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Jeffrey Clark

and 4 more

Introduction: The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging. Methods: A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020 in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected. Results: A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging. Conclusion: In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.

Lysia Demetriou

and 11 more

Title PageTitle: A commentary on the need for support with mental as well as physical health for people with endometriosis during the COVID-19 pandemic and beyond.Authors:Lysia Demetriou, Emma Cox, Claire E. Lunde, Christian M Becker, Adriana L. Invitti, Beatriz Martínez-Burgo, Marina Kvaskoff, Kurtis Garbutt, Emma Evans, Elaine Fox, Krina T Zondervan, Katy Vincent.Corresponding author contact information:Prof Katy VincentNuffield Department of Women’s & Reproductive HealthUniversity of OxfordJohn Radcliffe HospitalOxfordOX3 9DUTel: 01865 220024Fax: 01865 769141 katy.vincent@wrh.ox.ac.ukAuthor information:Lysia Demetriou , PhD, lysimachi.demetriou@wrh.ox.ac.uk , Nuffield Department of Women’s and Reproductive Health, University of Oxford.Emma Cox , MSc, MBA, ceo@endometriosis-uk.org, Endometriosis UKChristian Becker , MD; christian.becker@wrh.ox.ac.uk; Nuffield Department of Women’s and Reproductive Health, University of OxfordClaire E. Lunde , BS, BA; claire.lunde@spc.ox.ac.uk; (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford. (2) Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children’s Hospital; (3) Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s HospitalAdriana Invitti , PhD, adriana.invitti@wrh.ox.ac.uk; (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford; (2) Departamento de Ginecologia, Universidade Federal de São Paulo.Beatriz Martínez-Burgo , PhD, beatriz.martinezburgo@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of OxfordMarina Kvaskoff , PhD, marina.kvaskoff@inserm.fr, Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, ”Exposome and Heredity” Team, CESP, F-94805, Villejuif, FranceKurtis Garbutt, EngD, kurtis.garbutt@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of Oxford.Emma Evans , DClinPsych, emma.evans@ouh.nhs.uk, Oxford University Hospitals NHS Foundation TrustElaine Fox, PhD, elaine.fox@psy.ox.ac.uk, Department of Experimental Psychology, University of Oxford.Krina Zondervan , DPhil, krina.zondervan@wrh.ox.ac.uk, (1) Nuffield Department of Women’s and Reproductive Health, University of Oxford; (2) Wellcome Centre for Human Genetics, University of OxfordKaty Vincent , DPhil, katy.vincent@wrh.ox.ac.uk, Nuffield Department of Women’s and Reproductive Health, University of Oxford.Running Title: Support for people with endometriosisManuscript word count: 1282 wordsThe coronavirus disease 2019 (COVID-19) pandemic meant an abrupt change in healthcare provision around the world. Whilst the primary focus was (rightly) on the care of those infected with SARS-CoV-2 and public health measures to prevent transmission/identify those most at risk, individuals with chronic conditions saw their treatments halted, cancelled or changed, with little information available and extremely limited access to clinicians1-3. As the first wave settled, many units began to restart their benign gynaecology services, however, this was within the limitations of social distancing, reduced staffing (due to sickness, shielding or COVID-19 contact) and the continued need for personal protective equipment (PPE). At a global level, the focus remained on public health measures and the search for a vaccine4.Everyone had their own personal experience of the initial lockdowns and ongoing restrictions, the extent and timing of which varied throughout the world. Many were able to find at least some positives to contrast with the limitation on freedom and continuing background threat from the virus. These included more time to spend with their nuclear family, reigniting interest in or starting new hobbies, the opportunity to tackle home improvements and more time to exercise. However, data also began to emerge on the significant impact the pandemic was having on mental health5, 6. Of particular relevance to Obstetricians and Gynaecologists was the finding that along with young people and those with small children at home, mental health was deteriorating most in women6.As endometriosis is a chronic disease, many of those affected rely on long term medication, whilst others require one or more procedures (surgery or fertility treatment). We were concerned as to the impact the pandemic might be having on the access to treatment for those with endometriosis. We therefore conducted an online survey study to determine this impact and understand priorities going forwards. The survey (open 11th May to 8th June 2020; University of Oxford Central University Research Ethics Committee approval reference: R69636/RE001) was available in English, French, German, Spanish and Portuguese and had 7246 respondents. 