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Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting.Τhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP.A retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation.A total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4-36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1-34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI30) (odds ratio: 3.664; 95% CI: 1.394-9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8-21.5) than for those without VAP (6.1%, 95% CI: 3.0-12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p 0.001), than cases without VAP.This is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.

Overcoming Limitations of Ecology and Engineering in Addressing Society’s Challenges By providing an integrated, systems-approach to problem-solving that incorporates ecological principles in engineering design, ecological engineering addresses, many of the limitations of Ecology and Engineering needed to work out how people and nature can beneficially coexist on planet Earth. Despite its origins in the 1950s, ecological engineering remains a niche discipline, while at the same time, there has never been a greater need to combine the rigour of engineering and science with the systems-approach of ecology for pro-active management of Earth’s biodiversity and environmental life-support systems. Broad consensus on the scope and defining elements of ecological engineering and development of a globally consistent ecological engineering curriculum are key pillars to mainstream recognition of the discipline and practice of ecological engineering. The Importance of Ecological Engineering in Society In this paper, the importance of ecological engineering education is discussed in relation to the perceived need of our society to address global challenges of sustainable development. The perceived needs of industry, practitioners, educators and students for skills in ecological engineering are also discussed. The Importance and Need for Ecological Engineering Education The need for integrative, interdisciplinary education is discussed in relation to the scope of ecology, engineering and the unique role of ecological engineering. Scope for a Universally Recognised Curriculum in Ecological Engineering The scope for a universally recognised curriculum in ecological engineering is presented. The curriculum recognises a set of overarching principles and concepts that unite multiple application areas of ecological engineering practice. The integrative, systems-based approach of ecological engineering distinguishes it from the trend toward narrow specialisation in education. It is argued that the systems approach to conceptualising problems of design incorporating ecological principles is a central tenant of ecological engineering practice. Challenges to Wider Adoption of Ecological Engineering and Opportunities to Increase Adoption Challenges and structural barriers to wider adoption of ecological engineering principles, embedded in our society’s reliance on technological solutions to environmental problems, are discussed along with opportunities to increase adoption of ecological engineering practice. It is suggested that unifying the numerous specialist activity areas and applications of ecological engineering under an umbrella encompassing a set of core principles, approaches, tools and way of thinking is required to distinguish ecological engineering from other engineering disciplines and scale up implementation of the discipline. It is concluded that these challenges can only be realised if ecological engineering moves beyond application by a relatively small band of enthusiastic practitioners, learning by doing, to the education of future cohorts of students who will become tomorrow’s engineers, project managers, procurement officers and decision makers, applying principles informed by a growing body of theory and knowledge generated by an active research community, a need whose time has come, if we are to deploy all tools at our disposal toward addressing the grand challenge of creating a sustainable future.

Background There are scenarios where pre-mixing and infusing analgesic and anaesthetic agents as a single intravenous (IV) solution is highly desirable; however, it is important to ensure the agents are compatible when mixed. As such, the long-term stability of a remifentanil-propofol mixture, and means of improving this, were assessed across a range of remifentanil concentrations, diluents, and time points. Methods Remifentanil was reconstituted with ultrapure water, 0.9% saline, 20% saline, or 8.4% sodium bicarbonate solution (the latter two chosen for their pH characteristics, rather than their use in pharmaceutical reconstitution) and then mixed with propofol (1%) or further diluted with water to derive concentrations of 10–50 μg mL− 1. Remifentanil and propofol concentrations were determined initially and then periodically for up to 24 h using high performance liquid chromatography (HPLC). Mass spectrometry (MS) was used to detect degradation products in solutions containing 30 μg mL− 1 of remifentanil. Statistical analysis was performed using ANOVA and Student’s t-test, with a significance value of 0.05. Results Isolated remifentanil (pH P Conclusions Remifentanil stability is affected by both the reconstitution solution used and when mixed with propofol, with pH appearing to be a contributing factor to degradation. If the pH of the solution and concentration of remifentanil are correctly controlled, e.g. through the use of a more acidic diluent, an admixture of remifentanil and propofol may be useful clinically.

Purpose Thyroid dysfunction in patients with cardiac disease is associated with worse outcomes. This study aimed to evaluate the prevalence and analyse predictors and outcomes of thyroid dysfunction in patients presenting with an acute myocardial infarction (AMI). Methods A prospective multicentre observational study of patients recruited from six acute hospitals within the North of England. Consecutive patients without previous thyroid disease presenting with both ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI) were recruited to the Thyroxine in Acute Myocardial Infarction 1 (ThyrAMI-1) cohort study between December 2014 and 2016. Thyroid profile, standard biochemistry measurements and demographic information were obtained within 12 h of admission to hospital. Multivariable logistic regression analyses were performed to assess the predictors of thyroid dysfunction and Cox proportional hazards analyses were utilised to compare all-cause mortality by categories of thyroid dysfunction up to June 2019. Results Of the 1802 participants analysed, 1440 (79.9%) were euthyroid, 312 (17.3%) had subclinical hypothyroidism (SCH), 22 (1.2%) had subclinical hyperthyroidism (SHyper) and 25 (1.3%) had low T3 syndrome (LT3S). Predictors for SCH were increasing age, female sex, higher thyroid peroxidase antibody (TPOAb) levels, higher serum creatinine levels and early morning sampling time (between 00:01–06:00 h). The predictors of SHyper were lower body mass index and afternoon sampling time (between 12:01 and 18:00 h). Predictors of LT3S were increasing age, higher creatinine levels and presence of previous ischaemic heart disease. Compared to the euthyroid group, patients with LT3S had higher all-cause mortality; adjusted hazard ratio (95% CI) of 2.02 (1.03–3.95), p = 0.04, whereas those with SCH and SHyper did not exhibit significantly increased mortality; adjusted hazard ratios (95% CI) of 1.05 (0.74–1.49), p = 0.79 and 0.27 (0.04–1.95), p = 0.19, respectively. Conclusions Thyroid dysfunction is common in AMI patients on admission to hospital and our data provide an understanding regarding which factors might influence thyroid dysfunction in these patients. Furthermore, the negative association between LT3S and increased mortality post-AMI has once again been highlighted by this study. More research is required to assess if treatment of thyroid dysfunction improves clinical outcomes.

The issue of fluctuation and personnel stabilization is a subject of discussion and study by several domestic and foreign authors. A typical situation in the Slovak labour market is a combination of factors for increasing demand for labour and a lack of qualified employees forcing hotel managers to internally change the perception of employees in terms of stability. The aim of the paper is to specify the causes of fluctuation and propose options for stabilizing the rate of turnover in the hospitality industry. A prerequisite for meeting the stated goal is to conduct a sociological inquiry in selected chains and independent hotels in Slovakia. This was achieved through a survey of hotels in 2018 highlighting the respondents' views on solving the challenges caused by increased fluctuation and the need for stability. The results identify the main reasons for employment turnover and helped formulate general conclusions and recommendations for the improvement of employee turnover.

Volunteer tourism is one of the fastest growing types of alternative travel, highlighting the need for sustainability. It has been studied in a number of researches that focus almost exclusively on the demand for certain projects in outbound tourism. With the aim of a more comprehensive view of the issue, this paper examines and compare the current state of demand for domestic and outgoing volunteer tourism within Slovakia. It is based on a quantitative survey conducted on a sample of 573 respondents who represent a representative picture of the population of Slovakia older than 15 years in terms of age and gender. It turns out that between 18 and 25% of the Slovak population participated in domestic volunteer tourism between 2013 and 2018 (in average 3-4% a year). Outbound volunteer tourism was 4 to 8% (approximately 1% a year). In both cases, potential demand clearly exceeds effective demand. As individuals grow older, participation in volunteer tourism decrease slightly, while participation in the home country is positively influenced by higher education while participation abroad is dependent on the individual's economic status. Participation in domestic volunteer tourism is largely influenced by volunteer-specific motives, this differs from outbound tourism, where tourist specific motives prevail. In the home country. Volunteers sometimes do not realize that they are involved in tourism; the altruistic motive of helping others is paramount. Important information about national volunteer tourism of Slovak residents is obtained mostly from direct sources. Time is the most decisive obstacle to people's participation in volunteer tourism. Comparing the demand of Slovak citizens for domestic and outgoing volunteer tourism shows the possibilities of its further development.

