Frailty and In-Hospital Outcomes for Management of Cardiogenic Shock without Acute Myocardial Infarction.

(1) Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Frailty and cardiovascular diseases are intertwined, commonly sharing risk factors and exhibiting bidirectional relationships. The relationship of frailty and non-acute myocardial infarction with cardiogenic shock (non-AMI-CS) is poorly described. (2) Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for non-AMI-CS. We classified them into frail and non-frail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. (3) Results: A total of 503,780 hospitalizations for non-AMI-CS were identified. Most hospitalizations involved frail adults (80.0%). Those with frailty had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 2.03-2.20, p < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, such as acute kidney injury, delirium, and longer length of stay. Importantly, non-AMI-CS hospitalizations in the frail group had lower use of mechanical circulatory support but not rates of cardiac transplantation. (4) Conclusions: Frailty is highly prevalent among non-AMI-CS hospitalizations. Those accompanied by frailty are often associated with increased rates of morbidity and mortality compared to those without frailty.

Phacomatosis pigmentokeratotica: Exploring extracutaneous comorbidities and topical therapy.

Phacomatosis pigmentokeratotica (PPK) is a RASopathy characterized by the presence of a sebaceous nevus and a papular speckled lentiginous nevus. This case report highlights the associated extracutaneous comorbidities, including life-threatening arrhythmia, and introduces topical rapamycin as a potential therapeutic avenue for sebaceous nevus in PPK patients.

Developmental outcome of electroencephalographic findings in SYNGAP1 encephalopathy.

SYNGAP1 haploinsufficiency results in a developmental and epileptic encephalopathy (DEE) causing generalized epilepsies accompanied by a spectrum of neurodevelopmental symptoms. Concerning interictal epileptiform discharges (IEDs) in electroencephalograms (EEG), potential biomarkers have been postulated, including changes in background activity, fixation-off sensitivity (FOS) or eye closure sensitivity (ECS). In this study we clinically evaluate a new cohort of 36 SYNGAP1-DEE individuals. Standardized questionnaires were employed to collect clinical, electroencephalographic and genetic data. We investigated electroencephalographic findings, focusing on the cortical distribution of interictal abnormalities and their changes with age. Among the 36 SYNGAP1-DEE cases 18 presented variants in the SYNGAP1 gene that had never been previously reported. The mean age of diagnosis was 8 years and 8 months, ranging from 2 to 17 years, with 55.9% being male. All subjects had global neurodevelopmental/language delay and behavioral abnormalities; 83.3% had moderate to profound intellectual disability (ID), 91.7% displayed autistic traits, 73% experienced sleep disorders and 86.1% suffered from epileptic seizures, mainly eyelid myoclonia with absences (55.3%). A total of 63 VEEGs were revised, observing a worsening of certain EEG findings with increasing age. A disorganized background was observed in all age ranges, yet this was more common among older cases. The main IEDs were bilateral synchronous and asynchronous posterior discharges, accounting for ≥50% in all age ranges. Generalized alterations with maximum amplitude in the anterior region showed as the second most frequent IED (≥15% in all age ranges) and were also more common with increasing age. Finally, diffuse fast activity was much more prevalent in cases with 6 years or older. To the best of our knowledge, this is the first study to analyze EEG features across different age groups, revealing an increase in interictal abnormalities over infancy and adolescence. Our findings suggest that SYNGAP1 haploinsufficiency has complex effects in human brain development, some of which might unravel at different developmental stages. Furthermore, they highlight the potential of baseline EEG to identify candidate biomarkers and the importance of natural history studies to develop specialized therapies and clinical trials.

The phenotypic spectrum of epilepsy associated with periventricular nodular heterotopia.

