Shallow suture at ventricular septal defect may safely reduce right bundle branch block.

BACKGROUND: To avoid rhythm disturbance, sutures for ventricular septal defect closure have been traditionally placed 2∼5 mm or more away from the edge of the ventricular septal defect. However, the traditional suturing method appears to induce right bundle branch block and tricuspid valve regurgitation after ventricular septal defect closure more than our alternative technique, shallow suturing just at the edge of the ventricular septal defect (shallower bites at the postero-inferior margin). We aimed to verify our clinical experience of perimembranous ventricular septal defect repair. METHODS: The alternative shallow suturing method has been applied since 2003 at our institution. We retrospectively reviewed the clinical data of 556 isolated perimembranous ventricular septal defect patients who underwent surgical closure from 2000 to 2019. We investigated the postoperative occurrence of right bundle branch block or progression of tricuspid regurgitation and analysed risk factors for right bundle branch block and tricuspid regurgitation. RESULTS: Traditional suturing method (Group T) was used in 374 cases (66.8%), and alternative suturing method (Group A) was used in 186 cases (33.2%). The right bundle branch block occurred more frequently in Group T (39.6%) than in Group A (14.9%). In multivariable logistic regression analysis, Group T and patch material were significant risk factors for late right bundle branch block. More patients with progression of tricuspid regurgitation were found in Group T. CONCLUSIONS: Shallow suturing just at the edge of the ventricular septal defect may reduce the rate of right bundle branch block occurrence and tricuspid regurgitation progression without other complications.

Expanded indication for EUS-guided radiofrequency ablation: management of adrenal tumors.

BACKGROUND AND AIMS: EUS-guided radiofrequency ablation (EUS-RFA) has been performed as an alternative to surgery for the treatment of pancreatic tumors. The promising results obtained using this procedure suggest that the indication for EUS-RFA could be expanded to the management of extrapancreatic tumors. Here, we evaluate the feasibility, efficacy, and safety of EUS-RFA in the treatment of left adrenal tumors. METHODS: This single-center, prospective study was conducted at Asan Medical Center between January 2016 and November 2021. A total of 11 patients with left adrenal tumors were enrolled in the study. The technical success rate, treatment response, and adverse events were evaluated. RESULTS: EUS-RFA was performed successfully in all patients (technical success rate, 100%). The indications for the procedure were an increase in tumor size (n = 8), and adrenal tumor with adrenal hormone excess (n = 3). After a median of 2 EUS-RFA sessions (range, 1-2), 73% of patients had a complete response, and 27% had a partial response. During follow-up, 5 patients experienced self-limiting mild abdominal pain; no moderate or severe adverse events were reported. CONCLUSIONS: EUS-RFA showed high technical feasibility, clinical success, and an acceptable safety profile in the treatment of left adrenal tumors. In patients at high surgical risk, EUS-RFA can be considered as an alternative therapeutic modality to surgery for the treatment of left adrenal tumors.

Randomized Open Investigation Determining Steroid Dose in Severe COVID-19: The ROIDS-Dose Clinical Trial.

Introduction Treatment with dexamethasone reduces mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia requiring supplemental oxygen, but the optimal dose has not been determined. Objective To determine whether weight-based dexamethasone of 0.2 mg/kg is superior to 6 mg daily in reducing 28-day mortality in patients with COVID-19 and hypoxemia. Materials and methods A multicenter, open-label, randomized clinical trial was conducted between March 2021 and December 2021 at seven hospitals within Northwell Health. A total of 142 patients with confirmed COVID-19 and hypoxemia were included. Participants were randomized in a 1:1 ratio to dexamethasone 0.2 mg/kg intravenously daily (n = 70) or 6 mg daily (n = 72) for up to 10 days. Results There was no statistically significant difference in the primary outcome of 28-day all-cause mortality with deaths in 12 of 70 patients (17.14%) in the intervention group and 15 of 72 patients (20.83%) in the control group (p = 0.58). There were no statistically significant differences among the secondary outcomes. Conclusion In patients with COVID-19 and hypoxemia, the use of weight-based dexamethasone dosing was not superior to dexamethasone 6 mg in reducing all-cause mortality at 28 days. Clinical trial registration This study was registered under ClinicalTrials.gov (identifier: NCT04834375).

