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jun huo

and 2 more

Due to their special geographical locations and environments, plateau lakes play a key role in maintaining regional water balance, but lake water storage changes are upsetting this balance. Based on data from lakes on the Tibetan Plateau (TP), this study used the Spatial Processes in Hydrology (SPHY) model to simulate the runoff process in the Siling Co basin from 2000-2016 and estimated the changes in water storage of Siling Co and the contribution of each component of runoff into the lake. The results showed that the water storage capacity of Siling Co has increased by 1.157 billion m 3/yr, declines in precipitation have significantly reduced baseflow(BF), rainfall runoff(RR), and Snow runoff(SR), while temperature increases have raised glacier runoff(GR). The simulated average runoff showed that BF, GF, RR, and SR contribute 24%, 22%, 16%, and 38%, respectively, of the flow into Siling Co. Based on hypothetical climate change scenarios and two Shared Socioeconomic Pathways (SSP1-2.6 and SSP3-7.0) from the MRI-ESM2-0 GCMs, this study estimated that a 10% increase in precipitation could lead to a 28.45% increase in total runoff, while a 1 °C increase in temperature could lead to a 9.49% decrease in runoff. The average runoff depth of the basin is expected to increase by 29.77-39.13 mm, since the temperature and precipitation may increase significantly from 2020-2050. The intensification of glacial melting caused by the increase in temperature continues, posing a greater challenge to many water resources management problems caused by the expansion of lakes.

sanda mrabet

and 10 more

The sarcoid-like reaction is a rare autoinflammatory disease that can affect lymph nodes or organs but does not meet the diagnostic criteria for systemic sarcoidosis. Several drug classes have been associated with the development of a systemic sarcoid-like reaction, which defines drug-induced sarcoidosis-like reactions and can affect a single organ. Anti-CD20 antibodies (rituximab) have rarely been reported as responsible for this reaction and this adverse effect has mainly been described during the treatment of Hodgkin’s lymphoma. We report a unique case of a sarcoid-like reaction complicating rituximab following the treatment of a mantle cell lymphoma and interesting only the kidney. The 60-year-old patient presented with severe acute renal failure six months after the end of his r-CHOP protocol and the urgent renal biopsy revealed acute interstitial nephritis rich in granulomas without caseous necrosis. After ruling out other causes of granulomatous nephritis, a sarcoid-like reaction was retained since infiltration was limited to the kidney. The temporal relationship between rituximab administration and the sarcoid-like reaction onset in our patient supported the diagnosis of a rituximab-induced sarcoidosis-like reaction. Oral corticosteroid treatment led to rapid and lasting improvement in renal function. Clinicians should be warned of this adverse effect and regular and prolonged monitoring of renal function should be recommended during the follow-up of patients after the end of treatment with rituximab.

jieru chen

and 7 more

Aims: The serratus anterior plane block (SAPB) has commonly been utilized as a regional anesthesia technique for pain management in various upper chest surgical procedures. The purpose of this study was to investigate the analgesic effect and pharmacokinetics of ropivacaine in continuous SAPB undergoing VATS. Methods: This prospective randomized study included patients scheduled for elective VATS. Patients first received a bolus of 20 ml of 0.2% (Group L) or 0.375% (Group H) ropivacaine that was administered beneath the serratus anterior muscle. The pump was connected to the catheter for continuous administration within 48 hours postoperatively, in which a background infusion at a rate of 7 ml·h−1 of low-dose at 0.2% (Group L) or high-dose at 0.375% (Group H) of ropivacaine was administered. The main results were to compare the analgesic effects and analyze the pharmacokinetics of different concentrations of ropivacaine. Results: Eighty-eight patients agreed to participate in the trial and were recruited. The VAS scores in Group H at 12, 24, and 48 hours postoperatively at rest and on coughing were significantly lower than those in Group L. The peak values of total ropivacaine plasma concentrations were observed at 48 hours (2.01 μg·mL−1 for Group L and 2.93 μg·mL−1 for Group H), which were far below the theoretical toxicity threshold. Postoperative rescue analgesia, complications, and other outcomes did not differ significantly. Conclusions: In VATS patients, the analgesic effect of 0.2% ropivacaine for continuous SAPB was not inferior to that of 0.375% ropivacaine, and the blood concentration of 0.2% ropivacaine was

