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Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder marked by excessive immune system activation. Diagnosing HLH is particularly difficult due to its diverse etiology and similar clinical presentation. Patients with HLH often require intensive critical care. The condition is divided into HLH syndrome (genetic defects) and HLH disease, and both can be triggered by factors such as infections, autoimmune diseases, or malignancies. We present here the first documented case of acute HLH secondary to tularemia with septic shock in a 62-year-old female. Initially suspected due to malignancy-induced acute HLH, she was treated with etoposide and dexamethasone and was immediately transitioned to antimicrobials once she was confirmed positive for Francisella tularemia on blood cultures at the state microbiology laboratory. She had a prolonged clinical course of 31 days, followed by an excellent recovery after treatment with antimicrobials. This case highlights the importance of recognizing tularemia as a potential cause of HLH. Identifying and addressing the causative agent promptly is crucial for effective management and treatment of HLH., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Brahmbhatt et al.)

Introduction The United States includes diverse geographic areas with distinct urban and rural settings. Urban areas served with higher health services and the rural regions with restricted facilities. This disparity results in higher rural mortality rates. Thus, the study uses the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database to assess the disparities in cardiac arrest mortality rates in urban versus rural areas. Methods This is a retrospective study to assess trends in overall mortality rates for urban versus rural areas in the United States between 1999 and 2020, using the CDC WONDER data for cardiac arrest (ICD-10 CODE I46), extracted on May 25, 2024. Urban/rural classification was based on the Metropolitan 2013 scheme. Statistical analysis was done via RStudio v.4.3.3 and included measures of central tendency, mortality rates per 100,000, and plotting of temporal trends. Results Between 1999 and 2020, the total number of deaths due to cardiac arrest in rural and urban areas was 103,115 and 262,505, respectively. Among the age groups, infants <1 year and elderly >85 years showed a high mortality rate in rural areas compared to urban areas. Gender analysis revealed both males (3.3 per 100,000) and females (3.52 per 100,000) had a high rural mortality rate, compared to urban rates of 1.51 and 1.54 per 100,000, respectively. Racial analysis showed that American Indian or Alaska Native and Asian or Pacific Islander populations had higher mortality in rural areas, with rates of 1.1 and 1.81 per 100,000, respectively, compared to the urban rates of 0.34 and 0.8 per 100,000. Conclusion Trends in mortality rate showed a general decline over time but the gap between urban and rural mortality persists, highlighting the need for continued efforts in rural areas., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Arefin et al.)

Indole is known as a versatile heterocyclic building block for its multiple pharmacological activities and has a high probability of success in the race for drug candidates. Many natural products, alkaloids, and bioactive heterocycles contain indole as the active principle pharmacophore. These encourage the researchers to explore it as a lead in the drug development process. The current manuscript will serve as a torchbearer for understanding the structurally diverse class of indole derivatives with extensive pharmacological activity. The current manuscript describes the intermediates and their functional groups responsible for superior biological activity compared to the standard. The review is written to help researchers to choose leads against their target but also to provide crucial insight into the design of a hybrid pharmacophore-based approach in drug design with enhanced potential. The present reviews on the indole derivatives correlate the structures with biological activities as well as essential pharmacophores, which were highlighted. The discussion was explored under challenging targets like dengue, chikungunya (anti-viral), antihypertensive, diuretic, immunomodulator, CNS stimulant, antihyperlipidemic, antiarrhythmic, anti-Alzheimer's, and neuroprotective, along with anticancer, antitubercular, antimicrobial, anti-HIV, antimalarial, anti-inflammatory, antileishmanial, antianthelmintic, and enzyme inhibitors. So, this review includes a discussion of 19 different pharmacological targets for indole derivatives that could be utilized to derive extensive information needed for ligand-based drug design. The article will guide the researchers in the selection, design of lead and pharmacophore, and ligand-based drug design using indole moiety., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Objectives: To assess differences in radiation exposure between transradial access (TRA) and transfemoral access (TFA) for coronary procedures., Background: TRA is associated with increased radiation exposure as compared to TFA. We compared radiation exposure between the two access sites., Methods: Databases were searched from June 2014 to August 2021 for randomized controlled trials (RCTs) reporting coprimary outcomes of fluoroscopy time (FT) and/or dose area product (DAP) comparing TRA with TFA. Meta-regression was performed to assess the behavior of weighted mean difference (WMD) in FT from 1995 to 2021. Observational study data was used for corroborative evidence., Results: Data from 8 RCTs (11,611 patients) showed the WMD of FT was 0.62 min (37 s) (95% confidence interval [CI]: [0.08-1.17], p = 0.023) in favor of TFA, WMD in DAP (9169 patients) was 1.94 Gy.cm 2 (95% CI: [-2.1 to 5.9], p = 0.35) showing no significant difference. Pooled data from OBS and RCTs (83,990 patients) showed a similar trend. Studies from outside US between 1995 and 2021 showed WMD of FT between TRA and TFA of 0.88 min (52 s) (95% CI: [0.67-1.09], p = 0.005) versus 2.1 min (126 s) (95% CI: [1.38-2.8], p = 0.005) for US in favor of TFA. Meta-regression showed a declining WMD of FT between TRA and TFA from 1.6 min (96 s) in 1996 to 0.5 min (30 s) in 2020 with the lower limit of CI crossing the zero line in 2019., Conclusion: Radiation exposure between TRA and TFA continues to decrease overtime and is becoming clinically nonsignificant., (© 2022 Wiley Periodicals LLC.)

