Reclassifying historical disasters: From single to multi-hazards.

Multi-hazard events, characterized by the simultaneous, cascading, or cumulative occurrence of multiple natural hazards, pose a significant threat to human lives and assets. This is primarily due to the cumulative and cascading effects arising from the interplay of various natural hazards across space and time. However, their identification is challenging, which is attributable to the complex nature of natural hazard interactions and the limited availability of multi-hazard observations. This study presents an approach for identifying multi-hazard events during the past 123 years (1900-2023) using the EM-DAT global disaster database. Leveraging the 'associated hazard' information in EM-DAT, multi-hazard events are detected and assessed in relation to their frequency, impact on human lives and assets, and reporting trends. The interactions between various combinations of natural hazard pairs are explored, reclassifying them into four categories: preconditioned/triggering, multivariate, temporally compounding, and spatially compounding multi-hazard events. The results show, globally, approximately 19 % of the 16,535 disasters recorded in EM-DAT can be classified as multi-hazard events. However, the multi-hazard events recorded in EM-DAT are disproportionately responsible for nearly 59 % of the estimated global economic losses. Conversely, single hazard events resulted in higher fatalities compared to multi-hazard events. The largest proportion of multi-hazard events are associated with floods, storms, and earthquakes. Landslides emerge as the predominant secondary hazards within multi-hazard pairs, primarily triggered by floods, storms, and earthquakes, with the majority of multi-hazard events exhibiting preconditioned/triggering and multivariate characteristics. There is a higher prevalence of multi-hazard events in Asia and North America, whilst temporal overlaps of multiple hazards predominate in Europe. These results can be used to increase the integration of multi-hazard thinking in risk assessments, emergency management response plans and mitigation policies at both national and international levels.

Kidney outcomes and prognostic factors of myeloma associated acute kidney injury in the contemporary era.

Myeloma cast nephropathy (MCN) has historically been associated with poor kidney outcomes. We aimed to evaluate the kidney outcomes and identify prognostic factors of myeloma-associated acute kidney injury (M-AKI) in the contemporary era of anti-plasma cell therapy. Patients who received anti-myeloma therapy with M-AKI (January 2012 to June 2020) from a single centre were identified from electronic medical records. Diagnosis of MCN was either biopsy confirmed (BC) or clinically suspected (CS), the latter defined as acute kidney injury with reduced estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 and involved serum free light chains (iSFLC) >500 mg/L at diagnosis. Twenty-six patients with M-AKI were identified (BC: n = 13, CS: n = 13). Median eGFR at diagnosis was 12 (interquartile range 6-20) mL/min/1.73 m2 . All six dialysis-requiring patients achieved dialysis independence after 71 (43-208) days. The best-achieved eGFR was 47 (32-67) mL/min/1.73 m2 after 120 (63-167) days post-treatment, which was maintained at 47 (33-66) mL/min/1.73 m2 12 months post-treatment. Patients with best-achieved eGFR above the median were more likely to have achieved an iSFLC of <20 mg/L (above median group 62% versus below median group 0%; p < .001) and lower best post-treatment iSFLC (20 (12-90) versus 67 (29-146) mg/L; p < .05). Best-achieved iSFLC was a prognostic factor for superior eGFR following treatment for M-AKI. Despite low eGFR at diagnosis, contemporary anti-myeloma therapy can achieve significant recovery of kidney function.

Co-leadership to co-design in mental health-care ecosystems: what does it mean to us?