Objectives We assessed the impact of diabetes mellitus (DM) on mortality after percutaneous coronary intervention (PCI) for left main stem (LMS) disease. Second, we compared mortality outcomes between non-insulin treated (NITDM) and insulin treated diabetes (ITDM) in different clinical settings. Background There is a paucity of "real world" outcomes data in diabetic patients undergoing LMS PCI. Methods We undertook a retrospective analysis of consecutive patients undergoing unprotected LMS PCI at 2 high volume tertiary centers. Diabetic status and clinical setting for PCI were recorded. The primary outcome measure was all-cause 30-day and long-term mortality (up to 36 months) post index PCI. Results Between 2003 and 2017, 2,675 patients undergoing index LMS PCI were analyzed. Of those, 77.1% were non-DM, 15.8% NITDM, and 7.1% ITDM. Overall, DM status was not associated with higher 30-day mortality (OR 1.39, 95% CI 0.89-2.16, p = .15). During a median follow-up of 36 months, there was a borderline statistical association of DM with long-term mortality in all PCI settings (HR 1.31, 95% CI 1.00-1.71, p = .05). Compared to non-DM, ITDM but not NITDM was associated with short- and long-term mortality in all clinical presentations. Conclusions Overall, DM did not impact on 30-day mortality and had only a borderline statistical association with long-term mortality. It did not have an influence on mortality in non-emergency LMS PCI. The impact of DM on mortality outcomes following LMS PCI was only significant in the insulin treated patients.

Triple Negative breast cancer (TNBC) is a subtype of breast cancer that lacks the expression of estrogen receptor (ER), progesterone receptor, and human epidermal growth factor receptor 2. TNBC accounts for 15-20% of all breast cancer cases but accounts for over 50% of mortality. We propose that Estrogen receptor-beta (ERβ) and IGF2 play a significant role in the pathogenesis of TNBCs, and could be important targets for future therapy. Tissue microarrays (TMAs) from over 250 TNBC patients' were analyzed for ERβ and IGF2 expression by immunohistochemistry. Expression was correlated with clinical outcomes. In addition, TNBC cell lines Caucasians (CA): MB-231/BT549 and African Americans (AAs): MB-468/HCC70/HCC1806 were used to investigate the effect of hormonal and growth factor regulation on cell proliferation. TMAs from AAs had higher expression of ERβ and IGF2 expression when compared to CA. ERβ and IGF2 were found to be upregulated in our TNBC cell lines when compared to other cell types. TNBC cells treated with ERβ agonist displayed significant increase in cell proliferation and migration when compared to controls. AA tissue samples from TNBC patients had higher expression of ERβ. African-American breast cancer TNBC tissue samples from TNBC patients have higher expression of ERβ. In addition, TNBC cell lines were also found to express high levels of ERβ. IGF2 increased transcription of ERβ in TNBC cells. Understanding the mechanisms of IGF2/ERβ axis in TNBC tumors could provide an opportunity to target this aggressive subtype of breast cancer.

Mobley M, Gantzer P, Benskin P, Hannoun I, McMahon S, Austin D, Scharf R. 2019. Hypolimnetic oxygenation of water supply reservoirs using bubble plume diffusers. Lake Reserv Manage. 35:247–265. Hyp...

Background Despite the associated dose-dependent cardiotoxicity, anthracyclines continue to form the backbone of modern chemotherapy regimens. Speckle Tracking Echocardiography (STE) has been a popular method of quantifying cardiac function but most studies have focused on left ventricular function. Research into the effects of anthracyclines on left atrial (LA) and right atrial (RA) function continues to be neglected. Purpose To investigate the effects of doxorubicin, a commonly used anthracycline, on both the LA and RA systolic and diastolic strain and strain-rate parameters in two groups of patients with lymphoma: Group 1 (G1) with a conventional drop in ejection fraction (EF Methods We retrospectively studied 46 patients treated for lymphoma between 2015 and 2018; G1 (n=12) and G2 (n=34). Echocardiograms performed at baseline (T0), mid-chemotherapy (T1), and post-chemotherapy (T2), were analysed by using offline vendor-independent software (TomTec, 2D Cardiac Performance Analysis). Using 2D STE, LA and RA reservoir, conduit and contractile strains, systolic and diastolic strain-rates were measured. Multi-level longitudinal model was used for statistical analysis.This study was ethically approved by the Health Research Association (REC Reference 18/SS/0139). Results Median age was 64 years (IQR 51–74 years) in G1, and 65 years (IQR 57–73 years) in G2. In G1, there was no significant change in LA reservoir strain with time, however a significant decline with an average mean difference of −7.52 was seen between T0 to T2 (p=0.016) in G2. LA conduit strain did not significantly change in either group with incremental doses of doxorubicin. However, LA contraction strain was seen to significantly increase in G1 between T1 to T2 (p=0.045) with an average change of 7.23. LA peak systolic strain rate, and late diastolic strain rate did not show any significant change with time in both groups. Yet, a significant increase was seen in LA early diastolic strain rate between T0 to T2 (p=0.017) in G1 but not G2. No significant changes were seen in the RA strain parameters in both groups. Conclusion In patient with a reduction in LV function, a significant change was noted in the left atrial contraction strain and early diastolic strain rate with incremental doses of doxorubicin. These changes shows the close relationship between the LA and LV, and the importance of LA in providing a compensatory mechanism for a decline in LV function secondary to anthracycline cardiotoxicity. Funding Acknowledgement Type of funding source: None

Funding Acknowledgements South Tees Research and Development Fund (UK) Background Anthracyclines are a cornerstone in the management of lymphoma. However, their use is associated with cardiotoxicity. Speckle tracking echocardiography (STE) has been established as a valid measure of quantifying cardiac function. However, most studies to this date have focused predominantly on left ventricular (LV) global longitudinal strain (GLS) with only a limited number assessing the right ventricle (RV) and other LV strain parameters. Purpose Using 2D STE, we assessed the effects of anthracyclines on LV and RV strain parameters, focusing on LV endocardial (GLS), LV myocardial GLS (myoGLS), LV radial strain (GRS), RV endocardial (RV GLS), myocardial GLS (RV myoGLS), and RV free wall strain (RVFWS). Methods We retrospectively collected data on patients treated for lymphoma between 2015-2018. Two groups (G) were defined: those with a conventional drop in LV ejection fraction (EF), (G1, n = 11) and those without (G2, n = 24). Echocardiograms were performed pre-chemotherapy (T0), mid-treatment (T1), and post-chemotherapy (T2) and were analysed offline using vendor-independent software (TomTec 2D CPA). LV and RV strain analysis was performed in both groups. This study was ethically approved by Health Research Association (REC Reference 18/SS/0139). Results Mean age was 61 ± 16 years (G1) and 65 ± 12 years (G2). 18% (G1) and 17% (G2) of patients had a history of IHD in each group. Mean cumulative dose of doxorubicin was 280 ± 31 mg/m2 (G1) and 280± 48mg/m2 (G2). In both groups, there was no significant change in LV or RV strain parameters from T0 to T1. In G1, between T1 and T2, patients exhibited a significant deterioration in LV GLS (-19.7 ± 2.6% vs.-15.6 ± 2.5% p Conclusion In patients with a reduction in LVEF, this analysis demonstrated a significant reduction in LV strain parameters secondary to anthracycline treatment. Novel strain parameters did not change in the normal EF group, or predate EF/GLS decline in those with reduced LVEF. Measurable RV dysfunction was noted in those with LV deterioration, highlighting the global cardiac insult of anthracycline treatment. Preventative and monitoring strategies in cardio-oncology should not overlook RV function.

