The right ventricle under pressure: Anatomy and imaging in sickness and health.

The right ventricle (RV) is an important structure which serves a multitude of vital physiological functions in health. For many years, the left ventricle has dominated the focus of understanding in both biology and pathophysiology and the RV was felt to be more of a passive structure which rarely had an effect on disease states. However, it is increasingly recognised that the RV is essential to the homoeostasis of normal physiology and disturbances in RV structure and function have a substantial effect on patient outcomes. Indeed, the prognosis of diseases of lung diseases affecting the pulmonary vasculature and left heart disease is intimately linked to the function of the right ventricle. This review sets out to describe the developmental and anatomical complexities of the right ventricle while exploring the modern techniques employed to image and understand its function from a clinical perspective.

From Hospital to the Community: Redesigning the Human Immunodeficiency Virus (HIV) Clinical Service Model to Respond to an Outbreak of HIV Among People Who Inject Drugs.

An outbreak of human immunodeficiency virus (HIV) among people who inject drugs in Glasgow, Scotland started in 2014. We describe 156 cases over 5 years and evaluate the impact of clinical interventions using virological and phylogenetic analysis. We established (1) HIV services within homeless health facilities, including outreach nurses, and (2) antiretroviral therapy (ART) via community pharmacies. Implementation of the new model reduced time to ART initiation from 264 to 23 days and increased community viral load suppression rates to 86%. Phylogenetic analysis demonstrated that 2019 diagnoses were concentrated within a single network. Traditional HIV care models require adaptation for this highly complex population.

New developments in the imaging of lung cancer.

Radiological and nuclear medicine methods play a fundamental role in the diagnosis and staging of patients with lung cancer. Imaging is essential in the detection, characterisation, staging and follow-up of lung cancer. Due to the increasing evidence, low-dose chest computed tomography (CT) screening for the early detection of lung cancer is being introduced to the clinical routine in several countries. Radiomics and radiogenomics are emerging fields reliant on artificial intelligence to improve diagnosis and personalised risk stratification. Ultrasound- and CT-guided interventions are minimally invasive methods for the diagnosis and treatment of pulmonary malignancies. In this review, we put more emphasis on the new developments in the imaging of lung cancer.

Sendaway capillary NT-proBNP in pulmonary hypertension.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker of cardiac ventricular wall stress that is incorporated into pulmonary hypertension (PH) risk stratification models. Sendaway sampling may enable patients to perform NT-proBNP tests remotely. This UK-wide study aimed to assess the agreement of sendaway NT-proBNP with standard venous NT-proBNP and to assess the effect of delayed processing. METHODS: Reference venous NT-proBNP was collected from PH patients. Samples for capillary and venous sendaway tests were collected contemporaneously, mailed to a reference laboratory and processed at 3 and 7 days using a Roche Cobas e411 device. Differences in paired measurements were analysed with Passing-Bablok regression, percentage difference plots and the % difference in risk strata. RESULTS: 113 patients were included in the study. 13% of day 3 capillary samples were insufficient. Day 3 capillary samples were not equivalent to reference samples (Passing Bablok analysis slope of 0.91 (95% CI 0.88 to 0.93) and intercept of 6.0 (95% CI 0.2 to 15.9)). The relative median difference was -7% and there were acceptable limits of agreement. Day 3 capillary NT-proBNP accurately risk stratified patients in 93.5% of cases. By comparison, day 3 venous results accurately risk stratified patients in 90.1% of cases and were equivalent by Passing-Bablok regression. Delayed sampling of sendaway tests led to an unacceptable level of agreement and systematically underestimated NT-proBNP. CONCLUSIONS: Sendaway NT-proBNP sampling may provide an objective measure of right ventricular strain for virtual PH clinics. Results must be interpreted with caution in cases of delayed sampling.

Not Just an Accident: A Case of Insulinoma.