6729 of these met inclusion criteria (\(\geq\)18 years old; self-reported endometriosis diagnosis by surgery or imaging) covering most regions of the world (Europe: n=4502; North America: n=973; Latin America and Caribbean: n=662; Oceania: n=379; Asia: n=35; Africa: n=28; Unknown: n=150).Overall, 80.7% (95% CI [79.7, 81.6]) reported an impact on their current or planned treatments. Based on enquiries to Endometriosis UK and what we were hearing clinically, we had expected many challenges with accessing medications especially injectables. However, 64.6% reported no impact of the pandemic on the availability of their usual treatments for endometriosis (n=4267). Although 20.3% (n=1337) did report difficulty obtaining repeat prescriptions, 10.5% having to change their hormone and/or painkiller (4.5% and 7.0% respectively), whilst 9.5% had to stop a medication altogether (hormones: 3.4%; painkillers 6.6%). The impact on planned care was much greater: 50.0% of responders reported cancelled/postponed appointments with gynaecologists and 14.7% described cancelled/postponed primary care appointments; 37.2% had procedures cancelled/postponed (surgery: 27.0%; fertility: 12.0%). These proportions were similar around the world (Table 1).Our data demonstrate the considerable impact the COVID-19 pandemic has had on the care of people around the world with endometriosis. These findings agree with studies in Urology7, Dermatology2 and a smaller Turkish endometriosis cohort (n=261)3, suggesting a significant impact on benign services. Concerns have also been expressed about the impact on those with chronic pain, both in terms of difficulties accessing treatments including physiotherapy and psychology and the possibility of medication issues due to telephone prescribing8. During this second wave and as we move forwards, it is essential that we minimise the impact on those with chronic conditions. Redesigning services with the priorities of those suffering with the conditions in mind will be essential to achieving this aim.In our survey we also asked “During the pandemic, what one thing would be most helpful to you, relating to endometriosis? ” and “As restrictions begin to ease and healthcare starts to go back to normal, what one thing do you think should be prioritised with regards to endometriosis? ”. Respondents considered that during the pandemic the most helpful things would be: contact with their gynaecologist (32.6%); dates booked for future surgery/fertility treatments (20.5%); and mental health support (20.3%). Improving availability of medication and contact with primary care were less popular (11.1% and 8.6% respectively). As restrictions ease, priorities are: arranging cancelled/postponed procedures (42.7%) or appointments with their gynaecologists (32.1%) and mental health support (13.0%). Considerably less chose medication availability (5.3%) or primary care appointments (3.8%). Figure 1 illustrates how similar these priorities were around the world.It was notable that the top three priorities during and immediately after the pandemic were remarkably consistent around the world. Given how rapidly telemedicine has been adopted globally, it should not be a challenge to arrange contact between patients and their gynaecologists by either telephone or video. However, this does necessitate gynaecologists being available to provide this service and argues against them being redeployed to cover emergency services as commonly occurred during the height of the first wave. We do not believe that primary care appointments should be recommended as a substitute for gynaecology appointments. These are clearly not the priority for those with endometriosis and primary care services have been placed under considerable pressures during the pandemic9. Whilst little can be done to reduce waiting times for procedures (both surgical and fertility treatments), we should at least be open with patients, giving a realistic timeframe in which we expect to be able to offer these.Although these first two priorities were not surprising, we did not expect to see such a high proportion prioritising mental health over and above all other aspects of their endometriosis care. There has been an increasing focus on comorbid mental health conditions in people with endometriosis over recent years, including two high profile UK investigations10, 11, yet guidance on the management of the condition does not reflect this. Whilst the pandemic continues, mental health support can be delivered virtually, both standalone and in the context of pain management12. However, this is one change we believe should continue for the long-term and therefore investment in psychology, ideally embedded within gynaecology services, will be essential. Integrating mental health support into the standard of care for endometriosis could be one positive to come out of this pandemic and might be expected to have a real impact on quality of life.Finally, we were concerned to see that more than half of respondents worried that their endometriosis makes them more vulnerable to COVID-19 (n=3635, 54.2% 95% CI [53.0, 55.4]; only n=22 did not answer this question). This may be because the known link to altered immunological responses has been misinterpreted as endometriosis being an autoimmune condition7, with additional concerns for those with thoracic endometriosis. Given that so far there is no evidence to support this belief, we consider it essential that clinicians address this issue with their patients, and education campaigns should be considered. Worries about their vulnerability to COVID-19 may add to the feelings of threat experienced during the pandemic and thus contribute to worsening mental health.In conclusion, COVID-19 has clearly had a devastating effect on health and healthcare around the world. At least in the initial phases, those with chronic conditions (including endometriosis) experienced a significant impact on their care, the longer-lasting effects of which remain to be determined. Moving forwards, it will be essential to take patient priorities into consideration as financially-strained healthcare providers redesign their services. We hope that this additional evidence of the desire for support with mental health in combination with other work highlighting this as an area of real need leads to a sustained change in the availability of psychologists within gynaecology services.