Radiological and clinical features of screening-detected pulmonary invasive mucinous adenocarcinoma.

OBJECTIVES: The current understanding of pulmonary invasive mucinous adenocarcinoma is largely based on studies of advanced stage patients and data about early-stage invasive mucinous adenocarcinoma are sparse. We evaluated the radiological and clinical features of screening-detected early-stage invasive mucinous adenocarcinoma (SD-IMA). METHODS: Data from 91 patients who underwent surgical treatment for SD-IMA (≤3 cm) from 2013 to 2019 were reviewed retrospectively. Data on radiological characteristics, clinicopathological findings, recurrence and survival were obtained. Disease-free survival rate was analysed. RESULTS: Radiologically, SD-IMAs presented as a pure ground-glass nodule (6.6%), part-solid nodule (38.5%) or solid (54.9%). Dominant locations were both lower lobes (74.7%) and peripheral area (93.4%). The sensitivity of percutaneous needle biopsy was 78.1% (25/32). Lobectomy was performed in 70 (76.9%) patients, and sublobar resection in 21 (23.1%) patients. Seventy-three (80.2%), 15 (16.5%) and 3 (3.3%) patients had pathological stage IA, IB and IIB or above, respectively. Seven patients developed recurrence, and 3 died due to disease progression. Pleural seeding developed exclusively in 2 patients who underwent needle biopsy. The 5-year disease-free survival rate was 89.4%. The disease-free survival rates at 5 years were 86.3% in the lobectomy group and 100% in the sublobar resection group. CONCLUSIONS: SD-IMAs were mostly radiologically invasive nodules. SD-IMAs showed favourable prognosis after surgical treatment.

Long-Term Outcomes in Stage I Lung Cancer After Segmentectomy with a Close Resection Margin.

BACKGROUND: In general, a 2-cm surgical margin is recommended for limited resection to obtain equivalent oncologic outcomes to lobectomy for lung cancer. This study aimed to examine the patterns of recurrence and prognostic factors for recurrence in patients with a close parenchymal resection margin. METHODS: From January 2009 to April 2017, 156 patients with stage I lung cancer who underwent segmentectomy with a close resection margin (<2 cm) were enrolled. Recurrence- free survival and overall survival were assessed. In addition, predisposing factors for recurrence were evaluated. RESULTS: The mean tumor size was 1.7±0.8 cm and the parenchymal resection margin was 1.1±0.6 cm. Recurrence developed in 17 (10.7%) of the 156 patients, and the 5-year recurrence-free survival rate was 88.9%. Distant metastasis (7.7%) was the predominant recurrence pattern. The isolated local recurrence rate was 1.9%. Multivariate Cox regression analysis revealed that age, tumor size, mediastinal lymph node dissection, postoperative complications, and histologic type were significant predisposing factors for recurrence. However, parenchymal margin distance did not significantly affect the long-term prognosis. CONCLUSION: Segmentectomy with a close resection margin for early-stage lung cancer in selected patients resulted in acceptable recurrence and survival. However, patients with tumors larger than 2 cm, squamous cell carcinoma histology, and insufficient mediastinal evaluation should be carefully followed up for recurrence.

Effect of the electron donating group on the excited-state electronic nature and epsilon-near-zero properties of curcuminoid-borondifluoride dyes.

