Rationale, Design, and Implications of Bifurcation Coronary Stenting: Insight from the Indian Bifurcation Stenting (IBIS) Registry.

Background Bifurcation coronary stenting (BCS) has unique therapeutic challenges. Several BCS strategies are prescribed for treatment, with conflicting data, and which is the best strategy for optimal short- and long-term outcomes remains a matter of debate. There is no systematic data from an Indian perspective in regard to patterns of BCS and its outcomes. Methods and analysis The Indian Bifurcation Stenting (IBIS) registry is a prospective, nationwide, endpoint-driven, investigator-initiated, multi-center, observational registry to compare the different bifurcation stent strategies, the effect of adjuvant techniques, and bifurcation anatomical differences in predicting short- and long-term clinical outcomes of bifurcation coronary interventions in India. A total of 1,000 patients from 20 clinical sites across the country will be enrolled in this study from September 2020 to August 2023. The primary endpoint will be the composite endpoint of major adverse cardiac events including cardiac death, target lesion myocardial infarction (MI), and ischemia-driven target lesion revascularization at the end of two years. The secondary endpoints include all causes of death, MI, target vessel revascularization, in-stent restenosis, stroke, and predefined procedural parameters. The safety endpoint is the occurrence of definite or probable stent thrombosis. Conclusion The aim of this prospective observational registry is to assess the practice patterns and clinical outcomes of patients undergoing coronary bifurcation lesion angioplasty in India. This will be extremely useful to provide an evidence-based insight as well as guidance to bifurcation angioplasty in India.

Comparison of resting and adenosine-free pressure indices with adenosine-induced hyperemic fractional flow reserve in intermediate coronary lesions.

OBJECTIVE: Fractional flow reserve (FFR) using adenosine has been the gold standard in the functional assessment of intermediate coronary stenoses in the catheterization laboratory. We aim to study the correlation of adenosine-free indices such as whole cycle Pd/Pa [the ratio of mean distal coronary pressure (Pd) to the mean pressure observed in the aorta (Pa)], instantaneous wave-free ratio (iFR), and contrast-induced submaximal hyperemia (cFFR) with FFR. METHODS: This multicenter, prospective, observational study included patients with stable angina or acute coronary syndrome (>48 h since onset) with discrete intermediate coronary lesions (40-70% diameter stenosis). All patients underwent assessment of whole cycle Pd/Pa, iFR, cFFR, and FFR. We then evaluated the correlation of these indices with FFR and assessed the diagnostic efficiencies of them against FFR ≤0.80. RESULTS: Of the 103 patients from three different centers, 83 lesions were included for analysis. The correlation coefficient (r value) of whole cycle Pd/Pa, iFR, and cFFR in relation to FFR were +0.84, +0.77, and +0.70 (all p values < 0.001), respectively, and the c-statistic against FFR ≤0.80 were 0.92 (0.86-0.98), 0.89(0.81-0.97), and 0.91 (0.85-0.97) (all p values < 0.001), respectively. The best cut-off values identified by receiver-operator characteristic curve for whole cycle Pd/Pa, iFR, and cFFR were 0.94, 0.90, and 0.88, respectively, for an FFR ≤0.80. By the concept of "adenosine-free zone" (iFR = 0.86-0.93), 59% lesions in this study would not require adenosine. CONCLUSION: All the three adenosine-free indices had good correlation with FFR. There is no difference in the diagnostic accuracies among the indices in functional evaluation of discrete intermediate coronary stenoses. However, further validation is needed before adoption of adenosine-free pressure parameters into clinical practice.

Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies.