PURPOSE: This study aims to demonstrate how service providers, service users and their families should be able to share the co-leadership, co-auspicing, co-ownership, and co-governance, of a the mental health-care ecosystem, at every level, as it develops upwards and wider, in a process of inclusivity, conviviality and polyphonic discourse, via the overlapping phases of co-creativity, codesign, co-production, co-delivery, co-evaluation, co-research and co-replication, to achieve outcomes of co-communal or organisational well-being. DESIGN/METHODOLOGY/APPROACH: "Co-design" is shorthand code for encouraging multiple pathways and trajectories toward forming and sustaining a sparkling web or vibrant network of inclusive opportunities for stakeholder participation and a collaborative partnership in organizational development, in these circumstances, for more effective mental health services (MHSs). FINDINGS: In a co-design framework, all partners should be entitled to expect and "to have and to hold" an ongoing equal stake, voice and power in the discourse from start to finish, in a bottom-up process which is fostered by an interdisciplinary leadership group, providing the strong foundation or nutrient-rich and well-watered soil and support from which a shared endeavor can grow, blossom and generate the desired fruit in ample quality and quantity. ORIGINALITY/VALUE: The authors should be working toward co-design and co-production of contemporary MHSs in a mental health-care ecosystem.

A Novel, Low-Cost Glaucoma Calculator to Identify Glaucoma Patients and Stratify Management.

Glaucoma is a leading cause of preventable blindness globally. Nearly, half of the patients who have glaucoma in the United States are unaware of their diagnosis, and this number is far greater in resource poor areas. The risk of progressive and irreversible loss of vision is decreased with an early diagnosis, and better access to treatment is vital to improve the visual outcome for patients. We therefore postulated that a minimally invasive, low-cost calculator used to predict the risk of glaucoma and inform the course of follow-up care will improve patient prognosis. We retrospectively examined data from 104 eyes of patients who underwent a complete ocular examination, visual field, and corneal pachymetry at Advanced Eye Care of New York (54 with glaucoma and 50 controls). Receiver operating curves (ROC) were utilized to determine the correct glaucoma classification rates of the Laroche glaucoma calculator (Range -3 to 18), a novel tool that combines age, intraocular pressure (IOP), and central corneal thickness (CCT) into a composite metric. Additionally, we compared the discriminatory power of this calculator to age, intraocular pressure (IOP), and central corneal thickness (CCT) separately. A score of greater than or equal to 6 on the Laroche glaucoma calculator (sensitivity 90.74%, specificity 64.00%, correct classification 77.88%) optimizes the accuracy of this tool. Compared to IOP (Area Under the Curve (AUC) = 0.72, chi2 = 4.21, p=0.04) and CCT (AUC = 0.53), chi2 24.72 p < 0.001), the Laroche glaucoma calculator (AUC = 0.81) was significantly better at discriminating against glaucoma patients vs. controls. These results demonstrate that the Laroche calculator is a novel, effective tool for identifying glaucoma, and it may provide a low-cost risk stratification tool, particularly in areas with limited resources.

Attitudes and Perceptions Toward the Use of Medical Marijuana by Glaucoma Specialists.

PRCIS: With expanding legality of medical marijuana (MMJ) in the United States, it is important for ophthalmologists to have greater understanding of the implications of MMJ and glaucoma treatment and how it can impact their patients. PURPOSE: Previous work has demonstrated that inhaled tetrahydrocannabinol can lower intraocular pressure. The stance of the American Glaucoma Society (AGS) is that MMJ is not an acceptable treatment for glaucoma. The purpose of this study is to evaluate the glaucoma specialists' perceptions and attitudes toward the use of MMJ for glaucoma. METHODS: An electronic survey was sent to members of the AGS which addressed attitudes and perceptions on the use of MMJ in the management of glaucoma. Study questions included practitioner demographics, previous experiences with patients discussing the topic, prescribing patterns, and knowledge regarding the use of MMJ for the treatment of glaucoma. RESULTS: Thirty-seven percent of respondents reported having patients who cited using MMJ for their glaucoma, and 38% of respondents were asked about MMJ by their patients at least once per week. Fifty-five percent of respondents had patients who asked them for MMJ prescriptions. When asked if they felt if there was a possible role for marijuana in the management of glaucoma patients, 27% of survey takers responded yes. Fourteen percent of survey respondents kept information on MMJ in their office. Finally, 76% of participants responded they would be interested in additional education on the topic. CONCLUSIONS: Over 25% of the glaucoma specialists responded that MMJ had a role in the treatment of glaucoma, despite the recommendation of the professional society. This group was least likely to have received education on the topic. Given the expanding legality and curiosity of patients with regards to marijuana in the United States, it is important for ophthalmologists to have a greater understanding of the implications of marijuana in glaucoma.