Incorporating headache/migraine operative procedures into an existing surgical practice may be challenging at first but can ultimately be very rewarding. There are several key reasons that might motivate physicians to incorporate this treatment specialty into their practice. First, some physicians are lucky enough to have trained at the rare academic center where these operative procedures are routinely taught and have seen the often life-changing results that these patients experience. For many of these physicians, there is a natural tendency to recreate their mentor’s style of practice. Other physicians may have a clinical, intellectual, or technical interest in peripheral nerve surgery from experience in hand surgery, facial nerve reconstruction, or other peripheral nerve procedures. However, the epidemiology of migraines is downright daunting. It is one of only eight disease states known to affect more than 10% of the world’s population and afflicts almost one in five Americans. Therefore, it is likely that many doctors may have friends, family, or personal experience dealing with migraines/chronic headaches and understand first-hand the immense burden these conditions place on patients and their loved ones. For these physicians, a significant motivation may be the simple desire to help ease this suffering. Moreover, some clinicians may have patients from the more than 36 million migraine sufferers in the United States who are impacted physically, socially, and occupationally by this debilitating condition and whom that have expressed to them an interest in surgical treatment for their chronic headaches. Finally, still other physicians may simply want to create a niche for their practice by offering a unique set of surgical procedures to this large and underserved patient population.

Objective The objective of this study was to determine the impact of blood sample timing on the diagnosis of subclinical thyroid dysfunction (SCTD) and mortality in patients with acute myocardial infarction (AMI). Patients, Design, and Main Outcome Measures Patients with AMI had thyroid function evaluated on admission between December 2014 and December 2016 and those with abnormal serum thyrotropin (TSH) had repeat thyroid function assessed at least a week later. The association between sample timing and SCTD was evaluated by logistic regression analysis. Secondary outcomes were confirmation of SCTD on repeat testing and all-cause mortality up to June 2018. Results Of the 1806 patients [29.2% women, mean (± standard deviation) age of 64.2 (±12.1) years] analyzed, the prevalence of subclinical hypothyroidism (SCH) was 17.2% (n = 311) and subclinical hyperthyroidism (SHyper) was 1.2% (n = 22) using a uniform TSH reference interval. The risk of being diagnosed with SCTD varied by sample timing in fully-adjusted models. The risk of SCH was highest between 00.01 and 06.00 hours and lowest between 12.01 and 18.00 hours, P for trend Conclusions Sample timing impacts on the diagnosis and prognosis of SCH in AMI patients. If sample timing is not accounted for, SCH is systemically misclassified, and its measurable influence on mortality is lost.

BACKGROUND The PRAMI and CvLPRIT trials support preventive percutaneous coronary intervention (PCI) for multivessel coronary disease found during ST-segment elevation myocardial infarction (STEMI). We assess our real-world experience of the management of multivessel disease identified during primary PCI (PPCI) in a large UK regional centre. PATIENTS AND METHODS All STEMI patients who underwent culprit-only PPCI during the study period (August 2011 to August 2013) were retrospectively assessed for eligibility to each trial. The two resulting groups were designated as the 'observational' cohorts. Primary outcomes were then determined and compared with the culprit-only revascularisation cohorts from the respective published randomized controlled trials (RCTs). RESULTS A total of 1143 consecutive cases were presented during the study period. Of these, 343 would have been suitable for inclusion to PRAMI and were included in the 'observational PRAMI' cohort; 196 patients were included in the 'observational CvLPRIT' cohort.The 'observational PRAMI' cohort experienced fewer primary outcome events (13.1 vs. 22.9%), cardiac deaths (0.6 vs. 4.3%) and nonfatal myocardial infarctions (3.5 vs. 8.7%) than the culprit-only PCI PRAMI cohort (n=231); there were significantly more diabetics (P=0.022) and anterior STEMI initial presentations in the culprit-only PCI PRAMI cohort. Primary outcomes were comparable to those of the preventive PCI PRAMI cohort.The 'observational CvLPRIT' cohort showed no significant difference in primary outcomes over 12 months (16.8 vs. 21.2%), but significantly lower all-cause mortality (2 vs. 6.9%) than the culprit-only PCI CvPLRIT cohort (n=146). The 30-day event rates were similar to the preventive PCI arm; the 12-month events were better than the nonpreventive, but not as good as the preventive RCT cohorts. CONCLUSION Outcomes from culprit-only primary PCI for multivessel disease in patients selected by the RCT criteria from an all-comers population representing real-life experience are better than those published in the two main RCTs. The RCTs may have selected a high-risk population for study exaggerating the benefits of preventive PCI.

Colorectal cancer is one of the leading causes for mortalities worldwide. The most common cause of colorectal cancer mortality is hepatic metastasis. There has been a limited advancement in the targeted-therapies for metastatic colorectal cancer. Conventional chemotherapeutic agent 5-fluorouracil has been used for various cancer treatments including colorectal cancer. Development of drug resistance and severe toxicity are major hurdles for its use in clinical setting. Resveratrol is a natural polyphenolic compound which has protective effects against aging-related diseases. In this study, we have tested whether combined treatments of resveratrol and 5-FU enhanced inhibitory effects against colorectal cancer cell growth. We herein showed that resveratrol and 5-FU combination treatments caused the anti-cancer activities by simultaneously inhibiting STAT3 and Akt signaling pathways. Resveratrol treatment induced S-phase specific cell cycle arrest, and when combined with 5-FU, it showed further increase in colorectal cancer cell apoptosis. Combined treatments of resveratrol and 5-FU inhibited epithelial-mesenchymal transition. Notably, resveratrol showed anti-inflammatory effects by downregulating inflammatory biomarkers, pSTAT3 and pNFκB. Resveratrol and 5-FU treatments inhibited STAT3 phosphorylation and its binding to the promoter region of human telomerase reverse transcriptase (hTERT). Our data provide the first evidence that resveratrol can enhance anti-telomeric and pro-apoptotic potentials of 5-FU in colorectal cancer, hence lead to re-sensitization to chemotherapy.

Angiofibroma is a locally advancing immensely vascular tumor that essentially arises from the nasopharynx. The clinical characteristics of extranasopharyngeal angiofibroma (ENA) do not accord to that of nasopharyngeal angiofibroma and can present a diagnostic confront. We describe a case of primary juvenile ENA in a 19-year-old patient who presented with a rapidly enlarging mass of the cheek region. The case is unusual because of its anatomic location. The diagnostic and management particulars are sketched.

Triple-negative breast cancer (TNBC) affects only about 10-15% of women with breast cancer (BC) but accounts for almost 50% of all BC deaths. At this time, development of targeted treatments for TNBC are urgently needed. Insulin-like growth factor-2 (IGF2) is highly expressed in TNBCs and mediates its proliferative effects via two hormone receptors, insulin-like growth factor -1 receptor (IGF1R) and insulin receptor (IR). Using a TNBC tissue microarray (TMA) consisting of 159 archival clinical samples, we confirm that IGF2 is highly expressed in tumor tissue as compared to nearby normal tissue (P Citation Format: Nalo M. Hamilton, Diana Marquez-Garban, David Austin, Neda Moatamed, Lorena P. Burton, David Elashoff, Begonya Comin-Anduix, Tristan Grogan, Madhuri Wadehra, Helena Chang, Adrienne Martinez, Mary-Lynn Brecht, Isabel Jabara, Richard Pietras, Yahya Elshimali, Jaydutt Vadgama, Michael Jung. Insulin-like growth factor-2 a potential target for screening and treatment in patients with triple negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 943.

