Medical Emergency Team call within 24 h of medical admission with a focus on sepsis: a retrospective review.

BACKGROUND AND AIMS: Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions. METHODS: A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital. RESULTS: 2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017). CONCLUSION: There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline.

Sinonasal Chondrosarcoma With Unusual Orbital Invasion.

A case is presented of a 43-year-old male with a chronic history of progressive nasal obstruction and epiphora. MRI confirmed a heterogeneous mass involving the middle and superior turbinates with T2 hyperintense and calcified components, with extension into the inferomedial orbit. Tissue biopsy revealed a grade 2 chondrosarcoma of the conventional subtype. Endonasal wide local resection of the lesion was performed with clear margins. The patient had no functional sequelae and will undergo routine surveillance.

Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial.

BACKGROUND: Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. METHODS: We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non-ST-segment-elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. RESULTS: In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3-5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613-£7015); and angiography+FFR, £4510 (£2721-£7415; P=0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60-87); and angiography+FFR, 75 (interquartile range, 60-90; P=0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR (P=0.64). CONCLUSIONS: A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01070771.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients.

OBJECTIVE: To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort. BACKGROUND: There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG. METHODS: We identified 20,081 patients with stable angina who underwent CTO PCI between 2007-2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233). RESULTS: Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64-2.78, p = .44), at 30-days (OR: 1.28, CI 0.79-2.06, p = .31) and 1 year (OR:1.02, CI 0.87-1.29, p = .87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69-1.49, p = .95) and procedural complications (OR:1.02, CI 0.88-1.18, p = .81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31-0.39, p < .001). The adjusted risk of target vessel revascularization (TVR) remained similar between the two groups at 30-days (OR:0.68, CI 0.40-1.16, P-0.16) and at 1 year (OR:1.01, CI 0.83-1.22, P-0.95). CONCLUSION: Patients with prior CABG presenting with stable angina and treated with CTO PCI in native arteries had more co-morbid illnesses but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality, MACE or TVR.

Air concentrations of volatile organic compounds associated with conventional and "green" cleaning products in real-world and laboratory settings.

The use of household cleaning products can result in exposure to potentially hazardous volatile and semi-volatile organic compounds (VOCs and SVOCs). "Green" cleaning products have become increasingly available, but there is no official "green" standard, and it is difficult for consumers to know what chemicals they may be exposed to while cleaning. We measured air concentrations of 46 VOCs and SVOCs of concern released from conventional and "green" cleaning products during both real-world household cleaning and a controlled chamber environment, with a focus on chemicals that might increase women's risk of breast cancer, including possible carcinogens, reproductive/developmental toxicants, or endocrine disruptors. Air samples were analyzed using gas chromatography-mass spectrometry and high-performance liquid chromatography. First, in a study of 50 women cleaning their own homes using either conventional or "green" cleaning products, we recorded the products used and collected air samples from the breathing zone to determine whether specific products or types of products were associated with increased concentrations of specific VOCs and SVOCs. The results showed that women who used conventional bleach products, disinfecting wipes, and dish soap had higher breathing zone air concentrations of several VOCs, including chloroform, carbon tetrachloride, hexaldahyde, and 1,4-dioxane, than women who did not use these products. While fewer "green" products were associated with increases in VOC air concentrations, use of "green" all-purpose cleaners was associated with increases in air concentrations of some fragrance chemicals of concern. In the laboratory, we then selected 9 of the most common conventional products and 7 "green" products used in the in-home study for measurement of the same VOCs using a continuous stirred cylindrical flow-through chamber. We found that 75% of the highest VOC emissions were emitted by conventional cleaning products, but we also identified VOC emissions of concern from green products. VOC emissions in the chamber largely agreed with the modeled associations from real-world cleaning.

Recurrent odontogenic keratocyst with orbital invasion.

Odontogenic keratocysts (OKCs) are aggressive lesions that have been variously classified as neoplasms or cysts according to the World Health Organisation (WHO). They can be challenging to surgically remove and the cysts can exhibit locally aggressive behaviour if incompletely excised. We describe a case of recurrent OKC invading the orbit requiring multidisciplinary approach for extended surgical excision, and review the current literature regarding this condition.