BACKGROUND: Periventricular nodular heterotopia (PVNH) is a congenital brain malformation often associated with seizures. We aimed to clarify the spectrum of epilepsy phenotypes in PVNH and the significance of specific brain malformation patterns. METHODS: In this retrospective cohort study, we recruited people with PVNH and a history of seizures, and collected data via medical record review and a standardized questionnaire. RESULTS: One hundred individuals were included, aged 1 month to 61 years. Mean seizure onset age was 7.9 years. Ten patients had a self-limited epilepsy course and 35 more were pharmacoresponsive. Fifty-five had ongoing seizures, of whom 23 met criteria for drug resistance. Patients were subdivided as follows: isolated PVNH ("PVNH-Only") single nodule (18) or multiple nodules (21) and PVNH with additional brain malformations ("PVNH-Plus") single nodule (8) or multiple nodules (53). Of PVNH-Only single nodule, none had drug-resistant seizures. Amongst PVNH-Plus, 55% with multiple unilateral nodules were pharmacoresponsive, compared to only 21% with bilateral nodules. PVNH-Plus with bilateral nodules demonstrated the highest proportion of drug resistance (39%). A review of genetic testing results revealed eight patients with pathogenic or likely pathogenic single-gene variants, two of which were FLNA. Five had copy number variants, two of which were pathogenic. CONCLUSIONS: The spectrum of epilepsy phenotypes in PVNH is broad, and seizure patterns are variable; however, epilepsy course may be predicted to an extent by the pattern of malformation. Overall, drug-resistant epilepsy occurs in approximately one quarter of affected individuals. When identified, genetic etiologies are very heterogeneous.

Quantifying the childhood and adolescent overnutrition attributable to specific risk factors: The Young Lives Study in Peru.

OBJECTIVE: Launching priority actions demand a comprehensive appraisal of the size effect that risk factors have on the burden of overweight and obesity. This study aimed to estimate the incidence of overweight and obesity among children and adolescents, with special emphasis on the role of specific risk factors. MATERIALS AND METHODS: Secondary analysis of data from the younger cohort of the Young Lives Study in Peru (2002-2017). The outcomes were: overweight and obesity, defined by the World Health Organization standards; whereas the exposures included caesarean birth, physical activity levels, sodas and sugar-sweetened beverages consumption, snacks consumption, and maternal body mass index (BMI). We used multilevel Poisson regression models, considering the repetitive nature of data, to estimate incidence rate ratios (IRRs) and population attributable fractions (PAFs). RESULTS: A total of 2052 children, mean age 1 (SD 0.4) year, and 50% girls, were enrolled at baseline. After 14 (SD 0.5) years of follow-up, the incidence of overweight and obesity were 7.9 (95% CI 7.6-8.2) and 2.2 (95% CI 2.0-2.4) per 100 person-year, respectively. Maternal BMI (IRRs 3.51; PAF 31.8%), low physical activity (IRR 1.64; PAF 27.4%), caesarean birth (IRR 1.63; PAF 11.4%), almost daily snack consumption (IRR 1.60; PAF 32.1%), and almost daily consumption of sweetened beverages (IRR 1.47; PAF 26.0%) increased the risk of developing obesity. CONCLUSIONS: This study provides evidence on the risk of overweight and obesity attributable to diet habits, physical activity and the obesogenic niche among children and adolescents in Peru, which may guide the implementation of evidence-based interventions.

A Control-Theoretical System for Modulating Hippocampal Gamma Oscillations Using Stimulation of the Posterior Cingulate Cortex.

Closed-loop stimulation for targeted modulation of brain signals has emerged as a promising strategy for episodic memory restoration. In parallel, closed-loop neuromodulation strategies have been applied to treat brain conditions including drug-resistant depression, Parkinson's Disease, and epilepsy. In this study, we seek to apply control theoretical principles to achieve closed loop modulation of hippocampal oscillatory activity. We focus on hippocampal gamma power, a signal with an established association for episodic memory processing, which may be a promising 'biomarker' for the modulation of memory performance. To develop a closed-loop stimulation paradigm that effectively modulates hippocampal gamma power, we use a novel data-set in which open-loop stimulation was applied to the posterior cingulate cortex and hippocampal gamma power was recorded during the encoding of episodic memories. The dataset was used to design and evaluate a linear quadratic integral (LQI) servo-controller in order to determine its viability for in-vivo use. In our simulation framework, we demonstrate that applying an LQI servo controller based on an autoregressive with exogenous input (ARX) plant model achieves effective control of hippocampal gamma power in 15 out of 17 experimental subjects. We demonstrate that we are able to modulate gamma power using stimulation thresholds that are physiologically safe and on time scales that are reasonable for application in a clinical system. We outline further experimentation to test our proposed system and compare our findings to emerging closed-loop neuromodulation strategies.

