Echocardiographic assessment of right ventricular function in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis

BackgroundPresence of right ventricular (RV) infarction imposes a higher risk of adverse events in inferior wall myocardial infarction (IWMI). In this study, we attempted to correlate various indices of RV function assessed by echocardiography with presence of a proximal right coronary artery (RCA) stenosis in patients with first episode of acute IWMI.MethodsIn a prospective study, patients with first episode of acute IWMI underwent echocardiographic assessment within 24 h of symptom onset and indices of RV function viz. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients who underwent coronary angiogram (CAG) within one month and they were classified into group 1 and group 2 based on the presence or absence, respectively, of a significant proximal RCA stenosis.ResultsThere were 90 patients with first episode of IWMI of which 67 patients underwent CAG. There was significant difference between group 1 (n = 26) and group 2 (n = 41) in TAPSE (13.5 ± 1.3 vs 21.3 ± 1.7, p < 0.001), MPI by tissue Doppler (0.87 ± 0.1 vs 0.55 ± 0.2, p < 0.001) and in tissue Doppler systolic velocity from RV free wall (S′ 9.8 ± 1.1 vs 15.0 ± 1.5, p < 0.001). There was a good interobserver correlation for TAPSE, MPI by TDI, and S′ velocity. TAPSE ≤ 16 (sensitivity 93%, specificity 100%), MPI-TDI ≥ 0.69 (sensitivity 94.7%, specificity 93.5%), S ≤ 12.3 (sensitivity 90.3%, specificity 94.3%) were useful in predicting presence of proximal RCA stenosis.ConclusionRV function indices like TAPSE, MPI-TDI and S′ velocity are useful in predicting proximal RCA stenosis in first episode of acute IWMI.     

Sevoflurane exposure time and the neuromuscular blocking effect of vecuronium

Purpose  To determine the effect of sevoflurane exposure time on the duration of vecuronium neuromuscular blockade. Methods  In 40 adult patients anesthesia was induced with 1.5–2 mg·kg⁻¹ propofol and 3–5 μg·kg⁻¹ fentanyl and the trachea was intubated without the aid of muscle relaxant. Patients were randomized into four groups of 10. In group 1, 0.05 mg·kg⁻¹ vecuronium was administered with N₂O and anesthesia was maintained by propofol infusion and fentanyl. Vecuronium was administered with sevoflurane 2% in 30 patients, commencing at the same time (group 2) and at 30, and 60 min after sevoflurane (groups 3, 4). Adductor pollicis force of contraction to train-of-four ulnar nerve stimulation was recorded. Times from vecuronium injection to 95%, maximal block, and recovery times to 25% recovery were recorded. Results  There were no differences in times to 95% and maximal block in the four groups. Recovery times were longer in groups 3 and 4 than in groups 2 and 1 (P < 0.01). Times to 5% recovery were 15.0 ± 3.7, 17.8 ± 4.8, 28.2 ± 9.9, and 29.5 ± 9.5, and to 25% recovery were 22.3 ± 5.2, 27.2 ± 6.4, 42.3 ± 16.3, and 50.5 ± 16.4 in groups 1, 2, 3, and 4 respectively. No differences were found between group 1 and group 2 nor between group 3 and group 4. Conclusion  Sevoflurane produced time-dependent potentiation of vecuronium. After 30 min exposure, 25% recovery was prolonged by 89% and after 60 min by more than 100% compared with the control group. Objectif  Déterminer l’effet du temps d’exposition au sévoflurane sur la durée du blocage neuromusculaire avec du vécuronium. Méthode  On a induit l’anesthésie avec 1,5–2 mg·kg⁻¹ de propofol et 3–5 μg·kg⁻¹ de fentanyl chez 40 patients adultes et on a procédé à l’intubation endotrachéale sans myorelaxant. Les patients ont été répartis en quatre groupes de 10. Dans le groupe 1, on a administré 0,05 mg·kg⁻¹ de vécuronium avec N₂O et on a maintenu l’anesthésie avec une perfusion de propofol et de fentanyl. Chez 30 patients, le vécuronium a été administré avec le sévoflurane 2 %, en même temps aux patients du groupe 2, mais 30 et 60 min après le sévoflurane à ceux des groupes 3 et 4. La force de contraction de l’adducteur du pouce à la stimulation en train-de-quatre du nerf cubital a été notée. Le temps nécessaire pour que le vécuronium injecté produise 95 % du bloc, puis le bloc maximal, et le temps nécessaire pour atteindre une récupération de 25 %, ont été enregistrés. Résultats  II n’y a pas eu de différence de temps intergroupe pour produire 95 % du bloc, ni pour le bloc maximal. La récupération s’est prolongée dans les groupes 3 et 4 comparés aux groupes 2 et 1 (P < 0,01). Le temps nécessaire pour atteindre une récupération de 5 % ont été de 15,0 ± 3,7, 17,8 ± 4,8, 28,2 ± 9,9, et de 29,5 ± 9,5, et pour une récupération de 25 % ont été de 22,3 ± 5,2, 27,2 ± 6,4, 42,3 ± 16,3, et de 50,5 ± 16,4 dans les groupes 1, 2, 3, et 4 respectivement. Aucune différence n’a été rapportée entre les groupes 1 et 2, ni entre les groupes 3 et 4. Conclusion  Le sévoflurane a produit une potentialisation du vécuronium dépendante du temps. Après 30 min d’exposition le temps nécessaire pour produire une récupération de 25 % s’est accru de 89 % et, après 60 min, de plus de 100 %, si on le compare au temps du groupe témoin.     