Outcomes of COVID-19-positive acute coronary syndrome patients: A multisource electronic healthcare records study from England.

BACKGROUND: Patients with underlying cardiovascular disease and coronavirus disease 2019 (COVID-19) infection are at increased risk of morbidity and mortality. OBJECTIVES: This study was designed to characterize the presenting profile and outcomes of patients hospitalized with acute coronary syndrome (ACS) and COVID-19 infection. METHODS: This observational cohort study was conducted using multisource data from all acute NHS hospitals in England. All consecutive patients hospitalized with diagnosis of ACS with or without COVID-19 infection between 1 March and 31 May 2020 were included. The primary outcome was in-hospital and 30-day mortality. RESULTS: A total of 12 958 patients were hospitalized with ACS during the study period, of which 517 (4.0%) were COVID-19-positive and were more likely to present with non-ST-elevation acute myocardial infarction. The COVID-19 ACS group were generally older, Black Asian and Minority ethnicity, more comorbid and had unfavourable presenting clinical characteristics such as elevated cardiac troponin, pulmonary oedema, cardiogenic shock and poor left ventricular systolic function compared with the non-COVID-19 ACS group. They were less likely to receive an invasive coronary angiography (67.7% vs 81.0%), percutaneous coronary intervention (PCI) (30.2% vs 53.9%) and dual antiplatelet medication (76.3% vs 88.0%). After adjusting for all the baseline differences, patients with COVID-19 ACS had higher in-hospital (adjusted odds ratio (aOR): 3.27; 95% confidence interval (CI): 2.41-4.42) and 30-day mortality (aOR: 6.53; 95% CI: 5.1-8.36) compared to patients with the non-COVID-19 ACS. CONCLUSION: COVID-19 infection was present in 4% of patients hospitalized with an ACS in England and is associated with lower rates of guideline-recommended treatment and significant mortality hazard.

Cost of coronary syndrome treated with percutaneous coronary intervention and 30-day unplanned readmission in the United States.

OBJECTIVES: This study aimed to examine the cost of coronary syndrome treated with percutaneous coronary intervention (PCI) and 30-day unplanned readmissions. BACKGROUND: There is limited understanding of the hospital cost of index PCI and 30-day unplanned readmissions. METHODS: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by cost of index PCI and first unplanned readmission within 30 days. RESULTS: This analysis included 2,294,244 patients who underwent PCI, and the mean cost was $23,541 ± $20,730 (~$10.8 billion/year). There was a modest increase in cost over the study years of 17.5%. Of the 9.4% with an unplanned readmission within 30 days, the mean total cost was $35,333 ± 24,230 versus $22,323 ± 19,941 for those not readmitted. The variables most strongly associated with the highest quartile of cost were heart failure (adjusted odds ratio (aOR) 25.60 [95% CI 21.59-30.35]), need for circulatory support (aOR 11.62 [10.13-13.32]), periprocedural coronary artery bypass graft (CABG, aOR 585.08 [357.85-956.58]), and readmission within 30 days (aOR 24.49 [22.40-26.77]). An acute kidney injury (AKI; 8.5%), major bleed (0.8%), vascular injury (0.8%), or need for periprodedural CABG (1.4%) had an average increased cost of $21,935; $30,898; $27,875; and $43,005, respectively, compared to PCI without adverse outcome. CONCLUSIONS: The annual 30-day hospital cost of PCI is approximately $10.8 billion, and the costs associated with in-hospital adverse events, particularly the need for AKI and periprocedural CABG, were significant.

The impact of 2018 ASCO-CAP HER2 testing guidelines on breast cancer HER2 results. An audit of 2132 consecutive cases evaluated by immunohistochemistry and in situ hybridization.

