Test of transformation mechanism of food waste and its impacts on sulfide and methane production in the sewer system.

Food waste (FW) management has become an important issue worldwide. Diverting FW into the sewer system is considered promising to tackle the FW issue. However, the transformation of FW in sewers and its impact on the sewer process have not received adequate attention due to the overlooked sewer networks. In this study, a laboratory-scale sewer reactor system was established to investigate the transformation of FW and the production of sulfide and methane under anaerobic conditions. The transformation of FW in the sewer reactor could result in an increase in the substrate level through hydrolyzing and converting biodegradable substances into preferred substrates. Moreover, the generated substrates from the addition of FW were preferable for the metabolism of key microbes in sewer biofilms. As a result, methane production from the sewer reactor could be enhanced from the addition of FW, whereas sulfide production was not affected at a low sulfate concentration. The findings of this study suggest that the diversion of FW may exert an adverse impact on sewers and the environment in terms of greenhouse gas emission. Hence, more research is necessary to clarify the detailed impacts on FW management and wastewater treatment.

Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up.

BACKGROUND: The rapid identification of deterioration in the pediatric population is complex, particularly in the emergency department (ED). A comprehensive multi-faceted Pediatric Early Warning System (PEWS) might maximize early recognition of clinical deterioration and provide a structured process for the reassessment and escalation of care. The objective of the study was to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS implemented in the ED of an urban public general hospital in British Columbia, Canada, and to guide provincial scale up. METHODS: We used a before-and-after design to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS (pediatric assessment flowsheet, PEWS score, situational awareness, escalation aid, and communication framework). Sources of data included patient medical records, surveys of direct care staff, and key-informant interviews. Data were analyzed using mixed-methods approaches. RESULTS: The majority of medical records had documented PEWS scores at triage (80%) and first bedside assessment (81%), indicating that the intervention was implemented with high fidelity. The intervention was effective in increasing vital signs documentation, both at first beside assessment (84% increase) and throughout the ED stay (> 100% increase), in improving staff's self-perceived knowledge and confidence in providing pediatric care, and self-reported communication between staff. Satisfaction levels were high with the PEWS scoring system, flowsheet, escalation aid, and to a lesser extent with the situational awareness tool and communication framework. Reasons for dissatisfaction included increased paperwork and incidence of false-positives. Overall, the majority of providers indicated that implementation of PEWS and completing a PEWS score at triage alongside the Canadian Triage and Acuity Scale (CTAS) added value to pediatric care in the ED. Results also suggest that the intervention is aligned with current practice in the ED. CONCLUSION: Our study shows that high-fidelity implementation of PEWS in the ED is feasible. We also show that a multi-component PEWS can be effective in improving pediatric care and be well-accepted by staff. Results and lessons learned from this pilot study are being used to scale up implementation of PEWS in ED settings across the province of British Columbia.

Computed Tomographic Perfusion Predicts Poor Outcomes in a Randomized Trial of Endovascular Therapy.

BACKGROUND AND PURPOSE: In the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), patients with large vessel occlusions and small infarct cores identified with computed tomography (CT)/CT angiography were randomized to endovascular therapy or standard of care. CT perfusion (CTP) was obtained in some cases but was not used to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome. METHODS: All CTP data acquired in ESCAPE patients were analyzed centrally using a semiautomated perfusion threshold-based approach. A penumbral pattern was defined as an infarct core <70 mL, penumbral volume >15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was good functional outcome at 90 days (modified Rankin Scale score, 0-2). RESULTS: CTP was acquired in 138 of 316 ESCAPE patients. Penumbral patterns were present in 116 of 128 (90.6%) of patients with interpretable CTP data. The rate of good functional outcome in penumbral pattern patients (53 of 114; 46%) was higher than that in nonpenumbral patients (2 of 12; 17%; P=0.041). In penumbral patients, endovascular therapy increased the likelihood of a good clinical outcome (34 of 58; 57%) compared with those in the control group (19 of 58; 33%; odds ratio, 2.68; 95% confidence interval, 1.25-5.76; P=0.011). Only 3 of 12 nonpenumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect. CONCLUSIONS: The majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Nonpenumbral patients were much less likely to achieve good outcomes.