Malaria has been a major parasitic disease in tropical and subtropical regions and is estimated to kill between one and two million people (mainly children) every year. Novel anti-malarial agents are urgently needed to combat the malarial parasites enduring resistance to the current medications, leading to increased morbidity and mortality. The heterocycles, holding a prominent position in chemistry and found in both natural and synthetic sources, have shown several biological activities including anti-malarial activity. Towards this goal, several research groups have reported the design and development of novel and potential anti-malarial agents like artemisinin, benzimidazole, benzothiazole, chalcone, cyclopeptide, fosmidomycin, furan, indole oxadiazole, 2-oxindoles, peroxides, pyrazole, pyrazolines, pyridines, pyrimidine, pyrrolidine, quinazoline, quinazolinone, quinolone, quinoline, thiazole, triazole and other scaffolds acting against newly emerging anti-malarial targets. The present work reports the complete quinquennial coverage of anti-malarial agents reported during 2016-2020 with a view of providing the merits and demerits of reported anti-malarial scaffolds, structure-activity relationship, along with their in vitro/ in vivo/ in silico profiles to the medicinal chemists working in the field of design and discovery of novel anti-malarial agents., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Nonhuman primates are used for research purposes such as studying diseases and drug discovery and development programs. Various clinical pathology parameters are used as biomarkers of disease conditions in biomedical research. Detailed reports of these parameters are not available for Indian-origin rhesus macaques. To meet the increasing need for information, we conducted this study on 121 adult Indian rhesus macaques (57 wild-sourced and 64 inhouse animals, aged 3-7 years). A total of 18 hematology and 18 biochemistry parameters were evaluated and reported in this study. Data from these parameters were statistically evaluated for significance amongst inhouse and wild-born animals and for differences amongst sexes. The reference range was calculated according to C28-A3 guidelines for reporting reference intervals of clinical laboratory parameters., Results: Source of the animals and sex appeared to have statistically significant effects on reference values and range. Wild-born animals reported higher WBC, platelets, neutrophils, RBC, hemoglobin, HCT, MCV, and total protein values in comparison to inhouse monkeys. Sex-based differences were observed for parameters such as RBCs, hemoglobin, HCT, creatinine, calcium, phosphorus, albumin, and total protein amongst others., Conclusions: Through this study, we have established a comprehensive data set of reference values and intervals for certain hematological and biochemical parameters which will help researchers in planning, conducting, and interpreting various aspects of biomedical research employing Indian-origin rhesus monkeys., (© 2022. The Author(s).)

