A randomized controlled trial comparing non-invasive ventilation delivered using neurally adjusted ventilator assist (NAVA) or adaptive support ventilation (ASV) in patients with acute exacerbation of chronic obstructive pulmonary disease.

PURPOSE: No study has compared neurally adjusted ventilator assist (NAVA) with adaptive support ventilation (ASV) during non-invasive ventilation (NIV) in subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). MATERIALS AND METHODS: In this randomized controlled trial, we compared NAVA-NIV with ASV-NIV for delivering NIV in consecutive subjects with AECOPD. The primary outcome was NIV failure rate (invasive mechanical ventilation). The key secondary outcomes were number of NIV manipulations, asynchrony index, and 90-day mortality. RESULTS: We enrolled 76 subjects (NAVA-NIV, n = 36, ASV-NIV, n = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. We found no difference in NIV failure rates between the two arms (NAVA-NIV vs. ASV-NIV; 8/36 [22.2%] vs. 8/40 [20%]; p = 0.83). The median physician manipulations for NIV were significantly less in the ASV-NIV arm than in the NAVA-NIV arm (2 [0.8-4] vs. 3 [2-5]; p= 0.014) during the initial 24-h. We found no difference in median asynchrony index (NAVA-NIV vs. ASV-NIV, 16.6% vs. 16.4%, p = 0.5) and 90-day mortality (22.2% vs. 17.5%, p = 0.67). CONCLUSION: The use of NAVA-NIV was not superior to ASV-NIV in reducing NIV failure rates in AECOPD. Both NAVA-NIV and ASV-NIV had similar asynchrony index and 90-day mortality. TRIAL REGISTRY: www. CLINICALTRIALS: gov (NCT04414891).

Does a Change in Device Design Alter Device Size Selection? A Comparison of Conventional and Occlutech Duct Occluder Designs.

AIM: The Occlutech duct occluder (ODO) with a novel design has been available for closure of patent ductus arteriosus (PDA) since 2011. Available data on initial experience with the ODO have shown that operators continue to choose device sizes based on their experience with conventional duct occluders (CDO). This study postulated that occlusion of the pulmonary arterial (PA) end of the ductus should achieve satisfactory PDA closure without additional complications. Accordingly, the size of the ODO was chosen such that the larger PA diameter in the new design exceeded the PA end of the ductus by 2-3 mm and 2-4 mm for normotensive and hypertensive ducts, respectively. It sought to examine the feasibility and safety of such an approach, and compared ODO and CDO devices with respect to device sizes deployed, to ascertain if the newer design had any advantages. METHODS: This prospective study enrolled 105 infants, children and a few adults with various duct morphologies and PA pressures for ductal closure using the ODO from 2018-2020. The control group consisted of 105 ducts closed with CDO. A comparison of the two groups with respect to duct diameter and implanted device sizes was performed using appropriate statistical software. RESULTS: The study found that 40% of the ducts had moderate-to-severe pulmonary hypertension. Most ducts measured between 3-4 mm in both groups. The mean weight of the subjects in both groups was 12 kg. Although there was no change in the way that duct occluders were chosen in both groups (2-3 mm over the pulmonary artery diameter), ODO could be significantly downsized in most ducts measuring between 2.5-6.4 mm in diameter (p<0.05). CONCLUSIONS: This study found successful closure of relatively larger PDA in infants and children using smaller ODO compared with CDO, without embolisation or aortic narrowing. It also demonstrated that a different device size selection technique may be safely employed with the ODO.

Axillary artery: An unanticipated choice of access in the cath lab!

Ventricular septal defects are increasingly being closed by transcatheter technique, with lesser morbidity and shorter hospital stay compared to open heart surgery. We report a case of embolization of a duct occluder deployed in a posterior muscular septal defect. The rare site of embolization necessitated an unusual approach for retrieval prior to subsequent closure using a double-disc device.

Delayed presentation of partial anomalous systemic venous connection.

Anomalies of systemic venous connections are extremely rare. We describe the case of an asymptomatic 29-year-old woman who was found to have systemic desaturation in the peripartum period and referred to us for suspected cyanotic heart disease. She was diagnosed to have hemianomalous systemic venous connection of the inferior vena cava (IVC) into the left atrium (LA). Transesophageal echocardiogram with contrast diagnosed anomalous connection of the IVC to the LA, further confirmed by computed tomography and conventional angiography. The patient underwent successful surgical correction with an uneventful postoperative course.

The impact of tissue-tracking strain on the left atrial dysfunction in the patients with left ventricular dysfunction.

