Obstructive Sleep Apnea as a Predictor of Inducible Atrial Flutter During Pulmonary Vein Isolation in Patients With Atrial Fibrillation: Clinical Significance and Follow-Up Outcomes.

Background: Atrial fibrillation (AF) and atrial flutter (AFL) often coexist in patients and may lead to severe symptoms and complications. Despite their coexistence, prophylactic cavotricuspid isthmus (CTI) ablation has failed to reduce the incidence of recurrent AF or new onset AFL. In contrast, the presence of inducible AFL during pulmonary vein isolation (PVI) has been shown to be predictive of symptomatic AFL during follow-up. However, the potential role of obstructive sleep apnea (OSA) as a predictor of inducible AFL during PVI in patients with AF remains unclear. Therefore, this study aimed to examine the potential role of OSA as a predictor of inducible AFL during PVI in patients with AF and reexamine the clinical significance of inducible AFL during PVI in terms of recurrent AFL or AF during follow-up. Methods: We conducted a single-center, non-randomized retrospective study on patients who underwent PVI between October 2013 and December 2020. A total of 192 patients were included in the study after screening 257 patients for exclusion criteria, which included a previous history of AFL or previous PVI or Maze procedure. All patients underwent a transesophageal echocardiogram (TEE) prior to their ablation to rule out a left atrial appendage thrombus. The PVI was performed using both fluoroscopic and electroanatomic mapping derived from intracardiac echocardiography. After the confirmation of PVI, additional electrophysiology (EP) testing was performed. AFL was classified as typical or atypical based on the origin and activation pattern. Descriptive and frequency statistics were performed to describe the demographic and clinical characteristics of the sample, and Chi-square and Fisher's exact tests were used to compare independent groups on categorical outcomes. Logistic regression analysis was performed to adjust for confounding variables. The study was approved by the Institutional Review Board, and informed consent was waived given the retrospective nature of the study. Results: Of the 192 patients included in the study, 52% (n = 100) had inducible AFL after PVI, with 43% (n = 82) having typical right AFL. Bivariate analysis showed statistically significant differences between the groups for OSA (P = 0.04) and persistent AF (P = 0.047) when examining the outcome of any inducible AFL. Similarly, only OSA (P = 0.04) and persistent AF (P = 0.043) were significant when examining the outcome of typical right AFL. Multivariate analysis showed that only OSA was significantly associated with any inducible AFL after controlling for other variables (adjusted odds ratio (AOR) = 1.92, 95% confidence interval (CI): 1.003 - 3.69, P = 0.049). Of the 100 patients with inducible AFL, 89 underwent additional ablation for AFL prior to completion of their procedure. At 1 year, the rates of recurrence for AF, AFL, and either AF or AFL were 31%, 10%, and 38%, respectively. There was no significant difference in the rates of recurrence of AF, AFL, or either AF/AFL at 1 year when accounting for the presence of inducible AFL or the efficacy of additional AFL ablation. Conclusions: In conclusion, our study found a high incidence of inducible AFL during PVI, particularly among patients with OSA. However, the clinical significance of inducible AFL in relation to the recurrence rates of AF or AFL at 1-year post-PVI remains unclear. Our findings suggest that successful ablation of inducible AFL during PVI may not provide clinical benefit in reducing AF or AFL recurrence. To establish the clinical significance of inducible AFL during PVI in various patient populations, further prospective studies with larger sample sizes and longer follow-up periods are necessary.

Extracranial Microvascular Complications of Moyamoya Disease Leading to Left Ventricular Systolic Dysfunction.

Moyamoya disease (MMD) was first used as a descriptor for a steno-occlusive process that affects primarily the internal carotid arteries (ICA) in a bilateral fashion in 1969. Characterized by recurrent ischemic events in the developing brains of young patients, the process is one that often decimates the quality of life of affected individuals. The vascular changes in MMD have been demonstrated to occur in an extracranial manner, thus it is logical to assume that the same steno-occlusive mechanism could induce dysfunction and ischemia in other organ systems. Our case presents a patient with MMD with cardiac manifestations that we suspect may be related to extracranial manifestations of MMD.