Epsilon-near-zero (ENZ) properties have been reported in organic molecular films. In particular, cyanine and squaraine films have been shown to exhibit ENZ properties in the visible spectral region with a strong 3rd order nonlinear optical response near the ENZ spectral region. Noting both cyanine and squaraine belong to the polymethine family, a series of six curcuminoid borondifluoride (Curc) derivatives were developed to examine whether such a polymethine character is positively correlated with the ENZ property of the organic films. Those Curc derivatives possess a Donor-Acceptor-Donor (D-A-D) architecture with acceptor, AcacBF2, located at the molecular center. The backbone of Curc is designed such that the donor strength can be tuned to transit between charge transfer (CT) and polymethine character. This balance between CT and polymethine character of the Curc series is examined based on the Lippert-Mataga plot. As donor strength in the D-A-D structure increases, CT character is less marked resulting in a more dominant polymethine character. The structural and optical properties of the Curc films with a thickness in the order of 30 nm were examined to correlate the polymethine character with the ENZ response. The results obtained in isotropic Curc thin films demonstrate that an increase of polymethine character associated with a stronger donor strength leads to an appearance/enhancement of the ENZ property in the visible spectrum range from 500 to 670 nm. Overall, this study provides useful guidelines to engineer new organic materials showing ENZ properties in a desired spectral range.

Pneumatosis Intestinalis in COVID-19: Case Series.

OBJECTIVE: To describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who developed pneumatosis intestinalis (PI). METHODS: This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State. Patients were included if they were identified as having confirmed COVID-19 as well as pneumatosis intestinalis from March 16, 2020 to July 31, 2020. Patient demographics, clinical characteristics, vasopressor use, anticoagulation use, opiate use, paralytic use, COVID-19 treatment regimen, serum lactate, arterial pH, serum bicarbonate, subsequent intervention, and outcomes during hospitalization were collected.  Results: A total of nine patients were identified. Average serum lactate was 4.33 mmol/L at time of diagnosis. Portal venous gas (56%) and bowel dilation (56%) were common radiographic findings. Subsequent morbidity (increased vasopressor requirements - 67%, acute kidney injury - 67%, increased oxygen requirements - 44%) and mortality (78%) were high. PI occurred despite a majority of patients being on anticoagulation (78%). Interleukin-6 (IL-6) inhibitors were commonly administered (56%) prior to development of PI. CONCLUSION: Pneumatosis intestinalis in COVID-19 is clinically significant, with high morbidity and mortality, and is also likely underdiagnosed.

Initial Experience with Epicardial Ultrasound Scanning in Coronary Artery Bypass Grafting.

BACKGROUND: The benefits of epicardial ultrasound scanning (EUS) in coronary artery bypass grafting (CABG) have not yet been established. The aim of this study was to evaluate the usefulness of EUS in CABG, including in the assessment of the quality of distal anastomoses, the identification of epicardial target vessels, and the evaluation of any graft issues other than the distal anastomoses. METHODS: Fifty-three patients undergoing CABG were enrolled between March 2018 and February 2019. Intraoperative EUS was performed along with transit-time flow measurement (TTFM). Graft evaluations were performed early (shortly after surgery) and 1 year after surgery for 53 (100%) and 47 (88.7%) patients, respectively. RESULTS: EUS was applied to assess the quality of all distal anastomoses, 32 target vessels, and 2 conduit trunks. Insufficient TTFM findings were obtained for 18 grafts. However, graft revision was performed for only 3 distal anastomoses; based on the EUS findings, the remaining 15 sites were not revised. The early and 1-year overall graft patency rates were 100% (141 anastomoses) and 96.1% (122 of 127 anastomoses), respectively. All 15 of the distal anastomoses that were not revised despite insufficient TTFM results were patent at the 1-year mark. CONCLUSION: The routine application of EUS in CABG could be beneficial by confirming the quality of surgery and reducing unnecessary procedures.

Pneumothorax in COVID-19 Acute Respiratory Distress Syndrome: Case Series.

