Tissue plasminogen activator dose and pulmonary artery pressure reduction in catheter directed thrombolysis of submassive pulmonary embolism.

PURPOSE: The purpose of this study is to assess the incremental effect of tissue plasminogen activator (t-PA) dose on pulmonary artery pressure (PAP) and bleeding during catheter directed thrombolysis (CDT) of submassive pulmonary embolism (PE). MATERIALS AND METHODS: Records of 46 consecutive patients (25 men, 21 women, mean age 55±14 y) who underwent CDT for submassive PE between September 2009 and February 2017 were retrospectively reviewed. Mean t-PA rate was 0.7±0.3 mg/h. PAP was measured at baseline and daily until CDT termination. Mixed-effects regression modeling was performed of repeated PAP measures in individual patients. Bleeding events were classified by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) and t-PA dose at onset. RESULTS: Mean t-PA dose was 43.0±30.0 mg over 61.9± 28.8 h. Mean systolic PAP decreased from 51.7±15.5 mmHg at baseline to 35.6±12.7 mmHg at CDT termination (p<0.001). Mixed-effects regression revealed a linear decrease in systolic PAP over time (ß = -0.37 (SE = 0.05), p<0.001) with reduction in mean systolic PAP to 44.8±1.9 mmHg at 12 mg t-PA/20 h, 39.5±2.0 mmHg at 24 mg t-PA/40 h, and 34.9±2.1 mmHg at 36 mg/60 h. No severe, one moderate, and 8 mild bleeding events occurred; bleeding onset was more frequent at ≤24 mg t-PA (p <0.001). One patient expired from cardiopulmonary arrest after 16 h of CDT (15.4 mg t-PA); no additional intra-procedural fatalities occurred. CONCLUSION: Increased total t-PA dose and CDT duration were associated with greater PAP reduction without increased bleeding events.

The utility of statistical moments in chromatography using trapezoidal and Simpson's rules of peak integration.

Modern chromatographic data acquisition softwares often behave as black boxes where the researchers have little control over the raw data processing. One of the significant interests of separation scientists is to extract physico-chemical information from chromatographic experiments and peak parameters. In addition, column developers need the total peak shape analysis to characterize the flow profile in chromatographic beds. Statistical moments offer a robust approach for providing detailed information for peaks in terms of area, its center of gravity, variance, resolution, and its skew without assuming any peak model or shape. Despite their utility and theoretical significance, statistical moments are rarely incorporated as they often provide underestimated or overestimated results because of inappropriate choice of the integration method and selection of integration limits. The Gaussian model is universally used in most chromatography softwares to assess efficiency, resolution, and peak position. Herein we present a user-friendly, and accessible approach for calculating the zeroth, first, second, and third moments through more accurate numerical integration techniques (Trapezoidal and Simpson's rule) which provide an accurate estimate of peak parameters as compared to rectangular integration. An Excel template is also provided which can calculate the four moments in three steps with or without baseline correction.

FDG PET-CT findings of extra-thoracic sarcoid are associated with cardiac sarcoid: A rationale for using FGD PET-CT for cardiac sarcoid evaluation.

PURPOSE: This retrospective study investigates the relationship between cardiac and extra-thoracic sarcoid findings on FDG PET-CT using a 72-hour pretest high-fat, high-protein, and very low-carbohydrate (HFHPVLC) diet. PATIENTS AND METHODS: A total of 196 consecutive FDG PET-CT scans with 72-hour HFHPVLC diet preparation were performed between December 2014 and December 2015 in known sarcoid patients. Of these scans, 5 were excluded for non-adherence to diet preparation or underlying cancer. Cardiac and extra-thoracic sarcoid lesions were categorized and measured for radiotracer uptake. RESULTS: A total of 188 patients had 191 eligible FDG PET/CT scans (3 follow-up scans), of which there were 20 (10%) positive, 6 indeterminate (3%), and 165 (86%) negative for CS. Among the 20 scans positive for CS, 8 (40%) had findings of both cardiac and extra-thoracic sarcoid. CONCLUSION: Our study shows that 40% of CS patients also have FDG PET-CT findings of extra-thoracic sarcoid. This makes an intriguing case for FDG PET-CT use with pretest diet prep over cardiac MRI (CMR) for cardiac sarcoid evaluation, given that CMR is likely to overlook these extra-thoracic sites of disease.

Separations at the Speed of Sensors.