Non-postoperative Central Retinal Artery and Ophthalmic Artery Occlusion With Compression Ischemia Due to Prolonged Sedation In Prone Position.

Central retinal artery occlusion (CRAO) after a prolonged period of lying prone is a rare condition with only a handful of cases reported, generally as a postoperative complication of spinal surgery. Only a few cases can be found describing acute visual loss following intravenous drug abuse and stupor leading to continuous pressure on the orbit while asleep. No cases can be found describing acute visual loss following the ingestion of oral sedating/antipsychotic medications. Urgent identification and workup with subsequent interventions are needed to offer the highest probability of full/partial visual restoration. Our patient presented with complete vision loss after ingesting oral antipsychotic medications leading to a prolonged sedated state in which compressive ischemia led to central retinal artery occlusion. The complex timeline regarding the patient's presentation and the implications relating to offered interventions are highlighted in this case report.

Trends in mortality from aortic dissection analyzed from the World Health Organization Mortality Database from 2000 to 2017.

BACKGROUND: We assessed trends in aortic dissection (AD) death rates in 23 countries from 2000 to 2017. METHODS: We extracted AD mortality data for countries with high usability data from the World Health Organization (WHO) Mortality Database and from the Center for Disease Control (CDC) WONDER Database for the United States of America (USA). Age Standardized Death Rates (ASDRs) per 100,000 population were computed. Trends were assessed by locally weighted scatter plot smoother (LOWESS) regression. RESULTS: Between 2000 and 2017, ASDRs from AD decreased in Australia, Belgium, Croatia, Denmark, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, and the USA for both sexes. Increasing AD mortality was observed in Austria, Czech Republic, Germany, Hungary, Israel, and Japan for both sexes. The largest absolute increases in ASDR were in Japan for men (+1.59) and women (+1.11). The largest percentage decreases were in Norway for men (-0.91) and in New Zealand (-0.6) for women. In 2017, the highest mortality rates were in Japan for both sexes (3.22 and 2.09, respectively). The lowest ASDR was in Kyrgyzstan for both sexes (0.16 and 0.10, respectively). ASDRs for AD in 2017 were higher for men than women in all countries included. Spain had the greatest difference between the gender's mortality rates with a 2.71-fold higher mortality average rate in men. CONCLUSION: We identified an overall decrease in AD mortality in most included countries, while an increase was noted in other countries including Israel and Japan.

Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study.

INTRODUCTION: Reduction mammaplasty in patients with gigantomastia is challenging. The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is the standard technique for reduction mammaplasty in our clinic. The aim of this study was to review our approach in cases with gigantomastia in comparison with the current literature. PATIENTS AND METHODS: From 01/2011 to 12/2017, we performed 831 reduction mammaplasties in 630 patients. The Double-Unit  Superomedio-Central  (DUS) pedicle and inverted-T incision was implemented as a standard procedure for gigantomastia. Patient demographics and the outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility, and surgical revision rate were obtained and retrospectively analyzed. RESULTS: In 37 patients, 55 reduction mammaplasties were performed with more than 1000 g per breast. Mean resection weight was 1311 g on right side and 1289 g on left side. Mean age was 52.5 years, mean body mass index was 32.8 kg/m2, mean sternal-notch-to-nipple distance was 38.3 cm. A free NAC graft was necessary in four breasts. Overall complication rate was 14.5%; secondary surgical revision rate was 12.7%. 91% of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensibility was rated "high" and "medium" in 83%. CONCLUSION: The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is very effective to achieve volume reduction and aesthetically pleasing reproducible results with a low complication rate in cases with gigantomastia. LEVEL OF EVIDENCE: Level of Evidence This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Central macular thickness in patients with sickle cell disease and no signs of retinopathy: a cross-sectional study of Jordanian patients.

