Outcomes of transulnar and transradial percutaneous coronary intervention using ultrasound guided access in patients selected based on an ultrasound algorithm.

We performed a prospective observational study of 215 patients (58 ± 11 years) and compared the outcomes of ultrasound guided ulnar (n = 98, 45.6%) vs. radial (n = 117, 54.4%) cardiac catheterization and percutaneous coronary intervention (PCI) in patients selected by an ultrasound based algorithm. Primary endpoints included the number of access attempts and conversion to femoral access. Secondary endpoints included all-cause mortality, cardiac mortality, myocardial infarction, stroke, repeat revascularization, stent thrombosis, in-stent restenosis, and access site complications. No significant difference was found in the primary endpoints between radial or ulnar. Ulnar access showed no significant hematomas. Therefore, ulnar PCI is a feasible alternative.

Outcomes of Dorsal Distal Radial, Radial, and Ulnar Artery Percutaneous Coronary Intervention With Ultrasound Guidance in Acute Myocardial Infarction.

Ultrasound utilization during access enables precise vessel cannulation. We sought to evaluate the outcomes of ultrasound guided dorsal distal radial artery (DDRA), radial, and ulnar cardiac catheterization (CC) and percutaneous coronary intervention (PCI). We performed a prospective observational study of 224 patients (58 ± 12 years) at an academic medical center from October 2016 to March 2020 (median follow-up of 13 months) and compared the outcomes of ultrasound guided DDRA, ulnar, or radial artery CC and PCI. Groups were divided into DDRA (n = 18, 8.0%), ulnar (n = 94, 42.0%) and radial access (n = 112, 50.0%). Primary endpoints included the number of access attempts and conversion to femoral access. Secondary endpoints included all-cause mortality, cardiac mortality, acute myocardial infarction (AMI), stroke, repeat revascularization, stent thrombosis, in-stent restenosis, and access site complications. In the primary endpoints, no significant difference was found amongst groups in the number of access attempts (P = 0.272) or conversion to femoral access (P = 0.381). In the radial group (59 ± 11 years, median follow-up of 16 months), 2 cardiac mortalities (1 lymphocytic myocarditis, 1 AMI) and 2 noncardiac mortalities occurred. None of the secondary endpoints occurred in the DDRA (66 ± 17 years, median follow-up of 13 months) or ulnar group (56 ± 11 years, median follow-up of 14 months). DDRA and ulnar PCI was safe and efficacious with no complications. Femoral conversion or the number of access attempts was not different between DDRA, ulnar, or radial. Therefore, DDRA and ulnar are viable alternatives for PCI, which can preserve radial for future use.

Elevated Lipoprotein A in South Asians and the Associated Risk of Cardiovascular Disease: A Systematic Review.

BACKGROUND: South Asians have a premature risk of cardiovascular disease and increased lipoprotein A which enhances their risk. METHODS: This systematic review evaluates the role of elevated lipoprotein A in cardiovascular disease risk for South Asians. It discusses the pathophysiology, clinical studies, and treatment of elevated lipoprotein A using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. RESULTS: A total of 72 articles was incorporated which consisted of clinical studies, case-control and cohort studies, meta-analysis, reviews, and editorials. Cardiovascular disease and myocardial infarction occurs prematurely in South Asians, which is further enhanced with an elevated lipoprotein A. CONCLUSIONS: South Asians with an elevated lipoprotein A have an increased risk of coronary artery disease so they should have early enactment of lifestyle modification and aggressive medical management.

Management of Angina Post Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: Our review discusses the management of post percutaneous coronary intervention angina (PPCIA) which negatively impacts 20-40% of patients and imposes a high burden on the healthcare system. RECENT FINDINGS: Mechanisms of PPCIA include microvascular dysfunction, distal coronary vasospasm or disease, microembolization, myocardial bridge, coronary artery disease (CAD) progression, and rarely stent thrombosis or in-stent restenosis. Nitrates, beta blockers (BB), calcium channel blockers, and ranolazine are the common medical management options. Only BB showed 1-year mortality benefit following myocardial infarction. Stress echocardiography and cardiac magnetic resonance are the best to detect CAD vs. microvascular dysfunction. Invasively, vasoprovocative testing and fractional flow reserve provide useful prognostic information. If the ischemia burden is ≤10%, conservative management should be considered based upon the individual patient scenario. The optimal management of PPCIA remains unclear and further research is necessary. Multiple treatment options exist, which should be implemented in an individualized fashion.

Systematic review of alternative access for cardiac catheterization and percutaneous coronary intervention: Dorsal distal radial and ulnar artery catheterization.

