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Abstract Objective To develop an automated, physiologic metric of immune effector cell‐associated neurotoxicity syndrome among patients undergoing chimeric antigen receptor‐T cell therapy. Methods We conducted a retrospective observational cohort study from 2016 to 2020 at two tertiary care centers among patients receiving chimeric antigen receptor‐T cell therapy with a CD19 or B‐cell maturation antigen ligand. We determined the daily neurotoxicity grade for each patient during EEG monitoring via chart review and extracted clinical variables and outcomes from the electronic health records. Using quantitative EEG features, we developed a machine learning model to detect the presence and severity of neurotoxicity, known as the EEG immune effector cell‐associated neurotoxicity syndrome score. Results The EEG immune effector cell‐associated neurotoxicity syndrome score significantly correlated with the grade of neurotoxicity with a median Spearman's R2 of 0.69 (95% CI of 0.59–0.77). The mean area under receiving operator curve was greater than 0.85 for each binary discrimination level. The score also showed significant correlations with maximum ferritin (R2 0.24, p = 0.008), minimum platelets (R2 –0.29, p = 0.001), and dexamethasone usage (R2 0.42, p

Abstract Background Nucleoside analog GS‐441524 is effective in treating cats with feline infectious peritonitis (FIP). Investigation into the use of parent nucleotide analog remdesivir (GS‐5734) is needed. Objectives To assess efficacy and tolerability of remdesivir with or without transition to GS‐441524 in cats with FIP and document clinical and clinicopathologic progression over 6 months. Animals Twenty‐eight client‐owned cats with FIP. Methods Cats were prospectively recruited between May 2021 and May 2022. An induction dosage of remdesivir 10 to 15 mg/kg intravenously or subcutaneously q24h was utilized for 4 doses, with a maintenance dosage of remdesivir (6‐15 mg/kg SC) or GS‐441524 (10‐15 mg/kg per os) every 24 hours continued for at least 84 days. Laboratory testing, veterinary, and owner assessments were recorded. Results Twenty‐four cats survived to 6 months (86%). Three cats died within 48 hours. Excluding these, survival from 48 hours to 6 months was 96% (24/25). Remission was achieved by day 84 in 56% (14/25). Three cats required secondary treatment for re‐emergent FIP. Remission was achieved in all 3 after higher dosing (15‐20 mg/kg). Adverse reactions were occasional site discomfort and skin irritation with remdesivir injection. Markers of treatment success included resolution of pyrexia, effusions, and presenting signs of FIP in the first half of treatment and normalization of globulin concentration, and continued body weight gains in the latter half of the treatment period. Conclusions and Clinical Importance Parenteral administration of remdesivir and oral administration of GS‐441524 are effective and well‐tolerated treatments for FIP. Early emphasis on clinical, and later emphasis on clinicopathologic response, appears prudent when monitoring treatment efficacy.

Abstract The algorithms of the present generation of practical differential relays are based on two methods. The first method is based on the ratio of the harmonic content of the differential current, and the second one is based on the length of the time interval between the zero‐crossing points of the differential current, called the gap‐detection method. However, these methods suffer from the installation of the fault current limiters (FCLs) in the power system and current transformer (CT) saturation phenomenon. This paper deals with a simple practical method for differential relays to secure their performance. In the suggested method, a classifying algorithm is used to categorize the input signal of the relay and then the best method of the present generation of differential relays is employed. By this simple decision, the method takes the advantage of harmonic‐based and gap‐detection methods, while avoiding their drawbacks. To prove the robustness of the suggested method, a test bench with a resistive solid‐state fault current limiter (SSFCL) is implemented and examined in different situations. The results validate the consistency and the accuracy of the modified technique not only in the absence and the presence of the FCL but in the case of CT saturation.

Abstract Purpose In this scoping review, we evaluated existing literature related to factors influencing treatment decision‐making for patients diagnosed with cancer in low‐ and middle‐income countries, noting factors that influence decisions to pursue treatment with curative versus non‐curative intent. We identified an existing framework for adult cancer developed in a high‐income country (HIC) context and described similar and novel factors relevant to low‐and middle‐income country settings. Methods We used scoping review methodology to identify and synthesize existing literature on factors influencing decision‐making for pediatric and adult cancer in these settings. Articles were identified through an advanced Boolean search across six databases, inclusive of all article types from inception through July 2022. Results Seventy‐nine articles were identified from 22 countries across six regions, primarily reporting the experiences of lower‐middle and upper‐middle‐income countries. Included articles largely represented original research (54%), adult cancer populations (61%), and studied patients as the targeted population (51%). More than a quarter of articles focused exclusively on breast cancer (28%). Approximately 30% described factors that influenced decisions to choose between therapies with curative versus non‐curative intent. Of 56 reported factors, 22 novel factors were identified. Socioeconomic status, reimbursement policies/cost of treatment, and treatment and supportive care were the most commonly described factors. Conclusions This scoping review expanded upon previously described factors that influence cancer treatment decision‐making in HICs, broadening knowledge to include perspectives of low‐ and middle‐income countries. While global commonalities exist, certain variables influence treatment choices differently or uniquely in different settings. Treatment regimens should further be tailored to local environments with consideration of contextual factors and accessible resources that often impact decision‐making.

Abstract IT services can be requested via cloud computing, a model based on services as well as the Internet. It includes all computer systems resources from hardware components to software platforms and software applications in a distributed environment. Scheduling is a key step in processing tasks using remote resources. Serious issues have been brought forward, including the ineffective use of resources and task execution failure. The concurrent provision of fault tolerance and resource optimisation is achallenging task. In the context of cloud computing, this research offers a brand‐new job scheduling and fault‐tolerant system. Tasks submitted by users are taken as an input for the proposed method. Several virtual machines (VM) are initially arranged for scheduling work and execution process. Initially, Horse Herd Optimisation is employed here to allocate the job based on key factors such as deadline and user budget. Once the jobs are assigned to each VM, then each job's deadline is confirmed and transferred to VM which has sufficient capacity. Here, the Reptile Search Optimisation technique is applied to identify the VM error. Any VM that does not have enough capacity is the one that has a problem. When a fault is found, a fault‐tolerant process is instantly started. A replication‐based fault‐tolerant mechanism is used in this manuscript. The proposed approach is tested with several metrics which attains better performance like 80 s response time, turnaround time of 32 s, 17% resource utilisation and a success rate of 92%. Thus the designed model is the best choice for fault‐tolerant aware task scheduling.