Background Guidelines recommend heart team discussion and coronary artery bypass graft consideration in patients with proximal left anterior descending ( LAD ) artery stenosis. Evidence suggests that outcomes of proximal LAD angioplasty might not differ from treatment of nonproximal LAD locations. We aim to determine clinical outcomes of patients undergoing percutaneous coronary intervention in the proximal LAD segment in comparison with nonproximal LAD angioplasty, using a thin‐strut drug‐eluting stent. Methods and Results In this analysis of the e‐Ultimaster registry, patients undergoing angioplasty in the proximal LAD territory were compared with those treated in nonproximal LAD locations. Multivariate analysis and propensity score were used to adjust for differences among the groups. The primary outcome was target lesion failure: a composite of cardiac death, target‐lesion–related myocardial infarction, and/or clinically driven target lesion revascularization at 1‐year follow‐up. Of the 17 805 patients (mean age, 64.2±11; 76% male), 5452 (30.6%) underwent proximal LAD and 12 353 (69.4%) nonproximal LAD percutaneous coronary intervention. Patients in the proximal LAD group had more multivessel disease (48.7% versus 43.5%; P P P =0.17 for proximal LAD versus nonproximal LAD angioplasty, respectively). In multivariate analysis, proximal LAD treatment was not an independent predictor of target lesion failure (odds ratio, 1.07; 95% CI, 0.88–1.31; P =0.48). Conclusions At 1‐year follow‐up, patients had similar clinical outcomes independent of stenting location, questioning whether proximal LAD treatment should be regarded differently from stenting in any other coronary artery territory.

Introduction In the current era of newer generation drug eluting stents, intravascular imaging and potent antiplatelet drugs, percutaneous coronary intervention (PCI) has become an acceptable treatment for left main stem (LMS) disease. Left main stem PCI poses several challenges which can be amplified by the presence of diabetes mellitus (DM). Patients with DM have more extensive and complex coronary artery disease (CAD) with higher rates of stent restenosis and thrombosis. There is a paucity of ‘real world’ outcome data in diabetic patients undergoing LMS PCI. Our study aims to assess the impact of non-insulin treated (NITDM) and insulin treated (ITDM) diabetes on mortality following LMS PCI. A secondary outcome is to assess mortality in these groups stratified to PCI setting. Methods We undertook a retrospective analysis of consecutive patients undergoing unprotected LMS PCI between 2004 and 2017 at 2 high volume tertiary centres in the North East of England. The PCI database was interrogated for procedures where at least one vessel treated was the LMS. Ostial LAD and/or circumflex PCI with stenting back to LMS were included. Protected LMS PCI and PCI for iatrogenic dissection were excluded. Diabetic status was recorded as non-diabetic (non-DM), non-insulin treated DM (NITDM) or insulin treated DM (ITDM). The clinical setting for PCI was recorded as ‘elective’ for stable angina, ‘urgent’ for non-ST elevation myocardial infarction and ‘primary’ for ST elevation myocardial infarction. The primary outcome measure was all-cause 30-day and long term mortality (up to 36 months) post index PCI. Mortality data was provided by the Office of National Statistics and assessed up to 1/10/18. Results A total of 2702 patients underwent 2778 LMS PCI between 2004 and 2017. Repeat LMS interventions were performed in 76 patients. Twenty-seven patients were excluded as their diabetic status was not known. Of the remaining 2675 patients, 2063 (77.1%) were non-DM, 422 (15.8%) NITDM and 190 (7.1%) ITDM. Overall 30-day mortality was 7.8% (figure 1). In a logistic regression model including all LMS PCI, DM status was not associated with 30-day mortality compared to non-DM (table 1). Insulin treated DM but not NITDM was significantly associated with 30-day mortality in the setting of primary PCI (OR 3.54, 95% CI 1.28–9.80, p=0.01). During a median follow up of 36 months, post 30-day long term mortality was 7.7%. Age, peripheral vascular disease and renal impairment but not diabetes status were associated with long term mortality in all PCI settings (p Conclusion The impact of DM on mortality outcomes following LMS PCI was only significant in insulin treated diabetics following primary PCI. Non-insulin treated DM did not affect short- and long-term mortality when adjusted for other confounders. Our data shows that DM is not an independent predictor of mortality in non-emergency LMS PCI. Conflict of Interest None

There are limited data on aspirin (ASA) desensitization for patients with coronary disease. We present our experience with a rapid nurse-led oral desensitization regimen in patients with aspirin sensitivity undergoing coronary angiography.This single-center retrospective observational study includes patients with a history of ASA sensitivity undergoing coronary angiography with intent to perform percutaneous coronary intervention (PCI).Between January 2012 and January 2017, 24 patients undergoing coronary angiography for stable coronary disease (7 cases) or acute coronary syndromes (non-ST-segment myocardial infarction [NSTEMI; 8 cases], STEMI [9 cases]) underwent aspirin desensitization having reported previous reactions to aspirin. At initial presentation, previous sensitivity reactions were reported as: mucocutaneous reactions in 17 patients (urticaria in 3 [13%], nonurticarial rash in 6 [25%], angio-oedema in 8 [33%]), respiratory sensitivity in 4 (17%), and systemic anaphylactoid reactions in 3 (13%). Seventeen (71%) patients underwent PCI. Desensitization was acutely successful in 22 (92%) patients and unsuccessful in 2 (8%) patients who both had a single short-lived episode of acute bronchospasm treated successfully with nebulized salbutamol. Fifteen successfully desensitized patients completed 12 months of aspirin; no patient had recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in 7 patients (replaced by warfarin [1 case], no antiplatelet or single antiplatelet clinically indicated and clopidogrel chosen [4 cases], patient choice without evidence of recurrent hypersensitivity [1 case], and death due to cardiogenic shock following STEMI [1 case]).A rapid aspirin desensitization protocol is safe and effective across a broad spectrum of hypersensitivity reactions and clinical presentations.

Herein we present the solution to the \(2^\mathrm{nd}\) YouTube-8M video understanding challenge which placed \(1^\mathrm{st}\). Competition participants were tasked with building a size constrained video labeling model with a model size of less than 1 GB. Our final solution consists of several submodels belonging to Fisher vectors, NetVlad, Deep Bag of Frames and Recurrent neural networks model families. To make the classifier efficient under size constraints we introduced model distillation, partial weights quantization and training with exponential moving average.

Background: Imbalances between the oxidant-antioxidant status have been implicated in the pathogenesis of several diseases, including cancer. The aim of this study was to evaluate the extent of lipid peroxidation and antioxidants in the tissue samples of oral squamous cell carcinoma (OSCC) patients of different clinical stages in comparison with the healthy controls. Materials and Methods: A case-control study was designed with 20 new histopathologically proven oral carcinoma patients and an equal number of age, sex, and tobacco chewing habit matched healthy subjects. Their tissue samples were subjected to evaluation of lipid peroxidation product and antioxidant enzymes, namely, superoxide dismutase (SOD), catalase (CAT), reduced glutathione (GSH), and glutathione peroxidase (GPx) using spectrophotometric methods. The data are expressed as mean ΁ standard deviation. The statistical comparisons between the study groups were performed by independent Student′s unpaired t-test and one-way analysis of variance. Post-hoc analysis was performed for within study group comparisons. Karl Pearson correlation was performed for the biochemical parameters within the group and between the groups. For statistically significant correlations, simple linear regression was performed using SPSS (α=0.05). Results: Significant reduction in lipid peroxidation (P < 0.001) SOD and CAT (P < 0.001) was observed in the tissue of OSCC patients as compared with the healthy controls. On the other hand, reduced GSH and GPx were significantly increased in tumor samples. Conclusion: Reduced lipid peroxidation and increased activity of reduced GSH and GPx provides the suitable environment for the local growth and invasion of the tumor and metastasis in the later stages. Among the antioxidant enzymes, GSH reductase appears to have a profound role in carcinogenesis and thus it can be considered as potential prognostic marker.

