Risk factors associated with 30-day mortality for out-of-center ECMO support: experience from the newly launched ECMO retrieval service.

Out-of-hospital extracorporeal membrane oxygenation (ECMO) implantation and ECMO transport have become a growing field useful for emergent treatment of heart or lung failure with increasing number of centers launching such service. This study was designed to present risk factors predicting 30-day mortality for patients receiving ECMO support in a newly launched ECMO retrieval service. From 01/2015 till 01/2017 28 consecutive patients received ECMO support in peripheral hospitals using a miniaturized portable Cardiohelp System® (Maquet, Rastatt Germany) for heart, lung or heart/lung failure as a bridge-to-decision as a part of our newly launched ECMO retrieval service. Outcomes and predictors for 30-day mortality were presented. The mean age was 56 ± 15 (maximum 78) years. The mean ECMO support duration was 97 ± 100 h, whereas 11 patients (40%) were weaned off support and discharged from hospital. Presence of hemolysis (p = 0.041), renal failure (p = 0.016), lower platelet count before ECMO implantation (p = 0.001), and higher lactate 24 h after initiation of support (p = 0.006) were factors associated with 30-day mortality. Initial success of an ECMO retrieval service depends on logistic organization and clinical management. Taking into consideration highly deleterious effects of hemodynamic malperfusion of end organs, rapid initiation of ECMO support is a vital factor for survival. This is highlighted by predictive factors of early mortality that are associated with peripheral organ failure or complications.

Structural Insights into the Antiparallel G-Quadruplex in the Presence of K+ and Mg2+ Ions.

G-Quadruplex (GQ) is a secondary structural unit of DNA, formed at the telomere region of the chromosome with a high guanine content. It is reported that the GQs can hinder many biological processes. Thus, research thrives to explore the structural stability of GQs. Studies based on circular dichroism (CD) and nuclear magnetic resonance (NMR) experiments established the vital role of cations such as K+ and Mg2+ in the stability of antiparallel G-quadruplexes (AGQs). However, there is a need to understand how stability in AGQ is attained in the presence of cations. Here, we employed molecular dynamics (MD) simulations, steered MD (SMD) simulations, and QM/MM calculations to understand the biophysical and electronic bases of the stability imparted to AGQs via cation binding. Our results showed that Mg2+ prefers to bind in the plane with the guanine tetrad, whereas K+ binds in between the AGQ tetrads. Thus, three Mg2+ cations or two K+ ions are needed to stabilize an AGQ molecule, where each and every tetrad binds to Mg2+ more robustly with a higher binding affinity. SMD revealed that the traversal of K+ through the AGQ central channel required less force than that of Mg2+, illustrating the presence of more strong interactions between Mg2+ and AGQ tetrads compared to K+. The stabilization in the AGQ tetrads due to cation binding is reassessed by employing ab initio simulations. Mixed QM/MM calculations confirmed that Mg2+ binds strongly to AGQ compared to K+, and it induces higher interactions between the guanine tetrads. However, K+ binding to AGQ induces a higher stabilization energy than Mg2+ binding to AGQ tetrads. Despite the higher binding energy, Mg2+ binding imparts lower stabilization to AGQ due to its unfavorable fermionic quantum energy.

Spectrum of Movement Disorders in Niemann-Pick Disease Type C.

Introduction: Niemann-Pick disease type C (NPC) is an autosomal recessive neurovisceral lipid storage disorder caused by mutations in the NPC 1 or 2 genes. Movement disorders can occur as the first symptom and as predominant symptom mainly in juvenile-onset. The frequency and heterogeneity of movement disorders in NPC are not well described. We studied the frequency and spectrum of movement disorders in patients with NPC of different age of onset. Methods: Retrospective chart review of patients with NPC diagnosed based on the Suspicion Index tool and demonstration of foamy macrophages/sea-blue histiocytes in bone marrow aspirate. Results: We report 9 cases of NPC with 2 patients of late-infantile, 4 juvenile-onset and 3 of adult-onset. The mean age at onset of symptoms was 11.7 ± 10.4 (range 4-38 years) and the median duration of illness was 4 years. Vertical supranuclear gaze palsy (VSGP) was noted in 8 patients and VSGP with slowing of saccade in 1 patient. Splenomegaly was seen in 5 patients. Movement disorders as the first symptom occurred in 4 patients. Dystonia was the first symptom in 2 patients and cerebellar ataxia in 2 patients. Cerebellar ataxia occurred during the course of illness in 5 patients, dystonia in 6 patients. One patient with late-infantile NPC had stimulus-sensitive myoclonus. Conclusion: Movement disorders are common in NPC and occur as a presenting symptom. Cerebellar ataxia and dystonia are the most common movement disorder in NPC. Vertical supranuclear gaze palsy along with the movement disorders should lead to clinical suspicion of NPC.

