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Background Management of acute decompensated heart failure (ADHF) requires accurate assessment of relative intravascular volume, which may be technically challenging. Inferior vena cava (IVC) collapsibility with respiration reflects intravascular volume and right atrial pressure (RAP). Subclavian vein (SCV) collapsibility may provide an alternative. Hypothesis The purpose of this study was to examine the relationship between SCV collapsibility index (CI) and IVC CI in ADHF. Methods This was a prospective study of non‐ventilated patients with ADHF who had paired IVC and SCV ultrasound assessments. As SCV CI is highly position‐dependent, measurements were performed supine at 30–45°. Results Thirty‐three patients were included with 36 encounters. The sample size was adequately powered for receiver‐operator characteristic (ROC) analysis. SCV CI correlated with IVC CI during relaxed breathing (R = .65, n = 36, p 33% corresponded to IVC CI 50% suggesting hypervolemia (sensitivity/specificity: 72%) and hypovolemia (sensitivity/specificity: 78%), respectively. Moderate to severe tricuspid regurgitation (TR) compared to less than moderate TR was associated with lower SCV CI (medians: 12.4% vs. 25.3%, p = .022) and IVC CI (medians: 9.6% vs. 35.6%, p = .0012). SCV CI and IVC CI were not significantly different among chronic kidney disease stages. Conclusion In non‐ventilated ADHF, SCV CI at 30–45° correlates with paired IVC CI, and may provide an alternative to IVC CI for assessment of relative intravascular volume, which may facilitate clinical management. Moderate to severe TR decreases SCV CI and IVC CI and may result in overestimation of relative intravascular volume.

Introduction: Accurate assessment of relative intravascular volume is needed to guide management of acute decompensated heart failure (ADHF). Current assessments include history and physical examination (specific but not sensitive), and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (sensitive but not specific).Ultrasound (US) of inferior vena cava (IVC) collapsibility with respiration is commonly used to assess intravascular volume and right atrial pressure (RAP) but may be technically challenging. US of subclavian vein (SCV) collapsibility may provide an alternative assessment. Hypothesis: In ADHF, SCV collapsibility index (CI) may correlate with IVC CI and RAP. Methods: Prospective study of non-ventilated patients with ADHF who had NT-proBNP within 24 hours of paired IVC and SCV diameter measurements by US. Results: Forty-two patients (median age 66.5 years, 45% female, and 64% white) were enrolled, with 52 encounters. Cardiovascular comorbidities included hypertension (93%), chronic kidney disease (64%), coronary artery disease (55%), atrial fibrillation/flutter (55%), and valvular disease (55%). Of 38 patients with known heart failure, 63% had HFrEF, 16% HFmrEF, and 21% HFpEF.Correlation of paired IVC CI and SCV CI with relaxed breathing was R = 0.65 (N = 36). Correlation of paired IVC CI and SCV CI with forced inhalation was R = 0.47 (N = 36). Log 10 NT-proBNP was inversely correlated with IVC CI (R = -0.35; N = 51) and SCV CI (R = -0.33; N = 36). For patients with right heart catheterization within 24 hours of US, correlation of RAP to IVC CI was R = -0.53 (N = 9), and RAP to SCV CI was R = -0.65 (N = 9). Moderate or severe tricuspid regurgitation decreased CI independently of intravascular volume and RAP (figure). Conclusions: US measurements of SCV CI correlate well with paired IVC CI in non-ventilated ADHF. RAP by RHC correlated better with SCV CI than with IVC CI. SCV CI may be a reliable alternative to IVC CI in assessing relative intravascular volume.

Background Subclinical diastolic dysfunction is a precursor for developing heart failure with preserved ejection fraction (HFpEF); yet not all patients progress to HFpEF. Our objective was to evaluate clinical and echocardiographic variables to identify patients who develop HFpEF. Methods Clinical, laboratory, and echocardiographic data were retrospectively collected for 81 patients without HF and 81 matched patients with HFpEF at the time of first documentation of subclinical diastolic dysfunction. Density-based clustering or hierarchical clustering to group patients was based on 65 total variables including 19 categorical and 46 numerical variables. Logistic regression analysis was conducted on the entire study population as well as each individual cluster to identify independent predictors of HFpEF. Results Unsupervised clustering identified 3 subgroups which differed in gender composition, severity of cardiac hypertrophy and aortic stenosis, NT-proBNP, percentage of patients who progressed to HFpEF, and timing of disease progression from diastolic dysfunction to HFpEF to death. Clusters that had higher percentages of women had progressively milder cardiac hypertrophy, less severe aortic stenosis, lower NT-proBNP, were diagnosed at an older age with HFpEF, and survived to an older age. Independent predictors of HFpEF for the entire cohort included diabetes, chronic kidney disease, atrial fibrillation, and diuretic use, with additional predictive variables found for each cluster. Conclusions Cluster analysis can identify phenotypically distinct subgroups of patients with diastolic dysfunction. Clusters differ in HFpEF and mortality outcome. In addition, the variables that correlate with and predict HFpEF outcome differ among clusters.