Radiopaque lesions of the jawbones are frequently encountered in dental radiographs. A variety of conditions such as chronic inflammation, soft tissue calcifications, fibrosseous lesions, odontogenic tumors, and bone neoplasms can manifest as radiopaque lesions on the jawbones. These radiopaque lesions are often difficult to distinguish from each other, hence making the formulation of differential diagnosis challenging. A thorough patient's history and clinical examination supplemented by appropriate investigations will enable the clinician in narrowing down the differential diagnosis and to identify the condition accurately. Presented here is a case of the large radiopaque lesion on posterior mandible surrounded by lytic areas in a 20-year-old male patient.

Introduction Despite advances in surgical and anaesthetic techniques, non-cardiac surgery still has a significant mortality. We hypothesised that pre-operative troponin levels might predict post-operative mortality. Methods Patients undergoing elective and urgent/emergency non-cardiac surgery excluding minor procedures were retrospectively assessed for known vascular disease (defined by diagnostic imaging or previous intervention rather than clinical assessment) and vascular risk factors including hypertension, treatment with lipid-modifying agents (irrespective of agent or dose) and chronic lung disease. Pre-operative high-sensitivity troponins and routine pre-operative bloods were recorded. Six- and twelve-month mortality data were collected; independent predictors of mortality and associations between pre-operative patient characteristics and pre-operative troponin were determined. Results 993 patients were assessed; 13% had an elevated pre-operative troponin with 3%>50 ng/L. 825 (83%) were elective patients; 8.6% had an elevated pre-operative troponin. Six-month mortality was 4.2% and 5.9% at twelve months. Elevated pre-operative troponin was associated with higher post-operative mortality; 2.5%, 12.5% and 25% for a troponin 50 ng/L respectively (figure?1). This trend was also evident at twelve months; 3.7%, 16.3% and 37% for the same troponin bands (figure 2). Lipid-modifying agents were independently associated with a lower rate of pre-operative troponin release (HR 0.446 (0.232 – 0.857) p=0.015). Impaired renal function (assessed as a continuous variable), emergency presentation and pre-operative troponin levels were independent predictors of six- and twelve-month mortality with emergency presentation the strongest predictor by hazard ratio (table 1). Age over 75 independently predicted twelve-month mortality only. Conclusion The role of pre-operative troponin monitoring and the prevalence of pre-operative troponin has not previously been established on an all-comer population. Pre-operative troponin level greater than 50 ng/L is an independent predictor of six and twelve-month mortality following non-cardiac surgery in an all-comers cohort although the mechanism of troponin release is not clear. The lower rate of troponin release associated with lipid-modifying medication has been seen in other studies (1). We hypothesise the known anti-inflammatory effects of statins may indicate a systemic inflammatory process responsible for the troponin release rather than unstable coronary disease. Further studies to assess this in the elective population may be useful to target pre-operative interventions. Reference Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. ?Berwanger O, Le Manach Y, Suzumura EA, et al. Eur Heart J2016Jan 7;37(2):177?–?85

Background Inflammation plays a key role in the pathophysiology of coronary heart disease (CHD) and its acute manifestation, acute coronary syndrome (ACS). Aging is associated with a decline of the immune system, a process known as immunosenescence. This is characterized by an increase in highly proinflammatory T cells that are involved in CHD progression, plaque destabilization, and myocardial ischemia–reperfusion injury. Telomere dysfunction has been implicated in immunosenescence of T lymphocytes. Telomerase is the enzyme responsible for maintaining telomeres during cell divisions. It has a protective effect on cells under oxidative stress and helps regulate flow-mediated dilation in microvasculature. Objective The TACTIC (Telomerase ACTivator to reverse Immunosenescence in Acute Coronary Syndrome) trial will investigate whether a telomerase activator, TA-65MD, can reduce the proportion of senescent T cells in patients with ACS with confirmed CHD. It will also assess the effect of TA-65MD on decreasing telomere shortening, reducing oxidative stress, and improving endothelial function. Methods The study was designed as a single-center, randomized, double-blind, parallel-group, placebo-controlled phase II trial. Recruitment started in January 2019. A total of 90 patients, aged 65 years or older, with treated ACS who have had CHD confirmed by angiography will be enrolled. They will be randomized to one of two groups: TA-65MD oral therapy (8 mg twice daily) or placebo taken for 12 months. The primary outcome is the effect on immunosenescence determined by a decrease in the proportion of CD8+ TEMRA (T effector memory cells re-expressing CD45RA [CD45 expressing exon A]) cells at 12 months. Secondary outcomes include leukocyte telomere length, endothelial function, cardiac function as measured by echocardiography and NT-proBNP (N-terminal fragment of the prohormone brain-type natriuretic peptide), systemic inflammation, oxidative stress, and telomerase activity. Results The study received National Health Service (NHS) ethics approval on August 9, 2018; Medicines and Healthcare products Regulatory Agency approval on October 19, 2018; and NHS Health Research Authority approval on October 22, 2018. The trial began recruiting participants in January 2019 and completed recruitment in March 2020; the trial is due to report results in 2021. Conclusions This pilot trial in older patients with CHD will explore outcomes not previously investigated outside in vitro or preclinical models. The robust design ensures that bias has been minimized. Should the results indicate reduced frequency of immunosenescent CD8+ T cells as well as improvements in telomere length and endothelial function, we will plan a larger, multicenter trial in patients to determine if TA-65MD is beneficial in the treatment of CHD in elderly patients. Trial Registration ISRCTN Registry ISRCTN16613292; http://www.isrctn.com/ISRCTN16613292 and European Union Drug Regulating Authorities Clinical Trials Database (EudraCT), European Union Clinical Trials Register 2017-002876-26; https://tinyurl.com/y4m2so8g International Registered Report Identifier (IRRID) DERR1-10.2196/19456

Importance Thyroid hormones play a key role in modulating myocardial contractility. Subclinical hypothyroidism in patients with acute myocardial infarction is associated with poor prognosis. Objective To evaluate the effect of levothyroxine treatment on left ventricular function in patients with acute myocardial infarction and subclinical hypothyroidism. Design, Setting, and Participants A double-blind, randomized clinical trial conducted in 6 hospitals in the United Kingdom. Patients with acute myocardial infarction including ST-segment elevation and non–ST-segment elevation were recruited between February 2015 and December 2016, with the last participant being followed up in December 2017. Interventions Levothyroxine treatment (n = 46) commencing at 25 µg titrated to aim for serum thyrotropin levels between 0.4 and 2.5 mU/L or identical placebo (n = 49), both provided in capsule form, once daily for 52 weeks. Main Outcomes and Measures The primary outcome measure was left ventricular ejection fraction at 52 weeks, assessed by magnetic resonance imaging, adjusted for age, sex, type of acute myocardial infarction, affected coronary artery territory, and baseline left ventricular ejection fraction. Secondary measures were left ventricular volumes, infarct size (assessed in a subgroup [n = 60]), adverse events, and patient-reported outcome measures of health status, health-related quality of life, and depression. Results Among the 95 participants randomized, the mean (SD) age was 63.5 (9.5) years, 72 (76.6%) were men, and 65 (69.1%) had ST-segment elevation myocardial infarction. The median serum thyrotropin level was 5.7 mU/L (interquartile range, 4.8-7.3 mU/L) and the mean (SD) free thyroxine level was 1.14 (0.16) ng/dL. The primary outcome measurements at 52 weeks were available in 85 patients (89.5%). The mean left ventricular ejection fraction at baseline and at 52 weeks was 51.3% and 53.8%, respectively, in the levothyroxine group compared with 54.0% and 56.1%, respectively, in the placebo group (adjusted difference in groups, 0.76% [95% CI, −0.93% to 2.46%];P = .37). None of the 6 secondary outcomes showed a significant difference between the levothyroxine and placebo treatment groups. There were 15 (33.3%) and 18 (36.7%) cardiovascular adverse events in the levothyroxine and placebo groups, respectively. Conclusions and Relevance In this preliminary study involving patients with subclinical hypothyroidism and acute myocardial infarction, treatment with levothyroxine, compared with placebo, did not significantly improve left ventricular ejection fraction after 52 weeks. These findings do not support treatment of subclinical hypothyroidism in patients with acute myocardial infarction. Trial Registration isrctn.org Identifier:http://www.isrctn.com/ISRCTN52505169