Reactor microbiome enriches vegetable oil with n-caproate and n-caprylate for potential functionalized feed additive production via extractive lactate-based chain elongation.

BACKGROUND: Biotechnological processes for efficient resource recovery from residual materials rely on complex conversions carried out by reactor microbiomes. Chain elongation microbiomes produce valuable medium-chain carboxylates (MCC) that can be used as biobased starting materials in the chemical, agriculture and food industry. In this study, sunflower oil is used as an application-compatible solvent to accumulate microbially produced MCC during extractive lactate-based chain elongation. The MCC-enriched solvent is harvested as a potential novel product for direct application without further MCC purification, e.g., direct use for animal nutrition. Sunflower oil biocompatibility, in situ extraction performance and effects on chain elongation were evaluated in batch and continuous experiments. Microbial community composition and dynamics of continuous experiments were analyzed based on 16S rRNA gene sequencing data. Potential applications of MCC-enriched solvents along with future research directions are discussed. RESULTS: Sunflower oil showed high MCC extraction specificity and similar biocompatibility to oleyl alcohol in batch extractive fermentation of lactate and food waste. Continuous chain elongation microbiomes produced the MCC n-caproate (nC6) and n-caprylate (nC8) from L-lactate and acetate at pH 5.0 standing high undissociated n-caproic acid concentrations (3 g L-1). Extractive chain elongation with sunflower oil relieved apparent toxicity of MCC and production rates and selectivities reached maximum values of 5.16 ± 0.41 g nC6 L-1 d-1 (MCC: 11.5 g COD L-1 d-1) and 84 ± 5% (e- eq MCC per e- eq products), respectively. MCC were selectively enriched in sunflower oil to concentrations up to 72 g nC6 L-1 and 3 g nC8 L-1, equivalent to 8.3 wt% in MCC-enriched sunflower oil. Fermentation at pH 7.0 produced propionate and n-butyrate instead of MCC. Sunflower oil showed stable linoleic and oleic acids composition during extractive chain elongation regardless of pH conditions. Reactor microbiomes showed reduced diversity at pH 5.0 with MCC production linked to Caproiciproducens co-occurring with Clostridium tyrobutyricum, Clostridium luticellarii and Lactobacillus species. Abundant taxa at pH 7.0 were Anaerotignum, Lachnospiraceae and Sporoanaerobacter. CONCLUSIONS: Sunflower oil is a suitable biobased solvent to selectively concentrate MCC. Extractive reactor microbiomes produced MCC with improved selectivity and production rate, while downstream processing complexity was reduced. Potential applications of MCC-enriched solvents may include feed, food and biofuels purposes.

nZVI Impacts Substrate Conversion and Microbiome Composition in Chain Elongation From D- and L-Lactate Substrates.