Proximal row carpectomy versus four-corner arthrodesis: a retrospective comparative study.

BACKGROUND: Four-corner arthrodesis with scaphoid excision (FCA) and proximal row carpal resection (PRC) are frequently performed in wrists with post-traumatic Scaphoid Non- Union Advanced Collapse (SNAC)/Scapho-Lunate Advanced Collapse (SLAC) osteoarthritis. The aim of this study was to compare the clinical outcomes of these two procedures. METHODS: This single-center, retrospective cohort study included all patients who had PRC or FCA between January 1st, 2009 and January 1st, 2019 and who were followed up. Follow-up included: mobility (radial deviation, ulnar deviation, flexion, extension), strength (grip test, pinch test), function (QuickDash, patient-rated wrist evaluation [PRWE]), subjective mobility, and global satisfaction scores. RESULTS: Among 25 patients included, 11 had PRC and 14 had FCA with a mean follow-up of 69.5 months [12-132]. Radial deviation was 18° versus 14° (p = 0.7), ulnar deviation was 21° versus 22° (p = 0.15), flexion was 39° versus 30° (p = 0.32), extension was 32.5° versus 29.5° (p = 0.09), grip test compared to the controlateral side was 72% versus 62% (p = 0.53), Quick Dash score was 12.5 versus 17.6 (p = 0.84), PRWE was 18.7 versus 17.6 (p = 0.38), subjective mobility was 7.8 versus 7.5 (p = 0.23), and satisfaction score was 8.7 versus 9 (p = 0.76), respectively, in the FCA group and the PRC group. Re-operation rates were 14% patients in the FCA group and 0% in the PRC group. CONCLUSION: This study found no significant difference between FCA and PRC on strength, mobility, and function in patients with post-traumatic SLAC or SNAC stage II wrist arthritis. Both FCA and PRC seem to be reliable surgical techniques with good outcomes with more revision in the FCA group.

Intelligence-based anti-doping via an Intelligence and Drug Testing Management (IDTM) system.

The Intelligence and Drug Testing Management (IDTM), a system that can enhance drug testing analytics with related horse information and intelligence in a single platform, can help identify and mitigate potential doping and other threats.

A role for the scaffolding adapter GAB2 in breast cancer.

The scaffolding adapter GAB2 maps to a region (11q13-14) commonly amplified in human breast cancer, and is overexpressed in breast cancer cell lines and primary tumors, but its functional role in mammary carcinogenesis has remained unexplored. We found that overexpression of GAB2 (Grb2-associated binding protein 2) increases proliferation of MCF10A mammary cells in three-dimensional culture. Coexpression of GAB2 with antiapoptotic oncogenes causes lumenal filling, whereas coexpression with Neu (also known as ErbB2 and HER2) results in an invasive phenotype. These effects of GAB2 are mediated by hyperactivation of the Shp2-Erk pathway. Furthermore, overexpression of Gab2 potentiates, whereas deficiency of Gab2 ameliorates, Neu-evoked breast carcinogenesis in mice. Finally, GAB2 is amplified in some GAB2-overexpressing human breast tumors. Our data suggest that GAB2 may be a key gene within an 11q13 amplicon in human breast cancer and propose a role for overexpression of GAB2 in mammary carcinogenesis. Agents that target GAB2 or GAB2-dependent pathways may be useful for treating breast tumors that overexpress GAB2 or HER2 or both.

One, two and three-dimensional ultrasound measurements of carotid atherosclerosis before and after cardiac rehabilitation: preliminary results of a randomized controlled trial.