The 2018 iteration of the ASCO-CAP HER2 testing guidelines proposes significant changes with an emphasis on the integration of concurrent immunohistochemistry (IHC) and in situ hybridization (ISH). We wished to evaluate the impact of these changes on clinical practice. Between Jan 2012 to Feb 2017, 2132 consecutive invasive breast carcinomas were evaluated with IHC and ISH for HER2. The sample tested was the breast primary or axillary nodes in all but 57 (2.7%) distant metastases. For 1824 cases with both dual-probe ISH and IHC results, the ISH subgroup was 1: 299 (16.4%), 2: 19 (1.0%), 1.0%, 3: 6 (0.3%), 4: 48 (2.6%) and 5: 1452 (79.6%). Ultimately 21% of group 2 and 4 cases and 80% of group 4 cases were positive. The change in HER2 status between the 2018 vs 2013 was: amplified in 323 (15.2%) vs 15.5%; not amplified in 1804 (84.6%) vs 82.2%; equivocal in 0 vs 2.3% previously. In 22 of 2127 cases (1.03%) the 2013 and 2018 results were discordant, all in groups 2-4. The discrepant cases included 15 of 331 (4.5%) of 2013 amplified cancers, now negative (all in groups 2 or 3) and 7 of 1796 (0.4%) 2013 nonamplified cases, now positive (all in group 4). Because of routine testing with both IHC and ISH, we found 6 of 1147 (0.52%) IHC negative (0 or 1+) cases were amplified by ISH. Further, 19 of 289 (6.6%) of IHC 3+ cases were nonamplified by ISH, circumstances not covered by these guidelines. In summary at the population level, the 2018 ASCO-CAP guidelines have a 99% agreement with the 2013 results. A major advantage is the abolishment of the clinically problematic equivocal category. Routine performance of both IHC and ISH uncovers a small proportion of cancers whose HER2 status is not addressed by these guidelines.

Complex regional pain syndrome: A rare but potentially disabling complication of transradial cardiac catheterization.

BACKGROUND: Chronic Regional Pain Syndrome (CRPS) is a rare complication following transradial cardiac catheterization. AIMS: To discuss the clinical features, pathophysiology, diagnosis and management of CRPS. METHODS: Literature review performed. RESULTS: CRPS is seen rarely in the literature following upper limb arterial access for coronary procedures, which may be due to a low incidence of the syndrome as well as limited recognition and underreporting. DISCUSSION: The diagnosis and management of CRPS are discussed in detail. CONCLUSION: If CRPS is a potential diagnosis then prompt early referral to a center with a specialist interest in CRPS is recommended. Prompt diagnosis and early commencement on the correct patient treatment pathway are essential, to avoid potentially life changing disability and the psychological consequences of living with intractable chronic undiagnosed pain.

Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy.

BACKGROUND: Climacturia affects up to 45% of men after radical prostatectomy (RP). Although urethral slings decrease the severity and frequency of stress incontinence after RP, their efficacy as a treatment for climacturia after RP has not been well studied. AIM: The aim of this study was to assess patient-reported changes in climacturia symptoms after implantation of a urethral sling as a treatment for stress incontinence after RP. METHODS: After Institutional Review Board approval, a retrospective chart review identified males aged 18-80 years who received urethral slings for stress incontinence after RP at our institution from 2012 to 2017. These patients were mailed an 11-item questionnaire asking them about climacturia symptoms before and after implantation of a urethral sling. Written informed consent was obtained from patients participating in the mailed questionnaire. OUTCOMES: Respondents were asked to report on climacturia frequency and severity, bother, partner bother, and incontinence before and after implantation of urethral slings. RESULTS: A total of 42 questionnaires were mailed; 17 were available for analysis. The median age (and interquartile range, IQR) of the sample at RP was 64 (59.5, 68.0). Almost all (94.1%) of the men were sexually active at the time of the study and 64.7% reported experiencing urinary leakage during sexual arousal. Most (58.8%) underwent the urethral sling procedure to treat general incontinence; 35.3% underwent the procedure to treat both general incontinence and incontinence during sexual activity and 1 (5.9%) underwent it for other reasons. A median of 28.1 months elapsed between RP and sling procedure (IQR: 18.36, 53.88; minimum: 8.00; maximum: 108.36). Statistically significant shifts toward improvement from presling to postsling were noted for frequency of leakage during sexual arousal or orgasm (P = .041) and for the degree to which leakage of urine during sexual arousal or orgasm was a "bother" (P = .027). While almost all (94%) of the men were incontinent before sling, this percentage dropped to 53% after sling (P = .031). CLINICAL IMPLICATIONS: Urethral slings should be discussed as a treatment strategy for climacturia during clinical consultations with patients. STRENGTHS & LIMITATIONS: Strengths include consistent surgical technique. Limitations include retrospective design, lack of a nonsling comparison group, subjective nature of outcome measures, possible response bias, and variability in time interval between RP and sling procedure. CONCLUSION: Use of urethral slings after RP is associated with improvements in climacturia symptoms, bother, and incontinence. Nolan J, Kershen R, Staff I, et al. Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy. J Sex Med 2020;17:1203-1206.