Background and Objectives: Early detection and treatment of oral cancer will significantly improve the survival rate and prognosis of the patients. Adjunctive diagnostic aids such as vital staining have been developed to supplement clinical examination and improve the diagnosis. The current study was conducted to evaluate the diagnostic efficacy of acetic acid (2%) (AA), lugol's iodine (3% dilution) (LIS), and toluidine blue (1%) (TBS) in oral leukoplakia (OL) and erosive variant of oral lichen planus (OLP). Materials and Methods: A hospital-based, cross-sectional study was conducted with 30 randomly selected subjects having clinically proven cases of OL and erosive OLP. Every patient underwent AA, LIS, and TBS application to their oral lesions in a sequential manner. Subsequently, clinical and histopathologic diagnosis was compared with staining results of each. Cases which were diagnosed as epithelial hyperplasia were considered as a control group. Data are presented in numbers and percentages. Chi-square test was used to compare between TBS, LIS and AA. Diagnostic efficiency and reliability was calculated by sensitivity and specificity test in terms of its utility in predicting the dysplastic nature of the lesion. Results: Sensitivity of both TBS and LIS staining was calculated as 90.48% whereas the specificity of the former test was 22.22% and latter was 11.11%. AA test showed a sensitivity of 57.14% and specificity of 33.33%. Multiple comparisons of staining with three agents and the histopathologic variants did not show any statistically significant difference. Conclusion: TBS and LIS staining showed high sensitivity in diagnosing OL and erosive OLP compared to AA. The specificity of all three modalities used was low.

There are limited data on aspirin desensitisation for patients with coronary disease.1 This study aimed to evaluate our single-centre experience with a rapid oral desensitisation regime in patients with aspirin sensitivity undergoing coronary angiography. Methods This single-centre retrospective observational study includes patients with self-reported hypersensitivity reactions to aspirin confirmed by clinical history who were planned to undergo coronary angiography with intent to perform percutaneous coronary intervention between Jan 2012 and Jan 2017. The aspirin desensitisation protocol is shown in table 1. All patients had blood pressure, oxygen saturation and peak flow measurements every 30 min during the dug administration and for 3 three hours after the final dose. Continuous ECG monitoring was not routinely performed unless clinically indicated. No patients received pre-treatment with steroids, antihistamines or antileukotrienes. The primary outcome was cessation of aspirin due to recurrent hypersensitivity reaction within 12 months. Results Twenty-four patients were included in the study including patients with both stable coronary disease (7 cases) and acute coronary syndromes (NSTEMI (8 cases), STEMI (9 cases)). Previous reactions reported were mucocutaneous reactions in 17 patients (urticaria in 3 (13%), non-urticarial rash in 6 (25%), angio-oedema in 8 (33%)), respiratory sensitivity in 4 patients (17%) and systemic anaphylactoid reactions in 3 patients (13%). Percutaneous coronary intervention (PCI) was performed in 17 patients (71%) and coronary artery bypass grafting in 1 patient (4.2%). Desensitisation was acutely successful in 22 patients (92%). Two cases were unsuccessful, both following primary PCI (previous true anaphylactoid reaction experienced bronchospasm requiring nebulised salbutamol (1 case), previous angio-oedema experienced an exacerbation of her poorly controlled asthma (but no angio-oedema) treated with nebulised salbutamol (1 case)). Both patients were discharged on single antiplatelet therapy (clopidogrel and prasugrel respectively). Fifteen successfully desensitised patients completed 12 months of aspirin; no patients suffered a recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in seven patients (replaced by formal anticoagulation (1 case), no antiplatelet or only single antiplatelet clinically indicated and clopidogrel chosen (4 cases), patient choice without evidence of recurrent hypersensitivity (1 case), death due to cardiogenic shock following STEMI (1 case)). Conclusion Our rapid desensitisation protocol is significantly faster than the ADAPTED registry protocol (120 vs 330 min) and appears as effective across a wide range of clinical presentations and hypersensitivity reactions. Reference . Rossini R, et al. Results of the Multicenter ADAPTED Registry (Aspirin Desensitization in Patients with Coronary Artery Disease). Circ Cardiovasc Interv. 2017;10:e004368.

OBJECTIVES: To study the relationship between diabetes mellitus (DM) and left ventricular (LV) function on outcomes following percutaneous coronary intervention (PCI).BACKGROUND: DM is a growing public health challenge worldwide and a significant risk factor for cardiovascular disease and heart failure.METHODS: All PCI procedures performed between 2006 and 2013 with LV function and diabetic status recorded in the BCIS-NICOR database were included. Demographic, procedural, and clinical outcomes data were collected. Multivariable logistic regression was used to provide adjusted estimates of clinical outcome by LV function and DM, including DM sub-type.RESULTS: Of 260,726 patients, DM was present in 52,160 (20%); moderate LV systolic dysfunction (LVSD) was present in 51,266 (20%), and severe LVSD in 18,148 (7%). Worsening LVSD in diabetic patients was associated with poorer prognosis following PCI; moderate LVSD odds ratio (OR) 2.03 (95% CI 1.72-2.38) and severe LVSD OR 4.17 (95% CI 3.52-4.93). There was a higher crude and adjusted mortality rate for patients with DM across all grades of LVSD. However, the relative effect of DM appeared attenuated in the severe LVSD group compared with moderate or good LV function, particularly evident in patients with insulin requiring DM (good LV OR 2.09 [95% CI 1.66-2.65]; moderate LVSD OR 1.56 [95% CI 1.26-1.93], poor LV OR 1.40 [95% CI 1.13-1.74]).CONCLUSIONS: DM was associated with increased 30-day mortality for all grades of LV function. The prognostic impact of DM was strongest in patients with normal LV function and less evident in patients with severe LV systolic dysfunction.

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality worldwide, and is a consequence of acute thrombotic events involving activation of platelets and coagulation proteins. Factor Xa inhibitors and aspirin each reduce thrombotic events but have not yet been tested in combination or against each other in patients with stable coronary artery disease.METHODS: In this multicentre, double-blind, randomised, placebo-controlled, outpatient trial, patients with stable coronary artery disease or peripheral artery disease were recruited at 602 hospitals, clinics, or community centres in 33 countries. This paper reports on patients with coronary artery disease. Eligible patients with coronary artery disease had to have had a myocardial infarction in the past 20 years, multi-vessel coronary artery disease, history of stable or unstable angina, previous multi-vessel percutaneous coronary intervention, or previous multi-vessel coronary artery bypass graft surgery. After a 30-day run in period, patients were randomly assigned (1:1:1) to receive rivaroxaban (2·5 mg orally twice a day) plus aspirin (100 mg once a day), rivaroxaban alone (5 mg orally twice a day), or aspirin alone (100 mg orally once a day). Randomisation was computer generated. Each treatment group was double dummy, and the patients, investigators, and central study staff were masked to treatment allocation. The primary outcome of the COMPASS trial was the occurrence of myocardial infarction, stroke, or cardiovascular death. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, 27 395 patients were enrolled to the COMPASS trial, of whom 24 824 patients had stable coronary artery disease from 558 centres. The combination of rivaroxaban plus aspirin reduced the primary outcome more than aspirin alone (347 [4%] of 8313 vs 460 [6%] of 8261; hazard ratio [HR] 0·74, 95% CI 0·65-0·86, pINTERPRETATION: In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.FUNDING: Bayer AG.

