One Pump for Two Hearts: Using an Impella 5.5 Micro-Axial Pump in Peripartum Cardiogenic Shock.

Cardiogenic shock (CS) occurs infrequently in pregnancy and has a high mortality rate. Medical treatment options are few, with limited evidence of efficacy. Temporary mechanical circulatory supports (tMCS) may play a key role in addressing this therapeutic lacuna. We report successfully managing second-trimester CS using an Impella 5.5 micro-axial pump. Our patient presented in the second-trimester with CS. Hemodynamic parameters indicated biventricular dysfunction (low cardiac index, low pulmonary artery pulsatility index). She received diuresis and inotropic support to optimize her fluid status and cardiac function. However, failure to improve to the point where she would be able to tolerate the hemodynamic stresses of labor despite optimizing medical therapy prompted consideration of tMCS. The Impella 5.5 was chosen for its higher output (to maximize fetal perfusion), relative longevity, and lower hemolysis rates compared to other devices. It was used to support her from gestational weeks 28-30 and through the delivery. Support was continued for 4 weeks postpartum to allow for any potential cardiac recovery. Hope unrealized, a workup for destination therapy was initiated. Patient preference and high panel reactive antibodies informed the decision to pursue destination left ventricular assist device (LVAD) therapy. After a 3 month neonatal intensive care unit (NICU) stay, mother and baby were successfully discharged home.

Determinants of Schistosoma mansoni transmission in hotspots at the late stage of elimination in Egypt.

BACKGROUND: In certain settings, the prevalence and severity of schistosoma infection do not lessen despite repeated rounds of preventative chemotherapy; these areas are known as hotspots. This study aimed to investigate the role of human practices, besides environmental and malacological factors, in the maintenance of the Schistosoma mansoni infection transmission chain in hotspot areas in Egypt. METHODS: This cross-sectional study was conducted between July and November 2019 in Kafr El-Sheikh Governorate, Egypt. A pre-designed structured interviewing questionnaire was used to collect humanitarian data. Stool samples were collected from children aged 6-15 years on three successive days and examined using the Kato-Katz technique. Simultaneously, water and snail samples were taken from watercourses surrounding houses. Snails were identified based on their shell morphology and structure and tested for cercaria shedding. Water samples were analyzed for their physicochemical and biological characteristics. RESULTS: A total of 2259 fecal samples (1113 in summer and 1146 in fall) were collected from 861 children. About 46.9% of the participants were males, and 31.8% were aged 6-10 years. The prevalence of S. mansoni infection was higher during the summer than during the fall (19.1% vs 7.2%, respectively, P < 0.01). The intensity of infection (light, moderate, and heavy) during summer versus fall was (93.55 vs 89.38%, 6.45 vs 8.85%, and 0.00% vs 1.77%), respectively (P < 0.05). A higher prevalence of human infection was observed among males than females [OR = 1.63, 95% confidence interval (CI):1.10-2.40, P = 0.015], children aged 11-15 years than among their counterparts aged 6-10 years (OR = 2.96, 95% CI: 1.72-5.06, P < 0.001), and mothers with a low level of education (OR = 3.33, 95% CI: 1.70-6.52, P < 0.001). The main identified risk factors were contacting the main body of water-canal for washing clothes (OR = 1.81, 95% CI: 1.12-2.49, P = 0.015), land irrigation (OR = 2.56, 95% CI: 1.32-4.96, P = 0.004), water collection (OR = 2.94, 95% CI: 1.82-4.73, P < 0.001), bathing (OR = 2.34, 95% CI: 1.21-4.31, P = 0.009), and garbage disposal (OR = 2.38, 95% CI:1.38-4.12, P < 0.001). The count of Biomphalaria alexandrina was distinct between seasons (P < 0.01) in consistent with statistically significant differences in water temperature, salinity, turbidity, the total concentration of coliforms, depth, velocity, and water level (P < 0.01). The presence of grasses and duckweeds was significantly associated with snail infection (P = 0.00 l). Significant effects of water depth, pH, temperature, and total dissolved solids on snail count were also observed (P < 0.05). CONCLUSIONS: The persistence of the infection is due to adoption of risky behaviors and environmental factors that enhance snail survival and infection. Schistosomiasis elimination in hotspots requires an integrated control approach that combines preventive chemotherapy with other complementary measures.

Repeatability of Corneal Hysteresis Measurements in Glaucoma Patients During Routine Follow Up and After Cataract Surgery.