BACKGROUND: The extracellular volume (ECV) calculated by T1 mapping, and tissue-tracking strain using cardiac magnetic resonance (CMR) are useful for assessing the left ventricular (LV) function. However, those parameters are controversial for assessing left atrial (LA) function. This study aimed to investigate the usefulness of CMR to evaluate the LA function using those parameters. Furthermore, those LA function parameters were compared in each LV function. METHODS: A total of 65 consecutive patients who underwent contrast CMR were prospectively enrolled (age 55.7 ± 14. 6 years, males 67.7%). Among the 65 patients, there were 15 without hypertension, diabetes, or atrial fibrillation (Healthy group). The remaining 50 patients were divided into two groups according to a left ventricular ejection fraction (LVEF) of 50%. We assessed the correlations between the LV- and LA-CMR parameters among the three groups (LVEF < 50%; n = 20, LVEF ≥ 50%; n = 30, and Healthy; n = 15). RESULTS: The LA-longitudinal strain for an LVEF < 50% was lower than that for the others (LVEF < 50%; 13.6 ± 7.9%, LVEF ≥ 50%; 24. 5 ± 13.5%, Healthy; 24.5 ± 9.8%, p = 0.003). However, the LA-ECV did not significantly differ among the three groups (LVEF < 50%; 50.3 ± 3.6%, LVEF ≥ 50%; 53.1 ± 4.9%, Healthy; 53.2 ± 6.5%, p = 0.12). A multiple regression model after adjusting for the patient background revealed that a worse LA-longitudinal strain was correlated with a low LVEF and large LA-volume, but the LA-ECV was not associated with those. CONCLUSIONS: The LA-strain in LV dysfunction patients was significantly lower. However, the LA-ECV did not significantly differ from that in those without LV dysfunction. Tissue-tracking strain is more useful for evaluating the LA dysfunction than T1 mapping.

Unguarded left atrioventricular orifice: An unusual cause of hypoplastic left ventricle and double-outlet right ventricle with intact ventricular septum.

An unguarded atrioventricular orifice is an extremely rare congenital anomaly characterized by the absence of the atrioventricular valve in varying proportions. While atresia of the mitral or aortic valves are usually described as causes for hypoplastic left heart, our case highlights the role of free atrioventricular valve regurgitation and consequent volume loss of the left heart, giving rise to a small left ventricle. There was an associated double-outlet right ventricle and Type B aortic interruption. While we have attempted to discuss the complex management options in this scenario, the parents decided to withdraw further care.

Guar gum modified upconversion nanocomposites for colorectal cancer treatment through enzyme-responsive drug release and NIR-triggered photodynamic therapy.

Multimodal therapeutic approach towards colorectal cancer (CRC) holds great promise. There is, however, no convincing strategy reported to date that employs a multimodal strategy in CRC treatment. The present study reports an intense green-emitting core-shell photoluminescent upconversion (CSGU) nanocrystal engineered to synergistically perform photodynamic and enzyme-triggered delivery of the chemotherapeutic agent for an enhanced therapeutic outcome on HT-29 colon carcinoma cells in vitro. The photodynamic activity is achieved by the energy transfer between CSGU and the chemically conjugated Rose Bengal (RB) molecules that are further protected by a mesoporous silica (MS) layer. The chemical assay demonstrates a remarkable FRET mediated generation of 1O2 under NIR (980 nm) excitation. The outermost MS layer of the nanoplatform is utilized for the loading of the 5FU anticancer drug, which is further capped with a guar gum (GG) polysaccharide polymer. The release of the 5FU is specifically triggered by the degradation of the GG cap by specific enzymes secreted from colonic microflora, which otherwise showed 'zero-release behavior' in the absence of any enzymatic trigger in various simulated gastro-intestinal (GI) conditions. Furthermore, the enhanced therapeutic efficacy of the nanoplatform (CSGUR-MSGG/5FU) was evaluated through in vitro studies using HT-29 CRC cell lines by various biochemical and microscopic assays by the simultaneous triggering effect of colonic enzyme and 980 nm laser excitation. In addition, the strong visible emission from the nanoplatform has been utilized for NIR-induced cellular bioimaging.

Rare Association of Leukocytoclastic Vasculitis in Visceral Leishmaniaisis.

A 30-year-old man presented with fever, hepatosplenomegaly, and a rash over his lower limbs (palpable purpura). Evaluation revealed pancytopenia and hypergammaglobulinemia. A subsequent bone marrow examination and serology confirmed visceral leishmaniasis (kala-azar), while the biopsy of skin lesion suggested leukocytoclastic vasculitis. No alternate cause of vasculitis was forthcoming, and the patient was treated with conventional amphotericin B for 14 days after which resolution of symptoms (including the rash) was noted. Cutaneous vasculitis is an extremely rare complication following visceral leishmaniasis with no known cases reported thus far. Hence, a high index of suspicion is warranted in achieving timely diagnosis and initiation of appropriate therapy.