Background— Rotational atherectomy (RA) is an important interventional tool for heavily calcified coronary lesions. We compared the early clinical outcomes in patients undergoing RA using radial or femoral access. Methods and Results— We identified all patients in England and Wales who underwent RA between January 1, 2005, and March 31, 2014. Eight thousand six hundred twenty-two RA cases (3069 radial and 5553 femoral) were included in the analysis. The study primary outcome was 30-day mortality. Propensity scores were calculated to determine the factors associated with treatment assignment to radial or femoral access. Multivariable logistic regression analysis, using the calculated propensity scores, was performed. Thirty-day mortality was 2.2% in the radial and 2.3% in the femoral group ( P =0.76). Radial access was associated with equivalent 30-day mortality (adjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.77–1.46; P =0.71), procedural success (OR, 1.04; 95% CI, 0.84–1.29; P =0.73), major adverse cardiac and cerebrovascular events (OR, 1.05; 95% CI, 0.80–1.38; P =0.72), and net adverse clinical events (OR, 0.90; 95% CI, 0.71–1.15; P =0.41), but lower rates of in-hospital major bleeding (OR, 0.62; 95% CI, 0.40–0.98; P =0.04) and major access site complications (OR, 0.05; 95% CI, 0.01–0.38; P =0.004), compared with femoral access. Conclusions— In this large real-world study of patients undergoing RA, radial access was associated with equivalent 30-day mortality and procedural success, but reduced major bleeding and access site complications, compared with femoral access.

Background: Potentially malignant disorders like oral submucous fibrosis (OSMF) often precede oral squamous cell carcinoma (OSCC). The rate of transformation of OSMF to OSCC ranges from 3 to 19%. OSMF is etiologically related to chewing of areca nut (betel nut), and the high copper content in areca nut plays an important role in the pathogenesis of the disorder. Even though many studies estimated and confirmed increased copper levels in areca nuts, studies tracing the source of the increased copper content are scarce. Interestingly, on review of agricultural literature, it was found that most of the areca nut plantations in South India commonly use a copper-based fungicide, bordeaux mixture (BM). Aim: The aim of the study was to estimate and compare the copper content in areca nuts from plantations with and without copper-based fungicide usage. Materials and Methods: Four areca nut plantations from Dakshina Kannada district, Karnataka (group A) and four plantations from Ernakulam district, Kerala (group B) were selected for the study. The plantations from Karnataka used copper-based fungicide regularly, whereas the latter were devoid of it. Areca nut samples of three different maturities (unripe, ripe, and exfoliated) obtained from all plantations were dehusked, ground, and subjected to atomic absorption spectrometry (AAS) for copper analysis. Results: There was statistically significant difference in the copper content of areca nuts from both groups. The areca nuts from plantations treated with copper-based fungicide showed significantly higher copper levels in all maturity levels compared to their counterparts in the other group (P < 0.05). Conclusions: The high copper content in areca nut may be related to the copper-based fungicide treatment on the palms. These areca nuts with high copper content used in quid or commercial products may be responsible for the increasing prevalence of OSMF.

Delayed arrival to a primary percutaneous coronary intervention (PPCI)-capable hospital following ST-elevation myocardial infarction (STEMI) is associated with poorer outcome. The influence of patient characteristics on delayed presentation during STEMI is unknown.This was a retrospective observational study. Patients presenting for PPCI from March 2008 to November 2011 in the north of England (Northumbria, Tyne and Wear) were included. The outcomes were self-presentation to a non-PPCI-capable hospital, symptom to first medical contact (STFMC) time, total ischaemic time and mortality during follow-up. STEMI patients included numbered 2297; 619 (26.9%) patients self-presented to a non-PPCI-capable hospital. STFMC of30 min and total ischaemic time of180 min was present in 1521 (70.7%) and 999 (44.9%) cases, respectively. Self-presentation was the strongest predictor of prolonged total ischaemic time (odds ratio, OR (95% confidence interval, CI): 5.05 (3.99-6.39)). Married patients (OR 1.38 (1.10-1.74)) and patients living closest to an Emergency Room self-presented more commonly (driving time (vs. ≤10 min) 11-20 min OR 0.66 (0.52-0.83),20 minutes OR 0.46 (0.33-0.64). Unmarried females waited longest to call for help (OR vs. married males 1.89 (1.29-2.78) and experienced longer total ischaemic times (OR 1.51 (1.10-2.07)). Married patients had a borderline association with lower mortality (hazard ratio 0.75 (0.53-1.05), p=0.09).Unmarried female patients had the longest treatment delays. Married patients and those living closer to an Emergency Room self-present more frequently. Early and exclusive use of the ambulance service may reduce treatment delay and improve STEMI outcome.

Objective: The purpose of this study is to evaluate the salivary cortisol levels in patients with dry mouth. Materials and Methods: The study population consisted of 20 patients with a complaint of dry mouth and 20 asymptomatic age- and sex-matched controls. In patients who complained of dry mouth, the salivary flow rate (ml/minute) was estimated by measuring the quantity of the saliva collected in the collector. The concentration of cortisol in the saliva (΅g/dl) was determined by using a salivary enzyme-linked immunoassay (ELISA) kit. Statistical Analysis: The results were evaluated using the Student's t-test. Results: There was only a mild increase in salivary cortisol in both stimulated and unstimulated saliva in patients with dry mouth compared to the controls (p-value 0.981 and 0.481, respectively), which was not statistically significant. Conclusion: There may not be a clear association between the salivary cortisol level and dry mouth. In older individuals, age-associated salivary gland hypofunction and life changes may be the main risk factors for dry mouth compared to stress and anxiety.

1,5Department Of Oral Medicine & Radiology , Sree Balaji Dental College & Hospital, Bharath University, Chennai, Tamil Nadu, India. 2Rajah Muthiah Dental College & Hospital, Annamalai University, Chidambaram, Tamil Nadu, India. 3Department of Periodontics , Sree Balaji Dental College & Hospital, Bharath University, Chennai, Tamil Nadu, India. 4Department Of Oral Medicine & Radiology , Sree Balaji Dental College & Hospital, Bharath University, Chennai, Tamil Nadu, India.

Background Drug-coated balloons (DCBs) have been developed for the percutaneous treatment of coronary artery disease. An initial focus has been the management of in-stent restenosis (ISR) but randomised controlled trials (RCTs) have been small and powered only for angiographic endpoints. Objective The aim of the work was to assess the clinical and angiographic outcomes of patients treated for ISR with DCB versus control (balloon angioplasty or drug-eluting stents) by a meta-analysis of RCTs. Methods A comprehensive search was performed of RCTs where patients with ISR were randomly assigned to either DCB or alternative coronary intervention. Outcome measurements were death, myocardial infarction (MI), target lesion revascularisation (TLR), binary definition of restenosis and in-lesion late luminal loss (LLL). Results Four studies were identified that fulfilled the inclusion criteria. Pooled odds ratios (ORs) were calculated for patients treated for ISR (n = 399). Mean follow-up duration was 14.5 months. DCBs were associated with lower rates of TLR [8.8 vs. 29.7 % OR (95 % confidence interval, CI) 0.20 (0.11–0.36), p

Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of acute coronary syndrome. The diagnosis of SCAD by an angiogram alone can be challenging and the increasing use of intracoronary imaging has proven an invaluable diagnostic adjunct in this regard. The appropriate initial management of SCAD has been a matter of significant debate. Owing to frequent spontaneous healing of coronary dissection and a higher risk of complications with percutaneous coronary intervention (PCI) in the setting of SCAD, a default approach of mechanical revascularization is not recommended. However in the presence of vessel occlusion and on-going myocardial infarction PCI is mandated. Bioresorbable vascular scaffolds (BVS) offer potential advantages over the conventional stents in the setting of SCAD. We describe a state-of-the-art approach to the acute treatment of SCAD causing STEMI, utilizing intravascular ultrasound (IVUS), optical coherence tomography (OCT) and BVS and discuss management strategies for the modern era.