Geographic variation and temporal trends in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States.

BACKGROUND: Limited studies have evaluated regional disparities in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). This study sought to evaluate 18-year national trends, resource utilization, and geographical variation in outcomes in AMI-CA admissions. METHODS AND RESULTS: Using the National Inpatient Sample (2000-2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs and length of stay. Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The West (6.0%) had higher prevalence compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p < 0.001. Admissions in the West had higher rates of STEMI, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p < 0.001). Compared with the Northeast, adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03-1.08]), South (OR 1.11 [95% CI 1.09-1.13]) and highest in the West (OR 1.16 [95% CI 1.13-1.18]), all p < 0.001. Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase. CONCLUSIONS: There remain significant regional disparities in the management and outcomes of AMI-CA.

Acute kidney injury in paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is not associated with progression to chronic kidney disease.

BACKGROUND: Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a rare complication of SARS-CoV-2 associated with single or multiorgan dysfunction. OBJECTIVE: We aimed to evaluate the incidence of acute kidney injury (AKI) and risk factors for kidney dysfunction in PIMS-TS, with reporting of 6-month renal follow-up data. We also evaluated renal involvement between first and second waves of the SARS-CoV-2 pandemic in the UK, the latter attributed to the Alpha variant. DESIGN: A single-centre observational study was conducted through patient chart analysis. SETTING: Data were collected from patients admitted to Great Ormond Street Hospital, London, UK, between April 2020 and March 2021. PATIENTS: 110 patients <18 years of age. MAIN OUTCOME MEASURE: AKI during hospitalisation. AKI classification was based on upper limit of reference interval (ULRI) serum creatinine (sCr) values. RESULTS: AKI occurred in 33 (30%) patients. Hypotension/hypoperfusion was associated with almost all cases. In univariate analysis, the AKI cohort had higher peak levels of triglycerides (OR, 1.27 (95% CI, 1.05 to 1.6) per 1 mmol/L increase) and C reactive protein (OR, 1.06 (95% CI, 1.02 to 1.12) per 10 mg/L increase), with higher requirement for mechanical ventilation (OR, 3.8 (95% CI, 1.46 to 10.4)) and inotropic support (OR, 15.4 (95% CI, 3.02 to 2.81)). In multivariate analysis, triglycerides were independently associated with AKI stages 2-3 (adjusted OR, 1.26 (95% CI, 1.04 to 1.6)). At follow-up, none had macroalbuminuria and all had sCr values

Functional coronary angiography in symptomatic patients with no obstructive coronary artery disease.

BACKGROUND: Patients without obstructive coronary artery disease (CAD) may have epicardial or microvascular dysfunction. The purpose of this study was to characterize patterns of epicardial and microvascular dysfunction in men and women with stable and unstable angina undergoing functional coronary angiography to inform medical therapy. METHODS: 163 symptomatic patients with ≤50% diameter stenosis and fractional flow reserve (FFR) > 0.8 underwent endothelium-dependent epicardial and microvascular function after intracoronary acetylcholine (10-4  M, 81 mcg over 3 minutes). Endothelium-independent function was assessed using coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) after intravenous adenosine (140 ug/kg/min). Coronary microvascular dysfunction (CMD) was defined as CFR < 2.5, HMR ≥2, or ≤50% change in coronary blood flow with acetylcholine (CBFACH ). RESULTS: Seventy-two percent had endothelial-dependent epicardial dysfunction (response to ACH: % ∆ in coronary artery diameter and ∆%CBFACH ) and 92% had CMD. Among CMD patients, 65% had CFR < 2.5, 35% had HMR ≥2, and 60% had CBFACH change ≤50%. CFR modestly correlated with HMR (r = -0.38, p < .0001). Among patients with normal CFR, 26% had abnormal epicardial and 20% had abnormal microvascular endothelial dysfunction. Women had a lower CFR (p = .02), higher FFR (p = .03) compared to men. There were no differences in epicardial and microvascular function between patients with stable and unstable angina. CONCLUSION: In patients with no obstructive CAD: CMD is prevalent, abnormal CFR does not correlate with epicardial or microvascular endothelial dysfunction, women have lower CFR, higher FFR but similar endothelial function compared to men.