Taha Ulutan Kars

and 4 more

Introduction: Rituximab, which is widely used in the treatment of B-cell lymphoma, is a chimeric monoclonal antibody directed against the CD20 antigen. Rituximab has many side effects, mainly allergic and neurological. Rituximab may cause thrombocytopenia in the long term after administration. Rare cases with rituximab-induced acute thrombocytopenia have been reported in the literature. Case Report: A 51-year-old female patient who newly diagnosed splenic marginal zone lymphoma recieved rituximab as first line therapy. Petechiae occurred in the lower extremities on the day following rituximab administration. The blood test showed a severe drop in the platelet count from 112,000/μL to 5,000/μL. Blood peripheral smear evaluation confirmed severe thrombocytopenia. Management and outcome: There was no change in hemoglobin or white blood cell levels. After the diagnosis of rituximab-induced acute thrombocytopenia, thrombocyte suspension was administered due to the risk of bleeding. Close clinical and laboratory observations were made. The platelet count began to rise gradually in the following period. Before the second week of rituximab administration, the platelet count was 122,000/μL. No complications developed after premedication and slow rituximab administration, and subsequent treatments were continued in the same way. Discussion: Rituximab has a widespread use, especially in malignancies and autoimmune diseases. Like many monoclonal antibodies, rituximab has several side effects. Thrombocytopenia is a long-term side effect associated with rituximab, and rituximab-induced severe acute thrombocytopenia has been rarely reported. Therefore, it should be kept in mind that severe acute thrombocytopenia may develop after rituximab administration.

Akhil Gupta

and 5 more

Background: Diabetes prior to conception may cause pregnancy complications through disruptions of placental function. Objectives/Key Questions: 1) To describe placental changes in women with pre-existing diabetes. 2) To determine if elastography can detect in-vivo placental changes? Search Strategy: PubMed, Embase, Medline, Cochrane database searches of English language reports published until July 2020. Selection Criteria: Question 1: Any study describing placental histopathology in women with known diabetes. Question 2: Any study using elastography to report in-vivo placental stiffness values. Data Collection and Analysis: For Key Question 1: we grouped placental pathologies using Amsterdam International Consensus Group definitions. For Key Question 2: we conducted a meta-analysis of placental stiffness scores reported in metres per second (m/s) or kilopascals (kPa). Main Results: Cumulative data from 14 studies showed no placental histopathology features pathognomonic for diabetes. Pooled analysis of 14 studies included 478 “high risk pregnancies” and 828 control/healthy pregnancies. Only one study reported stiffness scores for placentas of women with pre-existing diabetes (N < 10 women). Maternal-derived pathologies resulted in higher placental stiffness with mean difference 4.5kPa (95% CI 3.16, 5.87) compared to control / healthy pregnancies. Fetal-derived pathologies resulted in higher placental stiffness with mean difference of 6.5kPa (95% CI 1.08, 11.86) compared to control / healthy pregnancies. Conclusions: Shear Wave Elastography may provide in-vivo approximation of placental histopathology. Further studies in women with pre-existing diabetes may confirm this. Funding: primary author (AG) receives Western Sydney University Postgraduate Research Scholarship (Ainsworth Trust) and Australian Federal Government Research Training Program (RTP) Fees Offset.