BACKGROUND: It is still not known how patients who are post-transient ischemic attack (TIA) or post-stroke might benefit from prospectively planned comprehensive cardiac rehabilitation (CCR). In this pilot evaluation of a larger ongoing randomized-controlled-trial, we evaluated ultrasound (US) measurements of carotid atherosclerosis in subjects following TIA or mild non-disabling stroke and their relationship with risk factors before and after 6-months of CCR. METHODS: Carotid ultrasound (US) measurements of one-dimensional intima-media-thickness (IMT), two-dimensional total-plaque-area (TPA), three-dimensional total-plaque-volume (TPV) and vessel-wall-volume (VWV) were acquired before and after 6-months CCR for 39 subjects who had previously experienced a TIA and provided written informed consent to participate in this randomized controlled trial. We maintained blinding for this ongoing study by representing treatment and control groups as A or B, although we did not identify which of A or B was treatment or control. Carotid IMT, TPA, TPV and VWV were measured before and after CCR as were changes in body mass index (BMI), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP). RESULTS: There were no significant differences in US measurements or risk factors between groups A and B. There was no significant change in carotid ultrasound measurements for group A (IMT, p = .728; TPA, p = .629; TPV, p = .674; VWV, p = .507) or B (IMT, p = .054; TPA, p = .567; TPV, p = .773; VWV, p = .431) at the end of CCR. There were significant but weak-to-moderate correlations between IMT and VWV (r = 0.25, p = .01), IMT and TPV (r = 0.21, p = .01), TPV and TPA (r = 0.60, p < .0001) and VWV and TPV (r = 0.22, p = .02). Subjects with improved TC/HDL ratios showed improved carotid VWV although, this was not statistically significant. CONCLUSION: In this preliminary evaluation, there were no significant differences in carotid US measurements in the control or CCR group; a larger sample size and/or longer duration is required to detect significant changes in US or other risk factor measurements.

The association between dietary patterns, plasma lipid profiles, and inflammatory potential in a vascular dementia cohort.

Background: Inflammation and altered lipid dyshomeostasis have been implicated in the pathogenesis of Alzheimer's disease and vascular dementia. Objective: To determine if there are any associations between dietary patterns, plasma lipid profiles, and inflammatory potential in a vascular dementia cohort. Methods: One hundred fifty participants (36 subjects with Vascular Dementia and 114 healthy controls) from two Australian teaching hospitals completed a cross-sectional survey examining their dietary and lifestyle patterns. Each participant's diet was further evaluated using the Empirical Dietary Inflammatory Index. Some participants also donated blood samples for lipidomic analysis. Results: After adjusting for age, education, and socioeconomic status, participants with vascular dementia tend to have higher lipid profiles, do less exercise, and engage less frequently in social interaction, educational, or reading activities. They also tend to consume more deep-fried food and full-fat dairy compared to control subjects. However, there was no difference in Empirical Dietary Inflammatory Index between the two groups after adjusting for age, education, and socioeconomic status. Conclusion: Our findings suggest a graded inverse association between healthy lifestyle factors and vascular dementia.

Gelatinous Pleural Effusion: A Diagnostic Challenge for Pleural Mesothelioma in an 80-Year-Old Man.

BACKGROUND Gelatinous pleural effusion, due to raised hyaluronic acid, can be associated with pleural infection and malignancies, such as tuberculosis, metastatic pleural disease, and mesothelioma. This report is of an 80-year-old man presenting with a gelatinous pleural effusion and diagnosis of pleural mesothelioma. CASE REPORT An 80-year-old man with diabetes mellitus, ischemic heart disease, metastatic prostate cancer, 30-pack-year smoking history, and 5-year history of asbestos exposure (during his 30s), presented with a 4-week history of breathlessness and was found to have right-sided pleural effusion. Thoracic computed tomography (CT) showed mild right-sided pleural thickening. Pleural tap revealed exudative fluid, with a pH of 7.4, and unremarkable cytology and microbiology analyses. The patient was treated for pneumonia and para-pneumonic effusion and discharged home. He came back 5 weeks later with worsening of symptoms and re-accumulation of pleural fluid. Repeated thorax CT showed extensive right-sided pleural lobular thickening. Pleural tap again yielded an exudative fluid, with a pH of 7.37. Cytology and microbiology did not reveal any positive signs for malignancy or infection. This time the pleural fluid appeared gelatinous in consistency. Pleural biopsy showed atypical epithelioid mesothelial cells arranged in trabeculae, with a tubulo-papillary configuration. Also, immunohistochemistry panel showed tumor cells expressed calretinin, EMA, WT1, and D2-40, with negative TTF1, CEA, and BerEp4. Final diagnosis was epithelioid mesothelioma. CONCLUSIONS This report has shown that a gelatinous pleural effusion can be associated with malignant and inflammatory pleural diseases. In this case, imaging and pleural biopsy with histopathology confirmed a diagnosis of pleural mesothelioma.