PRCIS: Corneal hysteresis (CH) measurements are relatively stable during routine follow up of glaucoma patients over an intermediate time frame. Cataract surgery does not change the CH significantly after an average follow up of 6 months. PURPOSE: The aim was to assess the repeatability of CH measurements in glaucoma patients over time, during routine follow up and after cataract surgery. MATERIALS AND METHODS: Retrospective analysis of patients records in a glaucoma clinic where routine measurements by the Ocular Response Analyzer were done. Patients with at least 2 CH measurements were included. Repeatability was assessed using the intraclass correlation coefficient (ICC). RESULTS: A total of 164 eyes (87 patients) were included. Twenty-eight of them had measurements before and after cataract surgery with mean follow up time of 29.64±9.63 weeks. There was no evidence for a difference in CH between the before and after cataract surgery measurements (ICC=0.79, 95% confidence interval: 0.60-0.89). In the remaining 136 eyes, without any surgical treatment between measurements, there was moderate agreement among the repeated CH measurements (ICC=0.64, 95% confidence interval: 0.61-0.82) with mean time of 32.06±25.32 weeks between first and last measurement. CONCLUSION: CH measurements in glaucoma patients were repeatable over a 6-month period during routine follow up or following cataract surgery. These findings suggest that the intraocular pressure reduction following cataract surgery is unlikely to be because of a change in this biomechanical property.

Discontinuation of Transmission Precautions for COVID-19 Patients: Polymerase Chain Reaction Diagnostics, Patient Delays, and Cycle Threshold Values.

BACKGROUND: The decision of when it is safe to discontinue transmission-based precautions for SARS-CoV-2 coronavirus disease 2019 (COVID-19) hospitalized patients has been controversial. The Centers for Disease Control and Prevention offered reverse transcriptase polymerase chain reaction (PCR) diagnostic test- or symptom-based guidelines. METHODS: A retrospective chart review of Vidant Health system, Eastern North Carolina, was conducted. Length of stay, days in isolation unit, and date appropriate for discharge or isolation discontinuation based on the symptom-based strategy were recorded. RESULTS: Of 196 COVID hospitalized patients, 34 had repeated COVID PCR tests 3 or more days from their first positive test result. Half of these patients experienced delays in release from transmission-based precautions because of repeated positive PCR test results and use of the test-based approach. This resulted in an additional 166 days of hospitalization, costing an estimated $415,000. Furthermore, 2 subjects had a combined 16-day delay in necessary medical procedures. Most of the COVID PCR platforms yield quantitative results in the form of cycle threshold (Ct) values, the number of cycles needed to detect the genome. These values have also been used to assess whether patients are likely to remain contagious. None of our patients who met the criteria for symptom-based strategy for transmission-based precaution discontinuation had positive PCR test results with Ct values lower than 25, but 4 had Ct values lower than 30. CONCLUSIONS: Concerns surround immunocompromised patients and those treated with steroids who might be delayed or incapable of stopping viral replication and thus remain contagious. Our results suggest that clinicians use all available data including Ct values to evaluate the safety of discontinuation of transmission precautions.

Structure and antimicrobial comparison between N-(benzyl) chitosan derivatives and N-(benzyl) chitosan tripolyphosphate nanoparticles against bacteria, fungi, and yeast.

Chitosan (Ch) was reacted with seven benzaldehyde analogs separately through reductive amination in which the corresponding imines were formed and followed by reduction to produce N-(benzyl) chitosan (NBCh) derivatives. 1H NMR spectroscopy was used to characterize the products. The nanoparticles (NPs) of Ch and NBCh derivatives were prepared according to the ionotropic gelation mechanism between Ch products and sodium tripolyphosphate, followed by high-energy ultrasonication. Scanning electron microscopy, particle size, polydispersity index, and zeta potential were applied for the NPs examination. The particle size was ranged from 235.17 to 686.90 nm and narrow size distribution (PDI <1). The zeta potential of NPs was varied between -1.26 and -27.50 mV. The antimicrobial activity was evaluated against bacteria (Erwinia carotovora subsp. atroseptica, Erwinia carotovora subsp. carotovora, and Ralstonia solanacearum), fungi (Aspergillus flavus and Aspergillus niger), and yeast (Candida albicans). The action of NBCh derivatives was significantly higher than Ch. The NPs had considerably higher than the Ch and NBCh derivatives. The activity was directly proportional to the chemical derivatization of Ch and the zeta potential of the NPs. The antimicrobial efficacy of these derivatives formulated in a greener approach could become an alternative to using traditional antimicrobial applications in an environmentally friendly manner.