Long bone fracture characteristics in children with medical conditions linked to bone health.

BACKGROUND: Knowledge of fracture characteristics among children with medical conditions affecting bone could help to distinguish medical causes from child abuse. OBJECTIVE: Characterize long bone fracture morphology among children diagnosed with medical conditions linked to bone health. PARTICIPANTS AND SETTING: Patients <18 years at a single pediatric hospital diagnosed with a medical condition linked to bone health and ≥1 long bone fracture were studied. METHODS: This retrospective medical record review categorized underlying medical diagnoses as: metabolic bone disease, genetic disorder of connective tissue, neurologic disorder and other chronic disease. A pediatric radiologist reviewed plain films to determine fracture type and location. Descriptive statistics, as well as logistic regression were used to compare fracture types by clinical characteristics. RESULTS: Ninety-four patients were included and their diagnoses were genetic connective disorder (19; 20.2 %), metabolic bone disease (16; 17.0 %), neurologic disorder (27; 28.7 %), and other (32; 34.0 %). A total of 216 long bone fractures were sustained; 52.1 % of children had >1 long bone fracture. Of the 216 fractures, 55 (25.5 %) were in children < 1 year, 118 (54.6 %) were associated with known trauma, and 122 (56.5 %) were in non-ambulatory patients. Lower extremity fractures occurred with greatest frequency and most fractures occurred at the mid-diaphysis. Transverse was the most common fracture type in all diagnostic categories. Children with metabolic disorders had highest odds of transverse fracture (COR 3.55, CI 1.45-8.67; neurologic disorders as reference group). CONCLUSIONS: Diseases affecting bone health can influence fracture morphology. Transverse fractures were most common in bones impacted by disease.

Current state of the roles of alcohol septal ablation and surgical myectomy in the treatment of hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy is a genetically determined disorder resulting in left ventricular hypertrophy. In a majority of the estimated 20 million people affected worldwide, left ventricular outflow obstruction is present at rest or with provocation. The presence and degree of obstruction influence the symptomatic presentation, treatment strategies and prognosis of affected individuals. Pharmacologic therapy with beta-adrenergic blocking drugs and calcium channel blockers is the principal treatment strategy in symptomatic patients with left ventricular outflow obstruction but is ineffective in many patients. When symptoms of exertional shortness of breath, chest pain and/or syncope prove refractory to medical therapy and there is persisting left ventricular outflow obstruction, or when there is drug intolerance, septal reduction strategies (surgical myectomy and alcohol septal ablation) are quite effective. Selection of the optimal septal reduction strategy for a given patient has become controversial and is determined largely by the medical system providing treatment strategies for the patient. Regretably, there are no randomized trials comparing myectomy and ablation and none are anticipated. The comprehensive Hypertrophic Cardiomyopathy Guideline Statements published in 2011 and 2014 differ significantly with the earlier statement favoring surgical myectomy and the more recent statement giving equal class I status to the two septal reduction strategies in adult patients with drug-refractory symptoms. Recently published studies of long-term follow-up of patients after alcohol septal ablation in Europe, where surgical myectomy is rarely performed, confirm long-term safety and effectiveness with survival free of cardiac events exceeding 96% at 15 years. The lesser degree of discomfort and more rapid recovery associated with the minimally invasive catheter-based alcohol ablation procedure coupled with the recently published long-term safety data favor an increased use of this strategy in symptomatic adult patients with hypertrophic obstructive cardiomyopathy (HOCM).