Abstract Aim This study assessed, if use of herbal medicine (HM) among hypertensive patients is coincidence or planned. Design Cross‐sectional survey. Methods The study used a cross‐sectional survey for collection of data from four (4) herbal medicine clinics in the Tamale metropolis in northern Ghana. Results The final or overall regression model was significant at R2 = 0.350, F(7, 214) = 16.464, p

The use of mutation analysis of homologous recombination repair (HRR) genes to estimate PARP‐inhibition response may miss a larger proportion of responding patients. Here, we provide preclinical models for castration‐resistant prostate cancer (CRPC) that can be used to functionally predict HRR defects. In vitro, CRPC LNCaP sublines revealed an HRR defect and enhanced sensitivity to olaparib and cisplatin due to impaired RAD51 expression and recruitment. Ex vivo‐induced castration‐resistant tumor slice cultures or tumor slice cultures derived directly from CRPC patients showed increased olaparib‐ or cisplatin‐associated enhancement of residual radiation‐induced γH2AX/53BP1 foci. We established patient‐derived tumor organoids (PDOs) from CRPC patients. These PDOs are morphologically similar to their primary tumors and genetically clustered with prostate cancer but not with normal prostate or other tumor entities. Using these PDOs, we functionally confirmed the enhanced sensitivity of CRPC patients to olaparib and cisplatin. Moreover, olaparib but not cisplatin significantly decreased the migration rate in CRPC cells. Collectively, we present robust patient‐derived preclinical models for CRPC that recapitulate the features of their primary tumors and enable individualized drug screening, allowing translation of treatment sensitivities into tailored clinical therapy recommendations.

Abstract In pediatric clinical research, it is essential to implement ethical and regulatory requirements, training, and facilities to grant the proper management of specimens, considering that blood sampling may be difficult, the number of specimens is usually limited, and all efforts should be made to minimize sample volumes. In the context of the Pediatric Clinical Research Infrastructure Network (PedCRIN) project, an easy‐to‐use tool has been developed to guide investigators and sponsors in managing specimens and associated data in compliance with the applicable European rules in the context of pediatric clinical trials. Key topics and research questions to properly manage biosamples and related data in the context of pediatric trials were identified by PedCRIN partners; the current European regulatory/ethical and legal resources were searched for and analyzed; the items/measures/procedures to ensure regulatory compliance of a pediatric trial with regards to biosamples were defined. A checklist of the key items to be considered for the management of biological samples in pediatric clinical trials in compliance with the European applicable rules and legislation, was prepared. It is publicly available on the PedCRIN website https://ecrin.org/projects/pedcrin. Five different topics were covered: consent and assent; minimizing harm and maximizing welfare; sampling volume; skills, training and facilities required for sampling; and long‐term storage of biological material. This exercise addressed a specific need in the field of pediatric research to implement ad hoc procedures for specimen handling. In fact, specific guidance on the management of biosamples in pediatrics is not available.

Abstract Background Brucellosis in dogs caused by Brucella suis is an emerging zoonotic disease. Objectives To document clinical characteristics, serology, microbiology, and clinical response to treatment in B. suis‐seropositive dogs. Animals Longitudinal study of 27 privately‐owned dogs. Dogs that tested positive by serology, culture, or real‐time polymerase chain reaction (qPCR) were included in the study. Methods Clinical (physical examination and imaging) and laboratory (serology, hematology, serum biochemistry, and qPCR or culture) assessments were made at baseline and after approximately 3, 6, 12, and 18 months. Results Dogs were followed for 10 895 dog days, with 17/27 dogs completing the 18‐month follow‐up. Ten dogs had signs consistent with brucellosis before enrollment (n = 4), at baseline (n = 2) or during follow‐up (n = 6), with 2 dogs experiencing relapse of historical signs. Antibody titers persisted for the duration of follow‐up in 15/17 dogs (88%). Radiographic (n = 5) and ultrasound (n = 11) findings, of variable clinical relevance, were observed. Brucella DNA and organisms were detected in 3 dogs, all of which had clinical signs, including in the milk of a bitch around the time of whelping. Brucella DNA was not detected in blood (n = 92 samples), urine (n = 80), saliva (n = 95) or preputial swabs (n = 78) at any time during follow‐up. Six dogs underwent treatment, all of which achieved clinical remission although remission was not reflected by decreasing antibody titers. Conclusions and Clinical Importance Most dogs with B. suis infections have subclinical infections. Serology is poorly associated with clinical disease. Excretion of organisms appears rare except in whelping bitches. Clinical management using antibiotics with or without surgery is recommended.

Abstract Vaccination against SARS‐CoV2 has been the largest vaccination campaign over the past two decades. The aim of this study is to qualitatively assess the reported cases of acquired hemophilia A (AHA) that developed after COVID‐19 vaccination to further elaborate on incidence, presentation, treatment, and outcomes.We queried Medline (PubMed), Google Scholar, and Embase databases to find reported cases of AHA after COVID‐19 vaccines. We found 14 studies (19 cases) for this descriptive analysis. Most patients were elderly (mean age 73 years) and males (n = 12) with multiple comorbidities. All cases developed after mRNA vaccines ‐ BNT162b2 Pfizer‐BioNTech (n = 13) and mRNA‐1273 Moderna (n = 6). All except one patient were treated, with the most common therapy being a combination of steroids, immunosuppression, and rFVIII (n = 13). Two patients died due to acute respiratory distress, and gall bladder rupture with persistent bleeding, respectively. While evaluating a patient with bleeding diathesis after COVID‐19 vaccination, AHA should be kept in the differential diagnosis. Given the low incidence, we believe that the benefit of vaccination still outweighs the risk of disease acquisition.

Abstract Objectives This study compared the utility of corneal nerve measures with brain volumetry for predicting progression to dementia in individuals with mild cognitive impairment (MCI). Methods Participants with no cognitive impairment (NCI) and MCI underwent assessment of cognitive function, brain volumetry of thirteen brain structures, including the hippocampus and corneal confocal microscopy (CCM). Participants with MCI were followed up in the clinic to identify progression to dementia. Results Of 107 participants with MCI aged 68.4 ± 7.7 years, 33 (30.8%) progressed to dementia over 2.6‐years of follow‐up. Compared to participants with NCI (n = 12), participants who remained with MCI (n = 74) or progressed to dementia had lower corneal nerve measures (p