Pattern of Hemolytic Anemia Among Egyptian Pediatric Emergency Department Patients.

OBJECTIVES: The emergency department is considered the backbone of the medical service offered in any hospital. Yet, the data on the frequency of pediatric hematological presentation is scanty. Anemia occurs in 9% to 14% of pediatric emergency department (ED) patients. Glucose-6-phosphate dehydrogenase (G6PD) deficiency affects more than 400 million people worldwide. Unfortunately, we do not have screening program for G6PD deficiency in Egypt. The aim of this study is to assess the burden of hemolytic crisis among Egyptian children visiting ED. METHODS: This is a prospective cross-sectional study among children presenting with acute hemolytic crisis in the ED of New Children Hospital, Cairo University from March to June 2016. Cases underwent full history taking, clinical examination, and laboratory tests based on clinical judgment of the resident. We categorized the presenting hemolytic anemias into 3 groups: G6PD deficiency, acute hemolysis in previously diagnosed patients with chronic hemolytic anemia, and acute undiagnosed hemolytic anemia. RESULTS: Our study included 143 patients, 109 males (76.22%) and 34 females (23.76%), with a mean age 36 months (range, 3-188 months), who presented with hemolytic anemia in the ED. Seventy-six cases (53.1%) were diagnosed as G6PD deficiency, 36 (25.2%) were diagnosed as chronic hemolytic anemia, and 31 (21.7%) were diagnosed as undiagnosed acute hemolytic anemia. CONCLUSIONS: Hemolytic anemia is very common presentation in ED. G6PD deficiency is the most common cause, representing 53.1% of the hemolytic anemia.

How to Predict Intraocular Pressure Reduction after Cataract Surgery? A Prospective Study.

Purpose/Aim: To evaluate the best formula to predict intraocular pressure (IOP) reduction after cataract surgery. Materials and methods: In this prospective longitudinal study, we included consecutive patients with or without glaucoma, either with open or with narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Clinical factors and anterior segment parameters measured with optical biometry and optical coherence tomography were evaluated as preoperative predictors for IOP reduction at 6 months postoperatively. To find the best combinations of predictors, model selection was conducted using least absolute selection and shrinkage operator regression with cross-validation. Results: A total of 156 eyes from 109 patients were enrolled. The mean age of the patients was 74.89 (±8.54) years and the average preoperative IOP was 15.6 (±3.68) mmHg with 0.7 (range 0-4) glaucoma medications. The mean IOP reduction after phaco was 3.1 (±2.49) mmHg at postoperative month 6. After multivariate analysis, preoperative IOP (ß = 0.49 [0.4-0.59] P < .0001), gonioscopy score (ß = -0.14 [-0.23 to -0.06] P = .0001), anterior chamber depth (ß = -0.85 [-1.64 to -0.07] P = 0.033), lens thickness (LT) (ß = 0.87 [0.12-1.62] P = .024), and angle open distance 750 (ß = -2.2 [-3.96 to -0.44] P = 0.014) were associated with IOP reduction. The best formula to correlate with IOP reduction was -4.76 + (0.46 × preoperative IOP) - (0.42 × LT) - (0.1 × gonioscopy score) - (0.66 × glaucoma status). Conclusion: Different formulas were developed and were able to improve the predictive value of the preoperative IOP. When used in combination, these formulas may help the clinician to know how much IOP reduction to expect after cataract surgery at 6 months postoperatively.

Central Corneal Thickness Variances Among Different Asian Ethnicities in Glaucoma and Nonglaucoma Patients.

OBJECTIVE: To compare the central corneal thickness (CCT) between different ethnicities and particularly Asian subethnic groups that may contribute to the different glaucoma diagnoses using the optical low-coherence reflectometry technique. METHODS: A retrospective study of 6 years including 1512 eyes of 929 patients of the Beckman vision center, University of California, San Francisco from 2011 to 2017 had their biometric parameters, including CCT, measured with the Lenstar. Patients were categorized into African Americans, Caucasians, Hispanics, Pacific Islanders, and Asians. Asians were further subcategorized into Chinese, Vietnamese, Koreans, Filipinos, and Japanese. RESULTS: Among 1356 patients who had their CCT measured by Lenstar from 2011 to 2017, 1512 eyes of 929 patients were included. The study population included 462 Caucasians (52.96%), 60 African Americans (6.46%), 92 Hispanics (9.9%), 32 Pacific Islanders (3.44%), 130 Chinese (13.99%), 52 Filipinos (5.6%), 37 Vietnamese (3.98%), 34 Koreans (3.66%), and 30 Japanese (3.23%). African Americans had the thinnest CCT with a mean of 518.62±40.3 followed by Asians with a mean of 539.29±34.1. Among the Asian study sample, the Chinese had the thinnest CCT with a mean of 537.66±32.5. CCT was adjusted for age, sex, glaucoma diagnosis, diabetes status, and prostaglandin analogs use for >12 months. CONCLUSIONS: Optical low-coherence reflectometry is a widely used technology, which can measure CCT. Our study confirms that African Americans have the thinnest corneas followed by Asians. In the latter group, relatively thin CCT may partly explain their high rates of normal-tension glaucoma.