Background: A comparison of pneumonias due to SARS-CoV-2 and influenza, in terms of clinical course and predictors of outcomes, might inform prognosis and resource management. We aimed to compare clinical course and outcome predictors in SARS-CoV-2 and influenza pneumonia using multi-state modelling and supervised machine learning on clinical data among hospitalised patients., Methods: This multicenter retrospective cohort study of patients hospitalised with SARS-CoV-2 (March-December 2020) or influenza (Jan 2015-March 2020) pneumonia had the composite of hospital mortality and hospice discharge as the primary outcome. Multi-state models compared differences in oxygenation/ventilatory utilisation between pneumonias longitudinally throughout hospitalisation. Differences in predictors of outcome were modelled using supervised machine learning classifiers., Findings: Among 2,529 hospitalisations with SARS-CoV-2 and 2,256 with influenza pneumonia, the primary outcome occurred in 21% and 9%, respectively. Multi-state models differentiated oxygen requirement progression between viruses, with SARS-CoV-2 manifesting rapidly-escalating early hypoxemia. Highly contributory classifier variables for the primary outcome differed substantially between viruses., Interpretation: SARS-CoV-2 and influenza pneumonia differ in presentation, hospital course, and outcome predictors. These pathogen-specific differential responses in viral pneumonias suggest distinct management approaches should be investigated., Funding: This project was supported by NIH/NCATS UL1 TR002345, NIH/NCATS KL2 TR002346 (PGL), the Doris Duke Charitable Foundation grant 2015215 (PGL), NIH/NHLBI R35 HL140026 (CSC), and a Big Ideas Award from the BJC HealthCare and Washington University School of Medicine Healthcare Innovation Lab and NIH/NIGMS R35 GM142992 (PS)., Competing Interests: Declaration of interests PGL- Present work: efforts were supported by, BJC HealthCare Healthcare Innovation Lab “Big Ideas” award, Doris Duke Charitable Foundation, and Fund to Retain Clinical Scientists, # 2015215. Outside scope of present work- CDC MMC- Outside scope of present work, grants to institution: DOD PRMRP W81XWH-21-1-0009, NIH/ NIDDK R01-DK126933A -01, NIH/ NIGMS R35-13362546, NIH/NIGMS, R01-GM123193. Patent pending ARCD. P0535US.P2. APM- Outside scope of present work: Pfizer personal stock ownership. TK- Outside scope of present work: Grants: NIA, AHRQ, NLM, NCATS, NIMH; Licenses: Springer, Elsevier; Consultant: Pfizer, Inc; Presentations and Events: Department of Defense. CCS- Outside scope of present work: Grants: NIH, Department of Defense, Roche-Genentech, Quantum Leap Healthcare Collaborative; Consultant: Vasomune, Gen1e Life Sciences, Cellenkos, Janssen. SLW. AD, KD, TMP, SVB, AB, PS, EHG, BNR, MK, and AM have no conflicts of interest to report., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Robotic percutaneous coronary intervention (R-PCI) has been shown to provide benefits to operators and patients when compared with traditional percutaneous coronary intervention. Despite being available for 16 years in the United States, utilization of R-PCI remains low. This may be because of an expected learning curve with this technology. We sought to describe the characteristics and magnitude of the learning curve with R-PCI., Methods: Consecutive patients undergoing R-PCI (Corpath GRX-2) at a tertiary care center by a single operator were studied prospectively. Demographic, angiographic, and procedural variables were collected. The primary study endpoints included fluoroscopy time, procedure time, and contrast volume. The distributions of each of these variables were plotted against the case numbers in chronological sequence, and the best curve fits were identified. Using the best model, the slope of the relationships was analyzed. Flattening of the slope of these plots were considered suggestive of a learning effect., Results: A total of 546 R-PCI and 1654 traditional percutaneous coronary intervention procedures were studied; 22 crossovers to traditional percutaneous coronary intervention occurred. Most of the crossovers occurred in the first quartile of procedures; no crossovers occurred in the latter half of the cohort. Procedure time decreased as the procedure number increased, with the slope flattening at procedure number 50. Contrast volume decreased as experience increased, with a slope flattening at procedure number 30. Both parameters continued to decrease as experience increased. Fluoroscopy time demonstrated a flattening slope after procedure number 15. This likely is driven by the lower complexity by Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score remained stable over the procedure sequence, with no significant complexity change over the study period., Conclusion: The "learning effect" of R-PCI is observed with steep improvement in study metrics up to 50 procedures and a continuing improvement of lesser magnitude afterward.