The virtue of chemical sensors is speed and analyte specificity. The response time to generate an analytical signal typically varies from ∼1 to 20 s, and they are generally limited to a single analyte. Chemical sensors are significantly affected by multiple interferents, matrix effects, temperature, and can vary widely in sensitivity depending on the sensor format. Separation-based analyses remove matrix effects and interferents and are compatible with multiple analytes. However, the speed of such analyses has not been commensurate with traditional sensors until now. Beds of very small size with optimal geometry, containing core-shell particles of judicious immobilized selectors, can be used in an ultrahigh-flow regime, thereby providing subsecond separations of up to 10 analytes. Short polyether ether ketone lined stainless steel columns of various geometries were evaluated to determine the optimal bed geometry for subsecond analysis. Coupling these approaches provides subsecond-based detection and quantitation of multiple chiral and achiral species, including nucleotides, plant hormones, acids, amino acid derivatives, and sedatives among a variety of other compounds. The subsecond separations were reproducible with 0.9% RSD on retention times and showed consistent performance with 0.9% RSD on reduced plate height in van Deemter curves. A new powerful signal processing algorithm is proposed that can further enhance separation outputs and optical spectra without altering band areas on more complex separations such as 10 peaks under a second.

Unattended reaction monitoring using an automated microfluidic sampler and on-line liquid chromatography.

In-process sampling and analysis is an important aspect of monitoring kinetic profiles and impurity formation or rejection, both in development and during commercial manufacturing. In pharmaceutical process development, the technology of choice for a substantial portion of this analysis is high-performance liquid chromatography (HPLC). Traditionally, the sample extraction and preparation for reaction characterization have been performed manually. This can be time consuming, laborious, and impractical for long processes. Depending on the complexity of the sample preparation, there can be variability introduced by different analysts, and in some cases, the integrity of the sample can be compromised during handling. While there are commercial instruments available for on-line monitoring with HPLC, they lack capabilities in many key areas. Some do not provide integration of the sampling and analysis, while others afford limited flexibility in sample preparation. The current offerings provide a limited number of unit operations available for sample processing and no option for workflow customizability. This work describes development of a microfluidic automated program (MAP) which fully automates the sample extraction, manipulation, and on-line LC analysis. The flexible system is controlled using an intuitive Microsoft Excel based user interface. The autonomous system is capable of unattended reaction monitoring that allows flexible unit operations and workflow customization to enable complex operations and on-line sample preparation. The automated system is shown to offer advantages over manual approaches in key areas while providing consistent and reproducible in-process data.

Abdominal-pelvic scanning parameters revisited: a case for Z-axis reduction in patients with clinical suspicion for acute appendicitis.

PURPOSE: The purpose of this study was to determine if CT for appendicitis can be abbreviated to begin at the top of the L2 vertebral body level and still maintain the detection rate of appendicitis and other symptomatic pathology without omitting significant incidental findings. METHODS: Retrospective review of CT abdomen-pelvis exams for suspected appendicitis over a 5-month period was performed. The Z-axis scan length of the original full scans and theoretical limited scans from the top of L2 were recorded and calculated. Images were reviewed for incidental findings above the L2 vertebral body level and categorized by severity per American College of Radiology (ACR) white paper guidelines. Final diagnoses based on imaging findings were also recorded. RESULTS: One hundred nineteen patients (46 males, 73 females, mean age 29 ± 14) were included. Appendicitis was present in 26 cases (22%). Using a theoretical scan beginning at the top of the L2 vertebral body, none of the findings leading to diagnosis of appendicitis would have been missed. A total of 30 incidental findings were found above the L2 vertebral body. Per ACR white paper guidelines, 26 of these findings did not require additional imaging follow-up. Additional follow-up imaging was recommended for 3 of the findings above L2, and 1 right adrenal metastasis was found above L2 in a patient with previously undiagnosed NSCLC. This patient coincidentally also had appendicitis. No symptomatic pathology would have been missed had the scans begun at the top of the L2 vertebral body. Such an abbreviated scan would have resulted in a mean Z-axis reduction of 12.9 cm (30.3%). CONCLUSIONS: CT using abbreviated Z-axis scan length can reduce radiation dose and provide necessary imaging needed to diagnose appendicitis or other symptomatic pathology without omitting significant incidental findings.

Fundamental and Practical Insights on the Packing of Modern High-Efficiency Analytical and Capillary Columns.