Objective The study aims to describe the clinical characteristics and outcomes of patients with COVID-19 related acute respiratory distress syndrome (ARDS) who developed pneumothorax. Design and setting A retrospective chart review was performed of the electronic medical record. Patients were included if they were identified as having confirmed COVID-19 as well as pneumothorax from March 16, 2020 to May 31, 2020. Patients' demographic and clinical characteristics, mechanical ventilator parameters, lung compliance measurements and outcomes during hospitalization were collected. This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State. Patients A total of 75 patients were identified who were predominantly male (73.3%) with an average age of 62.8 years. Thirty (40%) were Hispanic, 20 (26.7%) were White, 16 (21.3%) were Asian, and nine (12%) were Black. Common comorbid conditions were hypertension (52%), diabetes mellitus (26.7%), hyperlipidemia (32.0%), and chronic pulmonary disease (8, 10.7%). Measurements and main results Most of the patients were diagnosed with pneumothorax while on mechanical ventilation (92%) despite overall adherence with lung-protective ventilation strategies. Average tidal volume was 6.66 mL/kg) of ideal body weight. The average positive end-expiratory pressure (PEEP) was 10.83 (cm) H2O. Lung compliance was poor, with average peak and plateau pressures of 41.9 cm H2O and 35.2 cm H2O, respectively. Inpatient mortality was high in these patients (76%). Conservative management with initial observation had a success rate (73.3%) with similar mortality and shorter length of stay (LOS) on average. Significant factors in the conservatively managed group included lack of tension physiology, the smaller size of pneumothorax, lack of underlying diabetes, presence of pneumomediastinum, and not being on mechanical ventilation during diagnosis. Conclusion Despite overall adherence to best practice ventilator management in ARDS, we observed a large number of pneumothoraces during the COVID-19 pandemic. Conservative management may be appropriate if there are no clinical signs or symptoms of tension physiology and pneumothorax size is small.

Dithia[3.3]paracyclophane Core: A Versatile Platform for Triplet State Fine-Tuning and Through-Space TADF Emission.

Thermally activated delayed fluorescence (TADF) based on through-space donor and acceptor interactions constitute a recent and promising approach to develop efficient TADF emitters. Novel TADF isomers using a dithia[3.3]-paracyclophane building block as a versatile 3D platform to promote through-space interactions are presented. Such a 3D platform allows to bring together the D and A units into close proximity and to probe the effect of their orientation, contact site and distance on their TADF emission properties. This study provides evidence that the dithia[3.3]paracyclophane core is a promising platform to control intramolecular through-space interactions and obtain an efficient TADF emission with short reverse-intersystem crossing (RISC) lifetimes. In addition, this study demonstrates that this design can tune the energy levels of the triplet states and leads to an upconversion from 3 CT to 3 LE that promotes faster and more efficient RISC to the 1 CT singlet state.

Control of the dual emission from a thermally activated delayed fluorescence emitter containing phenothiazine units in organic light-emitting diodes.

The development of single-component organic dual light-emitting molecules is of interest for a range of applications including white organic light-emitting diodes. Herein, a new thermally-activated delayed fluorescent molecule containing 4,6-bis-phenyl phenothiazine as donor units and 2-thiophene-1,3,5-triazine as acceptor unit was synthesized using a simple cost-effective method. This compound shows two stable molecular conformations due to the presence of the phenothiazine units in its molecular structure. These conformers exhibit different photophysical properties in both solution and thin films. The electroluminescence properties of this novel emitter were then examined in organic light-emitting diodes and the results provide useful insights into the influence of the device architecture on the dual emission characteristics. The experimental results were consistent with the optical simulations and the optimized architecture led to the fabrication of electroluminescent devices with an external quantum efficiency of 11.5% and a maximum luminance value of 10 370 cd m-2.

Synaptic Plasticity and Metaplasticity of Biological Synapse Realized in a KNbO3 Memristor for Application to Artificial Synapse.