Insulinomas are a rare cause of recurrent hypoglycemia in non-diabetic patients. Diagnosis requires hypoglycemia (plasma glucose <50 mg/dL), neuroglycopenic symptoms, and prompt relief of symptoms following the administration of glucose, known as Whipple's triad. The gold standard diagnostic tests are measuring insulin, C-peptide, and glucose during a 72-hour fast. In the preoperative period and in patients with unresectable or metastatic tumors, medical management with diazoxide and octreotide can be considered for recurrent hypoglycemia. We present a case of insulinoma in a 37-year-old woman who initially presented after a seizure-related motor vehicle accident. Upon admission, her initial glucose level was 32 mg/dL, indicating a likely hypoglycemic seizure. During her hospitalization, she had recurrent episodes of fasting and postprandial hypoglycemia, ranging from 32-70 mg/dL. She exhibited the characteristics of Whipple's triad when values dropped below 50 mg/dL. These episodes necessitated continuous infusions of 10% dextrose. Tests for insulin autoantibodies, sulfonylurea screens, and thyroid function yielded unremarkable results. A 72-hour fasting test was initiated to investigate potential endogenous causes of excessive insulin production. Laboratory results from a venous glucose level of 46 mg/dL indicated a notable rise in C peptide and insulin levels, alongside beta hydroxybutyrate suppression, all of which fulfilled the diagnostic criteria for insulinoma. An abdominal magnetic resonance imaging (MRI) unveiled a 1.3 cm mass in the pancreatic tail. This case emphasizes the importance of employing a focused approach when evaluating non-diabetic individuals displaying hypoglycemia with positive Whipple's triad. This targeted method not only enables early detection of this rare condition but also assists in eliminating other common causes of recurrent hypoglycemia in non-diabetic individuals. Moreover, in addition to this diagnosis being rare, it is important to note that patients with insulinomas typically do not exhibit a glucose level low enough to induce seizures during their initial presentation.

The MRC Dyspnoea Scale and mortality risk prediction in pulmonary arterial hypertension: A retrospective longitudinal cohort study.

Risk stratification models in pulmonary arterial hypertension (PAH) rely on World Health Organisation Functional Class (WHO FC). A high proportion of patients are classified as WHO FC III, a heterogenous group which limits the stratification abilities of risk models. The Medical Research Council (MRC) Dyspnoea Scale may allow a more precise assessment of functional status and improve current risk models. We investigated the ability of the MRC Dyspnoea Scale to assess survival in PAH and compared performance to WHO FC and the COMPERA 2.0 models. Patients with Idiopathic, Hereditary or Drug-induced PAH who were diagnosed between 2010 and 2021 were included. The MRC Dyspnoea Scale was retrospectively applied as derived from a combination of patient notes, 6MWD tests results and WHO functional status using a purpose-designed algorithm. Survival was assessed using Kaplan-Meier analyses, log rank testing and Cox proportional hazard ratios. Model performance was compared with Harrell's C Statistic. Data from 216 patients were retrospectively analyzed. At baseline, of 120 patients classified as WHO FC III, 8% were MRC Dyspnoea Scale 2, 12% Scale 3, 71% Scale 4 and 10% Scale 5. The MRC Dyspnoea Scale performed well compared to the WHO FC and COMPERA models at follow up (respectively, C-statistic 0.74 vs. 0.69 vs. 0.75). It was possible to use the MRC Dyspnoea Scale to subdivide patients in WHO FC III into groups which had distinct survival estimates. We conclude that at follow-up, the MRC Dyspnoea Scale may be a valid tool for the assessment of risk stratification in pulmonary arterial hypertension.

Remote exercise testing in pulmonary hypertension (PHRET).

Remote exercise tests for patients with pulmonary hypertension (PH) would improve the telemedicine strategies in this disease. The PHRET study assessed the validity and feasibility of four remote exercise tests performed by PH patients at home. Participants undergoing diagnostic assessment for PH were included. At baseline, patients completed a 6MWT followed by a range of study tests including a Timed Up and Go (TUG) test, a Sit-to-Stand (STS), a Step Test (ST), and a tele-6MWT (T6MWT) performed outside using a GPS-enabled smartphone. Patients performed these tests at home following discharge and at first follow-up. Analysis focused on comparing the results of study tests to the standard 6MWT. The discontinuation rate was 15%. Ninety-seven percent of patients were able to complete a TUG, 92% a STS, 73% a ST, and 49% a T6MWT. At baseline, correlation between the standard 6MWT and study tests, respectively, was T6MWT 0.93, ST 0.78, STS 0.71, and TUG -0.76 (p < 0.001). Direction of change in the study test agreed with the standard 6MWT in 68% of the follow-up ST, 68% of the STS, 71% of the TUG, and 79% of the T6MWT. Patients were able to complete the tests at home, there were no adverse incidents and ≥92% of patients were happy to continue performing home tests. Remote exercise testing is feasible. The T6MWT was a valid remote measure of exercise capacity, but could only be performed by a limited number of patients. The high discontinuation rate may impact the utility of remote tests.

Towards telemedicine in pulmonary hypertension: Assessing the feasibility of remote quality of life and exercise capacity assessment.