Construction of the real patient simulator system.

Simulation for perfusion education has been used for at least the past 25 years. The earlier models were either electronic (computer games) or fluid dynamic models and provided invaluable adjuncts to perfusion training and education. In 2009, the *North Shore-LIJ Health System at Great Neck, New York, opened an innovative "Bioskill Center" dedicated to simulated virtual reality advanced hands-on surgical training as well as perfusion simulation. Professional cardiac surgical organizations now show great interest in using simulation for training and recertification. Simulation will continue to be the direction for future perfusion training and education. This manuscript introduces a cost-effective system developed from discarded perfusion products and it is not intended to detail the actual lengthy process of its construction.

Living with gout in New Zealand: an exploratory study into people's knowledge about the disease and its treatment.

BACKGROUND: In New Zealand, gout disproportionately affects Maori and Pacific people who also experience symptoms at an earlier age. Gout occurs predominantly in men and is associated with cardiovascular disease, diabetes, and renal disease. The impact on daily social activities, family, and work is enormous, and many people remain inadequately treated. OBJECTIVES: The objectives of this study were to explore the knowledge and perceptions of people with gout toward the disease and to determine the impact gout has on lifestyle including possible barriers to treatment. METHODS: Sixty people with gout from the Auckland and Waikato regions of New Zealand were invited to participate in 30-minute semistructured interviews. The data were analyzed using a general inductive thematic approach. RESULTS: Although 85% of participants were aware of dietary triggers of gout, these were not always avoided. Less than 50% knew something about how their medicines worked, and only 33% knew which medicines to use both acutely and chronically. The negative impact of gout episodes was noted through the number participants unable to work or participate in family activities. Healthcare professionals were not always the main source of information, which is an area that could be developed to improve knowledge about gout. CONCLUSIONS: There were substantial gaps in the knowledge about gout and its causes and management. All healthcare providers could help identify patients with suboptimal knowledge and improve the management of gout.

Control of CNS cell-fate decisions by SHP-2 and its dysregulation in Noonan syndrome.

Within the developing mammalian CNS, growth factors direct multipotent precursors to generate neurons versus glia, a process that if perturbed might lead to neural dysfunction. In this regard, genetic mutations resulting in constitutive activation of the protein tyrosine phosphatase SHP-2 cause Noonan Syndrome (NS), which is associated with learning disabilities and mental retardation. Here, we demonstrate that genetic knockdown of SHP-2 in cultured cortical precursors or in the embryonic cortex inhibited basal neurogenesis and caused enhanced and precocious astrocyte formation. Conversely, expression of an NS SHP-2 mutant promoted neurogenesis and inhibited astrogenesis. Neural cell-fate decisions were similarly perturbed in a mouse knockin model that phenocopies human NS. Thus, SHP-2 instructs precursors to make neurons and not astrocytes during the neurogenic period, and perturbations in the relative ratios of these two cell types upon constitutive SHP-2 activation may contribute to the cognitive impairments in NS patients.

Substrate specificity of protein tyrosine phosphatases 1B, RPTPα, SHP-1, and SHP-2.