Medium-chain carboxylates (MCC) derived from biomass biorefining are attractive biochemicals to uncouple the production of a wide array of products from the use of non-renewable sources. Biological conversion of biomass-derived lactate during secondary fermentation can be steered to produce a variety of MCC through chain elongation. We explored the effects of zero-valent iron nanoparticles (nZVI) and lactate enantiomers on substrate consumption, product formation and microbiome composition in batch lactate-based chain elongation. In abiotic tests, nZVI supported chemical hydrolysis of lactate oligomers present in concentrated lactic acid. In fermentation experiments, nZVI created favorable conditions for either chain-elongating or propionate-producing microbiomes in a dose-dependent manner. Improved lactate conversion rates and n-caproate production were promoted at 0.5-2 g nZVI⋅L-1 while propionate formation became relevant at ≥ 3.5 g nZVI⋅L-1. Even-chain carboxylates (n-butyrate) were produced when using enantiopure and racemic lactate with lactate conversion rates increased in nZVI presence (1 g⋅L-1). Consumption of hydrogen and carbon dioxide was observed late in the incubations and correlated with acetate formation or substrate conversion to elongated products in the presence of nZVI. Lactate racemization was observed during chain elongation while isomerization to D-lactate was detected during propionate formation. Clostridium luticellarii, Caproiciproducens, and Ruminococcaceae related species were associated with n-valerate and n-caproate production while propionate was likely produced through the acrylate pathway by Clostridium novyi. The enrichment of different potential n-butyrate producers (Clostridium tyrobutyricum, Lachnospiraceae, Oscillibacter, Sedimentibacter) was affected by nZVI presence and concentrations. Possible theories and mechanisms underlying the effects of nZVI on substrate conversion and microbiome composition are discussed. An outlook is provided to integrate (bio)electrochemical systems to recycle (n)ZVI and provide an alternative reducing power agent as durable control method.

Right Atrial Pressure Is Associated With Outcomes in Patient With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support.

Background: We describe the association between longitudinal hemodynamic changes and clinical outcomes in patients with cardiogenic shock (CS) receiving acute mechanical circulatory support devices (AMCS) at a single center. We hypothesized that improved right atrial pressure is associated with better survival in CS. Methods: Retrospective analysis of patients from Tufts Medical Center that received AMCS for CS. Baseline characteristics and invasive hemodynamics were collected, analyzed, and correlated against outcomes. Hemodynamics were recorded at different time intervals during index admission [pre-AMCS, 24 h after AMCS (post AMCS), and last available set of hemodynamics (final-AMCS)]. Logistic regression was performed to determine variables associated with in-hospital mortality. Results: A total of 76 patients had longitudinal hemodynamics available. In hospital mortality occurred in 46% of the cohort. Mean baseline right atrial pressure (RAP) was significantly higher among non-survivors vs. survivors (19.5+6.6 vs. 16.4+5.3 mmHg). Change in right atrial pressure from baseline to before device removal (ΔRA:final AMCS-pre AMCS) was significantly different between survivors and non survivors (-6.5 ± 6.9 mmHg vs. -2.5 ± 6.2 mmHg p = 0.03). Unadjusted logistic regression revealed baseline RAP (OR: 1.1 95% CI: 1.0-1.2), 24 h post device implant RAP (OR: 1.3 95% CI: 1.1-1.4), and final RAP (OR: 1.3 95% CI: 1.1-1.5) to be significant predictors of in-hospital mortality. In a multivariate logistic regression baseline RAP was no longer significantly associated with mortality in the overall cohort, while 24 h (OR: 1.26 95% CI: 1.1-1.5) and final RAP (OR: 1.3 95% CI: 1.1-1.6) remained statistically significant. Conclusion: We report a novel retrospective analysis of hemodynamic changes in patients with CS receiving AMCS. Our findings identify the potential importance of venous congestion as a prognostic marker of mortality. Furthermore, early decongestion or reduced RA pressure is associated with better survival in these critically ill CS patients. These observations suggest the need for further study in larger retrospective and prospective cohorts of patients with varying degrees of CS severity.

Cross-regional phase amplitude coupling supports the encoding of episodic memories.