Novel Gonioscopy Score and Predictive Factors for Intraocular Pressure Lowering After Phacoemulsification.

PURPOSE: To evaluate a novel gonioscopy score as a potential predictor for intraocular pressure (IOP) reduction after cataract surgery. MATERIALS AND METHODS: This was a prospective study that included consecutive patients with or without glaucoma, either with open or narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Eyes with intraoperative complications and secondary glaucoma were excluded. A preoperative gonioscopy score was created, summing the Shaffer gonioscopy grading in 4 quadrants (range, 0 to 16). To determine variables associated with IOP change at 6 months, univariate and multivariate linear mixed-effects regression analysis was performed adjusting for age, sex, and preoperative IOP. RESULTS: In total, 188 eyes from 137 patients were enrolled. The mean age of the patients was 75.0 (±8.5) years and the average preoperative IOP was 15.6 (±3.6) mm Hg with 0.7 (range, 0 to 4) glaucoma medications. The mean IOP reduction after phacoemulsification was 3.0 (±2.6) mm Hg at postoperative month 6. After multivariate analysis, preoperative IOP [ß=0.49 (0.41-0.58), P<0.0001], gonioscopy score [ß=-0.17 (-0.24 to -0.09), P<0.0001], anterior chamber depth (ACD) [ß=-0.88 (-1.64 to -0.14), P=0.02], and IOP/ACD ratio [ß=0.45 (0.07 to 0.83) P=0.021] were associated with IOP reduction at 6 months. CONCLUSIONS: Preoperative predictors for IOP reduction after cataract surgery were preoperative IOP, ACD, gonioscopy score, and IOP/ACD ratio. The IOP/ACD ratio and gonioscopy score can be easy parameters to obtain and may help clinicians to estimate the IOP reduction after phacoemulsification.

Agreement of Anterior Segment Parameters Obtained From Swept-Source Fourier-Domain and Time-Domain Anterior Segment Optical Coherence Tomography.

Purpose: To assess the interdevice agreement between swept-source Fourier-domain and time-domain anterior segment optical coherence tomography (AS-OCT). Methods: Fifty-three eyes from 41 subjects underwent CASIA2 and Visante OCT imaging. One hundred eighty-degree axis images were measured with the built-in two-dimensional analysis software for the swept-source Fourier-domain AS-OCT (CASIA2) and a customized program for the time-domain AS-OCT (Visante OCT). In both devices, we examined the angle opening distance (AOD), trabecular iris space area (TISA), angle recess area (ARA), anterior chamber depth (ACD), anterior chamber width (ACW), and lens vault (LV). Bland-Altman plots and intraclass correlation (ICC) were performed. Orthogonal linear regression assessed any proportional bias. Results: ICC showed strong correlation for LV (0.925) and ACD (0.992) and moderate agreement for ACW (0.801). ICC suggested good agreement for all angle parameters (0.771-0.878) except temporal AOD500 (0.743) and ARA750 (nasal 0.481; temporal 0.481). There was a proportional bias in nasal ARA750 (slope 2.44, 95% confidence interval [CI]: 1.95-3.18), temporal ARA750 (slope 2.57, 95% CI: 2.04-3.40), and nasal TISA500 (slope 1.30, 95% CI: 1.12-1.54). Bland-Altman plots demonstrated in all measured parameters a minimal mean difference between the two devices (-0.089 to 0.063); however, evidence of constant bias was found in nasal AOD250, nasal AOD500, nasal AOD750, nasal ARA750, temporal AOD500, temporal AOD750, temporal ARA750, and ACD. Among the parameters with constant biases, CASIA2 tends to give the larger numbers. Conclusions: Both devices had generally good agreement. However, there were proportional and constant biases in most angle parameters. Thus, it is not recommended that values be used interchangeably.