Most of the currently marketed drugs consist of heterocyclic scaffolds containing nitrogen and or oxygen as heteroatoms in their structures. Several research groups have synthesized diversely substituted 1,2,4-oxadiazoles as anti-infective agents having anti-bacterial, anti-viral, anti-leishmanial, etc. activities. For the first time, the present review article will provide the coverage of synthetic account of 1,2,4-oxadiazoles as anti-infective agents along with their potential for SAR, activity potential, promising target for mode of action. The efforts have been made to provide the chemical intuitions to the reader to design new chemical entity with potential of anti-infective activity. This review will mark the impact as the valuable, comprehensive and pioneered work along with the library of synthetic strategies for the organic and medicinal chemists for further refinement of 1,2,4-oxadiazole as anti-infective agents., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Improvements in angiographic imaging systems technology provide options to decrease radiation exposure. The effect of these variations on image resolution is unknown., Methods: Using an American National Standards Institution phantom, a high-contrast (line-pair) and low contrast (Gammex 151) phantoms, 5 second images were acquired using a Phillips Allure angiographic suite, using fluoroscopic capture (FC) as well as cineangiography (CA) in posterior anterior (PA) and left anterior oblique (LAO) projections as well as high and low table positions. Image resolutions were measured as ranked by three independent trained observers blinded to the purpose of the assessments. Comparative analyses were performed. Interobserver agreement was evaluated., Results: High contrast image resolution was significantly lower with FC compared to CA (median [interquartile range], 1.69 [1.52-1.69] mm, vs 2.09 [1.88-2.09] mm, P < 0.001). No significant differences were observed in between PA and LAO projections as well as low and high table positions. Low contrast resolution was also lower with FC compared to CA (5 [6.5-5] vs 3 [5-3] mm, P < 0.001). No significant differences in high-contrast or low-contrast resolution were noted between PA and LAO projections, or high and low table positions. Both low and high-contrast image resolution improved with higher radiation exposure. Good interobserver agreement was noted (Fleiss-Kappa ranging from 0.69-0.74)., Conclusion: Image resolution was perceived to be better with CA compared to FC, although not significantly affected by beam angulation or table height. Aligning resolution needs with imaging modality and maximizing table height may improve procedural efficacy and safety., Competing Interests: Declaration of competing interest The authors hereby state that they have no conflict of interest relevant to this manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Radial artery occlusion (RAO) remains one of the most important complications of transradial access (TRA). Despite the identification of multiple predictors, the interaction between these predictors on the occurrence of RAO has not been evaluated., Methods: Consecutive patients undergoing TRA coronary angiography (CA) or percutaneous coronary intervention (PCI), were retrospectively analyzed to compare the effect of standard patent hemostasis using a one-bladder band versus two-bladder band with simultaneous ipsilateral ulnar artery compression and two introducer sizes on the primary endpoint of RAO. Access was obtained using 6-Fr slender introducer sheath or 7-Fr slender introducer sheath and hemostasis with either a one-bladder band or a two-bladder band. The radial artery was evaluated using ultrasound., Results: Total of 2019 patients undergoing CA or PCI were included in the analysis. In the one-bladder band group, the incidence of RAO with a 6-Fr slender introducer sheath was 4.2%. In those receiving hemostasis with a two-bladder band, RAO occurred in 1% of patients receiving a 6-Fr slender introducer sheath versus 0.9% in those receiving a 7-Fr slender introducer sheath (p = 0.68). Larger radial artery diameter, larger body weight, and a two-bladder hemostasis band with ipsilateral ulnar compression were independently associated with a lower incidence of RAO., Conclusion: A two-bladder band with simultaneous ipsilateral ulnar artery compression when used for radial artery hemostasis, is associated with a lower incidence of RAO, and can mitigate the penalty for a larger catheter with reassuring implications for use of a 7-Fr capable system for complex transradial PCI., (© 2022 Wiley Periodicals LLC.)

