Role of the vein of marshall in atrial fibrillation recurrences after catheter ablation: therapeutic effect of ethanol infusion

Vein of Marshall Ethanol in Recurrent AF. Introduction: Atrial fibrillation (AF) or flutter can recur after pulmonary vein (PV) antral isolation (PVAI). The vein of Marshall (VOM) has been linked to the genesis of AF. We hypothesized that the VOM may play a role in AF recurrences and that VOM ethanol infusion may have therapeutic value in this setting. Methods and Results: Sixty-one patients with recurrent AF or flutter after PVAI were studied. The VOM was successfully cannulated in 54; VOM and PV electrograms were recorded, and differential PV-VOM pacing was performed. VOM signals were present in all patients; however, VOM triggers of AF could not be demonstrated. VOM tachycardia was present in 1 patient. Left inferior (LIPV) and left superior (LSPV) reconnection was present in 32 and 30 patients, respectively. Differential pacing in VOM and LIPV showed VOM-mediated LIPV reconnection in 5/32 patients. In others, VOM and PV connected indirectly via left atrial tissues. Up to four 1 cc infusions of 98% ethanol were delivered in the VOM. Regardless of the reconnection pattern, ethanol infusion eliminated LIPV and LSPV reconnection in 23/32 and 13/30 patients, respectively. Ethanol terminated VOM and LIPV tachycardias in 2 patients. There were no acute procedural complications. Conclusions: VOM signals are consistently present in recurrent AF. VOM may rarely play a role in PV reconnection. However, VOM ethanol infusion can be useful in patients with recurrent AF after PVAI, assisting in achieving redisconnection of reconnected left PVs.     

Alveolar macrophages from overweight/obese subjects with asthma demonstrate a proinflammatory phenotype

Rationale: Obesity is associated with increased prevalence and severity of asthma. Adipose tissue macrophages can contribute to the systemic proinflammatory state associated with obesity. However, it remains unknown whether alveolar macrophages have a unique phenotype in overweight/obese patients with asthma. Objectives: We hypothesized that leptin levels would be increased in the bronchoalveolar lavage fluid from overweight/obese subjects and, furthermore, that leptin would alter the response of alveolar macrophages to bacterial LPS. Methods: Forty-two subjects with asthma and 46 healthy control subjects underwent research bronchoscopy. Bronchoalveolar lavage fluid from 66 was analyzed for the level of cellular inflammation, cytokines, and soluble leptin. Cultured primary macrophages from 22 subjects were exposed to LPS, leptin, or leptin plus LPS. Cytokines were measured in the supernatants. Measurements and Main Results: Leptin levels were increased in overweight/obese subjects, regardless of asthma status (P = 0.013), but were significantly higher in overweight/obese subjects with asthma. Observed levels of tumor necrosis factor-α were highest in overweight/obese subjects with asthma. Ex vivo studies of primary alveolar macrophages indicated that the response to LPS was most robust in alveolar macrophages from overweight/obese subjects with asthma and that preexposure to high-dose leptin enhanced the proinflammatory response. Leptin alone was sufficient to induce production of proinflammatory cytokines from macrophages derived from overweight/obese subjects with asthma. Conclusions: Ex vivo studies indicate that alveolar macrophages derived from overweight/obese subjects with asthma are uniquely sensitive to leptin. This macrophage phenotype, in the context of higher levels of soluble leptin, may contribute to the pathogenesis of airway disease associated with obesity.     