The femoral and radial arteries are the standard access routes for cardiac catheterization. In cases where the right radial artery has been previously utilized or is not suitable for repeat procedures, the left dorsal distal radial artery (anatomical snuff box) or the ulnar artery may be an alternative access site. In this systematic review, alternative access sites are described along with the techniques of cannulation, technical considerations, ultrasound imaging, clinical studies, and their complications. As we routinely perform more radial procedures, increased complications will arise, so it becomes important to gain expertise in alternative access for future coronary interventions. Such a systematic review has not been previously published so it will enhance the reader's knowledge of alternative access.

Curcumin ameliorates the targeted delivery of methotrexate intercalated montmorillonite clay to cancer cells.

Montmorillonite Clay (MMT) is aimed to develop as an orally administrable drug delivery vehicle with enhanced efficacy. Aiming to enhance the therapeutic index of methotrexate, curcumin is concomitantly used with methotrexate in the present study. Being folate antagonist in nature, methotrexate is internalized into cells by folate receptor (FR); which is over-expressed in certain human cancer cells such as cervical carcinoma cells (HeLa). Firstly, montmorillonite Clay (MMT) is organically modified (OMMT) with cetyl trimethyl ammonium bromide (CTAB) and used to intercalate curcumin and methotrexate separately, designated as OMMT-Cur and OMMT-MTX, respectively. XRD pattern demonstrated successful intercalation of therapeutics and an increase in clay interlayer distance facilitated by CTAB. The dissolution kinetics of methotrexate follows Higuchi model for both Simulated Gastric Fluid (SGF) and Simulated Intestinal Fluid (SIF), while the release kinetics for curcumin fitted into Higuchi model for SGF and Hixson-Crowell model for SIF, respectively. OMMT-MTX are able to discriminate FR-positive HeLa cells from FR-negative breast cancer cells (MCF7); irrespective of alike cellular phenotypes. Further, the pre-treatment of HeLa cells with curcumin improves its sensitivity towards methotrexate causing a greater killing of the Hela cells. Together, the results propose the concomitant use of curcumin and methotrexate for successfully targeting highly invasive FR-positive carcinomas by means of folate receptor using MMTs.

A Novel Approach of Diffusion Tensor Visualization Based Neuro Fuzzy Classification System for Early Detection of Alzheimer's Disease.

This study examined early detection of Alzheimer's disease (AD) by diffusion tensor visualization-based methodology and neuro-fuzzy tools. Initially, we proposed a model for the early detection of AD using the measurement of apparent diffusion coefficient, fractional anisotropy, and gray matter, which can determine neurological disorder patterns and abnormalities in brain white matter. These are used as input parameters into fuzzy tools, and using fuzzy rules, we evaluate the AD score as an output variable that provides a useful platform to physicians in determining the status of the disease. In the second stage, we present an investigative study on AD and used the neuro-fuzzy classification system for pattern recognition of either AD or healthy control. The experimental results are from 20 samples (14 for training, 3 for validation, and 3 for testing) used in an artificial neural network classification system. The neural network is trained with a training algorithm and the performance of the training algorithm is obtained by executing a fuzzy expert system. Out of 20 patients, 9 are AD patients and 11 are healthy control patients. We present a neuro-fuzzy tool as a better classifier for early detection of AD and obtain a satisfactory performance with 100% accuracy.

Efficacy of Low-Dose Compared With Standard-Dose Radiation for Cardiac Catheterization and Intervention (KAR RAD Study).

OBJECTIVES: We evaluated the efficacy of low-dose (LD) radiation (≤7.5 frames/second [f/s]) compared with standard-dose (SD) radiation (≥10 f/s) in cardiac catheterization (CC) and percutaneous coronary intervention (PCI). Patients undergoing CC with LD vs SD radiation have not been previously studied. METHODS: We performed an observational study of 452 consecutive patients (61 ± 12 years) who had coronary angiography or PCI from September 2016 to September 2017. Patients were divided into an LD radiation group (n = 136) consisting of 0.5 f/s and 1 f/s (n = 73), 4 f/s (n = 40), or 7.5 f/s fluoroscopy (n = 23) with 7.5 f/s cine angiography vs an SD group (n = 316) consisting of 10 f/s (n = 250), 15 f/s (n = 64), or 30 f/s fluoroscopy (n = 2) and 10-30 f/s cine angiography. Primary endpoints included air kerma, dose area product (DAP), fluoroscopy time, and contrast use. RESULTS: Compared with SD radiation, LD radiation was associated with a significant reduction in air kerma (100.70 mGy [IQR, 46.42-233.35 mGy] vs 660.96 mGy [IQR, 362.78-1373.65 mGy]; P<.001), DAP (723.60 µGy•m² [IQR, 313.09-2328.22 µGy•m²] vs 5203.40 µGy•m² [IQR, 2743.55-10064.71 µGy•m²]; P<.001), and contrast use (100 mL [IQR, 60-150 mL] vs 115 mL [IQR, 80-180 mL]; P<.03). No difference in fluoroscopy time was noted (13.33 min [IQR, 6.93-25.55 min] vs 12.75 min [IQR, 7.75-22.55 min]; P=.95). CONCLUSIONS: LD radiation in CC was efficacious, with significant radiation reduction and without an increase in fluoroscopy time or contrast utilization. All patients underwent successful LD radiation catheterization without conversion to SD.