BK virus-associated nephropathy in a lung transplant patient: case report and literature review.

BACKGROUND: BK virus-associated nephropathy (BKVAN) is a relatively common cause of renal dysfunction in the first six months after renal transplantation. It arises from reactivation of the latent and usually harmless BK virus (BK virus) due to immunosuppression and other factors including some that are unique to renal transplantation such as allograft injury. BKVAN is much rarer in non-renal solid organ transplantation, where data regarding diagnosis and management are extremely limited. CASE PRESENTATION: We report a case of a 58-year-old man found to have worsening renal dysfunction nine months after bilateral sequential lung transplantation for chronic obstructive pulmonary disease (COPD). He had required methylprednisolone for acute allograft rejection but achieved good graft function. Urine microscopy and culture and renal ultrasound were normal. BK virus PCR was positive at high levels in urine and blood. Renal biopsy subsequently confirmed BKVAN. The patient progressed to end-stage renal failure requiring haemodialysis despite reduction in immunosuppression, including switching mycophenolate for everolimus, and the administration of intravenous immunoglobulin (IVIG). CONCLUSIONS: This very rare case highlights the challenges presented by BK virus in the non-renal solid organ transplant population. Diagnosis can be difficult, especially given the heterogeneity with which BKV disease has been reported to present in such patients, and the optimal approach to management is unknown. Balancing reduction in immunosuppression against prevention of allograft rejection is delicate. Improved therapeutic options are clearly required.

Rates, predictors and the impact of cannabis misuse on in-hospital outcomes among patients undergoing percutaneous coronary intervention (from the National Inpatient Sample).

BACKGROUND: Whether cannabis use worsens outcomes in coronary heart disease is unknown and no previous study has evaluated the outcomes for patients who undergo percutaneous coronary intervention (PCI) according to cannabis use. METHODS: We analysed patients in the National Inpatient Sample between 2004 and 2014 who underwent PCI and evaluated rates, predictors and outcomes of patients according to cannabis misuse defined by cannabis abuse or dependence. RESULTS: A total of 7 306 012 patients were included and 32 765 cannabis misusers (0.4%). Cannabis misusers were younger (49.5 vs 64.6 years, P < .001) and were more likely to be male (82.7% vs 66.3%, P < .001). There was also a greater proportion of patients who were of black ethnicity in the cannabis misuse group (27.7% vs 7.9%, P < .001) and fewer elective admissions (7.8% vs 27.6%, P < .001). There was no difference in in-hospital mortality (OR 1.06 95% CI 0.80-1.40, P = .67), bleeding (OR 0.94 95% CI 0.77-1.15, P = .55) and stroke/transient ischaemic attack (OR 1.19 95% CI 0.98-1.45, P = .084) compared with non-cannabis misusers. Cannabis misusers had significantly lower odds of in-hospital vascular complications (OR 0.73 95% CI 0.58-0.90, P = .004). CONCLUSIONS: Our results suggest that cannabis misusers are more likely to be male, of black ethnicity and from the lowest quartile of income, but there was no evidence that cannabis misuse is associated with worse periprocedural outcomes following PCI when controlling for key proxies of health status.

Immunoglobulin G4 related disease: a single-centre experience from South Australia.