Long-term outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft: minimum 13-year review

BACKGROUND: Short-term results of anterior cruciate ligament reconstruction are well reported; however, there are no studies evaluating endoscopic reconstruction of the anterior cruciate ligament with a minimum 10-year follow-up. HYPOTHESIS: Anterior cruciate ligament reconstruction with patellar tendon graft affords good subjective results and clinical laxity assessments but may be associated with development of osteoarthritis over the long term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Endoscopic anterior cruciate ligament reconstruction was performed in 67 consecutive patients without significant articular surface damage. Patients were assessed at 5, 7, and 13 years after surgery with the International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, hop tests, kneeling pain, and radiographs. RESULTS: At 13-year review, self-reported assessments remained excellent; 96% of patients reported normal or nearly normal knee function. Grade 0 or 1 results were seen in more than 92% of patients on laxity testing. Patients who had undergone meniscectomy at the time of reconstruction had increased laxity between 7 and 13 years on instrumented testing (P = .03) and 6 times greater odds of anterior cruciate ligament graft rupture than if they had not undergone meniscectomy (95% confidence interval, 1-37). Degenerative changes on radiographs were found in 79% of patients at 13 years and were associated with meniscectomy (P = .006), loss of extension (P = .05), and greater laxity on Lachman test (P = .04). CONCLUSIONS: Endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft affords and maintains good self-reported assessments and clinical ligament evaluation up to 13 years. Radiographic degenerative changes were seen in three quarters of patients. Almost half developed loss of extension, suggesting onset of early osteoarthritis. Patients who had undergone meniscectomy at the time of reconstruction had increased clinical ligament laxity over time and greater odds of graft rupture, possibly reflecting the effect of prolonged increased strain on the graft. Continued follow-up is required to resolve concerns regarding integrity of the patellar tendon graft beyond 13 years, particularly in the absence of meniscal tissue.     

Induction of resistance against Schistosoma mansoni infection by passive transfer of an IgG2a monoclonal antibody.