Lipid emulsion for acute organophosphate insecticide poisoning - a pilot observational safety study.

INTRODUCTION: Organophosphate (OP) poisoning is an important public health concern in South-Asia especially in the farming population. Treatment of OP poisoning has remained unchanged since decades and case fatality is 10-40% despite best supportive care, anticholinergic agents and oximes. A new antidote is the need of the hour. Lipid emulsion being inexpensive, easily available and effective in management of other lipid soluble toxins may be a novel option. However, safety has not been established and efficacy is limited to animal studies and case reports in humans with OP poisoning. METHODS: An open-label pilot study was undertaken to establish the safety of lipid emulsion in OP poisoning. Patients with symptomatic OP poisoning, meeting the inclusion and exclusion criteria were treated with 100 mL of 20% intravenous lipid emulsion (after consent) in addition to standard of care. They were monitored for change in hemodynamic parameters, change in hematology and biochemical parameters at various intervals of time after initiation of therapy. Morbidity, mortality, and occurrence of adverse effects were compared with historical control group. RESULTS: Forty patients with symptomatic OP poisoning were enrolled in the study group. No significant change in hemodynamic parameters (pulse rate, systolic, diastolic blood pressure, and mean arterial pressure) or in hematology and biochemical parameters were seen. No adverse effects were noted. Compared to historical controls, no change in mortality was noted, although there was reduced duration of mechanical ventilation, hospital stay, and early resolution of hypernatremia. CONCLUSIONS: This study evaluates the safety of lipid emulsion in OP poisoning. Absence of change in hemodynamic parameters and adverse effects suggests lipid emulsion may be safe for this indication. Large randomized controlled trials are now required to assess clinical efficacy. ClinicalTrials.gov number: NCT03564574.

A rare cause of airway obstruction: Mediastinal cyst secondarily infected with Mycobacterium tuberculosis.

Mediastinal cysts are mostly congenital, but rarely, infections and malignancies can cause cystic degeneration of enlarged mediastinal lymph nodes. Diagnosis is challenging as the presenting symptoms are nonspecific. Surgical resection is the reference modality both for diagnosis and management. Secondary infection of mediastinal bronchogenic cyst with Mycobacterium tuberculosis is rare. Herein, we describe a young male who was managed as bronchial asthma with inhalational bronchodilators and glucocorticoids. Computed tomography revealed a cystic lesion in the subcarinal region. Endobronchial ultrasound-guided transbronchial needle aspiration was done to perform diagnostic and therapeutic aspiration of the cyst that showed infection with M. tuberculosis. A subsequent surgical resection confirmed the cystic lesion to be a bronchogenic cyst.

Diabetes mellitus and insulin resistance associate with left ventricular shape and torsion by cardiovascular magnetic resonance imaging in asymptomatic individuals from the multi-ethnic study of atherosclerosis.

BACKGROUND: Although diabetes mellitus (DM) and insulin resistance associate with adverse cardiac events, the associations of left ventricular (LV) remodeling and function with compromised glucose metabolism have not been fully evaluated in a general population. We used cardiovascular magnetic resonance (CMR) to evaluate how CMR indices are associated with DM or insulin resistance among participants before developing cardiac events. METHODS: We studied 1476 participants who were free of clinical cardiovascular disease and who underwent tagged CMR in the Multi-Ethnic Study of Atherosclerosis (MESA). LV shape and longitudinal myocardial shortening and torsion were assessed by CMR. A higher sphericity index represents a more spherical LV shape. Multivariable linear regression was used to evaluate the associations of DM or homeostasis model assessment-estimated insulin resistance (HOMA-IR) with CMR indices. RESULTS: In multiple linear regression, longitudinal shortening was lower in impaired fasting glucose than normal fasting glucose (NFG) (0.36% lower vs. NFG, p < 0.05); torsion was greater in treated DM (0.24 °/cm greater vs. NFG, p < 0.05) after full adjustments. Among participants without DM, greater log-HOMA-IR was correlated with greater LV mass (3.92 g/index, p < 0.05) and LV mass-to-volume ratio (0.05 /index, p < 0.01), and lower sphericity index (- 1.26/index, p < 0.01). Greater log-HOMA IR was associated with lower longitudinal shortening (- 0.26%/index, p < 0.05) and circumferential shortening (- 0.30%/index, p < 0.05). Torsion was positively correlated with log-HOMA-IR until 1.5 of log-HOMA-IR (0.16 °/cm/index, p = 0.030).), and tended to fall once above 1.5 of log-HOMA-IR (- 0.50 °/cm/index, p = 0.203). The sphericity index was associated negatively with LV mass-to-volume ratio (- 0.02/%, p < 0.001) and torsion (- 0.03°/cm/%, p < 0.001). CONCLUSIONS: Glucose metabolism disorders are associated with LV concentric remodeling, less spherical shape, and reduced systolic myocardial shortening in the general population. Although torsion is higher in participants who are treated for DM and impaired insulin resistance, myocardial shortening was progressively decreased with higher HOMA-IR and torsion was increased only with less severe insulin resistance. CLINICAL TRIAL REGISTRATION: Multi-Ethnic Study of Atherosclerosis (MESA): A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org/ . Study Start Date: January 1999 ( NCT00005487 ).