OBJECTIVES: To measure central macular thickness in Jordanian patients with sickle cell disease who did not have retinopathy and compare the findings with age- and sex-matched controls using spectral domain optical coherence tomography (SDOCT). METHODS: In this cross-sectional study, participants underwent visual acuity testing, slit-lamp bio-microscopy, dilated ophthalmoscopy, and SDOCT imaging to measure central macular thickness. Macular quadrant measurements and thickness difference indexes (TDIs) were compared between groups. RESULTS: Twenty eyes with sickle cell disease and 20 control eyes were enrolled. The median visual acuity in both groups was 20/20. The mean macular thickness was significantly lower in eyes with sickle cell disease than in matched controls (mean difference, 22.15 ± 6.44 µm). Peripheral quadrants were all significantly thinner in eyes with sickle cell disease, especially in superior and temporal quadrants. TDIs were lower in eyes with sickle cell disease than in control eyes. CONCLUSIONS: Eyes with sickle cell disease that had no clinical evidence of retinopathy exhibited significantly lower central macular thickness in all quadrants, compared with eyes in age- and sex-matched controls. SDOCT is a non-invasive imaging modality that can detect preclinical changes in eyes with sickle cell disease and can be used to screen and monitor the disease process.

How to treat venous thromboembolism (TVE) in cancer patients: ten years of multidisciplinary team meetings (MDTM) at Saint-Louis Hospital.

BACKGROUND: - The management of venous thromboembolism (VTE) is particularly challenging in patients with cancer who undergo complex treatment protocols. Cancer patients often have comorbidities which may affect the efficacy and safety of anticoagulant treatments. Coordinated multidisciplinary management of these complex cases can help optimize delivery of individualized anticoagulant treatment. AIMS: - To describe the multidisciplinary team meeting (MDTM) for the management of VTE in cancer patients at our institution and to document outcomes in these patients. METHODS: - Bi-monthly MDTMs attended by different physicians and nurses were established at Saint-Louis Hospital in 2008. We performed a retrospective analysis of all cases discussed between September 2008 and January 2018. RESULTS: - Over a 10-year period, 520 patients were discussed a total of 551 times. Their mean age was 63 years with 278 (53%) women. The most frequent primary cancer sites were breast (23%), genitourinary (21 %), hematological (20%), digestive (15%), and lung (9%). Fifty-two percent of patients had metastatic cancer, and 54% of them were receiving chemotherapy. The optimal treatment for pulmonary embolism (17%), deep vein thrombosis (16%), catheter-related thrombosis (20%) or combined events (46%) was discussed. Twenty-three patients (4.4%) were discussed for one VTE recurrence and 4 (0.8%) for 2 recurrences. CONCLUSIONS: - A dedicated MDTM for the management of VTE in cancer patients allows to discuss a wide range of clinical scenarios and contributes to optimal adherence to evidence-based clinical practices guidelines. The MDTM evaluation was successfully carried out within a short time-frame of VTE diagnosis and helped optimize individualized treatment plans.

Drug-drug interaction (DDI) with direct oral anticoagulant (DOAC) in patients with cancer.

Cancer-associated thrombosis (CAT) is the second leading cause of death in cancer patients after tumor progression. The treatment of CAT is challenging because of a high risk of VTE recurrence, a high risk of bleeding, common presence of comorbidities, poly-medication, and potential drug-drug interactions (DDI). Since 2018, direct oral anticoagulants (DOACs) represent a promising therapeutic alternative and have been recently included into the 2019 update of the International Initiative on Thrombosis and Cancer (ITAC-CME) clinical practice guidelines for management of CAT. However, pharmacokinetic studies suggest that concomitant treatment with P-gp or CYP3A4 inhibitors will result in an increased exposure to rivaroxaban and apixaban, but the clinical relevance of these studies is unknown. In addition, there is an important inter-individual variability in drug absorption, distribution, metabolism and elimination, even more in cancer patients. Overall, the risk of pharmacokinetic DDI should be estimated based on several individual (patient age, renal and liver function, number of comedications) and diseases-related factors, including inflammation, sarcopenia, and low body weight. In this context, DDI with clinical implications could be expected with anti-neoplastic agents or supportive care treatments, especially with drugs known to be moderate or strong inhibitors/inducers of CYP3A4 and P-gp. Consequently, in the presence of potential DDIs through CYP3A4, and/or P-gp, LMWHs remain the first-line anticoagulant of choice for the long-term treatment of CAT. Multidisciplinary consultation meetings and therapeutic patient education should be emphasized in the complex management of CAT.