Objective: The purpose of this study was to evaluate the efficacy of ultrasound in the diagnosis of inflammatory swellings of odontogenic origin. Study design: The study group consisted of 25 patients with inflammatory swellings of odontogenic origin. Only patients with unilateral swellings were considered for inclusion in the pathologic study group and normal contralateral side was taken as control. Results: Clinically, four cases were diagnosed as cellulitis and 21 cases as abscesses. Under ultrasonography (USG) diagnosis, six cases were diagnosed as edema and two cases as cellulitis and 15 cases as preabscess and two cases as abscesses, considering the intra operative diagnosis as the gold standard technique. The ultrasonography technique presented sensitivity of 92%. Conclusion: USG can differentiate facial edema, facial cellulitis, and dentoalveolar abscess. USG can also evaluate the extension of these swellings. It is prudent to subject patients with inflammatory swellings of the maxillofacial region to USG in order to determine the appropriate treatment plan.

Oral lichen planus (OLP) is a chronic inflammatory disease of unknown etiology. It seems to affect most ethnic groups and has a prevalence of 0.02-1.2% among various populations. The diagnosis of OLP can be made from the clinical features if they are sufficiently characteristic, particularly if typical skin or other lesions are present, but biopsy is recommended to confirm the diagnosis and to exclude dysplasia and malignancy. Atrophic/erosive OLP needs appropriate treatment, due to the pain and malignancy potential. Here we report a case of erosive lichen planus in a 60-year-old male patient in the oral cavity.

Fibrous dysplasia (FD) is a fibro-osseous lesion with no apparent familial, hereditary or congenital basis. It is a non-neoplastic developmental hamartomatous disease of the bone, characterised by a blend of fibrous and osseous elements in the region. It constitutes 2.5% of all bony neoplasms and 7% of all benign bony neoplasm. The treatment can be either conservative or complete resection. Here we report a case of fibrous dysplasia in a 64-year-old male patient on the right side of the face.

Oral squamous cell carcinoma (OSCC) is a significant public health problem worldwide. More than 95% of the carcinomas of the oral cavity are of squamous cell type, in nature. The development of OSCC is a multistep process requiring the accumulation of multiple genetic alterations, influenced by environmental influences, including tobacco products, alcohol consmption, viral infection, chronic inflammation and also patient's genetic predisposition. Here we present a case of oral squamous cell carcinoma of palate in a 62-year-old male patient.

Salivary gland tumors are rare, comprising less than 3% of all neoplasia of the head and neck region. Pleomorphic adenoma, also known as benign mixed tumor is the most common tumor of the salivary gland accounting for 60-80% of the benign variety. The tumor is almost always solitary and is usually found as a firm, mobile, painless slow growing mass. Multiple or bilateral pleomorphic adenomas are rare. After surgical resection, up to 43% of patients are at risk of recurrence, even as late as 45 years after the initial surgery. Here we report a case of recurrent pleomorphic adenoma in a 34-year-old male patient on the right side.

IntroductionVentilator-associated pneumonia (VAP) is a medical complication associated with prolonged mechanical ventilation. Most studies looking at VAP originate from major, tertiary intensive care units (ICUs). Our understanding of VAP in regional hospitals is limited. Given that patient characteristics often differ between metropolitan and regional centres, it is important to investigate VAP in a regional non-tertiary ICU. This project will establish and report the incidence, case characteristics and outcomes including mortality and length of stay related to VAP in a regional non-tertiary Australian ICU. Furthermore, it will compare the incidence of VAP in accordance with consultant diagnosed cases in the medical record, and by a post hoc screening of all cases against a list of previously published diagnostic criteria.Methods and analysisThis retrospective clinical audit study will screen medical records from the period 1 January 2013 to 31 December 2016. All cases requiring mechanical ventilation for ≥72 hours will be screened against previously reported diagnostic criteria for VAP. At the same time, their medical records will be screened for a documented diagnosis of VAP.Ethics and disseminationThis study has been granted ethical approval from the Central Queensland Hospital and Health Service (CQHHS) Human Research Ethics Committee (HREC/17/QCQ/11) and the Central Queensland University Human Research Ethics Committee (H17/05-102). This study will be submitted for publication in a peer-reviewed scientific journal and presented at internal workshops (within Queensland Health) and national and/or international scientific conferences.

Riga-Fede disease is a rare condition characterized by traumatic ulceration occurring on the ventral surface of the tongue of neonates and infants. It is most often associated with natal and neonatal teeth in newborns but may also occur in older infants after eruption of primary lower incisors. It is important to diagnose the lesion early and treat it by eliminating the cause of trauma to avoid untoward complications. Here we report a case of a thirty-three day old female baby with Riga-Fede disease associated with a natal tooth. After extraction of the mobile natal tooth, the ulcerative lesion healed satisfactorily in four days.

Objective We aimed to analyze trends in drug-eluting stents (DES) use in four international health care and regulatory settings. Background Accounts suggest a differential approach to DES internationally and recent reductions in use following reports of late stent thrombosis. Current studies of clinical practice are limited in their scope. Methods Data were pooled from angioplasty registries in Alberta (Canada), Belgium, Mayo Clinic (Rochester, MN), and Scotland (UK) that have routinely recorded consecutive patients treated since 2003. Trend analysis was performed to examine variations in DES use over time and by clinical subgroup. Results A total of 178,504 lesions treated between January 2003 and September 2007 were included. In the Mayo Clinic Registry, rapid adoption to a peak of 91% DES use for all lesions by late 2004 was observed. In contrast, Alberta and Scotland showed delayed adoption with lower peak DES use, respectively, 56% and 58% of lesions by early 2006. Adoption of DES in Belgium was more gradual and peak use of 35% lower than other registries. Reductions in DES use were seen in all data sets during 2006, although this varied in absolute and relative terms and by clinical subgroup. Conclusion Adoption and use of DES showed wide variation in four countries. The determinants of use are complex, and it is likely that nonclinical factors predominate. Recent reductions in use may be as a consequence of publicity and concerns regarding late stent thrombosis. The optimum application of DES in clinical practice is unclear and is reflected in the degree of international variation demonstrated.

Background— The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results— We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P =0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P =0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P =0.02). Conclusions— At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents.

To determine whether drug-eluting stent (DES) use varies among Scottish hospitals, and the extent to which any variations are explained by differences between operators, patients and lesions.Multi-level analysis of consecutive patients treated with percutaneous coronary intervention (PCI) between April 2005 and March 2006 in Scotland, using the Scottish Coronary Revascularization Registry.A total of 38 operators performed 5967 PCI procedures on 8489 lesions. Crude level of DES use was 47.6%, and the results varied among hospitals (range 30.6-61.8%, chi(2) = 341.6, P0.0001). There was significant between-operator variation in the null model. This was attenuated by the addition of hospital as a fixed effect. Nonetheless, the final model demonstrated significant between-operator variability [sigma(2) = 0.486 (0.249-0.971)] and between-hospital variation, after case-mix adjustment.Within Scotland, marked variation existed among hospitals in the use of DES. Operator was the most important factor at patient level, and hospital of treatment, rather than case-mix, was the most important modifier of between-operator variation. Patient selection for DES is complex and may contribute to much of the variations demonstrated. Consensus criteria would provide more detail than is included in current guidance, may aid decision-making for individual patients, reduce opportunity costs and ensure equity of access.