Laura Hrehova

and 1 more

Introduction: Prevalence of insomnia is higher in females and increases with higher age. Besides primary insomnia, comorbid sleep disorders are also common, accompanying different conditions. Considering the possible adverse effects of commonly used drugs to promote sleep, a nonpharmacologic approach should be preferred in most cases. Although generally considered first-line treatment, the nonpharmacologic approach is often underestimated by both patients and physicians. Objective: To provide primary care physicians an up-to-date approach to the nonpharmacologic treatment of insomnia. Methods: PubMed, Web of Science, and Scopus databases were searched for relevant articles about the nonpharmacologic treatment of insomnia up to December 2020. We restricted our search only to articles written in English. Main Message: Most patients presenting with sleep disorder symptoms can be effectively managed in the primary care setting. Primary care physicians may use pharmacologic and nonpharmacologic approaches, while the latter should be generally considered first-line treatment. A primary care physician may opt to refer the patient to a sleep medicine specialist for refractory cases. Conclusions: This paper provides an overview of current recommendations and up-to-date evidence for the nonpharmacologic treatment of insomnia. This article emphasizes the importance of cognitive-behavioral therapy for insomnia, likewise, exercise and relaxation techniques. Complementary and alternative approaches are also covered.

Sarah Engle

and 10 more

Background: The pathogenesis of atopic dermatitis (AD) results from complex interactions between environmental factors, barrier defects, and immune dysregulation resulting in systemic inflammation. Therefore, we sought to characterize circulating inflammatory profiles in pediatric AD patients and identify potential signaling nodes which drive disease heterogeneity and progression. Methods: We analyzed a population of 87 infants that were at high risk for atopic disease based on dermatitis diagnoses. Clinical parameters, serum, and peripheral blood mononuclear cells (PBMCs) were collected upon entry, and at one and four years later. Within patient serum, 126 unique analytes were measured using a combination of multiplex platforms and ultrasensitive immunoassays. Results: We assessed the correlation of inflammatory analytes with AD severity (SCORAD). Key biomarkers, such as IL-13 (corr=0.47) and TARC (corr=0.37), among other inflammatory signals, significantly correlated with SCORAD across all timepoints in the study. Flow cytometry and pathway analysis of these analytes implies that CD4 T cell involvement in type 2 immune responses were enhanced at the earliest time point (year 1) relative to the end of study collection (year 5). Importantly, forward selection modeling identified 18 analytes in infant serum at study entry which could be used to predict change in SCORAD four years later. Conclusions: We have identified a pediatric AD biomarker signature linked to disease severity which will have predictive value in determining AD persistence in youth and provide utility in defining core systemic inflammatory signals linked to pathogenesis of atopic disease.