Isolated Splenic Cold Abscesses in an Immunocompetent Individual.

Tubercular splenic abscess is extremely rare, but are reported commonly in HIV-positive and immunocompromised patients along with miliary or disseminated tuberculosis. Isolated tubercular splenic abscess in an immunocompetent individual is rarely reported. Here we present a case of a young, immunocompetent male with isolated splenic cold abscesses, who was diagnosed with splenic tuberculosis and managed successfully with percutaneous drainage and anti-tubercular therapy alone.

A quintessential syndrome with a rare marvelling aetiology: Rosai-Dorfman disease presenting as Conus-Cauda syndrome.

A 19-year-old woman presented with a history of severe lower backache and asymmetric proximal lower limb weakness during the past 3 months. In addition, she also suffered from lower motor neuron-type bladder and bowel symptoms. On examination, paraparesis was noted. Further, sensory examination suggested patchy asymmetric sensory loss in both lower limbs with saddle anaesthesia and areflexia. A clinical diagnosis of Conus-Cauda syndrome was made and contrast-enhanced MRI of the lumbar and sacral spine was done, which confirmed the presence of a mass lesion within the spinal canal involving the cauda equina extending up to the sacral level. She underwent partial resection of the lesion following which the neurological deficits and lower backache resolved. Histopathological evaluation and immunohistochemical analyses uncovered Rosai-Dorfman disease. There was no evidence of disease elsewhere in the body. Since the patient improved significantly following surgery and exhibited no further neurological worsening, she remains under close follow-up.

Correction to: Current concept in upright spinal MRI.

Unfortunately, the legend of Fig. 5 was incorrectly published in original publication. The corrected legend is given below.

Current concept in upright spinal MRI.

Magnetic resonance imaging (MRI) is the established technique for evaluating the spine. Unfortunately, the supine position of the patient during conventional MRI scanning does not truly reflect the physiological forces experienced by the discoligamentous structures during normal upright posture and ambulation. Upright MRI is a relatively new technique that allows the patient to be scanned in several different weight-bearing positions, which may potentially demonstrate occult pathology not visualised in the supine position. The imaging technique and current clinical indications of upright spinal MRI would be discussed.

Cardiovascular magnetic resonance in an adult human population: serial observations from the multi-ethnic study of atherosclerosis.

The Multi-Ethnic Study of Atherosclerosis (MESA) is the first large-scale multi-ethnic population study in the U.S. to use advanced cardiovascular magnetic resonance (CMR) imaging. MESA participants were free of cardiovascular disease at baseline between 2000 and 2002, and were followed up between 2009 and 2011 with repeated CMR examinations as part of MESA. CMR allows the clinician to visualize and accurately quantify volume and dimensions of all four cardiac chambers; measure systolic and diastolic ventricular function; assess myocardial fibrosis; assess vessel lumen size, vessel wall morphology, and vessel stiffness. CMR has a number of advantages over other imaging modalities such as echocardiography, computed tomography, and invasive angiography, and has been proposed as a diagnostic strategy for high-risk populations. MESA has been extensively evaluating CMR imaging biomarkers, as markers of subclinical disease, in the last 15 years for low-risk populations. On a more practical level, some of the imaging biomarkers developed and studied are translatable to at-risk populations. In this review, we discuss the progression of subclinical cardiovascular disease and the mechanisms responsible for the transition to symptomatic clinical outcomes based on our findings from MESA.

The rising root sign: the magnetic resonance appearances of post-operative spinal subdural extra-arachnoid collections.

We present a case series of symptomatic post-operative spinal subdural extra-arachnoid collections that displace the cauda equina roots anteriorly. This is described as the "rising root sign".