Pu Reun Roh

and 9 more

Background and Purpose: Although the prevalence of nonalcoholic steatohepatitis (NASH) is rapidly increasing, effective therapy is lacking. Tenofovir alafenamide (TAF) is a widely used antiviral drug for hepatitis B. In this study, we investigated the potential pharmacological effects of TAF on NASH. Experimental Approach: Two different NASH mouse models were established: 1) by subcutaneous injection of streptozotocin (0.2 mg) and feeding the mice a high-fat, high-cholesterol (HFHC) diet, and 2) feeding the mice a choline-deficient, L-amino acid-defined, high-fat (CDAHF) diet. Key Results: Serum alanine aminotransferase and triglyceride levels in TAF-treated NASH mice were significantly lower than those in the mock-treated ones. The livers from the TAF-treated NASH mice showed attenuated mononuclear phagocyte (MP) infiltration compared to those from the mock-treated ones. TAF-treated NASH mice exhibited decreased liver infiltration of activated MPs (IAIE+/PD-L1+/MerTK+). In ex vivo experiments using sorted human CD14+ monocytes treated with lipopolysaccharide (LPS) and/or TAF, we confirmed the decreased level of phosphorylated AKT in TAF-treated LPS-stimulated monocytes compared to that in the mock-treated ones. Mouse liver immunoblotting showed that phosphorylation levels of AKT were significantly lower in the TAF-treated NASH group than in the mock-treated group. Conclusion and Implications: TAF exerts anti-inflammatory effects in NASH livers by attenuating AKT phosphorylation in intrahepatic activated MPs. Therefore, TAF may serve as a new therapeutic option for NASH.

SUGUNA BIDARAHALLI

and 4 more

suocheng wei

and 4 more

Objective The present study aimed to explore if bovine parvovirus (BPV) impacts beta interferon (IFN-β) production and to reveal further molecular mechanism of BPV immune escape. Method The pCMV-Myc-BPV-VP1 recombinant plasmid was verified with both double enzyme digestion and sequence. HEK 293T cells were transfected with this recombinant protein, then infected with the vesicular stomatitis virus (VSV). Expression levels of IFN-β mRNA were detected using qPCR. Results Expression level of BPV VP1 mRNA in pCMV-Myc-BPV-VP1 group was significantly higher than those of the untreated group (UT) and pCMV-Myc vector group. BPV virus copies in bovine turbinate (BT) cells of BPV-VP1 group were raised (P<0.05) with an increment of 5.8×104. Expression levels of IFN-β mRNA of BPV VP1 group in HEK 293T cells were decreased (P<0.01). Following treatment of TBK1 and IRF3(5D), IFN-β expression levels in HEK 293T cells were depressed. Expression levels of TBK1, IRF3(5D), MDA5 and MAVS were lower than those of their self treatment. Conclusion pCMV-Myc-BPV-VP1 could heighten transcription levels of VP1 protein in BT cells, promote BPV proliferation and ascend the production of IFN-β. Overexpression of pCMV-Myc-BPV-VP decreased IFN-β mRNA expression in HEK 293T cells and inhibited IFN-β production induced by TBK1 and IRF3(5D). Furthermore, BPV VP1 obviously declined expression levels of TBK1, IRF3(5D), MDA5 and MAVS in RLR pathway. Our findings revealed a new mechanism evolved by BPV VP1 to inhibit type I IFN production and provided a solid basis into the immunosuppression of BPV, which is beneficial for developing novel strategy oftherapy of BPV disease.

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Omar Sharaf

and 4 more

Background: Dysphagia following cardiac surgery is common and associated with adverse outcomes. Among patients receiving left ventricular assist device (LVAD), we evaluated the impact of fiberoptic endoscopic evaluation of swallowing (FEES) on outcomes. Methods: A single-center pilot study was conducted in adults (≥18 years of age) undergoing durable LVAD (February 2019-January 2020). Six patients were prospectively enrolled, evaluated, and underwent FEES within 72 hours of extubation—they were compared to 12 control patients. Demographic, surgical, and postoperative outcomes were collected. Unpaired two-sided t-tests and Fisher’s Exact tests were performed. Results: Baseline characteristics were similar between groups. Intraoperative criteria including duration of transesophageal echo (314 ± 86 min) and surgery (301 ± 74 min) did not differ. Mean time of intubation was comparable (57.3 vs. 68.7 hours, p=0.77). In the entire cohort, 30-day, 1-year, 2-year, and 3-year mortality were 0%, 5.6%, 5.6%, and 16.7%, respectively. Sixty-seven percent of the patients that underwent FEES had inefficient swallowing function. The FEES group trended to a shorter hospital length of stay (LOS) (29.1 vs. 46.6 days, p=0.098), post-implantation LOS (25.3 vs 30.7 days, p=0.46), and lower incidence of postoperative pneumonia (16.7% vs. 50%, p=0.32) and sepsis (0% vs. 33.3%, p=0.25). Conclusions: FEES did not impact 30-day, 1-year, 2-year, or 3-year mortality. Patients who underwent FEES trended toward shorter LOS, and lower postoperative pneumonia and sepsis rates, though not statistically significant. A higher incidence of dysphagia among patients undergoing FEES despite comparable baseline risk factors with controls suggests FEES may detect subclinical dysphagia.