Frank van Haren

and 28 more

Objectives: To externally validate and compare Resorlu-Unsal stone score(RUSS), modified Seoul National University Renal Stone Complexity Score(S-ReSC), Ito’s nomogram and R.I.R.S. scoring systems for predicting capabilities of both the stone-free status and complications in a multi-institutional study. Materials and Methods: We performed a retrospective analysis of 949 patients who were underwent flexible ureterorenoscopy (f-URS) and laser lithotripsy for renal stones in two institutions between March-2015 and June-2020. The RUSS, modified S-ReSC, Ito’s nomogram and R.I.R.S. scores were calculated for each patient by same surgeon on imaging methods. Results were compared for their predictive capability of stone-free status and complications. Results: Of 949 patients 603 were male and 346 were female with a mean age of 47.2±14.3 (range 2-84years). Mean stone burden was 102.6±42.2 (48-270mm2). All nomograms predicted stone-free status (AUC were 0.689, 0.657, 0.303 and 0.690, respectively). All four scoring systems predicted complications with AUC values of 0.689, 0.646, 0.286 and 0.664 for RUSS, modified S-ReSC, Ito’s nomogram, R.I.R.S., respectively. Although all scoring systems were able to predict complications only Ito’s nomogram was able to predict Clavien ≥2 complications. Conclusion: All four scoring systems (RUSS, modified S-ReSC, Ito’s nomogram and R.I.R.S.) could predict stone-free status after f-URS, however the AUC values are not satisfactory in our large patient cohort. Although these scoring systems were not developed for predicting post-operative complications, they were associated with complications in our study. However, these four scoring systems have some significant limitations. The ideal scoring system is yet to be developed.

Onder Cinar

and 11 more

Abstract Aims of the study: The aim of this study was to investigate the impact of testosterone deficiency on cognitive functions in metastatic prostate cancer patients receiving androgen deprivation therapy (ADT). Methods: In this multicentric prospective study, 65 metastatic prostate cancer patients were evaluated. Demographic and clinical data were recorded. Cognitive functions were assessed using the Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test - Revised, and the Trail Making Test. Depressive symptoms were assessed using the Beck Depression Inventory. Cognitive functions and depressive symptoms were recorded before the androgen deprivation therapy and at the 3- and 6-month follow ups. Results: At the basal cognitive assessment, the mean Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test - Revised scores were 25.84 ± 17.54, 32.68 ± 10.60, and 17.63 ± 11.23, respectively, and the mean time for the Trail Making Test was 221.56 ± 92.44 s., and were similar at the 3-month, and 6-month controls (p > 0.05). The mean pretreatment, third and sixth month testosterone levels were 381.40 ± 157.53 ng/dL, 21.61 ± 9.09 ng/dL, and 12.25 ± 6.45 ng/dL (p < 0.05), and the total PSA levels were 46.46 ± 37.83 ng/mL, 1.41 ± 3.31 ng/mL, and 0.08 ± 0.14 ng/mL (p < 0.05), respectively. Conclusion: The ADT in patients with metastatic prostate cancer does not affect patients’ cognitive functions and depressive symptoms. However, further prospective randomized studies with higher cohorts and longer follow up periods are needed.