Purpose of Review: Robotics has been used in multiple areas of procedural medical intervention. Robotic percutaneous coronary intervention (PCI) has been available since 2004. Its adoption has been slow with initial application in simple cases., Recent Findings: With increasing adoption, robotic PCI has been applied to a broader variety of coronary substrates with demonstration of safety and efficacy. Improvements in the robotic console with future generation devices should add to the utility of this platform. Robotic PCI advances the innovations in endovascular space into a different dimension, removing the dependence of the procedure on patient-operator ergonomics and likely operator skill., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: The distal radial artery (dRA) approach at anatomical snuff box has gained attention of the interventional cardiologist in last few years. The procedural success rate by this novel approach depends on size of the radial artery and therefore the study was planned to study the size of distal radial artery., Methods: Total of 1004 patients of >18 years of age undergoing coronary catheterization were included in the study. The vessel diameter was measured from media to media in the anatomical snuff box a day prior to coronary catheterization., Results: The mean diameter of right radial artery at conventional access site was 2.56 ± 0.35 mm and at distal access site 2.23 ± 0.39 mm (p < 0.001). Females had significantly smaller radial artery diameter as compared to males at right conventional access site (2.42 ± 0.36 mm vs 2.60 ± 0.34 mm; p < 0.001) and distal access site (2.09 ± 0.38 mm vs 2.27 ± 0.39 mm; p < 0.001). The diameter of the right dRA was not significantly correlated with age (r 2 linear = 0.002, p = 0.0475) but was positively correlated with height and weight (r 2 linear = 0.076, p = <0.001 and r 2 linear = 0.005, p = <0.001) and negatively correlated with BMI (r 2 linear = 0.076, p = 0.519)., Conclusions: This study has shown the size of right dRA 2.27 + 0.39 mm in males and 2.09 + 0.38 mm in females. Diabetes, hypertension, height and weight are important predictors of dRA diameter., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Type-2 diabetes mellitus (T2DM) is a chronic immuno-inflammatory and metabolic disease characterized by hyperglycemia and insulin resistance with corresponding hyperinsulinemia. On the other hand, Alzheimer's disease (AD) is a neurodegenerative disease involving cognitive impairment, neuronal dysfunction, and memory loss. Several recently published literatures suggest a causal relationship between T2DM and AD. In this review, we have discussed several potential mechanisms underlying diabetes-induced cognitive impairment which include, abnormal insulin signaling, amyloid-β accumulation, oxidative stress, immuno-inflammation, mitochondrial dysfunction, advanced glycation end products, acetylcholinesterase and butyrylcholinesterase, advanced lipid peroxidation products, and apolipoprotein E. All these interconnected mechanisms may act either individually or synergistically which eventually leads to neurodegeneration and AD., Competing Interests: The authors have no conflict of interest to report., (© 2022 – The authors. Published by IOS Press.)

Background: Association of history of coronary artery bypass graft surgery (CABG) with clinical outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI) is unclear from current data., Methods: Using Nationwide Inpatient Sample (NIS) data from 2003 to 2014, adult patients hospitalized with principal diagnosis of STEMI were extracted. The cohort was divided into patients with a history of CABG and those without a history of CABG. The primary outcome measure was in-hospital mortality (IHM)., Results: 2,710,375 STEMI patients were included in final analysis of which 110,066 had history of CABG. Patients with history of CABG had higher unadjusted (12.2% vs. 8.8%, P  < 0.001) and adjusted (odds ratio [OR]1.16; 95% confidence interval [CI] 1.14 to1.19, P  < 0.001) IHM compared to those without previous CABG. Compared to a trend of decreasing IHM in STEMI patients without previous CABG, a trend of increasing IHM was observed over the study period in those with a history of previous CABG. Although patients with previous CABG when treated with primary PCI (PPCI) had a higher unadjusted IHM compared to those without previous CABG, (4.8% vs 4.3%, P  < 0.001), after adjusting for comorbidities and in-hospital complications no significant increase in IHM was observed in patients with previous CABG treated with PPCI., Conclusion: STEMI patients with previous CABG have a significantly higher IHM compared to those without previous CABG. PPCI improves IHM with no independent mortality disadvantage attributable to previous CABG., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Published by Elsevier B.V.)

Anatomical snuff box or distal radial artery approach for various percutaneous coronary angiograms and interventions has gained increased interest in recent years. The main advantage is the ergonomic comfort to the patient as it allows the patient's arm to be in more natural position. The safety and feasibility of this novel approach has been studied in past few years but still the data is limited and the distal radial artery approach has not been included in the guidelines. The present review focuses on the latest evidence, technique, advantages and disadvantages of this distal radial artery access., Competing Interests: Declaration of competing interest Nil., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Duplex Doppler ultrasonography (USG) remains the gold standard for evaluation of radial artery occlusion (RAO) after transradial access (TRA). The diagnostic accuracy of digital plethysmography, which is cheaper and widely available, for evaluation of RAO after TRA is not known., Methods: Patients undergoing TRA were prospectively studied. After undergoing TRA for diagnostic or interventional coronary procedure and obtaining radial artery hemostasis, the radial artery was evaluated for presence or absence of RAO using digital plethysmography of the ipsilateral index finger and the thumb using modified reverse Barbeau's test (MRBT) and USG. Sensitivity, specificity, predictive values, likelihood ratios and other metrics of evaluation of diagnostic performance of MRBT in reference to USG, the current gold standard, were evaluated., Results: 503 patients who underwent TRA for coronary procedures were studied. MRBT demonstrated a sensitivity = 96.2%, specificity = 99.8%, positive predictive value = 96.1, negative predictive value = 99.8, likelihood ratio (+) = 481, likelihood ratio (-) = 0.38, diagnostic accuracy = 99.6, diagnostic odds ratio = 11,904, Youden's index = 0.96, receiver operator characteristic derived c-statistic = 0.98 and Cohen's k = 0.98 when compared to USG. MRBT performed using the ipsilateral index finger and the thumb was no different. Agreement between absence of ipsilateral radial artery pulsation and RAO was weak (Cohen's k = 0.69)., Conclusions: MRBT using ipsilateral digital plethysmography performs comparably to USG for assessment of presence of RAO after TRA. There is no significant difference between MRBT performed using the ipsilateral thumb or the index finger., (Published by Elsevier Inc.)