Joshua Sink

and 1 more

Employing New Criteria for Confirmation of Conduction Pacing – Achieving True Left Bundle Branch Pacing May Be Harder Than Meets the EyeJoshua Sink, MD1, Nishant Verma, MD, MPH2Northwestern University, Feinberg School of Medicine, Department of Internal MedicineNorthwestern University, Feinberg School of Medicine, Division of CardiologyCorresponding Author:Nishant Verma, MD, MPH251 East Huron Street, Feinberg 8-503Chicago, IL 60611312-926-2148Nishant.Verma@nm.orgFunding: NoneDisclosures: Dr. Sink has nothing to disclose. Dr. Verma receives speaker honoraria from Medtronic, Biotronik and Baylis Medical and consulting fees from Boston Scientific, Biosense Webster, AltaThera Pharmaceuticals and Knowledge 2 Practice.Word Count: 1200In recent years, conduction system pacing (CSP) has garnered significant attention from the electrophysiology (EP) community. This movement has been driven by the hypothesis that using the natural conduction system activation is desirable and clinically beneficial in patients with advanced conduction disease and ventricular desynchrony. Permanent His-bundle pacing (PHBP) is generally seen as the purest form of conduction system activation. (Figure 1) PHBP was first described over 20 years ago but the idea has attracted substantial investigative effort in recent years. When successfully achieved, His bundle pacing has been associated with reduction in mortality, reduction in heart failure (HF) admissions, and improvement in left ventricular (LV) function compared to right ventricular (RV) pacing.1 Despite this, consistent achievability in real-world practice remains limited due to a variety of factors including narrow anatomic targetability, lead stability, high pacing thresholds, low ventricular sensing, and inability to correct the QRS in bundle branch block.2Thus, while waiting for the next iteration of improved delivery techniques, pacing leads and programming algorithms,, alternative methods of conductive system pacing have emerged, with the potential to surmount the challenges described.Left bundle branch pacing (LBBP) has recently emerged as an alternative method of CSP. The technique was first described by Huang et al. in 2017 and has seen a momentous rise in interest since.3 In 2019, Huang et al. produced a user manual for a successful LBBP procedure, and in it they attempted to develop the first iteration of criteria for the confirmation of LBBP.4 Utilizing these criteria, or close variations of them, a number of studies were published afterwards that demonstrated preliminary safety, feasibility, and efficacy of LBBP.5,6,7 LBBP became an attractive alternative to His bundle pacing because of the lower thresholds, improved lead stability, and higher procedural success rates. When compared against RV pacing in patients requiring a high burden of pacing, LBBP has demonstrated reduced mortality, HF admissions, and need for upgrade to a BiV device.8 In a small, non-randomized patient sample, LBBP showed greater improvement in LV ejection fraction (EF) compared to BiV pacing.9 Most notably, perhaps, is the astonishing rate of lead placement success, with achievement rates reported as high as 98% in sizable studies.6Differences between the two forms of CSP were apparent from the beginning, including in the appropriate QRS morphology after a successful case. Unlike PHBP, LBBP did not reproduce the native QRS and the QRS duration was often greater than at baseline (Figure 2). The arena of LBBP underwent a notable shift in the Fall of 2021 when Wu et al. proposed new criteria to prove LBBP.10 In this study, they presented an exquisite display of fundamental electrophysiologic principles by using mapping catheters positioned on the His and LV septum during LBB lead placement. Through this painstaking work, they clarified the difference between true LBBP and left bundle branch area pacing (LBBAP), which can incorporate both LBBP and left ventricular septal pacing (LVSP). In their proposed framework, without the presence of a His or LV septum mapping catheter, output dependent QRS transition from non-selective (NS-LBBP) to selective-LBBP (S-LBBP) or LVSP is necessary to prove LBBP and had a sensitivity and specificity of 100%.The present study by Shimeno et al, published in the current issue of the Journal of Cardiovascular Electrophysiology , is the first known effort