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Oktay Ucer

and 3 more

The sinoatrial node in medication-resistant inappropriate sinus tachycardia: to modify or to ablate?Khalil El Gharib1*1Hôtel-Dieu de France, Beirut, Lebanon*Author for correspondence: khalil.gharib@outlook.comKEYWORDS: IST, sinus node modification, sinus node ablation, radiofrequency ablation, surgical ablationNo conflict of interest to discloseFunding: noneInappropriate sinus tachycardia (IST) is defined as a resting heart rate >100 beats per minute (with a mean heart rate >90 beats per minute over 24 hours) associated with highly symptomatic palpitations(1). The syndrome is associated neither with structural heart disease nor with any secondary cause of sinus tachycardia(2) and evidence suggests that enhanced intrinsic automaticity of the sinoatrial node, which can be due to anti-β-adrenergic antibodies, is behind its genesis(3). However, it is benign in terms of clinical outcomes and echocardiographic evidence of ventricular dysfunction(4), being rarely associated with tachycardia-induced cardiomyopathy(3).Patients with IST are essentially treated with ß-blockers to alleviate their symptoms(5). Ivabradine, a drug that inhibits funny calcium channels, particularly abundant in the SA node, showed modest benefit, receiving class IIa recommen­dation in the treatment of IST(4). But, the duration of medical therapy might be indefinite, and, a considerable number of patients would respond inadequately, or have no response, even after prolonged therapy(5). Historically, such patients would have subtotal right atrial excision, atrioventricular junctional ablation with permanent pacemaker implantation, or chemical occlusion of the sinus node artery(6). These options are considered today unacceptable in this setting, and other therapeutic approaches should be unveiled when resistance to medical treatment appears.Electrophysiological study was initially purely diagnostic, but recent advances in technology have allowed us to intervene(7); patients with ventricular and supraventricular tachyarrhythmias are successfully treated with percutaneous catheter procedures. Of these, SA node ablation/ modification has been proposed as alternative approaches in IST that is not responding to medical treatment; trials reported auspicious results, highlighted here.Electrophysiologic mapping to the site of the earliest endocardial activation during either spontaneous sinus tachycardia or isoproterenol-induced sinus tachycardia has rendered these procedures feasible(8). Additionally, combination with intracardiac echocardiography permitted a more accurate electrophysiologic and anatomic localization of the sinoatrial node(9).Sinus node modification is not a focal ablation, but requires complete abolition of the cranial portion of the SA node complex, the one that exhibits the most of the autonomic activity(9). It is defined as successful when the heart rate decreases by 30 beats per minute (bpm) during isoproterenol infusion(8). Short-term success was also defined by other investigators when there was a reduction of the baseline sinus rate to less than 90 bpm and the sinus rate during isoproterenol infusion by more than 20% or by 25%(8). The acute success rate for modification has been varying between 76 and 100 % across trials, while long-term clinical outcomes are modest at best, with reported freedom from IST ranging from 23 to 85%(10).Complications specific to SA node modification include superior vena cava (SVC) syndrome, diaphragmatic paralysis, and sinus node dysfunction(10). And while modification with conventional methods has its setbacks, modification using laser energy can be considered in the setting of IST. This modality creates clear-cut homogenous transmural lesions of the myocardium that comprises the scattered “functional” SA node(11). The burnt myocardium will then heal into a dense fibrous scar, decreasing potential amplitudes. And when adapting laser energy settings to the thickness of the myocardial wall, collateral dam­ages such as esophageal fistulae, lung burns, and phrenic nerve palsy will be avoided(11); thus, this technique may prove itself as a new intriguing alternative for the safe and effective treatment of IST.SA node modification is apt in achieving acute reductions in postprocedural heart rate. However, and as aforementioned, success rates are suboptimal in terms of symptomatic control with a significant recurrence rate(12). Catheter ablation aiming at either total exclusion and obliteration of the SA node has been described and performed, success being defined as a slowing of >50% from the baseline rate of tachycardia along with a junctional escape rhythm(12). With radiofrequency (RF) applications, the earliest local atrial activation time would shift from a cranial location to a more caudal one, usually at the mid-lateral right atrium(5). Reviews have reported that acute success rates were consistently to be as high as 88.9%, with an overall frequency of recurrence of 19.6%, the latter occurring within a wide range of post-ablation intervals, anywhere from a few weeks to several