PFO closure. Records of patients with percutaneous PFO closure at Emory University Hospital from February 2002 to July 2009 were reviewed. Follow-up telephone questionnaire and chart review assessed recurrent stroke, migraine, and complications. Data was reviewed on 414 consecutive patients. Long-term follow-up was obtained in 207 of patients, and mean follow up was 4.6 ± 2.0 years. Cryptogenic stroke was the primary indication for intervention in 193 (93%) patients. Thirteen (7%) patients had a recurrent neurologic event post closure. In patients with multiple neurological events at baseline, 17% (n = 11) had a recurrent event, compared with 2% (n = 2) of patients with a single neurological event prior to PFO-closure (P < 0.002). Post closure, migraine frequency and severity declined from 4.5 to 1.1 migraine/month (P < 0.01) and 7.2 to 3.6 out of 10 (P < 0.01) in patients with history of migraine (n = 60). Thirty-day mortality was 1% (n = 2). One patient had device erosion 5 years post-procedure requiring emergent surgery. Atrial fibrillation was newly diagnosed in 8 (4%) patients within 6 months. In conclusion, the long-term rate of recurrent stroke after PFO closure is low in patients with a single neurological event at baseline. Serious long-term complications after PFO closure are rare. PFO closure may decrease the frequency and severity of migraine.

Expression of an anti-CD4 single-chain antibody fragment from the donor cornea can prolong corneal allograft survival in inbred rats.

AIM: To investigate whether expression of an anti-CD4 antibody fragment (scFv) by a lentivector-transduced donor cornea can prolong rat corneal allograft survival. METHODS: Inbred Fischer 344 rats received penetrating corneal allografts from Wistar-Furth donors after a 3 h transduction of the donor cornea with a lentivector carrying anti-CD4scFv cDNA (Lv-CD4scFv), a lentivector carrying the reporter gene-enhanced yellow fluorescence protein (LV-eYFP), or an adenoviral vector carrying anti-CD4 scFv cDNA (Ad-CD4scFv). Unmodified controls were also performed. Graft survival was assessed by corneal clarity, and rejection was confirmed histologically. RESULTS: In organ-cultured corneas, expression of anti-CD4 scFv was detected at 2 days post-transduction with the adenoviral vector, compared with 5 days post-transduction with the lentivector, and was 10-fold higher than the former. More inflammation was observed in Ad-CD4scFv-modified allografts than in Lv-CD4scFv-modified grafts at 15 days postsurgery (p=0.01). The median time to rejection for unmodified, LV-eYFP and Ad-CD4scFv grafts was day 17, compared with day 22 for Lv-CD4scFv grafts (p≤0.018). CONCLUSION: Donor corneas transduced with a lentiviral vector carrying anti-CD4scFv cDNA showed a modest but significant prolongation in graft survival compared with unmodified, Lv-eYFP and Ad-CD4scFv grafts. However, rejection still occurred in all Lv-CD4scFv grafts, indicating that sensitisation may have been delayed but was not prevented.

Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study.

OBJECTIVE: To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. BACKGROUND: The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. METHODS: Twenty-two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic-assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non-LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty-day adverse outcomes and long term follow up was obtained. RESULTS: In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug-eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30-day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. CONCLUSIONS: HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long-term durability of a LIMA-LAD bypass with the less invasive option of PCI in non-LAD targets with DES.

Hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of left main coronary stenosis.

BACKGROUND: Coronary artery bypass grafting is standard of care for left main (LM) coronary artery stenosis. Hybrid coronary revascularization (HCR) is an alternative therapy, combining a minimally invasive, sternal-sparing, off-pump left internal mammary artery to left anterior descending coronary anastomosis with percutaneous coronary stent placement through the LM into the circumflex coronary artery. METHODS: From October 8, 2003, to April 23, 2010, 27 patients with LM coronary disease had HCR at a US academic center. These patients were matched 3:1 to 81 contemporaneous patients treated with off-pump coronary artery bypass grafting through a sternotomy by an optimal matching algorithm using seven preoperative variables. In-hospital major adverse cardiac and cerebrovascular events and repeat revascularization during the study period were compared between groups. All-cause mortality was compared using the National Social Security Death Index. RESULTS: Patency of the left internal mammary artery to left anterior descending coronary anastomosis was confirmed in all cases before LM stenting, which was successful in all patients. There was no perioperative death, stroke, or myocardial infarction among the HCR patients. Major adverse cardiac and cerebrovascular events were similar between groups. During a median of 3.2 years of follow-up, patients treated with HCR had a higher incidence of repeat revascularization than those treated with off-pump coronary artery bypass grafting (2 of 27, 7.4% versus 1 of 81, 1.2%; p = 0.09), but this was not statistically significant. The incidence of blood transfusion was higher with off-pump coronary artery bypass grafting (50 of 81, 61.7% versus 9 of 27 33.3%; p = 0.01). CONCLUSIONS: Hybrid revascularization is a safe, feasible, and minimally invasive alternative to off-pump coronary artery bypass grafting for the treatment of LM coronary disease. Further investigation into the comparative effectiveness of this alternative strategy is warranted to identify optimal candidates for HCR.