to document achievement rates of LBBP by utilizing the modified criteria proposed by Wu et al.11 The primary finding of the study is that achieving true LBBP with an acceptable pacing threshold is likely harder than previously realized. As expected, there was improvement after a learning curve, but even in the last third of patients enrolled, the achievement rate of LBBP was only 50%. This is dramatically lower than previously reported achievement rates using the original Huang et al. criteria, and it suggests that not all patients in the previously described studies were actually achieving true LBBP. An unknown subset of patients in these studies was likely only achieving LVSP. This is probably due to a prior reliance on indicators such as a paced right bundle branch block (RBBB) pattern, identification of an intrinsic LBB potential, and/or use of V6 R-wave peak time cutoffs (RWPT) without clear output-dependent QRS transition. It is also worth noting that a variety of RWPT cutoffs have been used seemingly arbitrarily as ‘evidence of LBBP’. This presents a major dilemma and highlights the need for a clear set of LBBP criteria to be defined by the collective EP community. Despite these caveats, many of these previous studies did not fully confirm LBBP in their patients, yet the outcomes from these studies were still clinically promising. This raises the obvious question, does obtaining true LBBP matter? Future studies will need to explore the differences in clinical outcomes between true LBBP and LVSP.Secondarily, Shimeno et al. have provided a useful tool in identifying that LBB potential to QRS-onset ≥ 22ms had a specificity of 98% in predicting LBBP.11 This target measure can help future operators ensure proximal enough engagement of the LBB conduction system. Additionally, the group took a close look at validating a RWPT cutoff time for the prediction of LBBP. Unfortunately, a RWPT cutoff of 68 ms (in non-LBBB patients), determined by the ROC curve, was not highly predictive. This runs contrary to previous reports by Wu et al. and Jastrzebski et al., which reported higher predictive value of RWPT cutoffs10,12 Looking at the data surrounding RWPT cutoffs as a collective, it likely should not be used as a primary metric for confirming LBBP due to imperfect sensitivity and specificity, but it may be an alternative if output dependent QRS transition or change in RWPT of ≥10 ms is not observed. Additionally, in the event that capture thresholds are similar between the LBB and the adjacent myocardium, programmed stimulation is an option to try to reveal a QRS transition by exploiting differences in refractory periods.This study also highlighted one of the unique complications of LBBP by demonstrating a high rate of septal perforation. Paradoxically, more perforations were seen with increased experience, likely highlighting that deeper penetration into the septum is often sought as operators become more familiar with the procedure. The long-term clinical implications of this complication are, thus far, unknown.Looking forward, clear guidelines for confirmation of LBBP need to be defined. This is necessary to ensure quality before undertaking multi-center randomized controlled trials to assess LBBP in comparison to current pacing methods. To date, Wu et al. seem to have provided the best framework to achieve this.10 That said, there are concerns given that this has only been validated in 30 patients (and only 9 with LBBB). In an ideal world, these criteria would be validated in a larger population, though the work to accomplish this would be meticulous given the current gold standard of using an LV septal mapping catheter to prove conduction system capture. Shimeno et al. should be congratulated for their effort in putting this framework to practice. In their work, they have demonstrated that achieving true LBBP as defined by Wu et al. may be harder than meets the eye, and this is very important in assessing the practicality of using LBBP as a widespread alternative to other pacing methods.References:Abdelrahman M, Subzposh FA, Beer D, et al. Clinical Outcomes of His Bundle Pacing Compared to Right Ventricular Pacing. J Am Coll Cardiol . 2018;71(20):2319-2330. doi:10.1016/j.jacc.2018.02.048Zanon F, Abdelrahman M, Marcantoni L, et al. Long term performance and safety of His bundle pacing: A multicenter experience. J Cardiovasc Electrophysiol . 