Monoclonal antibodies can confer resistance to schistosome infections. This has led to identification of several protective antigens. An IgG2a monoclonal antibody designated BRL4 mAb identified a 74-kDa antigen in antigenic extract of Schistosoma mansoni adult worms. The target antigen was localized in gut and tegument. In 3 passive transfer experiments, the BRL4 mAb conferred 51.6, 41.9 and 53.8% protection levels into female Swiss mice. Histopathological examination revealed a marked decrease in number, size, collagen and reticular fibers of the liver granulomas. Further experiments using purified 74-kDa-target antigen as a candidate vaccine will be performed.     

Role of US-guided fine-needle aspiration with on-site cytopathologic evaluation in management of nonpalpable breast lesions

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate the accuracy of ultrasound (US)-guided fine-needle aspiration (FNA), with radiographic follow-up or surgical excision, in conjunction with on-site cytopathologic support in the management of nonpalpable breast lesions. MATERIALS AND METHODS: The findings of 266 consecutive mammographically or sonographically identified, nonpalpable lesions (228 patients) that underwent US-guided FNA were examined retrospectively. Clustered microcalcifications did not undergo biopsy with this method. Patients who underwent follow-up excisional biopsy or mammography with a duration of at least 24 months were included in the study. RESULTS: In all, 117 lesions met criteria for inclusion, of which 85 (73%) were diagnosed as benign at cytopathologic evaluation and underwent mammographic follow-up of at least 24 months (range, 24-67 months; mean, 36 months). Thirty-two lesions (27%) had either malignant or atypical cytopathologic findings, for which surgery was recommended. Eleven (9%) of the 32 had malignant cytopathologic findings from initial US-guided FNA, which were confirmed at surgical excision. The remaining 21 lesions (18%) were diagnosed as atypical on the basis of US-guided FNA results. Of these, 18 lesions underwent excisional biopsy: Two were diagnosed as carcinoma (not otherwise specified), and 16 were diagnosed with a variety of benign disorders. The remaining three patients with atypical lesions chose mammographic follow-up rather than surgical diagnosis, and their conditions have remained stable for more than 24 months. Of the 85 benign cases, one changed during follow-up (12 months) and underwent repeat biopsy, with malignancy noted. The sensitivity of US-guided FNA in identifying malignant lesions was 93% (13 of 14), and the specificity of a benign finding was 100% (102 of 102). The positive and negative predictive values of US-guided FNA supported by on-site cytopathologic evaluation were 100% (13 of 13) and 99% (102 of 103), respectively. CONCLUSION: Supported by appropriately trained on-site cytopathologists and in conjunction with follow-up mammography, US-guided FNA appears to be efficacious in the management of patients with abnormal radiographic findings. It is quick, relatively inexpensive, and minimally invasive, and, in the presence of competent cytopathologists, should be the modality of choice.     

Original research: Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence

Background and aimsWith the potential integration of artificial intelligence (AI) into clinical practice, it is essential to understand end users’ perception of this novel technology. The aim of this study, which was endorsed by the British Society of Gastroenterology (BSG), was to evaluate the UK gastroenterology and endoscopy communities’ views on AI.MethodsAn online survey was developed and disseminated to gastroenterologists and endoscopists across the UK.ResultsOne hundred four participants completed the survey. Quality improvement in endoscopy (97%) and better endoscopic diagnosis (92%) were perceived as the most beneficial applications of AI to clinical practice. The most significant challenges were accountability for incorrect diagnoses (85%) and potential bias of algorithms (82%). A lack of guidelines (92%) was identified as the greatest barrier to adopting AI in routine clinical practice. Participants identified real-time endoscopic image diagnosis (95%) as a research priority for AI, while the most perceived significant barriers to AI research were funding (82%) and the availability of annotated data (76%). Participants consider the priorities for the BSG AI Task Force to be identifying research priorities (96%), guidelines for adopting AI devices in clinical practice (93%) and supporting the delivery of multicentre clinical trials (91%).ConclusionThis survey has identified views from the UK gastroenterology and endoscopy community regarding AI in clinical practice and research, and identified priorities for the newly formed BSG AI Task Force.