AIMS: Left-sided prosthetic valve thrombosis (PVT) occurs frequently in developing countries and causes major morbidity and mortality. Fibrinolytic therapy (FT) is most commonly used as treatment, but increases the risk of stroke and bleeding. Urgent surgery may be more efficacious and cause fewer complications. Our aim was to compare the efficacy and safety of urgent surgery and FT for the treatment of left-sided PVT. METHODS AND RESULTS: We searched EMBASE and MEDLINE for articles which included at least five patients each treated with surgery and FT. The primary outcome was complete restoration of valve function. Other outcomes were in-hospital death, thrombo-embolism (stroke, transient ischaemic attack, or non-CNS systemic embolism), major bleeding, and recurrence of PVT on follow-up. We calculated odds ratios (ORs) for each outcome and pooled them using a random effects model. We included seven eligible studies with 690 episodes of PVT, 446 treated with surgery, and 244 with FT. There was no significant difference in the occurrence of the primary outcome (86.5 vs. 69.7%, OR 2.53, 95% CI 0.94-6.78, P = 0.066, I(2) = 74%) or death (13.5 vs. 9%, OR 1.95, 95% CI 0.63-5.98, P = 0.244, I(2) = 59%) between the two treatments. However, compared with FT, urgent surgery was associated with significant reductions in thrombo-embolism (1.6 vs. 16%, OR 0.10, 95% CI 0.04-0.24, P < 0.001, I(2) = 0%), major bleeding (1.4 vs. 5%; OR 0.27, 95% CI 0.08-0.98, P = 0.046, I(2) = 0%), and recurrent PVT (7.1 vs. 25.4%; OR 0.25, 95% CI 0.08-0.74, P = 0.013, I(2) = 59%). CONCLUSION: Urgent surgery was not superior to FT at restoring valve function, but substantially reduced the occurrence of thrombo-embolic events, major bleeding, and recurrent PVT. In experienced centres, urgent surgery should probably be preferred over FT for treating left-sided PVT, pending the results of randomized controlled trials.

A Case of Esophageal Candidiasis in a Healthy Child / 대한소아소화기영양학회지

Esophageal candidiasis is an opportunistic infection, often reported in patients who have acquired immune deficiency syndrome (AIDS), a neoplastic disease, or undergoing protracted antibiotic therapy. Impaired cell mediated immunity was often considered as the major predisposing factor in patients of esophageal mucosal colonization of Candida spp. However, it is increasingly reported that the occurrence of esophageal candidiasis with no underlying disease or immune suppression. We have experienced a case of esophageal candidiasis in a 15-year-old girl who was immunologically normal and have no underlying disease and whose main symptoms were epigastric and retrosternal pain with dysphagia. This case suggests the possibilities of candidal infections in children without predisposing factors such as immune compromised conditions, so it will be needed to differentiate the esophageal candidiasis among healthy children with symptoms of odynophagia and dysphagia.

CSF Examination in the First Febrile Seizure / 소아과

PURPOSE: This study was launched to classify subjects of the CSF examination and improve early diagnosis of meningitis and its treatment in children who have had a first febrile seizure. METHODS: From March 1995 to September 2003, children aged 3 months to 5 years who had had treatment for febrile seizure were analyzed as to their age at first seizure, type of seizure, CSF examination, and prevalence of meningitis. RESULTS:The largest age group distribution among the 780 children was 356(45.6%) children who were under 18 months. One hundred ninteen(15.3%) patients received the CSF examination, and out of those 68(19.1%) were less than 18 months old. Twenty five(3.2%) children were diagnosed with meningitis; those less than 18 months old were 15(4.2%). Two(0.2%) were diagnosed as bacterial meningitis. Out of 780 patients 599(76.8%) were simple febrile seizure patients. Out of 32(5.3%) who received the CSF examination, nine were diagnosed as meningitis. In complex febrile seizure, 86(52.1 %) out of 165(21.2%) received CSF examinations and 16(9.7%) of those were diagnosed as meningitis. Thus, there was a higher prevalence of meningitis in children presenting complex febrile seizure. CONCLUSION: To diagnose meningitis with the CSF examination in the first febrile seizure, the patient's general condition, such as clinical symptoms and types of seizure, are more important than the ages of the patients. We suggest that experienced physicians should be concerned with doing an early diagnosis of meningitis and thus reduce the number of CSF examinations of children with febrile seizures.