Societal Impact Statement Sandalwood and other high value tree species are under significant threat from illegal harvest. Illegal logging is an increasing problem contributing to deforestation, biodiversity loss, human rights abuses and funding transnational crime. Successful prosecution of illegal logging is hindered by a lack of methods to provide evidence of the origin of timber. New analytical techniques have been developed to trace timber back to its source. These methods, together with the establishment of sustainable sources of forest resources, can help protect vulnerable species by providing evidence to prosecute illegal harvest and ensure that commercially available forest products come from sustainable sources. Summary Sandalwood is highly valued for its fragrant oil and has a long history of cultural and economic importance in many regions of the world. Historical overharvest and poor management have depleted natural populations of sandalwood, which are slow to regenerate. The increasing establishment of plantation sandalwood creates an alternative resource for the sandalwood industry while potentially relieving harvesting pressure on natural stands. Due to the high demand for sandalwood, remaining wild populations are still under threat from illegal logging and methods to identify the source of harvested sandalwood are needed. Laws and regulations aimed at preventing illegal harvest and possession of sandalwood have been put in place but cannot be enforced without the forensic tools to independently verify claimed origin or product quality. The high value of sandalwood combined with the difficulties in enforcing illegal logging laws makes these species particularly vulnerable to poaching. There is an immediate need to develop tools that can identify illegally sourced and adulterated sandalwood products. This paper reviews the current and developing scientific tools that can help identify and control illegal activity in sandalwood supply chains and provides recommendations for future research. Topics include isotope and DNA analysis for tracing illegally harvested sandalwood, chemical profiling for quality control of sandalwood oils, network and policy development to establish a framework for future regulation of the sandalwood trade.

Abstract A subset of patients with metastatic renal cell carcinoma (mRCC) follow an indolent disease course and may benefit from initial active surveillance (AS). However, selecting patients suitable for this approach is challenging. To investigate this we sought to define outcomes of patients with mRCC suitable for initial AS. All patients with mRCC clinically selected for initial AS at the Edinburgh Cancer Centre between January 2010 and December 2020 were identified. Key inflammatory biomarkers (haemoglobin, white cell count, neutrophil count, platelets, C‐reactive protein [CRP], albumin, corrected calcium) and the International Metastatic RCC Database Consortium (IMDC) risk score were measured. The relationship between these and time to systemic anticancer therapy (tSACT) and overall survival (OS) was analysed. Data were available for 160 patients. Estimated median overall survival was 88.0 (interquartile range [IQR] 34.0–127.0) months. Median tSACT was 31.8 (IQR 12.0–76.3) months. On multivariate analysis, only CRP was predictive of tSACT (HR 2.47 [95% CI:1.59–3.85] p 10 mg/L were more likely to commence SACT within 1 year than those with CRP≤10 mg/L (41% vs. 18%, Relative Risk 2.16 (95% CI:1.18–3.96) (p = 0.012)). IMDC risk score was not predictive of tSACT or OS. Active surveillance is an appropriate initial management option for selected patients with mRCC. CRP, a biomarker of systemic inflammation, may provide additional objective information to assist clinical decision‐making in patients with mRCC being considered for initial AS. Although this is a retrospective observational study, the cohort is well defined and includes all patients managed with initial AS in an inclusive real‐world setting.

Abstract A study was conducted to determine the artificial breeding response, embryonic and larval development of giant snakehead, Channa marulius, with the application of various dosages of stimulatory hormones: Suprefact® (LHRH) agonist and Ovaprim® (GnRH + dopamine inhibitor). First and second hormonal dosages of Suprefact® (diluted) and Ovaprim® (0.3, 0.4, and 0.5 ml for male and 0.8, 0.9, and 1.0 ml for females per kilogram body weight) were used. There were three treatments T1, T2, and T3 and each treatment had three replicates. Male fish were treated with T1 (0.3), T2 (0.4), T3 (0.5) ml kg−1 of body weight while female fish with T1 (0.8), T2 (0.9), T3 (1.0) ml kg−1 of body weight. The results showed that fish stimulated with T3 (1.0) obtained better fecundity rate (2951.7) followed by T2 (0.4) (2678.3), while the lowest fecundity (466.7) was recorded in T1. The numerically higher values of gonado‐somatic index (males and females) and fertilization rate appeared in T2. The highest survival rate (97.1%) was found in T3 followed by T2 (97.0%), while the lowest (32.2%) in T1. In conclusion, the application of Suprefact® and Ovaprim® at 0.4 and 0.5 ml kg−1 body weight for male and 0.9 and 1.0 ml kg−1 for female fish successfully stimulated snakehead fish induced breeding.

Abstract This paper analyses the impact of square wave pulse voltage deadtime on the partial discharge (PD) and the lifetime of turn‐to‐turn insulation. A bipolar repetitive pulse voltage with a deadtime of 0–10 μs is produced using double half‐bridge solid‐state switches having push–pull technology controlled by a field‐programmable gate array. The mechanism of the discharge process at rising and falling edges of the pulse voltage before and after deadtime is analysed in detail. The discharge amplitude and PD probability at the rising/falling edges of the voltage waveform increase as the deadtime increases from 0 to 10 μs due to the remanent charges. The number of PD and their intensity is higher at the first rising/falling edges of pulse voltage as compared to the second rising/falling edges for all deadtimes 0–10 μs. As the deadtime increases beyond 2 μs, the number of PDs increases and concentrates at a specific phase angle of rising/falling edges. These localise discharges degrade the insulation material and reduce its lifetime. This study helps to identify the inverter‐fed motor insulation faults due to deadtime. It can provide guidelines to motor insulation designers to determine the limit value of deadtime to compensate PD and ensure the safer operation of such motors.

Abstract Objective The aim of the study was to assess the efficacy of cardiac resynchronization therapy (CRT) in patients with chemotherapy‐induced cardiomyopathy (CIC). Methods With the increasing incidence of CIC, the association of CRT with improvement in clinical outcomes, echocardiographic parameters, and New York Heart Classification (NYHA) class was assessed through this qualitative systematic review. Results The five studies included a total of 169 patients who underwent CRT after CIC, and of these, 61 (36.1%) patients were males. All studies showed an improvement in left ventricular ejection fraction (LVEF), among other echocardiographic parameters of LV volume. However, these findings are limited by short follow‐up periods, small sample sizes, and the absence of a control group. Conclusion CRT was associated with improvement in all patient parameters with CIC.

Abstract Background Our study hypothesized that an intelligent gradient boosting machine (GBM) model can predict cerebrovascular events and all‐cause mortality in mitral stenosis (MS) with atrial flutter (AFL) by recognizing comorbidities, electrocardiographic and echocardiographic parameters. Methods The machine learning model was used as a statistical analyzer in recognizing the key risk factors and high‐risk features with either outcome of cerebrovascular events or mortality. Results A total of 2184 patients with their chart data and imaging studies were included and the GBM analysis demonstrated mitral valve area (MVA), right ventricular systolic pressure, pulmonary artery pressure (PAP), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, and surgery as the most significant predictors of transient ischemic attack (TIA/stroke). MVA, PAP, LVEF, creatinine, hemoglobin, and diastolic blood pressure were predictors for all‐cause mortality. Conclusion The GBM model assimilates clinical data from all diagnostic modalities and significantly improves risk prediction performance and identification of key variables for the outcome of MS with AFL.