Phase amplitude coupling (PAC) between theta and gamma oscillations represents a key neurophysiological mechanism that promotes the temporal organization of oscillatory activity. For this reason, PAC has been implicated in item/context integration for episodic processes, including coordinating activity across multiple cortical regions. While data in humans has focused principally on PAC within a single brain region, data in rodents has revealed evidence that the phase of the hippocampal theta oscillation modulates gamma oscillations in the cortex (and vice versa). This pattern, termed cross-regional PAC (xPAC), has not previously been observed in human subjects engaged in mnemonic processing. We use a unique dataset with intracranial electrodes inserted simultaneously into the hippocampus and seven cortical regions across 40 human subjects to (1) test for the presence of significant cross-regional PAC (xPAC), (2) to establish that the magnitude of xPAC predicts memory encoding success, (3) to describe specific frequencies within the broad 2-9 Hz theta range that govern hippocampal-cortical interactions in xPAC, and (4) compare anterior versus posterior hippocampal xPAC patterns. We find that strong functional xPAC occurs principally between the hippocampus and other mesial temporal structures, namely entorhinal and parahippocampal cortices, and that xPAC is overall stronger for posterior hippocampal connections. We also show that our results are not confounded by alternative factors such as inter-regional phase synchrony, local PAC occurring within cortical regions, or artifactual theta oscillatory waveforms.

Single stick access using a VA-ECMO arterial return cannula for coronary intervention in cardiogenic shock.

Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is growing exponentially for cardiogenic shock and cardiac arrest, and many of these patients require percutaneous coronary intervention (PCI). In some cases, radial arterial access may not feasible among patients with peripheral vascular disease or if larger diameter guide catheters are required. Further, VA-ECMO is commonly used in combination with an intra-aortic balloon pump or Impella, thereby limiting vascular access options and increasing the risk of vascular complications including bleeding and limb ischemia. For these reasons, new approaches to perform PCI without the need for an additional arterial puncture are required. We describe a case of a 70-year-old man with cardiogenic shock referred for high-risk PCI while supported with VA-ECMO and an Impella CP and illustrate a novel method for single-stick access for PCI through the return cannula of the VA-ECMO circuit.

Trabajo del área de salud "19 de Abril" en la atención a enfermos de COVID-19, julio-octubre 2020

RESUMEN Introducción: La infección por ‎el virus SARS-CoV-2 de alta capacidad de propagación ha tenido un rebrote a nivel internacional y también en Cuba. Objetivo: Examinar el trabajo realizado en el área de salud "19 de Abril" en la atención a enfermos de COVID-19 durante el rebrote de la enfermedad según características demográficas y clínicas-epidemiológicas y el contraste de estas características con las del brote de marzo-junio de 2020. Métodos: Estudio descriptivo y transversal realizado en julio-octubre de 2020 en el área de salud "19 de Abril" en La Habana. El universo de estudio estuvo representado por los casos positivos de COVID-19. Se trabajó con la información disponible en la base de datos de Coronavirus creada en la Vicedirección de Higiene y Epidemiología y con información del Departamento de Estadísticas del Policlínico Docente Universitario "19 de Abril". Resultados: Se diagnosticaron 32 casos, 50 % de ellos asintomáticos; 14 (43,7 %) del sexo femenino, 17 (53,1 %) entre 35 y 59 años, 18 (56,2 %) de piel blanca y 20 (62,5 %) residentes en el consejo popular Plaza. En relación con el brote de marzo-junio, fueron mayores los porcentajes de casos asintomáticos, masculinos, de las edades entre 25 y 59 años, de piel blanca y predominaron los casos en el consejo popular Plaza. Conclusiones: La incidencia de casos de COVID-19 en el área de salud "19 de Abril" en el rebrote, es mayor y con características clínico-epidemiológicas similares a las del brote de marzo-junio. El trabajo realizado permitió que se impidiera la transmisión comunitaria de la enfermedad.