months after the procedure(12). Additionally, Takemoto and colleagues documented a significant drop in B-type natriuretic peptide levels, 6 to 12 months after ablation, suggesting fewer stretching shears on cardiac muscle.Two types of response of the sinus tachycardia to RFA were observed across studies, whether a step-wise reduction in sinus rate accompanying migration of the site of earliest atrial activation in a cranial-caudal direction along the lateral right atrial wall, or an abrupt drop in heart rate in response to RFA at a focal site of earliest atrial activation(13).However, RFA of inappropriate sinus tachycardia requires a large number of applications of radiofrequency energy and is, as in SA node modification, associated with a high recurrence rate(13). Complete remission is achieved only in approximately 50% of patients in some studies(14); longer history of IST and those reporting near syncope/syncope having a higher probability of recurrence(15).While other studies have shown that RF ablation of the SA node can achieve even longer-term reductions in the sinus rate and relief of symptoms in two-thirds of patients with drug-refractory, inappropriate sinus tachycardia(13), aiming specific sites related to the SA node should be elaborated, for better and optimal outcomes Killu and colleagues created a lesion in the arcuate ridge resulting in complete abolition of the tachycardia, since arrhythmias arising in this region may exhibit both electrocardiographic and clinical similarities to IST(16). This has led to consider ablation of the arcuate ridge as a treatment of refractory IST, necessitating larger trials to confirm its potential role.Phrenic nerve injury is a severe and dreaded complication of SN ablation(12). Pericarditis, right diaphragmatic paralysis, and SVC syndrome are other undesirable side effects of the procedures, variously reported in studies. but a common complication was observed in them all, atrial tachyarrhythmias(12). It has been hypothesized that myocardial pathology, such as inflammation and fibrosis, considered iatrogenic due to the ablation procedures, may be promoting arrhythmias both in the region of the SA node, as well as in remote locations(12). Through multivariable analysis, higher resting heart rates post-ablation and smaller cranial-to-caudal shifts have been defined as predictors of atrial arrhythmias(15). In conclusion, catheter ablation could be considered an effective treatment for highly symptomatic, drug-refractory patients, even for those who did not respond to SA node modification(5).The sinus node is located close to the epicardial surface and catheter-based ablations do not always make full-thickness lesions across the atrial muscle, leading to failure of the ablation(17), besides the numerous trabeculae and the widely variable anatomy.Surgical ablation is not a first-line or routine management strategy for IST, but it has been proposed when IST resists or recurs after SN modification/ endocardial ablation(17). Effectively, in several studies, epicardial lesions, through a single small incision in one of the intercostal spaces, successfully slowed heart rate and shifted activation to a more caudal location, and surprisingly, subsequent endocardial lesions led to an even greater drop in heart rate and more caudal site of earliest activation(18). These outcomes were again replicated when using minimally invasive thoracoscopic ablation of the epicardial site of the SA node, concluding of the promising efficacy and the safety of this approach, since it preserves the phrenic nerve(17), although continued follow-up after surgery is required.Medication-resistant IST remains a medical challenge for physicians and cardiologists; and in the era of great advances in interventional cardiology, its treatment remains debatable. Sinus node modification/ ablation is not recommended as first-line therapy in IST, this procedure should be considered only in drug-refractory patients who have severe symptoms(13). Although the number of patients in the available studies is generally small, both procedures have documented an encouraging success rate in the short-term, while being less impressive in the long-term. It has been hypothesized that this discrepancy is due to the relatively large potential area of atrial pacemaker cells(18); modification or ablation may fail to ablate or isolate all the pathways that comprise the functional SA node because they often target the anatomic part and the area of earliest atrial activation(19). Others have explained that the long-term slowing in rhythm fails because these procedures inconsistently produce transmural lesions in the right atrium. Surgical treatment of IST has proposed a solution to the latter conflict when isolating the SA node with a wide cuff of surrounding atrial muscle(19). And with the advent of bipolar RF clamps and minimally invasive cardiac surgical techniques with thoracoscopic guidance, this approach appears more appealing than before, especially when combined with endocardial ablation(19). But again, current data specifies employing these techniques in highly selected cases.