A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery.

The issue of complex nonlinear change processes is one of the least understood aspects of recovery and one of the most difficult to apply in recovery-oriented health care. The purpose of this article is to explore the recovery stories of 17 mental health peer support workers to understand their narrative identity reconstruction in recovery using a complexity perspective. Using the Life Story Model of Identity (LSMI), a narrative thematic analysis of interviews suggests that self-mastery as part of personal agency is an important component of participants' narrative identity reconstruction. Self-mastery is particularly evident in redemptive story turning points (positive outcome follows negative experience). A complexity perspective suggests that participants realized their adaptive capacity in relation to self-mastery as part of recovery and that its use at story turning points critically influenced their recovery journey. Further exploring self-mastery as adaptive growth in narrative identity reconstruction appears to be a fruitful research direction.

An insight into piscidins: The discovery, modulation and bioactivity of greater amberjack, Seriola dumerili, piscidin.

Antimicrobial peptides (AMPs) play an important role in the innate immune response of vertebrates by creating a hostile environment for any invading pathogens. Piscidins are potent teleost specific AMPs, which have a broad spectrum activity. We have identified a novel piscidin active peptide, in the greater amberjack, Seriola dumerili, that consists of 25 aa, which forms an amphipathic helix with distinct hydrophobic and positively charged regions. Following homology and phylogenetic analysis the greater amberjack piscidin was deemed to belong to the group 3 family of piscidins. Piscidin was expressed constitutively at immune sites, with transcript level highest in the spleen and gut, at an intermediate level in the gills and lowest in the head kidney. Following in vivo stimulation with PAMPs (poly I:C, LPS and flagellin) piscidin transcript level increased in gills in response to flagellin, in gut and spleen in response to poly I:C, and in head kidney in response to poly I:C, LPS and flagellin. Head kidney and spleen cells were then isolated from greater amberjack and incubated with each of the PAMPs for 4, 12 and 24 h. Piscidin expression was unchanged at 4 and 12 h post PAMP stimulation in head kidney cells but at 24 h transcript level was markedly upregulated compared to control (unstimulated) cells, especially with the bacterial PAMPs. In contrast, spleen cells upregulated piscidin expression by 4 h post stimulation with poly I:C and flagellin, and remained upregulated to 24 h with flagellin exposure, but had returned to baseline levels by 12 h using poly I:C. To determine if piscidin expression could be modulated by diet, greater amberjack were fed diets supplemented with MOS and cMOS for 30 days when transcript level was determined. It was found that MOS supplemented diets increased expression in the spleen, cMOS supplemented diets upregulated transcript levels in the gills and head kidney, whilst a diet containing both MOS and cMOS upregulated transcript in the gut, when compared to fish fed the control diet. Finally, a synthetic greater amberjack piscidin was produced and showed bacteriostatic activity against a number of bacterial strains, including both Gram positive and Gram negative fish pathogens.

The Left Internal Mammary Artery Graft: Durable and Self-Reparative.

After an unsuccessful left internal mammary artery (LIMA) to left anterior descending percutaneous coronary intervention (PCI) in an outside hospital, a patient presented with ST-segment elevation myocardial infarction. The patient was found to have LIMA occlusion and underwent a second PCI. However, there was a residual disruption of LIMA, subsequently, the patient was found to have complete LIMA recanalization, which emphasized the self-reparative nature of LIMA. (Level of Difficulty: Intermediate.).

Alcohol Ablation of Extracardiac Thoracic Tumor.