Tranexamic acid (TXA) is an antifibrinolytic which minimises bleeding and transfusions, with thrombotic risk. Our patient had known coronary artery disease with post-TXA acute ST-elevation myocardial infarction (STEMI) due to in-stent thrombosis. He had five drug-eluting stents (DES): two overlapping DES in mid-LAD (3 years ago), and two overlapping DES in distal right coronary artery and one DES in obtuse-marginal (1.5 years ago). After TXA, both overlapping stent locations thrombosed. Of nine reports of post-TXA acute MI, only one had complex stent anatomy (bifurcation stent to left circumflex/first obtuse-marginal) with other single stents, and only the complex stent thrombosed. Post-TXA MI was more often STEMI caused by arterial thrombosis, rather than non-STEMI caused by blood loss, hypotension or demand ischaemia. Overlapping and bifurcation stents thrombosed; single stents remained patent. In conclusion, overlapping stents, bifurcation stents, excessive stent length and previous in-stent restenosis/thrombosis may increase thrombotic risk. TXA should be administered cautiously with complex stent anatomy.

Background Parry-Romberg syndrome (PRS) is a rare craniofacial disease that causes progressive hemifacial atrophy of the soft tissue before spontaneously entering remission. Autologous fat grafting may provide a less invasive alternative, producing aesthetically pleasing results while avoiding the need for traditional microsurgical free flap coverage. Methods A systematic review of the literature was conducted. Inclusion and exclusion criteria were applied. The case report highlights the technique using two-dimensional and three-dimensional photography. Results Our review yielded 31 articles in addition to our case describing 147 cases of lipofilling to correct PRS soft-tissue defects. Patients underwent an average of 2.2 procedures, receiving on average 95 mL of grafted fat. Disease severity was classified into mild (41%), moderate (42%), and severe (17%) in the identified patients. Increasing disease severity correlated with an increasing number of procedures and fat-grafting volumes to achieve adequate aesthetic outcomes (mean, 1.5 and 38 mL; 2.3 and 81 mL; 3.7 and 129 mL, respectively). Reported benefits over flap-based reconstructions included reductions in cost (40%), operative time (50%), donor-site morbidity (52%), and rate of complications (33%). Aesthetic benefits cited included improved skin quality (65%), more natural contours (1%), and more natural facial expressions (10%). Conclusion Fat grafting for correction of PRS-associated soft-tissue defects is receiving heightened acceptance for its ability to restore natural facial contours. While additional fat-grafting procedures may be required with increased disease severity, autologous fat grafting may be a beneficial option as a sole modality to correct PRS-associated soft-tissue atrophy.

Clinical factors that predispose patients with asymptomatic diastolic dysfunction (DD) to develop heart failure with preserved ejection fraction (HFpEF) are not well understood. We hypothesized that machine learning could identify clusters of patients with distinct phenotypes of DD, in which