Abstract Periodontal diseases are prevalent and have significant implications for oral health and overall well‐being. Current diagnostic methods have limitations in accuracy and standardization. The recent Food and Drug Administration approval of Videa Perio Assist (VPA), an AI model for diagnosing periodontal diseases, presents a breakthrough in dental diagnostics. VPA is a cloud‐based, AI‐powered software that automatically measures and visualizes bone levels associated with each tooth from radiographic images. Clinical testing has demonstrated VPA's efficacy in accurately diagnosing periodontal diseases with high sensitivity and specificity. The integration of AI in dentistry has the potential to revolutionize periodontal disease diagnosis, improve patient care, and enhance decision‐making. However, further research, education, cost‐effectiveness, and collaboration are essential for maximizing the benefits of AI in dental settings. The approval and implementation of VPA mark a significant advancement in dental diagnostics, paving the way for more effective solutions and a healthier global population.

Background Residual risk of cardiovascular events and plaque progression remains despite reduction in low‐density lipoprotein cholesterol. Factors contributing to residual risk remain unclear. The authors examined the role of eicosapentaenoic acid and docosahexaenoic acid in coronary plaque regression and its predictors. Methods and Results A total of 240 patients with stable coronary artery disease were randomized to eicosapentaenoic acid plus docosahexaenoic acid (3.36 g/d) or none for 30 months. Patients were stratified by regression or progression of coronary fatty plaque measured by coronary computed tomographic angiography. Cardiac events were ascertained. The mean±SD age was 63.0±7.7 years, mean low‐density lipoprotein cholesterol level was

Abstract In this case report, we describe isolated left ventricular cardiac tamponade, a rare complication of cardiac surgery, diagnosed on point‐of‐care ultrasound (POCUS) in the emergency department (ED). To our knowledge, this is the first report of such a diagnosis made on ED bedside ultrasound. Our patient was a young adult female with a history of recent mitral valve replacement who presented to the ED with dyspnea and was found to have a large loculated pericardial effusion causing left ventricular diastolic collapse. Rapid diagnosis via POCUS in the ED allowed for expedited definitive treatment by cardiothoracic surgery in the operative room and emphasizes the importance of a standard 5‐view cardiac POCUS examination when post–cardiac surgery patients present to the ED.

Abstract Aims/Introduction Limited studies have identified risk factors linked to the progression of diabetic peripheral neuropathy (DPN) in type 2 diabetes. This study examined the association of risk factors with change in neuropathy measures over 2 years. Materials and Methods Participants with type 2 diabetes (n = 78) and controls (n = 26) underwent assessment of clinical and metabolic parameters and neuropathy using corneal confocal microscopy (CCM), vibration perception threshold (VPT), and the DN4 questionnaire at baseline and 2 year follow‐up. Results Participants with type 2 diabetes had a lower corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P ≤ 0.0001) and a higher VPT (P ≤ 0.01) compared with controls. Over 2 years, despite a modest reduction in HbA1c (P ≤ 0.001), body weight (P ≤ 0.05), and LDL (P ≤ 0.05) the prevalence of DPN (P = 0.28) and painful DPN (P = 0.21) did not change, but there was a significant further reduction in CNBD (P ≤ 0.0001) and CNFL (P ≤ 0.05). CNFD, CNBD, and CNFL decreased significantly in physically inactive subjects (P

Abstract The segmentation of building from satellite and airborne images is necessary for high‐resolution buildings maps generation and it is still challenging. On annotated pixel‐level images, trained deep convolutional neural networks (CNNs) were used to improve segmentation of building. The cost of labelling training data is high, which reduces their usage. Human labelling efforts can be significantly reduced using weakly supervised segmentation techniques. Here, a novel weakly supervised framework is introduced for building semantic segmenting that relies on deep seeds to construct a superpixels‐CRF model over superpixels segmentation in order to generate high‐quality initial pixel‐level annotations, as the initialization step. Then, the segmentation network is trained using the initial pixel‐level annotations. Next, the CRF model is used to refine the segmentation masks, and the segmentation network is retrained to achieve accurate pixel‐level annotations while iteratively optimizing the segmentation. The experimental results on three public building datasets demonstrate that the proposed framework significantly improved the quality of building semantic segmentation while remaining computationally efficient.

Abstract Aims Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline‐directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. Methods and results We recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta‐blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non‐cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non‐cardiovascular hospitalization (25.4% vs. 13.9%; P = 0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age‐adjusted survival after discharge, without differences in heart failure re‐hospitalization. De‐escalation of beta‐blockers occurred in 8% of hospitalizations, most often due to other non‐cardiovascular causes; this was not associated with post‐discharge survival or re‐hospitalization with heart failure. Conclusions De‐escalation of HFrEF GDMT is more common during non‐cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post‐discharge care plans should include robust plans to consider re‐escalation of GDMT in these cases.

Abstract Aims/Introduction This study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN), painful DPN and diabetic foot ulceration (DFU) in patients with type 2 diabetes in secondary healthcare in Qatar, Kuwait and the Kingdom of Saudi Arabia. Materials and Methods Adults aged 18–85 years with type 2 diabetes were randomly enrolled from secondary healthcare, and underwent clinical and metabolic assessment. DPN was evaluated using vibration perception threshold and neuropathic symptoms and painful Diabetic Peripheral Neuropathy was evaluated using the Douleur Neuropathique 4 questionnaire. Results A total of 3,021 individuals were recruited between June 2017 and May 2019. The prevalence of DPN was 33.3%, of whom 52.2% were at risk of DFU and 53.6% were undiagnosed. The prevalence of painful DPN was 43.3%, of whom 54.3% were undiagnosed. DFU was present in 2.9%. The adjusted odds ratios for DPN and painful DPN were higher with increasing diabetes duration, obesity, poor glycemic control and hyperlipidemia, and lower with greater physical activity. The adjusted odds ratio for DFU was higher with the presence of DPN, severe loss of vibration perception, hypertension and vitamin D deficiency. Conclusions This is the largest study to date from the Middle East showing a high prevalence of undiagnosed DPN, painful DPN and those at risk of DFU in patients with type 2 diabetes, and identifies their respective risk factors.

