Left main PCI: An observational analysis from large single-centre experience

BackgroundAlthough trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data.ObjectivesTo study long-term outcome after uLMPCI and identify predictors of adverse outcome.MethodsCase details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained.ResultsMean follow-up duration was 669.8 ± 404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p = 0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p = 0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p = 0.001]. Syntax score >32 was the only independent predictor of adverse outcome.ConclusionuLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.     

Percutaneous MR imaging-guided transvascular access of mesenteric venous system: study in swine model

PURPOSE: To determine if, with use of magnetic resonance (MR) imaging guidance alone, transcaval puncture of the superior mesenteric vein (SMV) and/or portal vein is feasible with a percutaneous femoral vein approach. MATERIALS AND METHODS: The Institutional Animal Care and Use Committee approved the animal studies. Ten inferior vena cava (IVC)-SMV punctures were performed in six pigs. An active MR intravascular needle system was used for all transvascular punctures, and all procedures were performed with a 1.5-T MR unit. The needle was introduced via a 12-F femoral vein sheath and advanced into the IVC by using a real-time gradient-recalled-echo sequence (3.4/1.2 [repetition time msec/echo time msec], 45 degrees flip angle, and six to eight frames per second). Fast transverse spoiled gradient-recalled acquisition in the steady state (SPGR) (6.0/1.5, 60 degrees flip angle, one frame per second) was performed to confirm needle trajectory. The needle system was advanced under real-time MR imaging to puncture the SMV. The location of the needle tip was confirmed with a fast spin-echo sequence (1904/4.5, 36-cm field of view). A direct MR portogram was obtained after the administration of gadopentetate dimeglumine at a concentration of 25% with fast SPGR (6/1.3, 90 degrees flip angle, no section selection, three frames per second). Success was defined as entry into the mesenteric venous system without traversal of any retroperitoneal organs or adjacent vasculature. RESULTS: Successful MR imaging-guided IVC-SMV punctures were performed in all 10 procedures (100%). The needle was fully visualized as it traversed the retroperitoneum and entered the SMV. MR portograms were successfully obtained following all punctures through the needle. Conventional transverse MR imaging helped confirm that the needle did not traverse any retroperitoneal organs or vessels. CONCLUSION: With use of only MR imaging guidance and an active MR imaging intravascular needle system, the authors were able to successfully puncture the SMV from the IVC with direct visualization of the needle and all retroperitoneal structures.     

A right-to-left or bidirectional ductal shunt in preterm neonates: grave implication?

We delineate the natural history of a right-to-left or bidirectional (RL/BD) patent ductus arteriosus (PDA) in preterm infants and compare outcomes of an RL/BD and a left-to-right (LR) ductal shunt. We performed a retrospective chart review of preterm infants (< 32 weeks), who, between 2 and 30 days of age, had an RL/BD PDA > 1.5 mm (study group; N = 74) or an LR PDA (N = 87) on echocardiogram (ECHO). In the study group, 27% of infants who were of significantly lower gestational age and birth weight had a "prolonged" RL/BD PDA on two or more ECHOs. Infants with RL/BD PDA required significantly greater surfactant (98.6% versus 94.2%) and less PDA therapy (27% versus 92%) and had higher mortality (48.6% versus 21.8%) compared with those with LR PDA. On regression analysis, lower gestation (odds ratio [OR] 1.45; 95% confidence interval [CI]: 1.15 to 1.83) and RL/BD PDA (OR 4.74; 95% CI: 2.18 to 10.3) were significantly associated with mortality. The independent association between an RL/BD PDA shunt and mortality warrants further investigation. Insights into the etiology of pulmonary hypertension may optimize outcomes in this population.     

Glycaemic response to maize, bajra and barley.

The postprandial glycaemic response to maize (Zea mays), bajra (Pennisetum typhoideum) and barley (Hordeum vulgare) was studied in a pool of 18 healthy volunteers and 14 patients having non-insulin-dependent diabetes mellitus (NIDDM). In response to maize, none of the variables examined was significantly different as compared to white bread. The glycaemic response to bajra was significantly lower than that to white bread in healthy subjects, but the two responses were indistinguishable in NIDDM subjects. The insulinaemic responses to bajra and white break were not significantly different in either group of subjects. The glycaemic response to barley was significantly lower than that to white bread in both groups of subjects. But the insulinaemic response to barley was significantly lower than that to white bread only in healthy subjects. In NIDDM subjects, there was a tendency for the response to barley to be higher than that to white bread 0.5 h after ingestion. Barley, with a low glycaemic index (68.7 in healthy and 53.4 in NIDDM subjects) and a high insulinaemic index (105.2) in NIDDM subjects seems to mobilize insulin in NIDDM. This makes it a specially suitable cereal for diabetes mellitus.     

MR-trackable intramyocardial injection catheter.

There is growing interest in delivering cellular agents to infarcted myocardium to prevent postinfarction left ventricular remodeling. MRI can be effectively used to differentiate infarcted from healthy myocardium. MR-guided delivery of cellular agents/therapeutics is appealing because the therapeutics can be precisely targeted to the desired location within the infarct. In this study, a steerable intramyocardial injection catheter that can be actively tracked under MRI was developed and tested. The components of the catheter were arranged to form a loopless RF antenna receiver coil that enabled active tracking. Feasibility studies were performed in canine and porcine myocardial infarction models. Myocardial delayed-enhancement (MDE) imaging identified the infarcted myocardium, and real-time MRI was used to guide left ventricular catheterization from a carotid artery approach. The distal 35 cm of the catheter was seen under MRI with a bright signal at the distal tip of the catheter. The catheter was steered into position, the distal tip was apposed against the infarct, the needle was advanced, and a bolus of MR contrast agent and tissue marker dye was injected intramyocardially, as confirmed by imaging and postmortem histology. A pilot study involving intramyocardial delivery of magnetically labeled stem cells demonstrated the utility of the active injection catheter system.     