ABSTRACT Introduction: Fast-spreading SARS-CoV-2 virus infection has had an epidemic regrowth worldwide and also in Cuba. Objective: Examine the work done in "19 de Abril" health area in the care of COVID-19 patients during the regrowth of the disease based on demographic and clinical-epidemiological characteristics versus those of the March-June 2020 outbreak. Methods: A descriptive cross-sectional study was conducted in "19 de Abril" health area in Havana from July to October 2020. The study universe was the positive COVID-19 cases. Data were obtained from the coronavirus database developed by the Hygiene and Epidemiology Division and from the Statistics Department at "19 de Abril" University Polyclinic. Results: A total 32 cases were diagnosed, of whom 50% were asymptomatic, 14 (43.7%) female, 17 (53.1%) aged 35-59 years, 18 (56.2%) of white skin color and 20 (62.5%) resided in Plaza People's Council. In comparison with the March-June outbreak, higher percentages were found of asymptomatic male white-skin subjects aged 25-39 years, and cases from Plaza People's Council prevailed. Conclusions: The incidence of COVID-19 cases in "19 de Abril" health area during the regrowth is higher, and the clinical-epidemiological characteristics are similar to those of the March-June outbreak. The work done prevented community transmission of the disease.

Invasive Hemodynamic Assessment and Classification of In-Hospital Mortality Risk Among Patients With Cardiogenic Shock.

BACKGROUND: Risk stratifying patients with cardiogenic shock (CS) is a major unmet need. The recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) stages as an approach to identify patients at risk for in-hospital mortality remains under investigation. We studied the utility of the SCAI stages and further explored the impact of hemodynamic congestion on clinical outcomes. METHODS: The CS Working Group registry includes patients with CS from 8 medical centers enrolled between 2016 and 2019. Patients were classified by the maximum SCAI stage (B-E) reached during their hospital stay according to drug and device utilization. In-hospital mortality was evaluated for association with SCAI stages and hemodynamic congestion. RESULTS: Of the 1414 patients with CS, the majority were due to decompensated heart failure (50%) or myocardial infarction (MI; 35%). In-hospital mortality was 31% for the total cohort, but higher among patients with MI (41% versus 26%, MI versus heart failure, P<0.0001). Risk for in-hospital mortality was associated with increasing SCAI stage (odds ratio [95% CI], 3.25 [2.63-4.02]) in both MI and heart failure cohorts. Hemodynamic data was available in 1116 (79%) patients. Elevated biventricular filling pressures were common among patients with CS, and right atrial pressure was associated with increased mortality and higher SCAI Stage. CONCLUSIONS: Our findings support an association between the proposed SCAI staging system and in-hospital mortality among patient with heart failure and MI. We further identify that venous congestion is common and identifies patients with CS at high risk for in-hospital mortality. These findings provide may inform future management protocols and clinical studies.

Transaxillary Intra-Aortic Balloon Pump Deployment Through a Novel Braided Sheath for Advanced Heart Failure Patients Requiring an Extended Duration of Temporary Circulatory Support.

For decompensated advanced heart failure patients, the intra-aortic balloon pump (IABP) is a commonly used mechanical circulatory support (MCS) device used to support pharmacotherapy-refractory myopaths. In the United States, the heart allocation policy was revised in 2018, placing patients who may receive a clinically indicated temporary MCS device, like an IABP, at elevated medical urgency on the transplantation waiting list. Percutaneous transaxillary IABP delivery for the decompensated advanced heart failure patient is a safe, tolerable and efficacious alternative to traditional transfemoral deployment, and allows for ambulation and meaningful physical therapy engagement in the patient who may require an extended duration of support awaiting advanced therapies. We present two cases of percutaneous transaxillary IABP delivery via the Super Arrow-Flex braided sheath (Teleflex, Morrisville, NC) in advanced heart failure patients. The Super Arrow-Flex Sheath is a braided, durable, non-kinking conduit that can negotiate tortuous vascularity while maintaining its internal integrity; transaxillary IABP delivery through this sheath offers the patient a wide latitude of ipsilateral upper extremity movement and ambulation with minimal risk of damage to the IABP catheter. The Super Arrow-Flex sheath may improve transaxillary IABP security, durability and longevity in the advanced heart failure population for whom long-term IABP is anticipated.