Patients with pulmonary hypertension (PH) are happy to perform simple exercise capacity tests at home and believe this is feasible. A proportion of patients are able to use an electronic form to complete quality of life questionnaires. These findings are being used to build a telemedicine strategy for PH patients.

Predicting Group II pulmonary hypertension: diagnostic accuracy of the H2FPEF and OPTICS scores in Scotland.

OBJECTIVE: Group II pulmonary hypertension (PH) can be challenging to distinguish from Group I PH without proceeding to right heart catheterisation (RHC). The diagnostic accuracy of the H2FPEF and OPTICS scores was investigated in Scotland. METHODS: Patients were included in the study if they were referred to the Scottish Pulmonary Vascular Unit between 2016 and 2020 and subsequently diagnosed with Group II PH or Group I PH which was either idiopathic, heritable or pulmonary veno-occlusive disease. The established cut offs for the H2FPEF and for the OPTICS scores were applied retrospectively to predict the presence of Group II PH. The diagnosis from the scores were compared with the MDT consensus diagnosis following RHC. RESULTS: 107 patients with Group I PH and 86 patients with Group II PH were included. Retrospective application of the OPTICS score demonstrated that pretest scoring would detect 28% of cases with Group II PH yet at the cost of misdiagnosing 4% of patients with Group I as Group II PH (specificity 0.96). The H2FPEF score had a far greater sensitivity (0.70) yet reduced specificity (0.91), leading to misdiagnosis of 9% of Group I PH cases. CONCLUSION: While the specificity of these scores was high, the lack of perfect specificity limits their utility as it results in missed patients with Group I PH. As a consequence, they cannot replace RHC as the means of diagnosing the aetiology of PH in their current form. The scores may still be used to support clinical judgement or to indicate the advisability for further provocative testing at RHC.

Hospital Specialist Palliative Care Team Influence on End-of-Life Care in Coronavirus Disease 2019? A Retrospective Observational Cohort Study.

Objectives: The coronavirus 19 disease (COVID-19) pandemic has led to a renewed focus on end-of-life care. The majority of COVID-19 deaths occur in hospital, with patients cared for by generalists and hospital specialist palliative care teams (HSPCTs). This project aims at exploring the potential influences of HSPCTs on end-of-life care in COVID-19. Methods: A retrospective observational study was carried out by exploring four end-of-life care themes in a Scottish hospital population who died from COVID-19. Comparison was made between cohorts seen by HSPCTs versus generalist clinicians. Results: Analysis of 119 patients across NHS Greater Glasgow and Clyde (NHSGGC) health board demonstrated that COVID-19 patients seen by HSPCTs were more likely to be younger (median 77 vs. 81 years; p = 0.02), have a cancer diagnosis (21.7% vs. 5.4%; p = 0.01), die sooner after admission (median four vs. six days; p < 0.01), and be commenced on a syringe driver (89.1% vs. 42.5%; p < 0.01). Differences detected across four end-of-life care themes comparing HSPCTs with generalist teams were minimal with documentation and prescribing in keeping with available guidance. Conclusion: Consistencies in end-of-life care observed across NHSGGC cohorts draw attention to the potential wider impact of HSPCT roles, including education, guideline development, and mentoring. Understanding such diverse effects is important to support funding and development of HSPCTs. Further research is required to better quantify the impact and heterogenous influences of HSPCTs in general.

Pulmonary hypertension for the non-specialist.

Pulmonary hypertension is a rare and complex disease that arises from a wide range of underlying conditions. Therapeutic options have expanded enormously over the last two decades resulting in major improvements in prognosis for some patients. As a consequence, it is vital that the disease is recognised early and referred on to specialist centres for further investigation and definitive diagnosis to improve prognosis in this life-altering condition. Unfortunately, it remains the case in the UK that there is a delay in the diagnosis of pulmonary hypertension, often months or years after the onset of symptoms. This review aims to highlight key points in initial management and referral of patients with suspected pulmonary hypertension and presents three cases to underline these areas.

Impairment of skeletal muscle oxygen extraction and cardiac output are matched in precapillary pulmonary hypertension.

In precapillary pulmonary hypertension, exercising muscles extract oxygen to a similar level seen in healthy individuals. Exercise limitation is a result of impaired oxygen delivery, which is matched to any impairment in skeletal muscle oxygen extraction. https://bit.ly/3hQUY8m.

Host-seeking behavior of Ixodes pacificus (Acari: Ixodidae) nymphs in relation to environmental parameters in dense-woodland and woodland-grass habitats.