Computed tomography in untreated congenital adrenal hyperplasia

Six children with untreated congenital adrenal hyperplasia (CAH) were examined by computed tomography (CT). Three cases demonstrated diffuse enlargement of both adrenal glands with preservation of normal configuration and two showed tumorous transformation in one of the enlarged glands. One had equivocal enlargement of the adrenal gland. Even the youngest in this group (age 2 years) also showed bilateral hyperplasia.     

Congenital adrenal hyperplasia among peripubertal girls with hyperandrogenism.

Fifteen girls with severe hyperandrogenism were investigated by us during the last 6 years. Thirteen of these were cases of untreated congenital adrenal hyperplasia (CAH) and 2 were cases of tumoral (one sertoli leydig cell tumor of the ovary and one adrenal adenoma) hyperandrogenism. Here we present the clinical profile and laboratory data of those with congenital adrenal hyperplasia. All the girls had masculinization of genitalia (clitoromegaly alone 5, clitoromegaly with varying degree of posterior labial fusion 8). Eleven cases had hirsutism and 9 had short stature. Two patients underwent unilateral adrenelectomy with diagnosis of adrenal adenoma. Hormonal profile confirmed the diagnosis of CAH with 21 hydroxylase deficiency (elevated 17 OHP levels with exaggerated 17 OHP response to ACTH) in 12 cases and 3 beta hydroxy steroid dehydrogenase deficiency (elevated DHEAS and 17 pregnenelone levels and exaggerated DHEAS and 17 pregnenelone response to ACTH) in one case.     

Development and evaluation of push-pull based osmotic delivery system for pramipexole

An oral push-pull system that can deliver pramipexole for extended period of time has been developed and characterized. A bilayer osmotic drug delivery system was developed using a basic design consisting of an oral controlled porosity osmotic pump. Unlike other osmotic systems, which require a preformed orifice for drug release, controlled porosity membranes contain water-soluble pore-formers in the coating membrane. When such systems come in contact with water, the additives dissolve resulting in an in-situ formation of a microporous membrane. The push layer swells releasing the drug at a controlled rate. In advanced Parkinson's disease the usual dose of pramipexole is 1.5 mg three to four times a day. Hence, an attempt was made to develop a once-a-day controlled release system. This may offer significant patient benefits by providing enhanced efficacy and reduced side effects and may also reduce the number of daily doses compared to conventional therapies. This developed push-pull system was compared with other types of osmotic delivery systems, such as an asymmetric membrane coating and a dense coat with mechanical drilling. An optimized system was selected to study the effect of the concentration of a pore-forming agent such as PEG 400 and dibutyl phthalate, the pH of dissolution media, the effect of agitation and osmotic agents on drug release. The osmotic pressure generated was determined using a 3D3 freezing point osmometer. The drug release was found to follow zero order kinetics. Drug release increased with an increase in osmotic pressure. The developed push-pull osmotic system showed the desired once-a-day release kinetics.     

Factors associated with post-acute functional status and discharge dispositions in individuals with spinal cord injury

BackgroundResearch has evaluated the effect of surgical timing on patient functional recovery in individuals with spinal cord injury (SCI); however, there is a critical need to assess how demographics, clinical characteristics, and process of care affect functional outcomes.ObjectiveWe examined the association between demographic, clinical, and process of care factors with post-acute functional status (locomotion and transfer mobility scores) and discharge disposition (home vs. institution) in individuals with SCI.MethodsThis study was a retrospective cohort analysis of the Pennsylvania Trauma Systems Outcomes Study (PTOS) database for individuals with traumatic SCI (N = 2223). We conducted multinomial and binomial logistic regression analyses to examine post-acute functional status and discharge disposition, respectively.ResultsThe results indicated that older age, longer length of stay, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), and individuals with tetraplegia had significantly lower motor functional score at discharge from an acute hospital. In addition, older age, individuals with public-sponsored insurance, longer length of stay, lower GCS, and higher ISS had significantly higher odds of being discharged to an institution, as compared to home. Individuals of Hispanic ethnicity, as compared to White, had lower odds of being discharged to an institution.ConclusionsThe regression models developed in this study were able to better classify discharge destinations compared to the functional outcomes at discharge from the acute hospital. Further research is necessary to determine how these factors and their associations vary nationally across the US, which have the potential to inform trauma and acute care post-SCI.     

Nutrient composition is a poor determinant of the glycaemic response

1. The glycaemic response of healthy males to potato, bread, rice and green gram (Phaseolus aureus Roxb.) was compared with that to meals equivalent to these foods in terms of carbohydrate, protein, fat and fibre content, but made up of maize flour, casein, maize oil and ispaghula husk. 2. Natural foods led to a higher postprandial glycaemia than their respective equivalents, but the difference was significant only in the case of potato at 0.5 h (P less than 0.05). 3. The insulin response, studied only in the case of rice and green gram, followed a trend similar to the glycaemic response but the differences between natural foods and equivalents were even more marked. 4. A food is more than the sum of its major nutrients. Several poorly understood factors may contribute to the glycaemic response to a food. In addition to the quantity of nutrients, the response may be the result of the specific type of nutrients, non-nutrient chemicals and anti-nutrients composing the food, and their unique physical arrangement within the food.