Cross-Sectional Area Reference Values of Nerves in the Upper and Lower Extremities using Ultrasonography in the Indian Population.

Background and Purpose: Cross-sectional area (CSA) is the most important parameter to study peripheral nerves by high-resolution ultrasonography. The aim was to acquire normative data of CSA of the main upper and lower limb nerves in the Indian population. Methods: CSA of nerves was determined in 100 healthy volunteers at 11 predetermined sites: median and ulnar at the wrist, mid-forearm, elbow; radial (spiral groove); tibial (popliteal fossa, medial malleolus); common peroneal (CPN, fibular head) and sural (lateral malleolus). Results: The mean age of participants was 40.7 ± 13.0 years (range: 18-79). Fifty were < 40 years of age. The mean height, weight and BMI were 161.5 ± 8.3 centimeters (range: 145-179), 58.6 ± 10.1 kilograms (range: 32-90) and 22.4 ± 3.2 kilogram/square meter (range: 14.03-30.44), respectively. The median and ulnar nerve measurements were non-uniform throughout its course, and the CSA was largest at the elbow and ulnar groove, respectively. With advancing age, there was a significant difference for median and ulnar nerves at the wrist (median P = 0.002, ulnar P = 0.009) and tibial nerve (popliteal fossa, P = 0.045, medial malleolus, P = 0.005), CPN (P = 0.047). Men had greater CSA of upper limb nerves and tibial nerves at popliteal fossa (P < 0.05) as compared to women. A positive correlation was noted with weight. Conclusion: It is apt for every defined population to have its own set of normative data of CSA as it varies with ethnicity, age, and the built of individuals. We provide a valuable set of CSA data for nerves in the Indian population, which can be used for comparison while investigating peripheral nerve disorders.

Coronavirus disease 2019 associated mucormycosis meandering its way into the orbit: a pictorial review.

BACKGROUND: There has been a recent deluge of coronavirus disease 2019 associated mucormycosis in our country. It affects the paranasal sinuses; however, it has a rapid extrasinus progression (the orbit being most common), which can be fatal if not detected early. It may meander into the orbit through various foramina without frank bone destruction. METHODS: This paper reviews the various gateways of the spread of coronavirus disease 2019 associated mucormycosis to the orbit, even before advent of bone destruction or ocular symptoms. Plausible pathways of invasion and subtle imaging findings are depicted, to enable an early diagnosis. RESULTS: Relevant anatomy and imaging examples have been illustrated to familiarise the surgeons with various routes of coronavirus disease 2019 associated mucormycosis spread to the orbit. Emphasis is laid on searching for subtle imaging findings for the detection of early orbital invasion. CONCLUSION: Early detection and extension of coronavirus disease 2019 associated mucormycosis is facilitated by knowledge of its gateways of spread, which aids the surgeon in prognostication and planning of the surgical approach.

The Effect of Two Soft Drinks on Bracket Bond Strength and on Intact and Sealed Enamel: An In Vitro Study.

BACKGROUND AND OBJECTIVES: This study was conducted to evaluate the effect of two soft drinks, Coca-Cola and Mirinda orange on bracket bond strength, on adhesive remnant on teeth after debonding the bracket, and to observe by means of scanning electron microscope (SEM) the effect of these drinks on intact and sealed enamel. METHODS: 120 non-carious maxillary premolar teeth already extracted for Orthodontic purposes were taken and divided into three groups, i.e., Coca-Cola drink, Mirinda orange, and control (artificial saliva) group. Brackets were bonded using conventional methods. Teeth were kept in soft drinks for 15 days, for 15 min, 3 times a day, separated by intervals of 2 h. At other times, they were kept in artificial saliva. The samples, thus obtained were evaluated for shear bond strength using the universal testing machine and subsequently subjected for adhesive remnant index (ARI) scores. SEM study on all the three groups was done for evaluating enamel surface of the intact and sealed enamel. RESULTS: The lowest mean resistance to shearing forces was shown by Mirinda orange group (5.30 ± 2.74 Mpa) followed by Coca-Cola group (6.24 ± 1.59 Mpa) and highest resistance to shearing forces by control group (7.33 ± 1.72 Mpa). The ARI scores revealed a cohesive failure in control samples and an adhesive failure in Mirinda and cola samples. SEM results showed areas of defect due to erosion caused by acidic soft drinks on intact and sealed enamel surface. CONCLUSION: Mirinda group showed the lowest resistance to shearing forces, followed by Coca-Cola group and with the highest resistance to shearing forces by the control group. There were significant differences between the control group and the study groups. Areas of defects, which were caused by erosion related to acidic soft drinks on the enamel surface around the adhesive, were seen. Areas of defects caused by Coca-Cola were more extensive when compared to Mirinda orange drink.