This case illustrates a novel percutaneous treatment of a highly vascular thoracic tumor impinging on the left atrium and right pulmonary artery by delivery of coils and alcohol ablation via a circumflex coronary artery feeder branch. (Level of Difficulty: Advanced.).

Increased parasite resistance of greater amberjack (Seriola dumerili Risso 1810) juveniles fed a cMOS supplemented diet is associated with upregulation of a discrete set of immune genes in mucosal tissues.

The main objective of this study was to determine the effect of two forms of mannan oligosaccharides (MOS: Bio-Mos® and cMOS: Actigen®, Alltech Inc, USA) and their combination on greater amberjack (Seriola dumerili) growth performance and feed efficiency, immune parameters and resistance against ectoparasite (Neobenedenia girellae) infection. Fish were fed for 90 days with 5 g kg-1 MOS, 2 g kg-1 cMOS or a combination of both prebiotics, in a Seriola commercial base diet (Skretting, Norway). At the end of the feeding period, no differences were found in growth performance or feed efficiency. Inclusion of MOS also had no effect on lysozyme activity in skin mucus and serum, but the supplementation of diets with cMOS induced a significant increase of serum bactericidal activity. Dietary cMOS also reduced significantly greater amberjack skin parasite levels, parasite total length and the number of parasites detected per unit of fish surface following a cohabitation challenge with N. girellae, whereas no effect of MOS was detected on these parameters. Of 17 immune genes studied cMOS dietary inclusion up-regulated hepcidin, defensin, Mx protein, interferon-γ (IFNγ), mucin-2 (MUC-2), interleukin-1ß (IL-1B), IL-10 and immunoglobulin-T (IgT) gene expression in gills and/or skin. MOS supplementation had a larger impact on spleen and head kidney gene expression, where piscidin, defensin, iNOS, Mx protein, interferons, IL-1ß, IL-10, IL-17 and IL-22 were all upregulated. In posterior gut dietary MOS and cMOS both induced IL-10, IgM and IgT, but with MOS also increasing piscidin, MUC-2, and IL-1ß whilst cMOS induced hepcidin, defensin and IFNγ. In general, the combination of MOS and cMOS resulted in fewer or lower increases in all tissues, possibly due to an overstimulation effect. The utilization of cMOS at the dose used here has clear benefits on parasite resistance in greater amberjack, linked to upregulation of a discrete set of immune genes in mucosal tissues.

UK trial of the Osseointegrated Prosthesis for the Rehabilitation for Amputees: 1995-2018.

BACKGROUND:: Amputation of a limb impacts on patients' self-perception and quality of life. Prostheses directly anchored to the skeleton are being investigated, aiming to avoid soft tissue complications. OBJECTIVES:: We report outcome data for the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees Implant System with a minimum of 9-year follow-up. METHODS:: Eighteen transfemoral amputees received unilateral implants between 1997 and 2008. Five were implanted before a formalised protocol, called Osseointegrated Prosthesis for the Rehabilitation of Amputees, was developed. Mean follow-up of the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group is 11.4 years (1.8-18.6 years), while for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group it is 12.3 years (2.9-15.9). RESULTS:: The Kaplan-Meier cumulative survivorship is 40% for the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group and 80.21% for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group. Five implants (28%) have been removed, three (17%) for deep infection, one (5.6%) for chronic pain, later proven to be infected and one (5.6%) due to implant fracture secondary to loosening due to infection. Two patients (11%) have peri-implant infections suppressed with oral antibiotics. Eleven cases (61%) of superficial infection were successfully treated with antibiotics. 36-Item short-form health survey and Questionnaire for persons with a Transfemoral Amputation showed significant improvements in quality of life up to 5 years after implantation. CONCLUSION:: This small cohort of patients demonstrates osseointegrated prosthesis allows prolonged usage and improves patients' quality of life compared to conventional prostheses. CLINICAL RELEVANCE: These prostheses may provide a future gold standard for amputees and this study provides the first outcome data over such a time period to be reported from outside of the developers group.