BACKGROUND: IgG4 related disease (IgG4RD) is a newly described multisystem fibro-inflammatory disorder. There is a paucity of literature describing the Australian experience of this rare condition. AIMS: To characterise the Royal Adelaide Hospital IgG4RD cohort with biopsy-proven disease. METHODS: A search of the Frome Road SA Pathology database was performed for all tissue biopsies containing the phrase 'IgG4 positive'. Case notes were reviewed for clinical details, laboratory and radiology results. Histological features according to the Boston Criteria were used. Patients with available case notes, highly suggestive or probable histology and clinical features to suggest IgG4RD were included. RESULTS: Twenty patients had definite or probable IgG4RD and suggestive clinical features; median age 59 (20-76), male : female 1.5:1. There was considerable delay in diagnosis (median diagnosis at 64 months). Organ involvement included: 11 exocrine gland, seven pancreatobiliary, seven nodal, seven soft tissue, five retro-orbital, three retroperitoneal fibrosis and two renal. Systemic symptoms at diagnosis were seen in eight patients. Seven (35%) had an elevated serum IgG4 (>1.35 g/L) at diagnosis. Only 12 (60%) required immunosuppressive treatment (corticosteroids); of these, four (20%) required a steroid-sparing agent and four (20%) required B-cell depleting therapy (rituximab). The median duration of follow up was 18 months. CONCLUSIONS: This is the first characterised Australian cohort with generalised IgG4RD, a rare, relatively indolent and under-recognised multisystem disorder. Diagnosis is difficult given lack of awareness of this rare condition among physicians, its presentation as a great disease mimic, challenges with histopathological assessment and the absence of a suitable serum biomarker.

The Influence of the Charlson Comorbidity Index on Procedural Characteristics, VARC-2 Endpoints and 30-Day Mortality Among Patients Who Undergo Transcatheter Aortic Valve Implantation.

BACKGROUND: Aortic stenosis (AS) is a common valvular abnormality and transcatheter aortic valve implantation (TAVI) is being increasingly used to treat patients considered too high risk for conventional surgery. We aimed to assess the prevalence of comorbid conditions in patients undergoing TAVI using the Charlson Comorbidity Index (CCI) and to assess their impact on clinical and procedural outcomes. METHODS: We analysed 158 patients who underwent a TAVI at our institution between June 2009 and September 2015 to define their co-morbid burden as measured with CCI, and study its impact on procedural characteristics and mortality at 30 days. RESULTS: One hundred fifty-eight (158) patients with a mean age of 82±8years and a mean CCI score of 2.67 underwent a TAVI. Only 12/158 patients had a CCI of 0. The commonest cardiovascular comorbidities were previous myocardial infarction (24%), congestive heart failure (15%) and diabetes mellitus (23%) whilst the commonest non-cardiovascular comorbidities were renal disease (46%) and chronic obstructive pulmonary disease (COPD) (29%). After multivariable adjustment, CCI was not independently associated with adverse clinical outcomes. The addition of CCI to scoring systems such as Logistic EuroScore (LES) and Society of Thoracic Surgeons (STS) risk models improved the area under the curve from 0.75 (95%CI: 0.44-1.00) and 0.83 (95%CI: 0.64-1.00) to 0.78 (95%CI: 0.53-1.00) and 0.89 (95%CI: 0.78-1.00) respectively. CONCLUSIONS: The burden of comorbid conditions in patients undergoing TAVI is significant. The CCI score was not independently associated with a higher risk of death but can be useful in addition to LES and STS risk models in informing decision making on the selection of patients for TAVI.

Real-time characterization of uptake kinetics of glioblastoma vs. astrocytes in 2D cell culture using microelectrode array.