We determined the substrate specificities of the protein tyrosine phosphatases (PTPs) PTP1B, RPTPα, SHP-1, and SHP-2 by on-bead screening of combinatorial peptide libraries and solution-phase kinetic analysis of individually synthesized phosphotyrosyl (pY) peptides. These PTPs exhibit different levels of sequence specificity and catalytic efficiency. The catalytic domain of RPTPα has very weak sequence specificity and is approximately 2 orders of magnitude less active than the other three PTPs. The PTP1B catalytic domain has modest preference for acidic residues on both sides of pY, is highly active toward multiply phosphorylated peptides, but disfavors basic residues at any position, a Gly at the pY-1 position, or a Pro at the pY+1 position. By contrast, SHP-1 and SHP-2 share similar but much narrower substrate specificities, with a strong preference for acidic and aromatic hydrophobic amino acids on both sides of the pY residue. An efficient SHP-1/2 substrate generally contains two or more acidic residues on the N-terminal side and one or more acidic residues on the C-terminal side of pY but no basic residues. Subtle differences exist between SHP-1 and SHP-2 in that SHP-1 has a stronger preference for acidic residues at the pY-1 and pY+1 positions and the two SHPs prefer acidic residues at different positions N-terminal to pY. A survey of the known protein substrates of PTP1B, SHP-1, and SHP-2 shows an excellent agreement between the in vivo dephosphorylation pattern and the in vitro specificity profiles derived from library screening. These results suggest that different PTPs have distinct sequence specificity profiles and the intrinsic activity/specificity of the PTP domain is an important determinant of the enzyme's in vivo substrate specificity.

Safety and feasibility of collateral blood flow augmentation after intravenous thrombolysis.

BACKGROUND AND PURPOSE: Collateral flow augmentation using partial aortic occlusion may improve cerebral perfusion in acute stroke. We assessed the safety and feasibility of partial aortic occlusion immediately after intravenous tissue plasminogen activator. METHODS: We conducted an open-label pilot study of partial aortic occlusion after thrombolysis. The primary end point was all serious adverse events within 30 days of treatment. RESULTS: None of the 22 patients enrolled developed symptomatic parenchymal hemorrhages. Asymptomatic hemorrhagic transformation occurred in 9 patients. Procedure-related adverse events were limited to groin complications (n=13). Seventy-seven percent of patients experienced neurological improvement (≥4-point improvement of the National Institutes of Health Stroke Scale score). CONCLUSIONS: Partial aortic occlusion as an adjunct to thrombolysis in the treatment of acute stroke appears safe. Studies aimed at determining the efficacy of this therapeutic approach are warranted. CLINICAL TRIAL REGISTRATION INFORMATION: URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01006993.

Comprehensive cardiac rehabilitation for secondary prevention after transient ischemic attack or mild stroke: I: feasibility and risk factors.

BACKGROUND AND PURPOSE: Comprehensive cardiac rehabilitation (CCR), which integrates structured lifestyle interventions and medications, reduces morbidity and mortality among cardiac patients. CCR has not typically been used with cerebrovascular populations, despite important commonalities with heart patients. We tested feasibility and effectiveness of 6-month outpatient CCR for secondary prevention after transient ischemic attack or mild, nondisabling stroke. This article presents risk factors. A future article will discuss psychological outcomes. METHODS: Consecutive consenting subjects having sustained a transient ischemic attack or mild, nondisabling stroke within the previous 12 months (mean, 11.5 weeks; event-to-CCR entry) with ≥1 vascular risk factor, were recruited from a stroke prevention clinic providing usual care. We measured 6-month CCR outcomes following a prospective cohort design. RESULTS: Of 110 subjects recruited from January 2005 to April 2006, 100 subjects (mean age, 64.9 years; 46 women) entered and 80 subjects completed CCR. We obtained favorable, significant intake-to-exit changes in: aerobic capacity (+31.4%; P<0.001), total cholesterol (-0.30 mmol/L; P=0.008), total cholesterol/high-density lipoprotein (-11.6%; P<0.001), triglycerides (-0.27 mmol/L; P=0.003), waist circumference (-2.44 cm; P<0.001), body mass index (-0.53 kg/m(2); P=0.003), and body weight (-1.43 kg; P=0.001). Low-density lipoprotein (-0.24 mmol/L), high-density lipoprotein (+0.06 mmol/L), systolic (-3.21 mm Hg) and diastolic (-2.34 mm Hg) blood pressure changed favorably, but nonsignificantly. A significant shift toward nonsmoking occurred (P=0.008). Compared with intake, 11 more individuals (25.6% increase) finished CCR in the lowest-mortality risk category of the Duke Treadmill Score (P<0.001). CONCLUSIONS: CCR is feasible and effective for secondary prevention after transient ischemic attack or mild, nondisabling stroke, offering a promising model for vascular protection across chronic disease entities. We know of no similar previous investigation, and are now conducting a randomized trial.