Low Coronary Wall Shear Stress Is Associated With Severe Endothelial Dysfunction in Patients With Nonobstructive Coronary Artery Disease.

OBJECTIVES: This study investigated the relationship between low wall shear stress (WSS) and severe endothelial dysfunction (EDFx). BACKGROUND: Local hemodynamic forces such as WSS play an important role in atherogenesis through their effect on endothelial cells. The study hypothesized that low WSS independently predicts severe EDFx in patients with coronary artery disease (CAD). METHODS: Forty-four patients with CAD underwent coronary angiography, fractional flow reserve, and endothelial function testing. Segments with >10% vasoconstriction after acetylcholine (Ach) infusion were defined as having severe EDFx. WSS, calculated using 3-dimensional angiography, velocity measurements, and computational fluid dynamics, was defined as low (<1 Pa), intermediate (1 to 2.5 Pa), or high (>2.5 Pa). RESULTS: Median age was 52 years, 73% were women. Mean fractional flow reserve was 0.94 ± 0.06. In 4,510 coronary segments, median WSS was 3.67 Pa. A total of 24% had severe EDFx. A higher proportion of segments with low WSS had severe EDFx (71%) compared with intermediate WSS (22%) or high WSS (23%) (p < 0.001). Segments with low WSS demonstrated greater vasoconstriction in response to Ach than did intermediate or high WSS segments (-10.7% vs. -2.5% vs. +1.3%, respectively; p < 0.001). In a multivariable logistic regression analysis, female sex (odds ratio [OR]: 2.44; p = 0.04), diabetes (OR: 5.01; p = 0.007), and low WSS (OR: 9.14; p < 0.001) were independent predictors of severe EDFx. CONCLUSIONS: In patients with nonobstructive CAD, segments with low WSS demonstrated more vasoconstriction in response to Ach than did intermediate or high WSS segments. Low WSS was independently associated with severe EDFx.

Coronary Artery Straightening Causing Acute Severe Mitral Regurgitation.

A 79-year-old woman had an atretic LIMA to LAD but without significant LAD stenosis, patent SVG to OM1, patent SVG to RCA, and severe tandem lesions in a very tortuous LCX for which she underwent PCI. Placement of a BMW coronary guidewire into the LCX resulted in the straightening of the vessel.

Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: A meta-analysis.

OBJECTIVES: This meta-analysis evaluated the effectiveness of hybrid coronary revascularization (HCR) compared to coronary artery bypass grafting (CABG) for the treatment of multivessel coronary artery disease (MVCAD). BACKGROUND: HCR involves a combination of surgical and percutaneous techniques, which in selected patients may present an alternative to conventional CABG. METHODS: Databases were searched through June 30, 2016, and studies comparing HCR with CABG for treatment of MVCAD were selected. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The primary outcome of interest was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all cause mortality, myocardial infarction, and stroke. RESULTS: The analysis included 2,245 patients from 8 studies (1 randomized controlled trial and 7 observational studies). The risk of MACCE with HCR and CABG were 3.6% and 5.4%, respectively (OR, 0.53; 95% CI, 0.24-1.16). Compared to CABG group, patients in HCR group had similar risk of all cause mortality (OR, 0.85; 95% CI, 0.38-1.88), myocardial infarction (OR, 0.72; 95% CI, 0.31-1.64), stroke (OR, 0.53; 95% CI, 0.23-1.20), and repeat revascularization (OR, 1.28; 95% CI, 0.58-2.83). The need for postoperative blood transfusions (OR, 0.29; 95% CI, 0.14-0.59) and hospital stay (weighted mean difference -1.20 days; 95% CI -1.52 to -0.88 days) was significantly lower in the HCR group. CONCLUSION: HCR appears to be safe, and has similar outcomes when compared with conventional CABG. HCR can be a suitable alternative to conventional CABG in select patients with MVCAD. © 2017 Wiley Periodicals, Inc.