[Is measuring by portable heart rate monitors (sport watches) dependable in patients with an implanted pacemaker?]. / Messen tragbare Herzfrequenz-Messgeräte (Sportuhren) bei Schrittmacherpatienten zuverlässig?

BACKGROUND AND OBJECTIVE: Regular physical exercise is advantageous for physical fitness and endurance. The intensity of exercising can be controlled by portable heart rate monitors. The aim of the study was to investigate if wearable monitors work properly in pacemaker patients. PATIENTS AND METHODS: In 30 patients with an implanted single or dual chamber pacemaker made by five different manufacturers their heart rate was determined simultaneously by surface ECG and Holter ECG, and was compared with the heart rates derived from portable heart rate monitors (Polar A1) at rest, during 6 minutes in-house walk, and while exercising at 25, 50, and 75 watts in a bicycle exercise test. The tests were done with pacing set at uni- as well as bipolar stimulation mode. RESULTS: At rest in two of 30 patients (6,6 %) paced in unipolar mode the portable heart rate monitors counted double. Under exercise conditions the portable monitors counted double in six of 26 patients (23 %) while being stimulated in unipolar mode. In bipolar stimulation mode, the portable heart rate monitors were working properly in all patients under all conditions. CONCLUSIONS: Patients with an implanted bipolar pacing system can control their physical exercising safely and accurately by means of portable heart rate monitors. Pacemaker patients who are planning regular physical exercising should be provided with an implanted bipolar pacemaker system.

Cardiopulmonary bypass copolymer surface modification reduces neither blood loss nor transfusions in coronary artery surgery.

OBJECTIVE: Surface-modifying additives (SMA) have been suggested for improving cardiopulmonary bypass (CPB) circuit biocompatibility, potentially minimizing inflammatory complications and bleeding associated with CPB. The purpose of this prospective, randomized clinical study was to compare a novel copolymer surface-modified CPB circuit (SMARXT; COBE Cardiovascular) against the unmodified circuit. METHODS: We randomized 122 patients with isolated coronary artery disease subjected to first-time surgery on CPB into either the SMA (n = 62) or the control group (n = 60). Exclusion criteria included renal insufficiency, liver disease, coagulopathy, anticoagulation therapy < 6 days preop, carotid artery stenosis > 70 %, and a history of stroke. We collected perioperative clinical data including drainage blood loss, transfusion requirements, duration of mechanical ventilation, and ICU stay. Platelet function was determined pre- and post-CPB. RESULTS: SMA patients received 3.2 +/- 0.9 (SD) grafts during 48 +/- 16 min of aortic cross clamp and 91 +/- 30 min CPB (Control: 3.0 +/- 0.9 grafts; p = 0.33, 46 +/- 14 min AXC; p = 0.36, and 84 +/- 23 min CPB; p = 0.14). In the SMA group, 23 patients (37 %) received red blood-cell transfusions, 9 patients (15 %) fresh frozen plasma, and 3 patients (5 %) received platelets (control: n = 27 [46 %], p = 0.44; n = 10 [17 %], p = 0.91; and n=4 [7 %], p = 0.71, respectively). Platelet count on CPB fell to the same level in both groups. In SMA patients, platelet function decreased from 94.2 +/- 24.9 % pre-CPB to 79.5 +/- 32.8 % post-CPB (p = 0.043) (control: from 87.7 +/- 25.6 % to 69.4 +/- 34.7 %; p = 0.001). Postoperative drainage blood loss, mechanical ventilation duration, and ICU stay were similar in both groups (p > 0.3). One patient of the control group was excluded due to surgical bleeding, and one SMA patient died. CONCLUSIONS: Our results show that the surface-modified CPB circuit decreased neither blood loss nor transfusions despite slightly better platelet function preservation compared to the unmodified circuit. This type of CPB circuit surface modification does not appear to improve clinical outcome in low-risk coronary artery surgery patients.