Relief of methacholine-induced bronchospasm with extrafine beclomethasone dipropionate/formoterol in comparison with salbutamol in asthma

BackgroundShort-acting beta2-agonists like salbutamol and terbutaline are used as rescue medications for acute bronchoconstriction and relief of symptoms due to their rapid onset of action. The aim of this study was to assess whether inhaled beclomethasone dipropionate (BDP)/formoterol fumarate (FF) combination in extrafine formulation is non-inferior to salbutamol in the speed of reverting methacholine-induced bronchoconstriction and symptoms.MethodsFifty-six asthmatic patients were examined in a multicentre, randomised, double blind, double dummy, active treatment and placebo controlled three period cross-over study. On three different days, a single dose of BDP/FF 100/6 μg in pressurised metered-dose inhaler (pMDI) extrafine formulation or salbutamol 200 μg pMDI or placebo was inhaled after FEV₁ had dropped by 30–45% with methacholine challenge.ResultsThe median time to recovery of FEV₁ to 85% of baseline was similar for BDP/FF and salbutamol (3.66 and 2.15 min, respectively), but significantly longer for placebo (21.1 min). The planned analysis on adjusted mean time to recovery showed that the difference from methacholine-induced bronchoconstriction between BDP/FF and salbutamol was 3.82 min (95% confidence interval: ?0.85 to 8.5), therefore greater than 3 min supposed in the study design. The difference between BDP/FF and salbutamol was not clinically significant. The two active treatments were also comparable in terms of the relief of symptoms (as assessed by the Borg dyspnoea scale).ConclusionsBDP/FF combination has a fast onset of action, similar to that of salbutamol, and may represent a good alternative as rescue medication in asthmatic patients.     

Intraocular endoscopy: A review

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.     

Resuming eye bank services during the COVID-19 pandemic: Experience and inferences

Purpose:The aim of this study was to formulate a methodological approach for resuming eye bank services during COVID-19 pandemic.Methods:Eye bank operations were temporarily halted in March after the government-mandated “Lockdown” in response to COVID-19 pandemic. Before restarting eye bank operations in May, we studied sources of exposure, performed risk assessment, instituted additional process validations and redefined the Standard Operating Procedures (SOPs) in consultation with the guidelines published by the Eye bank Association of India and All India Ophthalmological Society. The eye bank staff were rigorously trained before and after operations were restarted. We conducted a survey at the end of July to gauge staff attitude and reaction.Results:Eye banks services resumed on 20^th May 2020. Since reopening till the end of July total 41 keratoplasties have been done. 91.75% of all keratoplasties done were therapeutic surgeries and 17% of the surgeries were done using glycerine preserved tissues. No staff had COVID-19 symptoms when the operations restarted and none developed symptoms up to the end of July. All eye bank staff were aware of COVID-19 pandemic and 86% said they felt safe working at the eye bank. 86% of the staff said that they received adequate training and 66% of the staff expressed that they always received proper PPE and kits. Overall, 93% of the staff expressed that the measures taken by the eye bank ensured their safety.Conclusion:Based on our experience we suggest the following activities for planned resumption of eye bank services during the pandemic: Exposure Risk Analysis, Personal Protective Equipment usage training, SOP Revision and staff training on modified SOPs. Criteria based selection of donor sources, participatory planning involving the staff and double-checking at critical process junctions helped us in managing a smooth transition.     

Endoscopic visualization-assisted corneal bee sting removal

Purpose:Deeply embedded corneal foreign bodies and intrastromal foreign body removal can often be a challenge. The aim of this report was to describe the utility of endoscopy in visualization and removal of an embedded corneal bee stinger.Methods:A 44-year-old male patient developed toxic keratopathy after injury from a bee stinger. On examination, the bee stinger was noted to be deeply embedded in the corneal stroma. A superficial keratectomy was initially attempted; however, the stinger was noted to be intrastromal and protruding into the anterior chamber and could not be removed. An Endoscopy-assisted visualization was used to remove the stinger.Results:The bee stinger was successfully removed and the patient''s vision improved to 20/100 from an initial CFCF (counting fingers close to face) at time of presentation. At the end of 3 months follow-up, there was residual corneal edema along with cataractous changes in the lens as a sequelae of the initial bee sting injury. The patient subsequently underwent an endothelial keratoplasty along with phacoemulsification with intraocular lens implantation and the final BCVA improved to 20/40.Conclusion:Endoscopyassisted visualisation of anterior chamber and angle structures can be valuable in removal of retained and deeply embedded corneal or intracameral foreign bodies.