Abstract Aims Pulmonary artery pressure (PAP)‐guided therapy in patients with heart failure (HF) using the CardioMEMS (CMM) device, an implantable PAP sensor, has been shown to reduce HF hospitalizations in previous studies. We sought to evaluate the clinical benefit of the CMM device in regard to 30, 90, and 180 day readmission rates in real‐world usage. Methods and results We queried the Nationwide Readmissions Database (NRD) to identify patients who underwent CMM implantation (International Classification of Diseases 9 and 10 codes) between the years 2014 and 2019 and studied their HF readmissions. Moreover, we compared CMM patients and their readmissions with a matched cohort of patients with HF but without CMM. Multivariable Cox regression analysis was performed to adjust for other predictors of readmissions. Prior to matching, we identified 5 326 530 weighted HF patients without CMM and 1842 patients with CMM. After propensity score matching for several patients and hospital‐related characteristics, the cohort consisted of 1839 patients with CMM and 1924 with HF without CMM. Before matching, CMM patients were younger (67.0 ± 13.5 years vs. 72.3 ± 14.1 years, P

Background Patients with acute ischemic stroke onset during hospital admission often have concurrent illnesses, increased underlying comorbidities and are often associated with a delayed recognition of stroke onset, compared with patients with stroke onset in the community (community‐onset stroke [COS]). Endovascular thrombectomy (EVT) for large‐vessel occlusion in acute ischemic stroke has been proven to be effective, though the safety and feasibility of EVT among patients with in‐hospital stroke (IHS) onset remains undetermined. We aim to compare the workflow and clinical outcomes for patients undergoing EVT following IHS onset and COS. Methods Using data from a national stroke registry, we used propensity score‐matched individual‐level data of patients who underwent EVT, following IHS and COS, between October 2015 and March 2020. Univariate analysis was performed to assess the procedural, functional, and safety outcomes. Results We included 4353 patients (COS, 4104 [249 after propensity score matching]; IHS, 249 [249 after propensity score matching]). Compared with COS, patients with IHS had similar modified Rankin Scale on discharge (odds ratio [OR], 0.98 [95% CI, 0.72–1.34]; P=0.96) and at 6 months (OR, 1.25 [95% CI, 0.71–2.24]; P=0.48). No significant difference in achieving good functional outcome (modified Rankin Scale ≤ 2 at discharge; 31.3% [IHS] versus 29.3% [COS]; OR,=1.10 [95% CI 0.74–1.60]; P=0.61), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b–3), P=0.82; or safety outcomes of symptomatic intracranial hemorrhage (P=0.64) and in‐hospital mortality (P=0.26) were demonstrated. Shorter time interval from stroke onset to imaging in the IHS group (IHS, 80±88 versus COS, 216±292 minutes) was observed. The imaging‐to‐arterial‐puncture time was not significantly different between the groups (IHS, 160±140 versus COS, 162±184 minutes; P=0.85). Conclusions EVT in patients with IHS is safe and feasible, with comparable functional and safety outcomes to patients with COS, in this national stroke registry. Continued efforts are required to improve the inpatient stroke workflow in recognizing stroke symptoms and initiating reperfusion treatment for eligible patients with IHS.

Abstract Objective Many clinical and preclinical studies have implicated an association between atrial fibrillation (AF) and its progression to imbalances in the gut microbiome composition. The gut microbiome is a diverse and complex ecosystem containing billions of microorganisms that produce biologically active metabolites influencing the host disease development. Methods For this review, a literature search was conducted using digital databases to systematically identify the studies reporting the association of gut microbiota with AF progression. Results In a total of 14 studies, 2479 patients were recruited for the final analysis. More than half (n = 8) of the studies reported alterations in alpha diversity in atrial fibrillation. As for the beta diversity, 10 studies showed significant alterations. Almost all studies that assessed gut microbiota alterations reported major taxa associated with atrial fibrillation. Most studies focused on short‐chain fatty acids (SCFAs), whereas three studies evaluated TMAO levels in the blood, which is the breakdown product of dietary l‐carnitine, choline, and lecithin. Moreover, an independent cohort study assessed the relationship between phenylacetylglutamine (PAGIn) and AF. Conclusion Intestinal dysbiosis is a modifiable risk factor that might provide newer treatment strategies for AF prevention. Well‐designed research and prospective randomized interventional studies are required to target the gut dysbiotic mechanisms and determine the gut dysbiotic‐AF relationship.

Background Obstructive sleep apnea (OSA) is common in heart failure with preserved ejection fraction (HFpEF). However, current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in HFpEF. This study assessed the association between adherence to PAP therapy and health care resource use in patients with OSA and HFpEF. Methods and Results Administrative insurance claims data linked with objective PAP therapy usage data from patients with OSA and HFpEF were used to determine associations between PAP adherence and a composite outcome including hospitalizations and emergency room visits. One‐year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 4237 patients (54.0% female, mean age 64.1 years); 40% were considered adherent to PAP therapy (30% intermediate adherent, 30% nonadherent). In the matched cohort, PAP‐adherent patients had fewer health care resource use visits than nonadherent patients, a 57% decrease in hospitalizations, and a 36% decrease in emergency room visits versus the year before PAP initiation. Total health care costs were lower in adherent patients than nonadherent patients ($12 732 versus $15 610, P

Abstract To avoid the complexity of the circuit for in‐memory computing, simultaneous execution of multiple logic gates (OR, AND, NOR, and NAND) and memory behavior are demonstrated in a single device of oxygen plasma‐treated gallium selenide (GaSe) memtransistor. Resistive switching behavior with RON/ROFF ratio in the range of 104 to 106 is obtained depending on the channel length (150 to 1600 nm). Oxygen plasma treatment on GaSe film created shallow and deep‐level defect states, which exhibit carriers trapping/de‐trapping, that lead to negative and positive photoconductance at positive and negative gate voltages, respectively. This distinguishing feature of gate‐dependent transition of negative to positive photoconductance encourages the execution of four logic gates in the single memory device, which is elusive in conventional memtransistor. Additionally, it is feasible to reversibly switch between two logic gates by just adjusting the gate voltages, e.g., NAND/NOR and AND/NAND. All logic gates presented high stability. Additionally, memtransistor array (1×8) is fabricated and programmed into binary bits representing ASCII (American Standard Code for Information Interchange) code for the uppercase letter “N”. This facile device configuration can provide the functionality of both logic and memory devices for emerging neuromorphic computing.