Management of cancer-related thrombosis in the era of direct oral anticoagulants: A comprehensive review of the 2019 ITAC-CME clinical practice guidelines. On behalf of the Groupe Francophone Thrombose et Cancer (GFTC).

Venous thromboembolism (VTE) is a common disease complication in cancer patients and the second cause of death after cancer progression. VTE management and prophylaxis are critical in cancer patients, but effective therapy can be challenging because these patients are at higher risk of VTE recurrence and bleeding under anticoagulant treatment. Numerous published studies report inconsistent implementation of existing evidence-based clinical practice guidelines (CPG), including underutilization of thromboprophylaxis, and wide variability in clinical practice patterns across different countries and various practitioners. This review aims to summarize the 2019 ITAC-CME evidence-based CPGs for treatment and prophylaxis of cancer-related VTE, which include recommendations on the use of direct oral anticoagulants specifically in cancer patients. The guidelines underscore the gravity of developing VTE in cancer and recommend the best approaches for treating and preventing cancer-associated VTE, while minimizing unnecessary or over-treatment. Greater adherence to the 2019 ITAC guidelines could substantially decrease the burden of VTE and improve survival of cancer patients.

Lung ultrasound in early diagnosis of neonatal transient tachypnea and its differentiation from other causes of neonatal respiratory distress.

BACKGROUND: Transient tachypnea of the newborn (TTN) is one of the most common causes of neonatal respiratory distress (RD). However, distinguishing TTN from other causes of RD may be difficult during the first 12:24 h after birth. Lung ultrasonography (LUS) has been successfully utilized in the diagnosis and differential diagnosis of neonatal RD. This study aimed to investigate the diagnostic value of LUS for early diagnosis of TTN as well as differentiate it from other causes of neonatal RD in near and full term Egyptian neonates. METHODS: LUS was performed in 65 near and full term neonates presented with RD within the first 12:24 hours of admission in NICU of Suez Canal University, Ismailia, Egypt. RESULTS: Among the 65 neonates included in the study, 73.8% were diagnosed to have TTN, 18.5% were diagnosed to have pneumonia, 4.6% had meconium aspiration syndrome (MAS) and 3.1% had respiratory distress syndrome (RDS). The Double lung point has 69.6% sensitivity, 100% specificity, 100% PPV and 39.1% NPV for detecting TTN. We have novel data showing a positive correlation between the degree of alveolar-interstitial syndrome (AIS) and the type of oxygen support offered to neonates diagnosed with TTN. CONCLUSION: We found LUS to be a reliable and non-invasive tool for the early diagnosis of TTN and its differentiation from other causes of neonatal RD in near and full term Egyptian neonates.

Assessing the performance of a method of simultaneous compression and encryption of multiple images and its resistance against various attacks.

We introduce a double optimization procedure for spectrally multiplexing multiple images. This technique is adapted from a recently proposed optical setup implementing the discrete cosine transformation (DCT). The new analysis technique is a combination of spectral fusion based on the properties of DCT, specific spectral filtering, and quantization of the remaining encoded frequencies using an optimal number of bits. Spectrally multiplexing multiple images defines a first level of encryption. A second level of encryption based on a real key image is used to reinforce encryption. A set of numerical simulations and a comparison with the well known JPEG (Joint Photographic Experts Group) image compression standard have been carried out to demonstrate the improved performances of this method. The focus here will differ from the method of simultaneous fusion, compression, and encryption of multiple images (SFCE) [Opt. Express 19, 24023 (2011)] in the following ways. Firstly, we shall be concerned with optimizing the compression rate by adapting the size of the spectral block to each target image and decreasing the number of bits required to encode each block. This size adaptation is achieved by means of the root-mean-square (RMS) time-frequency criterion. We found that this size adaptation provides a good tradeoff between bandwidth of spectral plane and number of reconstructed output images. Secondly, the encryption rate is improved by using a real biometric key and randomly changing the rotation angle of each block before spectral fusion. By using a real-valued key image we have been able to increase the compression rate of 50% over the original SFCE method. We provide numerical examples of the effects for size, rotation, and shifting of DCT-blocks which play noteworthy roles in the optimization of the bandwidth of the spectral plane. Inspection of the results for different types of attack demonstrates the robustness of our procedure.