Prevalence and Clinical Correlates of Extended Mechanical Support in Patients Undergoing High-Risk Percutaneous Coronary Intervention in Current Clinical Practice: Insights from the cVAD Registry.

BACKGROUND: High-risk percutaneous coronary interventions (HR-PCI) are prone to hemodynamic instability, resulting in poor outcomes. Acute mechanical circulatory support (AMCS) devices are used during HR-PCI to improve outcomes. However, the clinical criteria for extended AMCS have not been well characterized. The aim of this study was to describe the prevalence and clinical correlates of extended AMCS in patients undergoing elective or urgent HR-PCI. METHODS: We retrospectively analyzed 507 patients enrolled in the catheter-based ventricular assist device (cVAD) registry who underwent elective or urgent HR-PCI with prophylactic use of Impella. The study population was divided into two groups: Impella support removed immediately after PCI (Group A, n = 464) and extended support after PCI (Group B, n = 43). Multivariable regression analysis was used to identify independent predictors of extended AMCS. RESULTS: Baseline characteristics were similar between the groups. Non-ST-elevation myocardial infarction in 26.3% in Group A vs 41.8% in Group B (p = 0.03). PCI of left main was common in Group A (p = 0.02), whereas the right coronary artery was common in Group B (p < 0.001). The mean duration of Impella support 1.1 ±â€¯0.6 h in Group A vs 11.4 ±â€¯16.8 h in Group B (p < 0.001). Death and vascular complications were higher with extended Impella support. Revascularization of chronic total occlusion (CTO) was an independent predictor of extended Impella support (OR 3.2, 95% CI 1.20-8.53). CONCLUSIONS: About 9% of patients enrolled in the cVAD registry undergoing elective or urgent HR-PCI received extended Impella support. In-hospital mortality was about 12% in patients requiring extended Impella support. CTO was associated with a higher likelihood of extended AMCS. The hemodynamic benefits of extended AMCS support must be weighed in terms of risk of complications.

Consecutive lactate formation and chain elongation to reduce exogenous chemicals input in repeated-batch food waste fermentation.

The production of biochemicals from renewables through biorefinery processes is important to reduce the anthropogenic impact on the environment. Chain elongation processes based on microbiomes have been successfully developed to produce medium-chain fatty acids (MCFA) from organic waste streams. Yet, the sustainability of chain elongation can still be improved by reducing the use of electron donors and additional chemicals. This work aimed to couple lactate production and subsequent chain elongation to decrease chemicals input such as electron donors and hydroxide for pH control in repeated-batch food waste fermentation. Food waste with adjusted pH was used as substrate and fermentation proceeded without pH control. During fermentation, lactate was first formed through the homolactic pathway and then converted to fatty acids (FA), mainly n-butyrate and n-caproate. The highest n-caproate carbon selectivities (mmol C/mmol CFA) and production rates were 38% and 4.2 g COD/L-d, respectively. Hydroxide input was reduced over time to a minimum of 0.47 mol OH-/mol MCFA or 0.79 mol OH-/kg CODFA. Lactate was a key electron donor for chain elongation and its conversion was observed at pH as low as 4.3. The microbiome enriched in this work was dominated by Lactobacillus spp. and Caproiciproducens spp. The high abundance of Caproiciproducens spp. and their co-occurrence with Lactobacillus spp. suggest Caproiciproducens spp. used lactate as electron donor for chain elongation. This work shows the production of n-caproate from food waste with decreased use of hydroxide and no use of exogenous electron donors.

Percutaneous Management of Outflow Graft Obstruction in Patients With Continuous Flow Left Ventricular Assist Devices.

Outflow graft obstruction (OGO) has been reported as a cause of left ventricular assist device dysfunction. The incidence, diagnosis, and treatment of OGO remains poorly understood. We present our experience with the diagnosis and management of OGO in the cardiac catheterization laboratory. (Level of Difficulty: Advanced.).