Beauty is a complex phenomenon intrinsic to interactions between individuals. It is generally agreed that facial beauty is related to vertical and horizontal proportions of various facial features. Universal beauty, however, is almost impossible to define because of differences in time, culture, ethnicity, and age. The surgeon, however, relies on certain facial proportions and relationships to provide a basis for diagnosis and planning in facial plastic surgery. Previous studies have addressed ideal vertical and horizontal proportions of facial features. Few of these have addressed the location of the malar or zygomatic prominence, as it is a less distinct landmark than other facial features and its position is difficult to define. The cheekbone, however, “is the second most frequently fractured bone on the craniofacial skeleton” (Donald PJ, quoted in Czerwinski et al1), and accurate localization is important for surgical reconstruction. Although vertical positioning of the malar prominence is in common usage during facial reconstruction, no extensive studies have actually reported the vertical location of this feature. Various previous studies have related ideal vertical and horizontal facial proportions to the Golden Ratio, or “phi” φ.2–7 [The Golden Ratio, also known as the Divine Proportion, is that which is obtained when one divides any length into two parts in which the ratio of the larger part to the smaller is the same as that of the whole to the larger part. This ratio, φ, is an irrational number whose value is (√5 + 1)/2 ≈ 1.618]. The presumption is that certain proportions, described using φ, are aesthetically pleasing and that attractive facial features correspond to these aesthetic proportions. Ricketts2–4 identifies the “golden relations” between various facial proportions using 10 frontal-view photographs of male and female models taken from magazine advertisements and “allegedly selected for outstanding beauty.”2 He claims that vertical facial proportions are accurate to within 95–99% of the predicted values based on the Golden Ratio. Measurements of the location of the zygomatic prominence were not determined in these analyses2,3 despite the fact that this feature is included in his figures. By extracting from 2 of the figures presented in Ricketts’ articles,2–4 an overall proportion for vertical cheek height (malar prominence) can be found, with respect to chin (menton) and eye (lateral canthus) locations (Fig. ​(Fig.1).1). The ratio of the height of the malar prominence from the chin compared with the height of the eyes from the chin is given by: (φ + 0.5)/(φ + 1) ≈ 0.809. Fig. 1. Predicted location of the malar prominence based on the Golden Ratio. Lines demonstrate localization of the malar prominence based on Golden Ratio relationships to other facial features.2–4 The position of all lines drawn is those shown in Ricketts. ... Other studies have divided the face into thirds to determine ideal facial proportions. Richardson8 reproduces Dr. Gottfried Schadow’s work on The Proportions of the Human Body of Figures of Both Sexes and Various Ages, 1886. Similarly, Prendergast9 also describes division of the face into thirds. In these, the face is divided roughly into thirds—upper third from hairline to glabella, middle third from glabella to subnasal, and lower third from subnasal to menton. The lower two thirds can each be further divided into 3 parts—in essence dividing the face roughly into ninths. In both of these, the malar prominence appears within the middle third, at about four ninths from the chin, and the eye canthus appears at about five ninths from the chin. The malar prominence is thus found at approximately four fifths of the distance from chin to eye canthus. This value, 0.8, is almost identical to the value of 0.809, which is based on the Golden Ratio. Prendergast and Schoenrock10 measured the location of several facial landmarks, including the horizontal and vertical position of the malar eminence in a small group of subjects. Twenty models were used, all of whom were white women except 1 black and 1 Asian model who were “judged to have white faces.”10 The location of the malar eminence was found to be similar to the values obtained using either the Golden Ratio or the trisection of the face. Our purpose was to evaluate the vertical location of the malar prominence with respect to facial landmarks (chin and eye) in a large group of subjects and to determine whether the location of this feature was consistent among individuals. We also assessed whether any measured differences were associated with gender, age, or ethnicity. The value we obtained for the vertical position—that is, ratio of cheek height to eye height—was then compared with the values based on the Golden Ratio or used in artistry as a proxy for attractiveness. Our study comprises a larger cohort than any of the previous articles. Moreover, we have a mixed population with respect to age, gender, and ethnicity, and subjects were not selected based on attractiveness. No previous studies have examined the location of the malar prominence with respect to gender, age, or ethnicity in a population that was not selected for attractiveness. These results may be more applicable to the population in general.

BACKGROUND: Few studies of pediatric cardiac injuries have been conducted in large cohorts. We, therefore, investigated the epidemiology of these injuries in the United States. METHODS: We identified patients with traumatic cardiac injury from the National Trauma Data Bank, using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinical data, and in-hospital outcomes were compared among 5 age groups. A logistic regression model was used to determine adjusted mortality among these groups. RESULTS: Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion; 36%, laceration. Penetrating injuries proved more severe than blunt, having lower average Glasgow Coma Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68% vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%), hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%, thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%), most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%), compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significant differences that were lost after adjustment for confounding variables. CONCLUSIONS: The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults), frequently paired with contusion. Pediatric cardiac injury is associated with excessive in-hospital mortality (40%), with no age-related difference in adjusted mortality. Language: en