Objectives: The study evaluated the association between distance from radiation source and radiation exposure., Background: Radiation exposure during medical procedures is associated with increased risk of cancer and other adverse effects., Methods: An American National Standards Institute phantom was used to study the relationship between measured entrance surface exposure (MESE) and distance from the X-ray source in postero-anterior, left anterior oblique, and right anterior oblique projections. Three distance settings for table height were evaluated with "low" defined as 52 cm, "mid" 66 cm, and "high" 80 cm from the focal point of the X-ray source. Air-kerma and dose-area product measurements were recorded. Operator exposure with each of these conditions was measured, in a short operator (150 cm) as well as in a tall operator (190 cm)., Results: Aggregate results for the three projections were as follows. MESE (μGy/frame) significantly decreased as table-height increases (median, interquartile range, p-value) (low table-height 192.5 [122.4-201.2], mid table-height 105.8 [82.7-115.8], and high table-height 71.7 [58.4-75], p < .0005). The operator exposure (μGy/frame), significantly increased as the table-height increased (low table-height 0.0943 [0.0598-0.1157], medium table-height 0.1128 [0.0919-0.1397], and high table-height 0.158 [0.1339-0.2165], p < .0005). A shorter operator received higher radiation exposure compared to a taller operator (short operator 0.1405 [0.1155-0.1758] and tall operator 0.0995 [0.0798-0.1212], p < .0005)., Conclusions: Increasing table-height is associated with a significant decrease in MESE. Operator radiation exposure increases with increasing table-height and shorter operators receive greater radiation exposure compared to taller operators., (© 2020 Wiley Periodicals LLC.)

Background: Lack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in-hospital outcomes after out-of-hospital ventricular fibrillation (OHVFA) arrest is unclear., Hypothesis: Lack of health insurance is associated with worse in-hospital outcomes after out-of-hospital ventricular fibrillation arrest., Methods: From January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in-hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization., Results: Of 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in-hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in-hospital mortality (O.R = 1.53, 95% C.I. [1.46-1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79-0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p-value) ($) (39 650 [18 034-93 399] vs. 35 965 [14 568.50-96 163], p < .001)., Conclusion: Lack of health insurance is associated with higher in-hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking., Research Question: Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg?, Study Design and Methods: This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD)., Results: A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups., Interpretation: In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction The 60/60 sign in 2D transthoracic echocardiography (TTE) - a combination of pulmonary acceleration time (PAT) less than 60 milliseconds and tricuspid regurgitation (TR) jet gradient of less than 60 mmHg - has been found to be specific for the diagnosis of pulmonary embolism (PE). Materials and methods An observational prospective analysis was carried out on cases of suspected PE presenting to the emergency room (ER). TTE was performed on all cases with suspected PE prior to computed tomography pulmonary angiography (CTPA). Emphasis was placed on measurement of PAT and early systolic notching (ESN) on the pulsed wave (PW) Doppler of the pulmonary valve, TR jet gradient, right ventricle systolic excursion velocity (RV S') by tissue doppler imaging (TDI), tricuspid annular plane systolic excursion (TAPSE), and right ventricle to left ventricle end-diastolic dimension ratio (RV:LV EDD) in modified parasternal short-axis view. These signs were taken as screening tests and compared to CTPA as the standard test. Patients were followed up until hospital discharge or death. Observations Fifty-six cases of suspected PE were enrolled for the study. Of these, 24 cases of PE were confirmed by CTPA. Out of 24 cases of PE, 15 were high-risk PE, six were intermediate high-risk PE, and three were intermediate low-risk PE. The mean age was 53.07±9.79 years with a male-to-female ratio of 1.95:1. The 60/60 sign was present in 70.83% of cases of PE. RV:LV EDD in a modified short-axis view of more than 0.9 was present in 91.67% of cases of PE, and ESN on the PW Doppler of the pulmonary valve was present in 75% of cases of PE. The 60/60 sign, RV:LV EDD ratio more than 0.9, and ESN showed sensitivities of 70.83%, 91.67%, 75%, and specificities of 93.75%, 75%, and 100%, respectively for PE. For prediction of mortality, presence of the 60/60 sign (Odds Ratio=8.13, p-value=0.034) and ESN (Odds Ratio=17.50, p-value=0.02) were statistically significant. Conclusions 60/60 sign and ESN are specific for the diagnosis of PE but have poor sensitivity., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Shah et al.)