A Novel Approach of Mathematical Theory of Shape and Neuro-Fuzzy Based Diagnostic Analysis of Cervical Cancer.

This study aims to detect the abnormal growth of tissue in cervix region for diagnosis of cervical cancer using Pap test of patients. The proposed methodology classifies cervical cancer for pattern recognition either benign or malignant stages using shape and neuro-fuzzy based diagnostic model. In this experiment, firstly the authors segment Pap smear images of cervical cells using fuzzy c-means clustering algorithm and shape theory to classify them according to the presence of abnormality of the cells. Secondly the features extraction process is performed in the part of nucleus and cytoplasm on the squamous and glandular cells and the authors used input variables such as cytoplasm area (CA), cytoplasm circularity (CC), nucleus area (NA), nucleus circularity (NC), nucleus-cytoplasm ratio (NCR), and maximum nucleus brightness (MNB) in fuzzy tools and used fuzzy rules to evaluate the cervical cancer risk status as an output variable. The proposed neuro-fuzzy network system was developed for early detection of cervical cancer. A neural network was trained with 15-Pap image datasets where Levenberg-Marquardt(LM) a feed-forward back-propagation algorithm was used to get the status of the cervical cancer. Out of 15 samples database, 11 data set for training, 2 data set for validation and 2 data set for test were used in the ANN classification system. The presented fuzzy expert system(FES) successfully identified the presence of cervical cancer in the Pap smear images using the extracted features and the use of neuro-fuzzy system(NFS) for the identification of cervical cancer at the early stages and achieve a satisfactory performance with 100% accuracy.

Outcomes of New-Generation Drug-Eluting Stents in Women with Acute Myocardial Infarction.

PURPOSE OF REVIEW: This review discusses the outcomes of percutaneous coronary intervention (PCI) in women who experience acute myocardial infarction (AMI) and are treated with drug-eluting stents (DES). The review also describes the role of the new-generation DES compared with the early generation. RECENT FINDINGS: Recent literature shows that the new-generation DES can be effective in women who present with AMI. Women with AMI may be undertreated and are underrepresented in studies of AMI. Recently, it has been shown that the newer generation DES are effective and beneficial in women with AMI, similar to men. As further generations of DES are created, the future appears promising for continued advancements in women's cardiovascular health.

The Role of Percutaneous Coronary Intervention in the Treatment of Chronic Total Occlusions: Rationale and Review of the Literature.

BACKGROUND: Chronic total occlusion (CTO) of a coronary artery is defined as an occluded segment with no antegrade flow and a known or estimated duration of at least 12 weeks. OBJECTIVE: We considered the current literature describing the indications and clinical outcomes for denovo CTO- percutaneous coronary intervention (PCI), and discuss the role of CTO-PCI and future directions for this procedure. METHODS: Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL were searched and relevant studies of CTO-PCI were selected for review. RESULTS: The prevalence of coronary artery CTO's has been reported to be ~ 20% among patients undergoing diagnostic coronary angiography for suspected coronary artery disease. Revascularization of any CTO can be technically challenging and a time-consuming procedure with relatively low success rates and may be associated with a higher incidence of complications, particularly at non-specialized centers. However, with an increase in experience and technological advances, several centers are now reporting success rates above 80% for these lesions. There is marked variability among studies in reporting outcomes for CTO-PCI with some reporting potential mortality benefit, better quality of life and improved cardiac function parameters. Anecdotally, properly selected patients who undergo a successful CTO-PCI most often have profound relief of ischemic symptoms. Intuitively, it makes sense to revascularize an occluded coronary artery with the goal of improving cardiovascular function and patient quality of life. CONCLUSION: CTO-PCI is a rapidly expanding specialized procedure in interventional cardiology and is reasonable or indicated if the occluded vessel is responsible for symptoms or in selected patients with silent ischemia in whom there is a large amount of myocardium at risk and PCI is likely to be successful.