2019;30(9):1594-1601. doi:10.1111/jce.14063Huang W, Su L, Wu S, et al. A Novel Pacing Strategy With Low and Stable Output: Pacing the Left Bundle Branch Immediately Beyond the Conduction Block. Can J Cardiol . 2017;33(12):1736.e1-1736.e3. doi:10.1016/j.cjca.2017.09.013Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P. A beginner’s guide to permanent left bundle branch pacing. Heart Rhythm . 2019;16(12):1791-1796. doi:10.1016/j.hrthm.2019.06.016Padala SK, Master VM, Terricabras M, et al. Initial Experience, Safety, and Feasibility of Left Bundle Branch Area Pacing: A Multicenter Prospective Study. JACC Clin Electrophysiol . 2020;6(14):1773-1782. doi:10.1016/j.jacep.2020.07.004Su L, Wang S, Wu S, et al. Long-Term Safety and Feasibility of Left Bundle Branch Pacing in a Large Single-Center Study. Circ Arrhythm Electrophysiol . 2021;14(2):e009261. doi:10.1161/CIRCEP.120.009261Huang W, Wu S, Vijayaraman P, et al. Cardiac Resynchronization Therapy in Patients With Nonischemic Cardiomyopathy Using Left Bundle Branch Pacing. JACC Clin Electrophysiol . 2020;6(7):849-858. doi:10.1016/j.jacep.2020.04.011Sharma PS, Patel NR, Ravi V, et al. Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry. Heart Rhythm . 2022;19(1):3-11. doi:10.1016/j.hrthm.2021.08.033Wu S, Su L, Vijayaraman P, et al. Left Bundle Branch Pacing for Cardiac Resynchronization Therapy: Nonrandomized On-Treatment Comparison With His Bundle Pacing and Biventricular Pacing. Can J Cardiol . 2021;37(2):319-328. doi:10.1016/j.cjca.2020.04.037Wu S, Chen X, Wang S, et al. Evaluation of the Criteria to Distinguish Left Bundle Branch Pacing From Left Ventricular Septal Pacing. JACC Clin Electrophysiol . 2021;7(9):1166-1177. doi:10.1016/j.jacep.2021.02.018Shimeno K, Tamura S, Hayashi Y, et al. Achievement Rate and Learning Curve of Left Bundle Branch Capture in Left Bundle Branch Area Pacing Procedure Performed to Demonstrate Output-Dependent QRS Transition.J Cardiovasc Electrophysiol . 2022Jastrzębski M, Kiełbasa G, Curila K, et al. Physiology-based electrocardiographic criteria for left bundle branch capture. Heart Rhythm . 2021;18(6):935-943. doi:10.1016/j.hrthm.2021.02.021Figure LegendsFigure 1: Permanent His Bundle PacingPanel A: A 12-lead electrocardiogram (EKG) shows baseline conduction in a patient with exertional intolerance. The PR interval is markedly prolonged and, with exercise, this patient developed AV block. A permanent His-bundle pacemaker was implantedPanel B: An EKG demonstrating permanent His-bundle pacing in the same patient as panel A. Selective His-bundle capture results in reproduction of the intrinsic QRS complex.Figure 2: Non-Selective Left Bundle Branch PacingA 12-Lead electrocardiogram showing non-selective left bundle branch pacing. The paced QRS morphology is not a direct match for native conduction and the QRS duration is longer than at baseline. However, conduction system capture was confirmed with an output dependent QRS morphology change.FiguresFigure 1: Permanent His-Bundle Pacing
Title: Percutaneous Lead Extraction in Patients with Large Vegetations: Limiting our Aspirations.Robert D. Schaller, DO11The Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PennsylvaniaFunding: This work was supported in part by the Mark Marchlinski EP Research & Education FundKey words: Lead extraction, vegetation, pulmonary embolism, thrombus, aspirationDisclosures: NoneWord count: 1547Transvenous lead extraction (TLE) in the 1960’s involved orthopedic-style pulley systems that joined the exposed portion of the lead to progressively heavier weights hanging from the bed. Sustained tension on the lead was maintained until the patient experienced discomfort, ventricular arrhythmias, or noticeable resistance developed, and was maintained for minutes to days. The location of the lead within the chest was monitored with daily chest radiographs and the ensuingbang of the weight hitting the floor of the intensive care unit signified case conclusion; at which point the patient was assessed. Complications were erratic and included lead laceration and possible migration, injury to the tricuspid valve (TV), myocardial avulsion, tamponade, and death.1 Due to the immature nature of the procedure at that time, it was relegated to infectious indications including lead-related endocarditis, at that time referred to as “catheter