Amorphous KNbO3 (KN) films were grown on a TiN/SiO2/Si substrate to synthesize a KN memristor as a potential artificial synapse. The Pt/KN/TiN memristor exhibited typical and reliable bipolar switching behavior with multiple resistance levels. It also showed the transmission properties of a biological synapse, with a good conductance modulation linearity. Moreover, the KN memristor can emulate various biological synaptic plasticity characteristics including short-term plasticity, long-term plasticity, spike-rate dependent plasticity, paired-pulse facilitation, and post-tetanic potentiation by controlling the number and rate of the potentiation spike. Spike-timing-dependent plasticity (STDP), which is an essential property of biological synapses, is also realized in the KN memristor. The synaptic plasticity of the KN memristor can be explained by oxygen vacancy movement and oxygen vacancy filaments. The metaplasticity of biological synapses was also implemented in the KN memristor, including the metaplasticity of long-term potentiation and depression, and of STDP. Therefore, the KN memristor could be used as an artificial synapse in neuromorphic computing systems.

Synthesis by a Cost-Effective Method and Electroluminescence of a Novel Efficient Yellowish-Green Thermally Activated Delayed Fluorescent Molecule.

A new thermally activated delayed fluorescent molecule, TRZ 3(Ph-PTZ), containing three phenothiazines as donor units and a 2,4,6-triphenyl-1,3,5-triazine as the acceptor unit was synthesized using a simple cost-effective method based on a cobalt catalyzed cross-coupling. This compound was tested in organic light-emitting diodes and was found to show superior yellowish-green electroluminescence performance with a maximum external quantum efficiency of 17.4% and a maximum luminance value of 7430 cd/m2.

Spontaneous rupture of the extensor pollicis longus tendon in a tailor.

A spontaneous rupture of the extensor pollicis longus (EPL) tendon is associated with rheumatoid arthritis, fractures of the wrist, systemic or local steroids and repetitive, and excessive abnormal motion of the wrist joint. The authors encountered a case of a spontaneous rupture of the EPL tendon. The patient had no predisposing factors including trauma or steroid injection. Although the patient had a positive rheumatoid factor, he did not demonstrate other clinical or radiological findings of rheumatoid arthritis. During surgery, the EPL tendon was found to be ruptured at the extensor retinaculum (third compartment). Reconstruction of the extensor tendon using the palmaris longus tendon was performed. At the 18-month follow-up, the patient showed satisfactory extension of the thumb and 40° extension and flexion at the wrist.

Airways are more reactive to histamine than to methacholine in patients with mild airway hyperresponsiveness, regardless of atopy.

BACKGROUND: The airway muscles from allergen-sensitized animals in vitro show a heightened response to histamine, but not to carbachol. This study investigated whether the airway responsiveness to histamine in vivo is comparable to that of methacholine in human subjects with varying degrees of atopy. METHODS: One-hundred-and-sixty-eight consecutive adult asthma patients or volunteers underwent bronchoprovocation tests to both histamine and methacholine after determining their blood eosinophil counts, serum total IgE levels and skin test reactivity to 10 common aeroallergens. RESULTS: The responsiveness to histamine was significantly related to that to methacholine (r=0.609, p<0.001), but many individuals with a negative methacholine test response showed a positive response to histamine. The histamine-bronchial reactivity index (BRindex) was significantly higher than the methacholine-BRindex in subjects with a positive response to none (n=69, p<0.01) or only one (n=42, p<0.001) of histamine and methacholine, while there was no significant difference in the subjects with positive responses to both of them (n=57). The histamine-BRindex was significantly higher than the methacholine-BRindex in the subjects with mild histamine hyperresponsiveness (n=58, 1.28+/-0.01 vs. 1.20+/-0.02, respectively, p<0.001). Both histamine and methacholine responsiveness was significantly related to the atopy markers. However, the histamine-BRindex/methacholine-BRindex ratio of the atopics was not significantly different from that of the non-atopics. CONCLUSIONS: The airway responsiveness to histamine is comparable to that of methacholine in the subjects with positive responses to both histamine and methacholine, but the airway responsiveness to histamine is greater than that to methacholine in those subjects with mild airway hyperresponsiveness, regardless of atopy.