Percutaneous Mechanical Circulatory Support Devices for High-Risk Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: Percutaneous mechanical circulatory support devices (PMCSD) consist of the intra-aortic balloon pump (IABP), Impella (Abiomed Inc., Danvers, Massachusetts), Tandem Heart (Cardiac Assist, Inc., Pittsburgh, Pennsylvania), or extracorporeal membranous oxygenation (ECMO). They augment cardiac output, cardiac index, and cardiac power which allow the operator to mitigate hemodynamic perturbations during high-risk percutaneous coronary intervention (HR-PCI). This review discusses PMCSD and their contemporary literature. RECENT FINDINGS: Recent literature has substantiated the hemodynamic benefits of PMCSD in HR-PCI and cardiogenic shock, but no mortality benefit was found. As stent technology improves, PCI is expanding into high-risk cases in which PMCSD provide hemodynamic support allowing safe and complete revascularization.

Transulnar cardiac catheterization and percutaneous coronary intervention: techniques, transradial comparisons, anatomical considerations, and comprehensive literature review.

Ulnar arterial access for cardiac catheterization and intervention is an alternative approach compared with radial or femoral access. Ulnar access is infrequently performed since the radial artery is readily palpable and is commonly used worldwide to minimize vascular complications from femoral access. Nevertheless, ulnar access provides a suitable access site in patients who are poor candidates for femoral access, have pre-existing radial occlusion, radial artery hypoplasia or hyperplasia from prior radial artery procedures, radial stenosis, radial loops, radial tortuosity, small radial arteries, and/or have future need for radial graft for dialysis or coronary artery bypass graft. Furthermore, femoral access is the standard default option if radial access fails. Consequently, learning ulnar access provides a suitable forearm alternative to avoid femoral access when deemed high risk or undesirable. This review discusses the techniques of ulnar access, advantages and disadvantages of ulnar versus radial access, the clinical trials on ulnar cardiac catheterization and its associated complications.

Double right coronary artery and its clinical significance: Review of the literature.

Double right coronary artery is a very rare anomaly that is usually discovered incidentally during conventional coronary angiography. Double right coronary artery may have clinical implications in symptomatic patients requiring percutaneous coronary intervention and may be associated with other congenital abnormalities, myocardial ischemia and ventricular fibrillation in the absence of atherosclerosis. Here the reported cases in the literature are reviewed and a case of double right coronary artery with ischemia in inferior left ventricular wall is presented.

A mathematical theory of shape and neuro-fuzzy methodology-based diagnostic analysis: a comparative study on early detection and treatment planning of brain cancer.

BACKGROUND: Investigation of brain cancer can detect the abnormal growth of tissue in the brain using computed tomography (CT) scans and magnetic resonance (MR) images of patients. The proposed method classifies brain cancer on shape-based feature extraction as either benign or malignant. The authors used input variables such as shape distance (SD) and shape similarity measure (SSM) in fuzzy tools, and used fuzzy rules to evaluate the risk status as an output variable. We presented a classifier neural network system (NNS), namely Levenberg-Marquardt (LM), which is a feed-forward back-propagation learning algorithm used to train the NN for the status of brain cancer, if any, and which achieved satisfactory performance with 100% accuracy. METHODS: The proposed methodology is divided into three phases. First, we find the region of interest (ROI) in the brain to detect the tumors using CT and MR images. Second, we extract the shape-based features, like SD and SSM, and grade the brain tumors as benign or malignant with the concept of SD function and SSM as shape-based parameters. Third, we classify the brain cancers using neuro-fuzzy tools. In this experiment, we used a 16-sample database with SSM (µ) values and classified the benignancy or malignancy of the brain tumor lesions using the neuro-fuzzy system (NFS). RESULTS: We have developed a fuzzy expert system (FES) and NFS for early detection of brain cancer from CT and MR images. In this experiment, shape-based features, such as SD and SSM, were extracted from the ROI of brain tumor lesions. These shape-based features were considered as input variables and, using fuzzy rules, we were able to evaluate brain cancer risk values for each case. We used an NNS with LM, a feed-forward back-propagation learning algorithm, as a classifier for the diagnosis of brain cancer and achieved satisfactory performance with 100% accuracy. The proposed network was trained with MR image datasets of 16 cases. The 16 cases were fed to the ANN with 2 input neurons, one hidden layer of 10 neurons and 2 output neurons. Of the 16-sample database, 10 datasets for training, 3 datasets for validation, and 3 datasets for testing were used in the ANN classification system. From the SSM (µ) confusion matrix, the number of output datasets of true positive, false positive, true negative and false negative was 6, 0, 10, and 0, respectively. The sensitivity, specificity and accuracy were each equal to 100%. CONCLUSION: The method of diagnosing brain cancer presented in this study is a successful model to assist doctors in the screening and treatment of brain cancer patients. The presented FES successfully identified the presence of brain cancer in CT and MR images using the extracted shape-based features and the use of NFS for the identification of brain cancer in the early stages. From the analysis and diagnosis of the disease, the doctors can decide the stage of cancer and take the necessary steps for more accurate treatment. Here, we have presented an investigation and comparison study of the shape-based feature extraction method with the use of NFS for classifying brain tumors as showing normal or abnormal patterns. The results have proved that the shape-based features with the use of NFS can achieve a satisfactory performance with 100% accuracy. We intend to extend this methodology for the early detection of cancer in other regions such as the prostate region and human cervix.