Acute ischemic stroke is a leading cause of death and major disability worldwide. Approximately 50% of ischemic strokes are caused by atherothrombotic occlusion of the cerebral arteries, and antiplatelets are the mainstay of secondary stroke preventative treatment. Aspirin is beneficial if given early, and short‐term treatment using aspirin and clopidogrel is increasingly used for patients with intracranial atherosclerotic disease, minor stroke, and or transient ischemic attack. However, up to 50% of patients continue to have recurrent stroke and major vascular events, which may be partly attributable to resistance to aspirin and or clopidogrel. Although the precise mechanisms are unknown, clinical and genetic factors associated with bioavailability and binding to target receptors are implicated. This narrative review begins with the concept of aspirin and clopidogrel resistance in ischemic stroke and transient ischemic attack, potential mechanisms including genetic polymorphisms, and an overview of platelet function measures and limitations. We conclude by highlighting practical issues in the management of patients with aspirin andclopidogrel resistance including the emerging interest in ticagrelor, prasugrel, and cilostazol as well as directions for future trials in transient ischemic attack and acute ischemic stroke.

Background Obstructive sleep apnea (OSA) is a common comorbidity in patients with heart failure, although current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in patients with heart failure. This study assessed the impact of adherence to PAP therapy on health care resource utilization in patients with OSA and heart failure with reduced ejection fraction. Methods and Results Administrative insurance claims data linked with objective PAP therapy use data from patients with OSA and heart failure with reduced ejection fraction were used to determine associations between PAP adherence and a composite outcome of hospitalizations and emergency room visits. One‐year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 3182 patients (69.9% male, mean age 59.7 years); 39% were considered adherent to PAP therapy (29% intermediate adherent, 31% nonadherent). One year after PAP initiation, adherent patients had fewer composite visits than matched nonadherent patients, driven by a 24% reduction in emergency room visits for adherent patients. Composite visit costs were lower in adherent versus nonadherent patients ($3500 versus $5879, P=0.031), although total health care costs were not statistically different ($13 028 versus $14 729, P=0.889). Conclusions PAP therapy adherence in patients with OSA with heart failure with reduced ejection fraction was associated with a reduction in health care resource utilization. This suggests that greater emphasis should be placed on diagnosing and effectively treating OSA with PAP in patients with heart failure with reduced ejection fraction.

Abstract Rift Valley fever is an important yet ignored viral hemorrhagic fever claiming many lives of African and Arabian countries over the past decade. Unfortunately, a recent outbreak of Rift Valley fever is currently ravaging in Mauritania. Death toll is rising continuously with 23 deaths reported in the month of October, 2022. Our article aims to shed light on the ongoing Rift Valley fever outbreak and recommendations to eradicate this potential threat to public health. Online databases including PubMed, the Lancet, and Science Direct as well as conferences, news, and press releases were used to for data collection. All the available medical literature related to Rift Valley fever in Mauritania were taken into consideration while writing the manuscript. As of October 17, 2022, 47 cases have been documented out of which 23 are dead. Case fatality rate has been reached to 49% which has given a wakeup call to the authorities. Efforts are being made by the concerned authorities and World Health Organization to halt the progression of this outbreak. Further investigations are required to completely eradicate the recurrent outbreaks in Mauritania especially in the area of vaccine development. Active involvement of public with the government authorities is of extreme significance in combating this disease.

Abstract This study presents a data‐driven approach in conjunction with an adaptive extended Kalman filter (AEKF) to estimate lithium‐ion batteries' state of charge (SOC) online. The Thevenin battery model is used to evaluate the effects using battery voltage and current. The advantages of the Lagrange multiplier method are utilized to model the lithium‐ion battery. The Lagrange multiplier method continuously decreases the model error to adjust the Kalman gain of AEKF for accurate SOC estimation. Various current profiles such as hybrid pulse test, dynamic stress test, and Beijing dynamic stress test are used to verify the proposed approach's adaptability, robustness, and accuracy. It is observed that the proposed approach outperforms other methodologies (recursive least square–AEKF and forgetting factor recursive least square–AEKF) due to its high accuracy (mean average error of 0.32%). Additionally, the proposed approach exhibits robustness and high convergence speed despite deliberate erroneous initialization of parameters, thus indicating its applicability in online SOC estimation applications.

Abstract Objective Light chain (AL) amyloidosis is a life‐threatening disorder characterised by extracellular deposition of amyloid leading to dysfunction of multiple organs. Peripheral nerve involvement, particularly small fibre neuropathy, may be associated with poorer survival. Corneal confocal microscopy (CCM) is a rapid and non‐invasive imaging technique to quantify corneal small nerve fibres and immune cells in vivo. We aimed to evaluate CCM as a tool for early diagnosis of peripheral nerve involvement in AL amyloidosis. Methods CCM and nerve conduction studies (NCS) were undertaken in 21 newly diagnosed, treatment‐naïve AL amyloidosis patients and 21 age‐ and sex‐matched healthy controls. Corneal nerve fibre density (CNFD), corneal nerve branch density and fibre length, and cell infiltrates were quantified in the sub‐basal layer of the cornea. Results There was a significant reduction in CNFD and nerve fibre length, even without large fibre affection and an increase in cell density, particularly around corneal nerve fibres in patients with AL amyloidosis compared to controls. Additionally, cell infiltration correlated with reduced nerve fibre density in patients with AL amyloidosis, but reduced CNFD did not correlate with laboratory parameters of organ dysfunction. Interpretation Our study is the first to show that CCM allows rapid non‐invasive identification of early small nerve fibre damage associated with immune cell infiltration in patients with AL amyloidosis. CCM detects peripheral nerve involvement more sensitively than NCS.

ABSTRACT Aims/Introduction Sodium–glucose cotransporter 2 inhibitors (SGLT‐2i) improve glycemic control and weight, but might be associated with dehydration, hypotension and ketoacidosis, especially in patients with type 2 diabetes mellitus who fast during Ramadan. This meta‐analysis evaluates the effects of Ramadan fasting on patients with type 2 diabetes mellitus treated with SGLT‐2i. Materials and Methods A literature search was carried out in PubMed, Embase and the Cochrane Library. Quality assessment was carried out using the ROBINS‐I and Cochrane tools for risk of bias, and analyses were carried out using RevMan version 5.3. Results A total of five studies were included in this meta‐analysis. During Ramadan, there was a significant reduction in glycated hemoglobin (P

Abstract Most commonly caused by trauma, basal skull fractures present with a range of clinical signs. These include periorbital ecchymosis, as seen in this case, as well as rhinorrhea, otorrhoea and post‐mastoid ecchymosis. Suspected cases must be managed with appropriate imaging and medical or surgical treatment as indicated.