fever”.Contemporary TLE has evolved into a highly refined practice with a multitude of tools and predictable results, and procedural indications that now span infection, venous occlusion, management of redundant leads, and access to magnetic resonance imaging.2Procedural imaging with computed tomography (CT) and real-time ultrasound-based tools have similarly changed the TLE experience with identification of adhesions, thrombi, vegetations, and complications.3 Large lead-related masses have historically caused angst due to the possibility of being sheared off by the extraction sheath and embolizing to the lung, and still represent a relative contraindication to percutaneous TLE.2In this issue of the Journal of Cardiovascular Electrophysiology , Giacopelli, et al.4 present the outcomes of 25 consecutive patients (mean age 64 years, 68% male) including 5 with pacemakers, 10 with implantable cardioverter-defibrillators, and 10 with cardiac resynchronization therapy devices, who underwent TLE with vegetations ≥10 mm on transesophageal echocardiography (TEE). Contrast-enhanced CT was performed before and after TLE with 18 (72%) patients showing subclinical pulmonary embolism (PE). Vegetation size (median of 17.5 mm and maximum of 30 mm) did not differ in those with and without PE (20.0 mm vs. 14.0 mm, p=0.116). Complete TLE success was achieved in all patients with 76% requiring advanced tools and 2 needing femoral snaring, and there were no significant procedural complications. In the group with pre-TLE PE, a post-TLE scan confirmed the presence of PE in only 14/18 (78%) and there were no patients with new PE formation. During a median follow-up period of 19.4 months, no re-infection of the new implanted systems was reported and there were 5 deaths (20%); with no differences between the groups. The authors concluded that subclinical PE was common in this clinical scenario but did not influence the complexity or safety of the procedure.Several aspects of this paper warrant comment. No data are reported on the size or location of the PEs nor the time between the first and second CT. It is possible that small PEs would not be identified on subsequent studies days after antibiotics had already been started. Patients also received acute and chronic anticoagulation if PE was identified, which in the setting of vegetations, is generally not indicated and could potentially lead to bleeding. The authors did not provide information regarding infectious pathogens or the timing of culture clearance, which could influence treatment. Additionally, it is unclear which patients received new CIED systems including the type and timing of reimplantation, which might influence subsequent infectious risk. A vascular occlusion balloon was not used in any patients in this report. While this tool is associated with a reduced risk of death in the setting of a superior vena cava laceration when used properly, it has also been shown to be thrombogenic during long dwell times,5 and use could impact post-operative CTs in future studies. Despite utilizing transthoracic echocardiography during TLE, neither TEE nor intracardiac echocardiography were used intraoperatively and thus no information regarding the precise location of the vegetations within the heart is known. Importantly, no information regarding the characteristics of the vegetations other than size was reported.Not all lead-related masses are created equal with two distinct sub-types previously described.6 The first is composed of thickened endocardium and fibrous tissue covering the leads and ultimately forming into connective tissue. These masses, commonly found on leads behind the TV, are caused by a vortical flow pattern leading to low shear stress on the lead surface and provoking neointimal hyperplasia,7 and range from small fibrous strands to large, smooth organized thrombus (Figure, left column). Despite their sterile nature, TLE in the setting of a large, mature thrombus could result in embolization and obstruction of the pulmonary artery resulting in symptomatic PE. The second type, frequently seen in the setting of infective endocarditis, is composed of inflammatory cells, platelets, adhesion molecules, fresh fibrin, and bacteria binding to coagulum and forming vegetations. They are typically longer, more likely to be multi-lobular, and commonly span several chambers of the