Jerome FERRARA

and 10 more

Background: There is insufficient evidence regarding the comparison of Rapid Deployment aortic valve replacement(RDAVR) to TAVR in intermediate-risk patients with severe symptomatic aortic stenosis(AS) Aims: We compare the 2-years outcomes between RDAVR with INTUITY and TAVR with SAPIEN 3 in intermediate-risk patients with AS. Methods: Inclusion criteria: severe AS implanted with RDAVR or TAVR; EUROSCORE II ≥ 4% and clinical evaluation by Heart Team. Regression adjustment for the propensity score was used to compare RDAVR with TAVR(1:1). Primary endpoint: composite criterion of death, disabling stroke or rehospitalization. Secondary endpoints: occurrence of major bleeding post-operative complications, paravalvular regurgitation (PVR)≥2 and patient-prosthesis mismatch(PPM) at 1 month and pacemaker implantation at 2 years. Results: A total of 152 patients were included from 2012 to 2018: 48 in the RDAVR group and 104 in the TAVR group. Mean age was 82.7±6, 51.3% were female, mean Euroscore II was 6.03±1.6% and mean baseline LVEF was 56±13%,mean indexed iEOA was 0.41±0.1cm/m2, mean gradient was 51.7±14.7mmHg. Patients with RDAVR were younger(79.5±6vs82.6±6,p=0.01), at higher risk (EUROSCORE2 6,61±1,8%vs5,63±1,5%, p=0.005), combined surgery was performed in 28 patients(58.3%). Twenty-two patients(45.99%) met the primary outcome in the RDAVR group and 32 patients(66.67%) in the TAVR group. By 1:1propensity score matching analysis, there was a significant difference between both groups in favor of RDAVR(HR=0.58[95%CI:0.34;1.00],p=0.04). No difference were observed in PPM occurrence(0.83;[0.35-1.94];p=0.67),major bleeding events(1.33;[0.47-3.93];p=0.59),PVR≥2(0.33[0-6.28],p=0.46), and pacemaker implantation (0.84[0.25-2.84],p=0.77).Conclusion: RDAVR is associated with better 2-years outcomes than TAVR in intermediate-risk patients with severe symptomatic AS.

Francesca Mori

and 10 more

Onder Cinar

and 12 more

Purpose: To investigate the effect of mirabegron 50 mg/daily for JJ stent-related symptoms after ureteroscopic stone surgery. Methods: Medical records of 145 patients who were given a single daily oral dose of 50 mg of mirabegron for relieving stent-related symptoms were retrospectively analyzed. Demographic and clinical data and stone parameters were recorded. All participants completed the Turkish version of the Ureter Symptom Score Questionnaire (USSQ-T) on the postoperative seventh day, and again after at least three weeks, before JJ stent removal. The severity of stent-related symptoms was statistically compared before and after the mirabegron treatment. Results: The mean urinary symptoms score decreased significantly from 30.87 ± 9.43 to 22.61 ± 6.78 (p < 0.0001), mean body pain score decreased significantly from 21.82 ± 11.22 to 14.03 ± 7.52 (p < 0.0001), mean work performance score decreased from 10.50 ± 8.61 to 7.02 ± 6.51 (p < 0.0001), and mean general health score decreased significantly from 15.43 ± 6.50 to 11.12 ± 3.70 (p < 0.0001). The mean sexual matters score significantly decreased from 3.88 ± 3.40 to 2.48 ± 2.03 (p < 0.0001), the additional problem score decreased from 9.31 ± 4.61 to 6.51 ± 2.83 (p < 0.0001), and the overall quality of life (QoL) score decreased from 5.18 ± 1.94 to 4.23 ± 1.71 after mirabegron use (p < 0.0001). Conclusion: Daily use of 50g of mirabegron significantly improved stent-related symptoms, sexual matters, and quality of life.

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