Clinical correlates of hand-held ultrasound-guided assessments of the inferior vena cava in patients with acute decompensated heart failure.

BACKGROUND: Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF. METHODS: In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter; <0.5 representing hypervolemia) was calculated. Primary study endpoint was 30-day readmission. Research activities were independent of clinical decision-making. RESULTS: Data for 106 patients was analyzed. Mean age was 66.7 ± 13.8 years, of which 53.8% were females, and a mean ejection fraction was 39 ± 18%. Initial scan of the IVC was obtained at an average time of 5.2 ± 8.04 hours from first diuretic dose. 81.2% of patients at admission had an IVC-CI <0.5. 63.2% patients had an IVC-CI <0.5 at discharge. There were no significant differences in age, length of stay, diuretic dose, or 30-day readmissions between patients with a discharge IVC-CI <0.5 vs ≥ 0.5. CONCLUSION: Hand-held ultrasound assessment of IVC-CI in ADHF patients, although a feasible concept, is unable to predict 30-day readmissions in our study. Further prospective studies are necessary.

Trabajo del área de salud "19 de Abril" en la atención a enfermos de COVID-19 (marzo-junio 2020)

RESUMEN Introducción: La infección por ‎el virus SARS-CoV-2 tiene capacidad alta de propagación. Las personas de edad avanzada y con comorbilidades ‎presentan un mayor riesgo de padecer formas graves de la enfermedad y morir. Objetivo: Examinar el trabajo realizado en el área de salud "19 de Abril" en la atención a enfermos de COVID-19 según características demográficas y clínicas-epidemiológicas. Métodos: Estudio descriptivo de corte transversal realizado en los meses marzo-junio de 2020 en el área de salud "19 de Abril" en La Habana. El universo de estudio estuvo representado por los casos positivos de COVID-19. Se trabajó con la información disponible en la base de datos de coronavirus creada en la Vicedirección de Higiene y Epidemiología y con información del Departamento de Estadísticas del Policlínico Docente Universitario "19 de Abril". Resultados: Se diagnosticaron 14 casos de COVID-19, 57 % de ellos asintomáticos; 4 (28,5 %) del sexo femenino, 9 (64,2 %) entre 25 y 59 años, 8 (57,7 %) de raza blanca y 6 (42,8 %). residentes en el consejo popular "Plaza". No se produjo transmisión comunitaria en el área. Conclusiones: Las características clínico-epidemiológicas de la COVID-19 en el área son similares a las de las restantes áreas de salud del municipio, provincia y país. El cumplimiento estricto de los protocolos aprobados por el Ministerio de Salud Pública contribuyó a evitar que se produjeran focos de transmisión en el área.

ABSTRACT Introduction: The infection by SARS-CoV-2 has a high spreading ability. Older people with comorbilities have a higher risk of suffering severe forms of the disease and to die. Objective: To study the work carried out at "19 de Abril" health area in the care to COVID-19 patients according to demographic and clinical epidemiological characteristics. Methods: Descriptive, cross-sectional study carried out in the period March-June 2020 in the health area called "19 de Abril" in Havana. The study sample was formed by COVID-19 positive cases. It was checked the information available in the coronavirus related database created in the Vice-Direction of Hygiene and Epidemiology and the information from the Statistics Department of "19 de Abril" Teaching University Policlinic. Results: 14 cases of COVID-19 were diagnosed, 57% of them were asymptomatic, 4 cases (28,5%) were females, 9 cases (64.2%) were in the ages from 25 to 59 years, 8 cases (57,7%) were white, and 6 cases (42.8%) were living in "Plaza" district. There was not community transmission of the disease in the area. Conclusions: Clinical-epidemiological characteristics of COVID-19 in "19 de Abril" health area are similar to the ones of other health areas in the municipality, the province and the country. The strict compliance of the protocols approved by the Ministry of Public Health contributed to avoid the onset of transmission sources in the area.