heart (Figure, right column). These vegetations that are typically acute, with friable finger-like projections, characteristically break apart upon being sheared off during TLE, with reports showing low risk of symptomatic PE.8 Vegetations that are lobular, however, have been associated with worse outcomes.9Despite acute procedural success in the setting of lead-related vegetations, mortality rates at 1 year approach 25%.10 Indeed, despite successful TLE in this report, 20% of patients were dead at 1.5 years. Although complete understanding of the mechanism of these poor outcomes remains unknown, septic emboli, lung abscesses, and infected lead “ghosts” have been implicated.11 Vegetation removal prior to TLE has thus represented an appealing therapeutic option with reports of successful percutaneous aspiration prior to TLE showing promising results, albeit with unknown long-term benefit.12,13 Although the lack of new PEs after TLE in this report does not directly support the effort, cost, and added risk of such a strategy, “debulking” of infectious burden remains a tempting complementary treatment. Importantly, the acute safety of TLE with large vegetations in this study should not be extrapolated to chronic, large lead-related masses, which are more like to cause acute PE if embolized. While aspiration of these sterile masses prior to TLE is appealing from a procedural outcome perspective, their morphologic characteristics, and the imperfect, but evolving, aspiration sheaths currently available are limiting, and requires consideration of surgical extraction. Further advancements in aspiration catheter technology and the development of right ventricular outflow track filters might influence future management.TLE continues to represent the gold standard for the management of lead-related infection.2 Due to the extensive work of the pathfinders in the vanguard of procedural development, the sound of crashing weights has been supplanted by those that power advancing sheaths. Yet despite the safe and predictable nature of modern-day TLE, the sobering long-term mortality of patients with infectious indications remains out of proportion to acute procedural success. While infectious “debulking” continues to represent the most attractive and practical complementary option to address this incongruity, future studies should concentrate both on identification of mass characteristics that suggest success, as well as determining if long-term benefits exist above and beyond lead removal. However, if improvement in clinical outcomes that warrant this added cost and effort are not identified, we should likely limit our aspirations.

Wenjing Li

and 2 more

The sulfur cycle is one of the geochemical element cycles in which microorganisms play a key driving role. The microbial function of soil S cycling in response to desert degradation, however, remains largely unknown. We used metagenomics to analyze the characteristics of microbial communities and their functional genes involved in the S cycles under natural water gradients with three typical halophytes shrubs in the Ebinur Lake Basin Desert, China. Our results showed that the rhizosphere effect, water gradient, and halophyte type played a major role in shaping the S cycle. On the whole, in the rhizosphere type and low water environment, the functional genes involved in the S cycle had high abundance, and the SOX system in Alhagi sparsifolia had a high expression level. In the S cycle network structure, as the soil water content decreased, the complexity in S gene networks increased, showing the characteristics of clustering and high connectivity. Indicates the strengthening mode in microbial interactions with the water content. Interestingly, the negative correlation of the network changed with the water content, and there was more competition among communities under the low water gradient and more cooperation under the high water gradient. Through the correlation between environmental factors and the network, nitrate (NO 3 −) and soil available S (AS) constrained most S gene ecology networks. The key species involved in the S cycle were halophilic microorganisms. These results can enhance the understanding of soil S biogeochemical processes and contribute to the mitigation of desertification by improving soil conservation.

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