New stationary phases are continuously developed for achieving higher efficiencies and unique selectivities. The performance of any new phase can only be assessed when the columns are effectively packed under high pressure to achieve a stable bed. The science of packing columns with stationary phases is one of the most crucial steps to achieve consistent and reproducible high-resolution separations. A poorly packed column can produce non-Gaussian peak shapes and lower detection sensitivities. Given the ever larger number of stationary phases, it is impossible to arrive at a single successful approach. The column packing process can be treated as science whose unified principles remain true regardless of the stationary phase chemistry. Phenomenologically, the column packing process can be considered as a constant pressure or constant flow high-pressure filtration of a suspension inside a column with a frit at the end. This process is dependent on the non-Newtonian suspension rheology of the slurry in which the particles are dispersed. This perspective lays out the basic principles and presents examples for researchers engaged in stationary phase development. This perspective provides an extensive set of slurry solvents, hardware designs, and a flowchart, a logical approach to optimal column packing, thus eliminating the trial and error approach commonly practiced today. In general, nonaggregating but high slurry concentrations of stationary phases tend to produce well packed analytical columns with small particles. Conversely, C18 packed capillary columns are best packed using agglomerating solvents.

Total peak shape analysis: detection and quantitation of concurrent fronting, tailing, and their effect on asymmetry measurements.

Most peak shapes obtained in separation science depart from linearity for various reasons such as thermodynamic, kinetic, or flow based effects. An indication of the nature of asymmetry often helps in problem solving e.g. in column overloading, slurry packing, buffer mismatch, and extra-column band broadening. However, existing tests for symmetry/asymmetry only indicate the skewness in excess (tail or front) and not the presence of both. Two simple graphical approaches are presented to analyze peak shapes typically observed in gas, liquid, and supercritical fluid chromatography as well as capillary electrophoresis. The derivative test relies on the symmetry of the inflection points and the maximum and minimum values of the derivative. The Gaussian test is a constrained curve fitting approach and determines the residuals. The residual pattern graphically allows the user to assess the problematic regions in a given peak, e.g., concurrent tailing or fronting, something which cannot be easily done with other current methods. The template provided in MS Excel automates this process. The total peak shape analysis extracts the peak parameters from the upper sections (>80% height) of the peak rather than the half height as is done conventionally. A number of situations are presented and the utility of this approach in solving practical problems is demonstrated.

Quinine bonded to superficially porous particles for high-efficiency and ultrafast liquid and supercritical fluid chromatography.

Two new anion-exchange columns were prepared by bonding tert-butyl carbamoylated quinine to 2.7 µm superficially porous particle (SPP) silica to create chiral stationary phases for high-efficiency and ultrafast chromatography. Performance and retention parameters of these new columns are compared with an analogous 5 µm fully porous particle (FPP) based Chiralpak QNAX column and a 3-4 fold increase in efficiency was observed. Ultrafast separations ranging from 12 s down to sub-second are shown using 2.7 µm SPPs bonded via hydrosilation to the selector. Potential benefits of 2.7 µm SPP based columns for increased LC-MS compatibility were investigated. A van Deemter plot comparison showed 2.7 µm SPP based columns provided a lower reduced plate height and a higher optimal linear velocity compared to the 5 µm FPP based column. With geometry-independent kinetic plots, 2.7 µm SPP and 5 µm FPP based columns were assessed for their kinetic performance and the maximal number of plates each column can generate in a given analysis time. The 2.7 µm SPP based column showed remarkable performance improvements in speed and efficiency as indicated by the kinetic plots.

Salient Sub-Second Separations.

Sub-second liquid chromatography in very short packed beds is demonstrated as a broad proof of concept for chiral, achiral, and HILIC separations of biologically important molecules. Superficially porous particles (SPP, 2.7 µm) of different surface chemistries, namely, teicoplanin, cyclofructan, silica, and quinine, were packed in 0.5-cm-long columns for separating different classes of compounds. Several issues must be addressed to obtain the maximum performance of 0.5 cm columns with reduced plate heights of 2.6 to 3.0. Modified UHPLC hardware can be used to obtain sub-second separations provided extra-column dispersion is minimized and sufficient data acquisition rates are used. Further, hardware improvements will be needed to take full advantage of faster separations. The utility of power transform, which is already employed in certain chromatography detectors, is shown to be advantageous for sub-second chromatography. This approach could prove to be beneficial in fast screening and two-dimensional liquid chromatography.

Advances in high-throughput and high-efficiency chiral liquid chromatographic separations.