In the far-western United States, the bacteria that cause Lyme disease (Borrelia burgdorferi, Bb) and human granulocytic anaplasmosis (Anaplasma phagocytophilum, Ap) are transmitted by the western black-legged tick (Ixodes pacificus). In a dense woodland, human behaviors involving contact with wood were recently found to pose greater risk for encountering I. pacificus nymphs than behaviors entailing exclusive exposure to leaf litter. A four-year follow-up study was undertaken in the same woodland and, as a comparison area in one year only, in a nearby woodland-grass habitat to explore the biotic and abiotic factors that might elevate human exposure to host-seeking nymphs. Nymphs were active in the dense woodland throughout the daytime, but no consistent pattern of activity was observed with respect to time of day, temperature, or relative humidity. Significantly more nymphs were collected from the southern aspects of dense-woodland trunks than from other aspects, and more nymphs quested at a height of < or = 1 m vs 1-2 m aboveground. The prevalence of bacterial infection in ticks from the dense woodland was highly variable among years, with maxima of 22.6% and 42.9% for Bb, and 15.6% and 1.8% for Ap, in nymphs from logs and trunks, respectively. The mean densities of nymphs, and of Bb- or Ap-infected nymphs, were typically higher on logs and trunks than in adjoining leaf litter or grass in both habitats. The acarologic risk of encountering an infected nymph on dense-woodland logs or trunks was 2.8 to 11 times higher for Bb than for Ap in two of three years, and it was usually higher in dense woodland than in woodland-grass for both agents. Coinfections were rare (0.27%, n = 369 nymphs from both habitats). Individuals having prolonged contact with logs or trunks in spring would be well advised to employ personal protective measures to minimize exposure to I. pacificus nymphs and their attendant bacterial zoonotic agents.

Demineralized bone matrix composite grafting for posterolateral spinal fusion.

In a prospective series, the 24-month fusion status was evaluated radiographically among patients undergoing instrumented posterolateral lumbosacral spinal fusion. Seventy-three patients had a diagnosis of degenerative disk disease or degenerative spondylolisthesis and had supplemental bone grafting with demineralized bone matrix (DBM) putty (Grafton DBM; Osteotech, Eatontown, NJ) enriched with aspirated bone marrow (DBM bone marrow), DBM putty combined with iliac crest autograft (DBM autograft), or autograft. Overall, approximately 63% (12 of 19) of DBM bone marrow, 70% (19 of 27) of DBM autograft, and 67% (18 of 27) of autograft patients were fused at 24 months (P = .875). These findings suggest that both DBM composites offer similar performance to autograft in posterolateral spinal fusion.

Grafting long bone fractures with demineralized bone matrix putty enriched with bone marrow: pilot findings.

In this pilot study, the preliminary effectiveness of a composite graft consisting of demineralized bone matrix (DBM) putty (Grafton DBM) and aspirated bone marrow was evaluated for treating long bone fractures. Patients were ssigned randomly to treatment with the DBM putty composite (n = 10) or iliac crest autograft (n = 8), and had a minimum of 12 months of radiographic follow-up. Ninety percent of DBM patients (9/10) achieved full bone formation compared to 75% of autograft patients (6/8) (P = .41). Additionally, all 10 DBM patients were healed compared with 63% of autograft patients (5/8) (P = .07). These findings suggest that DBM putty enriched with bone marrow may be comparable to autograft for treating long bone fractures.

Glycemic characteristics in continuously monitored patients with type 1 and type 2 diabetes: normative values.

OBJECTIVE: The purpose of this study was to generate normative values for periods of euglycemia as well as for daily patterns of glycemic excursions in patients with type 1 and type 2 diabetes monitored continuously for a maximum period of 21 days and blinded to glucose levels. RESEARCH DESIGN AND METHODS: This was a multicenter, prospective observational study in which 101 consecutive patients with type 1 (n = 60) or type 2 (n = 41) diabetes underwent blinded continuous glucose monitoring. Serial glucose measurements were divided into periods of euglycemia (70-180 mg/dl), hyperglycemia (>180 mg/dl), and hypoglycemia (<70 mg/dl). The proportions of time patients were hypoglycemic, euglycemic, and hyperglycemic and the total areas under the curves (AUCs) were determined. RESULTS: During the observation period the 101 subjects contributed an average 287 +/- 132 h of continuous glucose values. Subjects remained in the euglycemic range for approximately 63% of the total day, were hypoglycemic 8%, and were hyperglycemic 29%. Hypoglycemia was more prevalent nocturnally (11 vs. 7%) and hyperglycemia diurnally (31 vs. 25%). Compared with subjects with type 2 diabetes, type 1 diabetic subjects had more frequent hypoglycemic episodes per day (2.1 vs. 1.0; P < 0.001) that were of longer duration (1.1 vs. 0.7 h; P < 0.0001), reflecting a greater number of hours per day in the hypoglycemic range (2.3 vs. 1.0 h; P < 0.0001). The mean hypoglycemic AUC values were >150% higher for type 1 compared with type 2 diabetic subjects (41 vs. 16, respectively; P < 0.0001). CONCLUSIONS: These normative data will assist in study and sample size planning for future investigations of continuous glucose monitoring and allow for qualitative comparisons with trials of therapeutic interventions aimed at reducing the occurrence of glycemic excursions.