Abstract This paper proposes a novel reversible data hiding (RDH) technique using sorting and pairwise prediction error expansion (PEE) to improve embedding capacity (EC) while retaining the quality of cover image. The proposed scheme traverses alternate pixels of the cover image in a zig‐zag order to construct two independent sets for sequential embedding. The pixels of each set are sorted in an increasing order of their rhombus mean followed by a two‐pass data embedding by dividing the sets into 1 × 3 size blocks based on some pre‐defined criteria. In pass 1, two prediction errors are calculated for the first and the last pixels using their rhombus means; and pairwise mapping is modified and exploited to embed the secret data in such a way that the value of the first pixel is either increased or remains unchanged, and the value of the last pixel is either decreased or remains unchanged. In pass‐2, the middle pixel is utilised to predict the first and last pixels and the values of the first pixel and the last pixel are either decreased or remains unchanged and either increased or remains unchanged, respectively. In contrast to some existing recovery‐based methods, the proposed pass‐2 guarantees to complement the changes made in pass‐1, thereby boosting the quality along with increased EC. The experimental results show that the proposed method achieves better embedding performance than the state‐of‐the‐art RDH techniques. More specifically, the proposed method gets an increment by an average of 0.46 dB and 1.01 dB for embedding 10,000 bits and 20,000 bits respectively over its closest prior art.

Background We examined arterial stiffness in individuals with type 1 diabetes, and explored whether differences between Hispanic, non‐Hispanic Black (NHB), and non‐Hispanic White (NHW) individuals were attributable to modifiable clinical and social factors. Methods and Results Participants (n=1162; 22% Hispanic, 18% NHB, and 60% NHW) completed 2 to 3 research visits from ≈10 months to ≈11 years post type 1 diabetes diagnosis (mean ages of ≈9 to ≈20 years, respectively) providing data on socioeconomic factors, type 1 diabetes characteristics, cardiovascular risk factors, health behaviors, quality of clinical care, and perception of clinical care. Arterial stiffness (carotid–femoral pulse wave velocity [PWV], m/s) was measured at ≈20 years of age. We analyzed differences in PWV by race and ethnicity, then explored the individual and combined impact of the clinical and social factors on these differences. PWV did not differ between Hispanic (adjusted mean 6.18 [SE 0.12]) and NHW (6.04 [0.11]) participants after adjustment for cardiovascular risks (P=0.06) and socioeconomic factors (P=0.12), or between Hispanic and NHB participants (6.36 [0.12]) after adjustment for all factors (P=0.08). PWV was higher in NHB versus NHW participants in all models (all P

Abstract A Fano Factor‐based adaptive overcurrent protection scheme, that automatically adjusts the protection settings in response to the prevailing conditions of the power system, is presented. Both phase and ground overcurrent relays are based on the same mathematical algorithm to calculate the operating time using Fano Factors (FFs) estimated for phase and ground current signals, respectively. Effectiveness of the proposed adaptive overcurrent method is validated for various fault types under a plethora of loading current levels, besides a wide range of fault inception angles and fault resistance. Simulation results confirm that the proposed algorithm can detect series and shunt faults, differentiate between grounding and phase faults, and adapt the relay operating time settings using the FF for all conditions examined. The relay algorithm speed and sensitivity are controllable using both the FF setting values and moving data window size. Moreover, it is characterized by being simple, reliable, accurate, and can be implemented practically as a base of digital protective relay for use in substation automation systems and phasor measurement units.

Abstract Objective This systematic review aimed to evaluate the performance of echocardiography‐based programming in comparison with the intracardiac electrocardiogram (IEGM)‐based method for the optimization of cardiac resynchronization therapy (CRT). Methods A literature review was conducted using digital databases to systematically identify the studies reporting CRT optimization through echocardiography compared with IEGM. Detailed patient‐level study characteristics including the type of study, sample size, therapy, the New York Heart Classification (NYHA) status, lead placement, and other parameters were abstracted. Finally, postprogramming outcomes were extracted for each article. Results In a total of 11 studies, 919 patients were recruited for the final analysis. Overall, 692 (75.29%) were males. The mean duration of the QRS complex in our study population ranged from 145.2 ± 21.8 ms to 183 ± 19.9 ms. There was an equal improvement in the NYHA class between the two methods while the left ventricular ejection fraction (LVEF) demonstrated an improvement by IEGM. Many studies supported IEGM to increase the 6‐minute walk test and left ventricular outflow tract velocity time interval (LVOT VTI) when compared to echocardiography. The mean time for echocardiography‐based optimization was 60.15 min while that of IEGM‐based optimization was 6.65 min. Conclusion IEGM is an alternative method for CRT optimization in improving the NYHA class, LVEF, and LVOT VTI, and is less time‐consuming when compared to the echocardiography‐based methods.

Abstract Background and Aims Little is known about the clinical relevance of pericardial fat volume (PFV), compared to other conventional cardiovascular risk factors, as predictors of coronary atherosclerosis severity among postmenopausal women. Our main aim was to assess the association of PFV and cardiovascular risk factors with coronary atherosclerosis burden, including occlusive coronary artery disease (CAD) (luminal stenosis >50%), coronary artery calcium score (CAC) >100, and plaque types in postmenopausal women. Methods Patients who had chest pain of angina and referred for 64‐slice multi‐detector CT (MDCT) angiography examination to exclude occlusive CAD presence were enrolled in this retrospective study. Results A total of 241 women with absence of menses for more than 2 consecutive years and not taking hormone replacement therapy were enrolled in the present study. Increased PFV (OR [CI] = 1.1 [1−1.3], p = 0.004), age (OR [CI] = 1.1 [1−1.4], p = 0.002), and diabetes mellitus (OR [CI] = 2 [1−4], p = 0.025) were significant predictors of occlusive CAD presence. Increased PFV (OR [CI] = 1.1 [1−1.4], p = 0.017) and increased age (OR [CI] = 1.2 [1.1−1.4], p 100 than other cardiovascular risk factors. Regarding coronary plaque types, increased age (OR [CI] = 1.1 [1.1−1.3], p = 0.001) showed a significant association with coronary calcified plaque presence while increased body mass index(OR [CI] = 1.2 [1−1.4], p = 0.018) showed a significant association with coronary non‐calcified plaque presence. Conclusion Higher PFV values showed an independent association with occlusive CAD and significant coronary calcification. This may imply that increased PFV is likely associated with the development of advanced and severe phenotype of coronary atherosclerosis among postmenopausal women with suspected CAD.

Abstract Jejunal diverticula are rare medical conditions with an incidence of 0.3%–2.5%, mostly discovered perioperatively. Our patient, 60 years old female, presented in an emergency with complaints of constipation, vomiting, abdominal pain, and distension. On examination, her abdomen was markedly distended with generalized tenderness. An erect abdominal X‐ray revealed multiple air‐fluid levels, which suggests small bowel obstruction. A diagnosis of jejunal diverticula was made on exploratory laparotomy. No evidence of granuloma or malignancy was seen on histopathological examination. Segmental resection of the affected jejunum was carried out, followed by end‐to‐end primary anastomosis. The patient was discharged on postoperative Day 6 with complete recovery at 2 weeks follow‐up visit.