The need for improved liquid chromatographic chiral separations has led to the advancement of chiral screening techniques as well as the development of new, high efficiency chiral separation methods and stationary phases. This review covers these advancements, which primarily occurred over the last 15 years. High throughput techniques include multi-column screening units, multiple injection sequences, and fast gradient SFC screening. New separation methods and column technologies that aim at high efficiency chiral separations include the use of achiral UHPLC (i.e. sub-2µm) columns for separating derivatized chiral analytes or using chiral additives in the run buffer, UHPLC chiral stationary phases, and superficially porous particle based chiral stationary phases. Finally, the enhancement of chiral separations through these new technologies requires that certain instrumental considerations be made. Future directions in continuing to improve chiral separations are also discussed.

Gram Scale Conversion of R-BINAM to R-NOBIN.

A mild, operationally simple, and single-step transition-metal-free protocol for the synthesis of enantiomerically pure (R)-(+)-2'-amino-1,1'-binaphthalen-2-ol (R-NOBIN) from (R)-(+)-1,1'-binaphthyl-2,2'-diamine (R-BINAM) is reported. The one-pot conversion proceeds with good yield and shows no racemization. The hydroxyl on the R-NOBIN product was shown to have come from water in the reaction medium via an H2(18)O study. The correct value of the specific rotation of R-NOBIN was reported.

Gone in seconds: praxis, performance, and peculiarities of ultrafast chiral liquid chromatography with superficially porous particles.

A variety of brush-type chiral stationary phases (CSPs) were developed using superficially porous particles (SPPs). Given their high efficiencies and relatively low back pressures, columns containing these particles were particularly advantageous for ultrafast "chiral" separations in the 4-40 s range. Further, they were used in all mobile phase modes and with high flow rates and pressures to separate over 60 pairs of enantiomers. When operating under these conditions, both instrumentation and column packing must be modified or optimized so as not to limit separation performance and quality. Further, frictional heating results in axial thermal gradients of up to 16 °C and radial temperature gradients up to 8 °C, which can produce interesting secondary effects in enantiomeric separations. It is shown that the kinetic behavior of various CSPs can differ from one another as much as they differ from the well-studied C18 reversed phase media. Three additional interesting aspects of this work are (a) the first kinetic evidence of two different chiral recognition mechanisms, (b) a demonstration of increased efficiencies at higher flow rates for specific separations, and

Enantiomeric separation of biaryl atropisomers using cyclofructan based chiral stationary phases.

Normal phase chiral HPLC methods are presented for the enantiomeric separation of 30 biaryl atropisomers including 18 new compounds recently produced via a novel synthetic approach. Three new cyclofructan based chiral stationary phases were evaluated. Separations were achieved for all but six analytes and the LARIHC™ CF6-P alone provided 15 baseline separations. Effects of polar modifiers and temperature effects also were studied. Apparent thermodynamic parameters were determined by van't Hoff plots. Preparative scale methods were developed and employed resulting in the first ever isolation of these novel atropisomers in their pure enantiomeric form. Insights into the mechanism of retention and chiral discrimination are presented.

Comparison of clinical features and outcomes of medically attended influenza A and influenza B in a defined population over four seasons: 2004-2005 through 2007-2008.

BACKGROUND: There are few prospectively collected data comparing illnesses caused by different subtypes of influenza. We compared the clinical presentation and outcomes of subjects with primarily outpatient-attended influenza A and B infections during four consecutive influenza seasons (2004-2005 through 2007-2008). METHODS: Patients were prospectively enrolled and tested for influenza following an encounter for acute respiratory illness. Influenza infections were confirmed by culture or reverse transcription polymerase chain reaction; subtype was determined for a sample of influenza A isolates each season. Clinical characteristics of influenza A and B infections were compared across and within individual seasons. RESULTS: We identified 901 cases of influenza A and 284 cases of influenza B; 98% of cases were identified through an outpatient medical encounter. Thirty-six percent of patients with each strain had received seasonal influenza vaccine prior to illness onset. There were no consistent differences in symptoms associated with influenza A and B. Influenza A infection was associated with earlier care seeking compared with influenza B during the 2005-2006 and 2007-2008 seasons, when H3N2 was the dominant type A virus, and in a combined analysis that included all seasons. Twenty-six (2·2%) of 1185 cases were diagnosed with radiographically confirmed pneumonia, and 59 (5%) of 1185 patients were hospitalized within 30 days of illness onset. CONCLUSIONS: Over four influenza seasons, aside from shorter intervals from illness onset to clinical encounter for infections with the A(H3N2) subtype, clinical symptoms and outcomes were similar for patients with predominantly outpatient-attended influenza A and B infections.