Hybrid coronary revascularization versus off-pump coronary artery bypass grafting for the treatment of multivessel coronary artery disease.

BACKGROUND: Hybrid coronary revascularization (HCR) combines a minimally invasive (3-cm anterolateral thoracotomy), sternal-sparing, off-pump left internal mammary artery-left anterior descending (LIMA-LAD) coronary artery anastomosis with percutaneous coronary intervention (PCI) to non-LAD coronary arteries. We compared outcomes of HCR versus traditional off-pump coronary artery bypass grafting (OPCAB) for the treatment of multivessel coronary artery disease (CAD). METHODS: Between October 8, 2003 and April 23, 2010, 147 patients with multivessel coronary disease were treated with HCR at a US academic center. These were matched 4:1 to 588 contemporaneous patients treated with multivessel OPCAB by sternotomy using an optimal matching algorithm with 8 preoperative variables: age, gender, ejection fraction, presence of diabetes, myocardial infarction (MI), number of diseased vessels, left main coronary artery disease, and Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score. In-hospital major adverse events (MACCE) and the need for repeated revascularization during follow-up were compared between groups. All-cause mortality was determined using the Social Security Death Index (SSDI). RESULTS: Matching produced groups with similar coronary anatomy and statistically similar preoperative risk factors. The incidence of MACCE was similar between groups (3/147 HCR versus 12/588 OPCAB). During a median 3.2 years of follow up, the need for repeated revascularization was higher for HCR than for OPCAB (18/147 [12.2%] versus 22/588 [3.7%]; p < 0.001). The incidence of blood transfusion was higher for the OPCAB group. Estimated 5-year survival was similar between groups (OPCAB, 84.3% versus HCR, 86.8%; p = 0.61). CONCLUSIONS: Hybrid coronary revascularization is a minimally invasive treatment for multivessel CAD. Although repeated revascularization was greater with HCR, both in-hospital and midterm outcomes were comparable with those of traditional OPCAB. Further investigation into the comparative effectiveness of this alternative strategy is warranted.

The expression of beta human chorionic gonadotrophin (ß-HCG) in human urothelial carcinoma.

INTRODUCTION: Studies regarding the immuno-histological expression and relevance of Beta-Human Chorionic Gonadotrophin (=-HCG) in urothelial carcinoma are few. There is also no clear cut way of predicting exactly which superficial urothelial carcinomas would subsequently recur or progress and which muscle-invasive urothelial tumours would progress. The objective of the study was to study the immunohistological expression of =-HCG in urothelial carcinoma with regards to grade, category and outcome following treatment METHODS: The expression of =-HCG in urothelial carcinomas of 86 patients was studied with regards to grade, stage and outcome using an immunohistological (ABC) method and formalin fixed/paraffin embedded tumours. RESULTS: Of the 86 tumours (55 superficial and 31 muscle-invasive) studied 45, 16 and 26 were graded as G1, G2, and G3 respectively. Thirteen of the 55 superficial tumours were positively stained for ß=-HCG and 42 negatively stained. Twenty of the 31 muscle-invasive tumours studied were positively stained for ß=-HCG and 11 were negative. Of the 13 ß=-HCG positive superficial tumours only one did not recur at follow up and 12 subsequently recurred, of the 42 ß=-HCG negative superficial tumours 19 did not recur and 23 recurred. Only one of twenty patients with ß=-HCG positive muscle-invasive tumours survived; 6 of 11 patients with ß=-HCG negative muscle-invasive tumours survived. The results indicate that positive staining of the tumours was more commonly associated with tumours of higher grade, higher stage and inferior outcome. CONCLUSION: The Immunohistological expression of ß=-HCG would likely predict superficial tumours that would recur and muscle-invasive tumours with inferior outcome.