Hybrid therapy with right atrial catheter ablation and previously ineffective antiarrhythmic drugs for the management of atrial fibrillation.

BACKGROUND: Many patients with paroxysmal atrial fibrillation (AF) become refractory to antiarrhythmic drugs (AADs). Early studies suggested that linear catheter ablation in the right atrium may provide sufficient substrate modification to reestablish therapeutic efficacy of previously ineffective AADs. METHODS: This prospective before-after multicenter trial evaluated the safety and effectiveness of hybrid therapy that included right atrial catheter ablation coupled with a regimen of previously ineffective AADs on AF episode frequency and symptoms in drug refractory patients with paroxysmal AF. A standard linear lesion set (lateral, septal, isthmus) was used in all subjects. AF episode frequency, clinical arrhythmia symptoms, condition-specific (AFSS) and global health-related quality of life (SF-36) were assessed prior to ablation and at 6 months. RESULTS: Ninety-three subjects, refractory to an average 2.9 AADs at baseline, qualified for inclusion and underwent right atrial catheter ablation. Eighty-four subjects (90%) provided 6 month AF episode frequency data which demonstrated a significant decrease compared to baseline (3.4 vs. 9.5, p < 0.0001). Forty-nine subjects (58%) were considered a clinical success by virtue of achieving a pre-specified target level episode frequency reduction of 50% or greater. Substantial and statistically significant improvements were realized almost uniformly for all measured arrhythmia symptoms as well as for both quality of life measures. The incidence of major complications was 5.4%. CONCLUSIONS: The addition of right atrial catheter ablation to a regimen of previously ineffective AADs is associated with a significant reduction in the frequency, duration and severity of AF episodes and symptoms.

Reducing the risk of deep wound infection in primary joint arthroplasty with antibiotic bone cement.

Despite significant advances in intraoperative antimicrobial procedures, deep wound infection remains the most serious complication associated with primary, cemented total joint arthroplasty. A systematic review was conducted to evaluate studies of antibiotic bone cement prophylaxis for reducing the risk of deep wound infection. The literature included 22 articles providing estimates of the prophylactic effectiveness of antibiotic cement. In reducing deep wound infection, antibiotic cement was consistently superior to plain cement, similar to systematic antiobiotics, and independent and additive in effect when combined with other prophylactic measures. Randomized controlled trials in particular had important methodological limitations. However, the collective results nearly unanimously favored prophylactic use of antibiotic cement in primary arthoplasty procedures.

Donor age and gender effects on osteoinductivity of demineralized bone matrix.

Allogeneic demineralized bone matrix (DBM) has been used extensively as a clinical graft material because of its inherent osteoinductive and osteoconductive properties. There is continued debate over the acceptable age range of donors for bone and whether the effectiveness of the tissue as a graft is influenced by gender. Contradictory evidence has been obtained with DBM prepared from both animals and humans. The goal of the present investigation was to evaluate the effect of donor age and gender on the osteoinductivity of DBM prepared from human donors [male (133) and female (115) donors grouped in 10-year age brackets up to 85 years] with a statistically relevant sample size using the athymic rat ectopic bone formation model. Among males, there was a statistically significant linear association between age and osteoinductivity value (p <.001), but not among females (p =.20). The rate of change among males was 0.009 units per year. The biological relevance of such a small change in osteoinductivity is likely to be negligible, as the total variation explained by the regressions was only 8.2%. A two-way ANOVA as related to donor age (only donors < 76 years of age) and gender yielded no significant statistical association of osteoinductivity with age group, gender, and their interaction. The results confirm that properly processed demineralized bone from donors through at least 85 years of age is a viable grafting material.