Simultaneous fusion, compression, and encryption of multiple images.

We report a new spectral multiple image fusion analysis based on the discrete cosine transform (DCT) and a specific spectral filtering method. In order to decrease the size of the multiplexed file, we suggest a procedure of compression which is based on an adapted spectral quantization. Each frequency is encoded with an optimized number of bits according its importance and its position in the DC domain. This fusion and compression scheme constitutes a first level of encryption. A supplementary level of encryption is realized by making use of biometric information. We consider several implementations of this analysis by experimenting with sequences of gray scale images. To quantify the performance of our method we calculate the MSE (mean squared error) and the PSNR (peak signal to noise ratio). Our results consistently improve performances compared to the well-known JPEG image compression standard and provide a viable solution for simultaneous compression and encryption of multiple images.

Incidence and risk factors for post-renal transplant diabetes mellitus.

INTRODUCTION: Posttransplant diabetes mellitus (PTDM) is a common, serious complication of renal transplantation. The aim of this retrospective study was to estimate the incidence and to identify potential factors predisposing to PTDM. PATIENTS AND METHODS: We evaluated 296 adult nondiabetic patients who underwent kidney transplantation at our center. PTDM was defined according to 2003 international consensus guidelines. Potential factors predisposing to PTDM were analyzed individually and simultaneously using a logistic regression model. RESULTS: Over 2054.5 years of cumulative follow-up, 51 patients (17.2%) developed diabetes corresponding to an annual incidence of 2.5%. PTDM was diagnosed after a median of 2.9 months (range: 0.2-168). The mean age of affect individuals was 33.3±7.4 years. Patients with PTDM were significantly older (P<.0005) and showed an higher body mass index (BMI; P<.004). Univariate analysis revealed that age, BMI, family history of diabetes, vascular nephropathy, and hepatitis C infection were associated with PTDM. Multivariate analysis rescaled the roles of age (relative risk [RR]=1.046/y; P<.04), BMI (RR=1.107/kg/m2, P<.05), vascular nephropathy (RR=7.06, P<.03), and hepatitis C infection (RR=2.72, P<.03) as independent factors predisposing to PTDM. CONCLUSION: Among our relatively young kidney transplant recipients, in whom only 8% received tacrolimus, PTDM was a frequent complication. We suggest that the use of oral glucose tolerance tests to screen patients identifies those predisposed to develop this complication.

Study of anticardiolipin antibody in hepatitis C virus-positive patients

Several antibodies, including anticardiolipin antibodies (ACA), have been detected among chronically infected hepatitis C virus (HCV) patients. The present work aimed at ascertaining the clinical significance of ACA levels among HCV infection associated with two commonly encountered diseases, thrombocytopenia and arteriovenous-shunt malfunction. Six groups were studied, 11 HCV-positive thrombocytopenic patients (group I), 14 HCV-positive non-thrombocytopenic patients (group II) and 15 healthy controls (group III), 11 anti-HCV-positive hemodialysis patients with non-functioning shunt (group IV), 14 anti-HCV-positive hemodialysis patients with patent shunt (group V) (Bain Medical Equipment Co., China) and 15 healthy controls (group VI). Anticardiolipin antibody (ACA) assay was performed on all patients and controls whereas tumor necrosis factor α (TNF-α) assay was carried out on thrombocytopenic patients and controls. Thrombocytopenic groups presented an inverse correlation between IgG ACA levels and both thrombocytopenia and TNF-α levels. During the follow-up period, no other clinical manifestations related to ACA were developed. Hemodialysis groups showed a significant elevation in IgG ACA levels in groups IV and V compared to the controls, with statistically higher levels in group IV than group V. Three group IV patients were hypercholesterolemic. We can conclude that induction of proinflammatory cytokines such as TNF-α by persistent HCV infection may promote the generation of ACA. Complications of HCV, including thrombocytopenia and thrombosis in arteriovenous shunt, are more strongly correlated with IgG ACA than with IgM ACA.(AU)