Diagnosis and treatment of spontaneous coronary artery pseudoaneurysm: Rare anomaly with potentially significant clinical implications.

Spontaneous coronary artery pseudoaneurysm (PSA, false aneurysm) is an extremely rare occurrence with the precise incidence unknown. It is defined as an outwardly bulging monolayer or double layer within the coronary artery that lacks all 3 layers (intima, media, and adventitia) of the arterial wall. Coronary PSA commonly occurs from arterial dissection or perforation induced by catheter intervention, infection, pregnancy, or trauma. Traumatic dissection or perforation of the coronary artery after a percutaneous coronary intervention (PCI) remains the most common cause. Such cases may progress to myocardial ischemia, acute myocardial infarction, or acute coronary artery rupture causing death from cardiac tamponade. Intravascular ultrasound or cardiac computed tomography may aid in the diagnosis. Treatment options include PCI with a covered stent, bare or drug-eluting stent, coil embolization, coronary artery bypass graft with isolation of the PSA, or conservative management with vigilant clinical follow-up. In this review, we sought to describe the diagnosis, etiology, treatment, and the limited literature on spontaneous coronary artery PSA. © 2017 Wiley Periodicals, Inc.

Effect of ultrahigh diluted homeopathic medicines on the electrical properties of PVDF-HFP

In an effort to improve the electrical properties of the electroactive Poly(vinylidene fluoridehexafluoropropylene) (PVdF-HFP), we introduced a novel and simple approach to synthesize PVDFHFP composite films by incorporating ultrahigh dilutions of two homeopathic medicines Ferrum metallicum (FM) and Zincum oxidatum (ZO) in different potencies. The homeo-PVDF-composite films (HPCF) were synthesized by simple solution casting technique. XRD, FESEM, FTIR studies were performed to check the presence of nanoparticles in the film. The electrical properties of the HPCF samples get enhanced significantly due to the incorporation of the medicines and the effect increases with the increase in potency of the medicines. (AU)

Effect of ultrahigh diluted homeopathic medicines on the electrical properties of PVDF-HFP

In an effort to improve the electrical properties of the electroactive Poly(vinylidene fluoride-hexafluoropropylene) (PVdF-HFP), we introduced a novel and simple approach to synthesize PVDFHFP composite films by incorporating ultrahigh dilutions of two homeopathic medicines Ferrum metallicum (FM) and Zincum oxidatum (ZO) in different potencies. The homeo-PVDF-composite films (HPCF) were synthesized by simple solution casting technique. XRD, FESEM, FTIR studies were performed to check the presence of nanoparticles in the film. The electrical properties of the HPCF samples get enhanced significantly due to the incorporation of the medicines and the effect increases with the increase in potency of the medicines.

Cardiovascular implications of obstructive sleep apnea associated with the presence of a patent foramen ovale.

Patent foramen ovale (PFO) is a common congenital cardiac abnormality of the atrial septum which occurs in 25% of the population. It allows communication between the right and left atrium enabling right to left shunting of deoxygenated blood (after birth) which may be linked to strokes or transient ischemic attacks. PFO may also have an association with obstructive sleep apnea (OSA). OSA is a common medical condition occurring in 9% of adult males and 4% of adult females. It may increase the risk of cardiovascular disease. OSA causes intermittent hypoxia from episodes of apnea and hypopnea during sleep. Consequently, hypoxic pulmonary vasoconstriction ensues which produces an increased right atrial pressure which may generate a right to left shunt during apneic episodes promoting the occurrence of thromboembolic events. The existence of a PFO may be higher in patients with OSA. The presence of a PFO and OSA may increase the risk of stroke. In this review, the association of PFO and OSA is described along with their implications for cardiovascular disease. The relevant literature and treatment options are discussed to elaborate on the significance of the associated pathology.