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = < 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Introduction Despite the irrefutable benefit of mechanical thrombectomy for patients with isolated intracranial large vessel occlusions (LVO), the effect of endovascular treatment in patients with tandem lesions remains unclear. In this study from the multi‐center PICASSO registry, we compare efficacy and safety outcomes in TLs patients treated in the early versus late window. Methods In this study, we used the data from the multi‐center PICASSO (Proximal Internal Carotid Artery Acute Stroke Secondary to Tandem Occlusion Thrombectomy) registry. PICASSO collaboration is a retrospective observational registry from 17 stroke centers. We compared efficacy and safety outcomes in TLs patients treated in the early versus late window. Patients were divided into two groups depending on last known well (LKW) to puncture time: Early time‐window group (

Introduction The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice. Methods In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed. Results Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and >12 hour time window subgroups. No significant treatment interaction was observed in all subgroups. Conclusions In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset.

Introduction Tandem occlusions represent 10–20% of all acute ischemic stroke patients.1 Endovascular Thrombectomy (EVT) for this subset of patients is more challenging given the proximal underlying steno occlusive disease. Emergent carotid artery stenting could achieve a considerably high chance of reperfusion and functional independence.2 Methods This is a case report of a 73‐year‐old woman who presented with left MCA syndrome‐NIHSS 13 found to have left ICA/MCA tandem occlusions. EVT was pursued, initial angiographic run of the left common carotid artery demonstrated severe stenosis at the origin of left cervical ICA which harbors a mid‐cervical ICA loop and proximal left MCA occlusion. Following our retrograde revascularization approach, an intracranial pass using an embotrap 5mm x 37 mm stent retriever (SR) was attempted however given proximal cervical ICA tortuosity and underlying proximal stenosis, the stability of triaxial system prevented optimal placement of the SR and achieving intracranial reperfusion. An antegrade revascularization approach was then pursued with uneventful cervical ICA angioplasty followed by extracranial carotid closed cell Xact stent placement. A stable triaxial system was navigated through the stented cervical ICA. An ideal SR pass was performed. Upon retrieving the clot‐incorporated SR with the intention to fully retrieve the SR into the locally placed aspiration catheter (AC) in the supraclinoid ICA under continuous aspiration, the triaxial system collapsed into the distal CCA, likely due to the mid cervical ICA loop, leading to entanglement of the proximal end of SR and distal ICA stent (Figure1‐A). Large thrombus was recovered from the AC aspirate. Results Numerous attempts to disentangle the SR from the ICA stent including attempts to re‐sheath the SR with different size microcatheters and guide catheters were unsuccessful. The cervical ICA lumen remained patent without evidence of dissection or residual thrombus however, the presence of SR pusher‐wire would preclude safe termination of the procedure. Surgical bailout with emergent carotid endarterectomy and removal of the stent/SR metal mesh was considered.3,4 However, given the high surgical risk with recent intravenous load of antithrombotics for emergent stent placement, this option was deemed as a last resort. We decided to attempt safe separation of the SR from its pusher wire and leave behind the patent ICA stent/SR in place. A gradual pulling pressure was applied to the SR wire while maintaining adjacent microwire access and fully inflated Viatrac 5mm x 30 mm extracranial balloon over the entangled portion to ensure continuous vascular access (Figure1‐B). The SR wire was then separated from the SR and fully retracted outside the body (Figure1‐C). Delayed angiographic runs continued to demonstrate full patency of the ICA lumen (Figure1‐D). No residual dissection, spasm or thrombus noted. Patient was discharged home with NIHSS of 3. Conclusions Exposure to EVT technical complications and bailout techniques are of utmost importance.

Introduction Intracranial pseudoaneurysms are rare lesions that represent less than 1% of all intracranial aneurysms.1They typically occur due to disruption of the arterial wall layers and subsequent extramural/extraluminal hematoma formation following traumatic brain injury, resulting in a higher risk of rebleeding than that of saccular cerebral aneurysms.2Pseudoaneurysms have higher incidence in children and young adults, and given their association with high morbidity and mortality, early detection and management is essential.2‐4The purpose of this study is to highlight the importance of early recognition and management of traumatic pseudoaneurysms prior to decompressive hemicraniectomy. Methods This is a case report of a six‐year‐old previously healthy male who presented as a level 1 trauma alert after sustaining a gunshot wound to the face while manipulating an unsecured weapon at his residence. Upon arrival, lack of airway protection requiring intubation, entry wound to the anterior forehead, and diffuse forehead and periorbital edema were observed. CT head demonstrated multicompartmental hemorrhage with 6mm right to left midline shift and diffuse cerebral edema. CTA head and neck noted possible thrombosed right anterior cerebral artery (ACA) pseudoaneurysm in the right frontoparietal region (Figure 1‐A). Prior to decompressive hemicraniectomy, neuro‐endovascular consultation was obtained, and emergent cerebral angiogram was recommended. This case highlights the findings demonstrated on cerebral angiography, the technique by which the pseudoaneurysm was detected and secured, and the importance of doing so prior to further neurosurgical interventions. Results The patient was taken for diagnostic cerebral angiogram via femoral artery access. Initial angiographic run of the right internal carotid artery demonstrated distal right pericallosal artery slowing without clear evidence of underlying vascular injuries. Given concern for underlying thrombosed pseudoaneurysm and its parent branch, selective catheterization of the proximal pericallosal artery off the distal ACA was performed. Gentle angiographic run was obtained via microcatheter that demonstrated superior parietal artery pseudoaneurysm without active extravasation (Figure 1‐B). The microcatheter was advanced and placed in the proximal portion of the pseudoaneurysm sac and five platinum coils were deployed to fully obliterate the pseudoaneurysm and its parent feeder while protecting the adjacent paracentral artery (Figure 1‐C, 1‐D). Following completion of the endovascular procedure, the patient was transferred to the operative room for right decompressive hemicraniectomy and clot evacuation, which were completed successfully. Conclusions Prompt detection and securement of traumatic intracranial pseudoaneurysms are essential prior to invasive neurosurgical interventions to reduce risk of recurrent bleeding. Selective angiographic evaluation of the parent injured vessel(s) is crucial for optimal assessment of the underlying lesion. Neuro‐endovascular interventions including coil embolization, stenting, flow‐diverter implantation, and parental artery occlusion have emerged as alternatives to conventional neurosurgical management.2 This case highlights the successful early detection and treatment of a traumatic intracranial pseudoaneurysm with coil embolization followed by uncomplicated decompressive hemicraniectomy.