Extracellular measurement of uptake/release kinetics and associated concentration dependencies provides mechanistic insight into the underlying biochemical processes. Due to the recognized importance of preserving the natural diffusion processes within the local microenvironment, measurement approaches which provide uptake rate and local surface concentration of adherent cells in static media are needed. This paper reports a microelectrode array device and a methodology to measure uptake kinetics as a function of cell surface concentration in adherent 2D cell cultures in static fluids. The microelectrode array simultaneously measures local concentrations at five positions near the cell surface in order to map the time-dependent concentration profile which in turn enables determination of surface concentrations and uptake rates, via extrapolation to the cell plane. Hydrogen peroxide uptake by human astrocytes (normal) and glioblastoma multiforme (GBM43, cancer) was quantified for initial concentrations of 20 to 500 µM over time intervals of 4000 s. For both cell types, the overall uptake rate versus surface concentration relationships exhibited non-linear kinetics, well-described by a combination of linear and Michaelis-Menten mechanisms and in agreement with the literature. The GBM43 cells showed a higher uptake rate over the full range of concentrations, primarily due to a larger linear component. Diffusion-reaction models using the non-linear parameters and standard first-order relationships are compared. In comparison to results from typical volumetric measurements, the ability to extract both uptake rate and surface concentration in static media provides kinetic parameters that are better suited for developing reaction-diffusion models to adequately describe behavior in more complex culture/tissue geometries. The results also highlight the need for characterization of the uptake rate over a wider range of cell surface concentrations in order to evaluate the potential therapeutic role of hydrogen peroxide in cancerous cells.

Incidence and Clinical Course of Limb Dysfunction Post Cardiac Catheterization　- A Systematic Review.

BACKGROUND: We systematically reviewed the available literature on limb dysfunction after transradial access (TRA) or transfemoral access (TFA) cardiac catheterization. Methods and Results: MEDLINE and EMBASE were searched for studies evaluating any transradial or transfemoral procedures and limb function outcomes. Data were extracted and results were narratively synthesized with similar treatment arms. The TRA group included 15 studies with 3,616 participants and of these 3 reported nerve damage with a combined incidence of 0.16% and 4 reported sensory loss, tingling and numbness with a pooled incidence of 1.61%. Pain after TRA was the most common form of limb dysfunction (7.77%) reported in 3 studies. The incidence of hand dysfunction defined as disability, grip strength change, power loss or neuropathy was low at 0.49%. Although radial artery occlusion (RAO) was not a primary endpoint for this review, it was observed in 3.57% of the participants in a total of 8 studies included. The TFA group included 4 studies with 15,903,894 participants; the rates of peripheral neuropathy were 0.004%, sensory neuropathy caused by local groin injury and retroperitoneal hematomas were 0.04% and 0.17%, respectively, and motor deficit caused by femoral and obturator nerve damage was 0.13%. CONCLUSIONS: Limb dysfunction post cardiac catheterization is rare, but patients may have nonspecific sensory and motor complaints that resolve over a period of time.

Changes in Arterial Access Site and Association With Mortality in the United Kingdom: Observations From a National Percutaneous Coronary Intervention Database.

BACKGROUND: The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. METHODS AND RESULTS: Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66-0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275-650), and we estimate that an additional 264 (95% confidence interval=153-399) lives would have been saved if TRA adoption were uniform nationally. CONCLUSIONS: TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.

Balloon aortic valvuloplasty in contemporary practice.

BACKGROUND: There has been a revival of balloon aortic valvuloplasty (BAV) for severe aortic stenosis, as a result of an increasing number of patients undergoing trans-catheter aortic valve implantation (TAVI). However, there has not been universal adoption of BAV as a standalone, nor bridging therapy. METHODS: A retrospective analysis of the practice at our institution between June 2009 and May 2016 was performed. Demographic, clinical, procedural, and follow-up data on all patients were collected. RESULTS: A total of 200 patients with a median age of 82 years and severe symptomatic aortic stenosis underwent BAV from June 2009 to May 2016. All patients had appreciable comorbidity with a mean logistic Euro SCORE of 48 ± 11 and mean standard Euro SCORE 15 ± 4. BAV was performed for palliation in 118 (59%), as a bridging therapy for TAVI in 55 (27.5%) and bridging to surgical AVR in 27 patients (13.5%), respectively. Major complications occurred in 14 patients (7%) including 2 in-patient deaths (1%). A statistically significant improvement in symptoms and a decrease in trans-valvular gradient were observed. CONCLUSION: BAV is an effective treatment strategy, either as a bridge to definitive therapy or as a palliative procedure, with an acceptable mortality. BAV is associated with a significant improvement in symptoms and is valuable as a palliative treatment in high-risk patients, where no other invasive option is available.