Finasteride treatment inhibits adult hippocampal neurogenesis in male mice.

INTRODUCTION: The 5-alpha-reductase inhibitor finasteride is used for the treatment of androgenic alopecia, benign prostate hyperplasia and prostate cancer. Besides inhibiting the conversion of testosterone to the biologically more active 5alpha-dihydrotestosterone, it also inhibits the production of neurosteroids. Decreased neurosteroid levels are postulated to be involved in the pathophysiology of psychiatric disorders such as depression. As neurosteroids metabolized by 5-alpha-reductase influence neural plasticity, we investigated whether finasteride treatment alters adult hippocampal neurogenesis, implicated in the pathophysiology of depression. METHODS: Male C57BL/6N mice were treated subchronically (7 days) with finasteride or vehicle. Adult neurogenesis was assessed at two different time points after treatment (day 1; day 35) using immunohistochemistry. RESULTS: Finasteride treatment led to a significant decrease in brain 5alpha-dihydrotestosterone levels and induced a reversible reduction in the number of newborn cells and young neurons in the hippocampus. 35 days after the last finasteride injection, neurogenesis had returned to normal. DISCUSSION: These data indicate that inhibition of 5-alpha-reductase activity by finasteride treatment influences neuronal plasticity on a structural level. These changes might contribute to the pathophysiology of depressive episodes observed after finasteride treatment.

[Epidemiological and clinical characteristics of intestinal microsporidiosis]. / Caractéristiques épidémiologiques et cliniques de la microsporidiose intestinale chez les immunodéprimés vus à Tunis.

INTRODUCTION: Intestinal microsporidiosis is an opportunistic parasitological infection affecting mainly immunocompromised patients, particularly those infected with HIV. PURPOSE: The purpose of this study was to analyse the epidemiological and clinical characteristics of intestinal microsporidiosis and the treatments available for it. MATERIAL AND METHODS: This retrospective study examined records collected over a 13-year period (from January 1995 through December 2007). It included 572 immunocompromised patients (279 HIV-infected patients and 293 without HIV infection) with symptoms suggesting intestinal microsporidiosis. All were tested systematically for microsporidia spores by modified (Weber's) Trichrome staining. RESULTS: Fourteen patients (10 men, 4 women) were diagnosed with intestinal microsporidiosis, for a prevalence of 2.4% overall, 3.6% in HIV-infected patients and 1.4% in those without HIV infection. Intestinal microsporidiosis affected 10 HIV-infected patients, 70% of whom had a CD4 count <100 cells/mm3. Their mean age was 30+/-15 years (range: 15 months to 48 years). The average age of HIV-infected patients (36 years) was significantly higher than of those without HIV infection (15 years). Thirteen patients had symptoms, most frequently diarrhea (11 cases), sometimes associated with dehydration (5 cases). Eight patients (57%) received only symptomatic treatment, and 4 (28.6%) received albendazole. No treatment was recommended in 2 cases (14.3%). Clinical course was marked by improvement in 6 cases, death in 5, and persistence of asymptomatic carriage in one. Two patients were lost to follow-up. CONCLUSION: Intestinal microsporidiosis is a parasitological disease that mainly affects AIDS patients with CD4 counts <100 cells/mm3. Its diagnosis requires special techniques. Its symptomatology is dominated by chronic diarrhea that can cause dehydration. Effective treatment requires identification of the species.