Frontotemporal dementia - features, diagnosis and management.

BACKGROUND: Frontotemporal dementia is the third or fourth most common form of dementia in the 45-65 years age group. It causes significant morbidity as well as a six to eightfold increase in mortality risk. OBJECTIVE: This article provides an overview of the pathophysiology of frontal lobe function and the genetics of frontotemporal dementia. It also summarises the clinical features, diagnosis and management of frontotemporal dementia. DISCUSSION: While the clinical presentation of frontotemporal dementia was described as early as the nineteenth century, recent advances in genetics have resulted in greater understanding of the pathophysiology of this disease. While imaging may support the diagnosis of frontotemporal dementia, it is essentially a clinical diagnosis based on the presence of typical clinical features and the findings of neuropsychological tests. Clinical management of frontotemporal dementia remains a challenge and is largely centred on behavioural management. Pharmacological agents such as selective serotonin reuptake inhibitors and antipsychotics may be helpful, although evidence to support their use is minimal.

Access to Translator (AT&T) project: Interpreter on Wheels during the COVID-19 pandemic.

We report our experience in using virtual technology in our emergency department (ED) to meet communication needs of our patients who have limited English proficiency (LEP) during the COVID-19 pandemic. Our project aim was to improve communication between our ED staff and patients who have LEP. Specifically, our primary aim was to eliminate the use of healthcare staff as ad hoc interpreters by 50% in our ED by using virtual medical interpreters within 2 months. To achieve our goal, several strategies were employed. First, we assessed the need for interpreters in our ED by tracking the number of times our nursing staff is pulled away from their nursing role to help other staff as an ad hoc interpreter. Second, a patient survey was conducted to understand their thoughts and needs for interpretation in the ED. Third, we developed strategies in improving access to interpreters in our ED. During the COVID-19 pandemic, we conducted a trial of using 'Interpreter on Wheels' (IOW) in our ED. In a 2-month period, we had 477 virtual interpretation encounters totaling 4123 interpretation minutes of IOW usage. We found that it satisfied not only our communication needs but also reduced some of our potential infection control risks during the pandemic.

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

OBJECTIVES: To identify root causes of preventable adverse drug events (pADEs) contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community. METHODS: Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported. RESULTS: Most common pADE-related medical conditions: chronic obstructive pulmonary disease/asthma (13.3%), bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%) and pneumonia (5%). Most common root causes were: providers not confirming that the patient/family understands information given (29.2%), can identify how a medication helps them/have their concerns addressed (16.7%), can identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%); absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented. CONCLUSIONS: To prevent pADEs, providers need to confirm that patients/families understand information given, how a medication helps them, how to recognise and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient's/families' medication use and monitoring competency.

A novel buddy balloon technique to recross a T-stented bifurcation.

The T technique is not uncommonly used to stent bifurcation lesions. It requires recrossing into the side branch with a guidewire and balloon to perform final Kissing Balloon dilations, but recrossing can be difficult. We describe a case of bifurcation stenting where balloon recrossing following guidewire placement into the side branch proved very challenging, and was finally achieved via a combination of forward pressure on a low-profile balloon with its tip wedged at the stent struts along with simultaneous low-pressure inflation of a larger parallel balloon. This altered the stent architecture and also allowed for a more favorable vector of force transmission to allow recrossing and hence successful completion of the procedure.