Background: Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis., Methods: Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation., Results: MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death., Conclusions: In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.

Background: Radial artery occlusion (RAO) occurs after transradial access (TRA), limiting future ipsilateral access. Pragmatic RAO-lowering strategies need to be developed., Methods: Patients undergoing transradial cardiac catheterization were randomized to receive postprocedural hemostasis with either a single-bladder radial compression band (group 1) or a double-balloon band capable of simultaneous ipsilateral ulnar artery compression (group 2). Hemostatic compression was performed for 120 minutes. Patients in group 2 received ipsilateral ulnar artery compression for the first 60 minutes of radial hemostasis. The primary endpoint of the study was achievement of patent hemostasis, defined as radial artery patency at 15 minutes after onset of hemostatic compression. Radial artery patency was measured at 15 minutes, 60 minutes, 90 minutes, and 120 minutes after onset of compression and 1 hour after removal of the compression bands., Results: A total of 253 patients were randomized (127 in group 1 and 126 in group 2). Patent hemostasis was achieved significantly more frequently in group 2 vs group 1 (96.8% vs 74.8%, respectively; P<.001). RAO at 1 hour post band removal was significantly lower in group 2 vs group 1 (1.6% vs 10.2%, respectively; P<.001). Rebound bleeding occurred less frequently in group 2 vs group 1 (1.6% vs 7.9%, respectively; P=.03)., Conclusion: Ipsilateral ulnar compression performed for the initial 1 hour during the radial hemostatic process after TRA using a dedicated double-balloon device is associated with higher rates of patent hemostasis and lower incidence of RAO compared with a single-balloon band.

Background: Resting electrocardiogram (ECG) identification of long QT syndrome (LQTS) has limitations. Uncertainty exists on how to classify patients with borderline prolonged QT intervals. We tested if exercise testing could help serve to guide which children with borderline prolonged QT intervals may be gene positive for LQTS., Methods: Pediatric patients (n = 139) were divided into three groups: Controls (n = 76), gene positive LQTS with borderline QTc (n = 21), and gene negative patients with borderline QTc (n = 42). Borderline QTc was defined between 440-470 (male) and 440-480 (female) ms. ECGs were recorded supine, sitting, and standing. Patients then underwent treadmill stress testing with Bruce protocol followed by a 9-minute recovery phase., Results: Supine resting QTc, age, and Schwartz score for the three groups were: (a) gene positive: 446 ± 23 ms, 12.4 ± 3.4 years old, 3.2 ± 1.8; (b) gene negative: 445 ± 20 ms, 12.1 ± 2 years old, 2.0 ± 1.2; and (c) control: 400 ± 24 ms, 15.0 ± 3 years old. The three groups could be differentiated by their QTc response at two time points: standing and recovery phase at 6 minutes. Standing QTc ≥460 ms differentiated borderline prolonged QTc patients (gene positive and gene negative) from controls. Late recovery QTc ≥480 ms distinguished gene positive from gene negative patients., Conclusion: Exercise stress testing can be useful to identify children who are gene positive borderline LQTS from a normal population and gene negative borderline QTc children, allowing for selective gene testing in a higher risk group of patients with borderline QTc intervals and intermediate Schwartz scores., (© 2020 Wiley Periodicals LLC.)

Objectives: Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure., Design: Retrospective analysis of prospectively collected clinical data., Setting: Five community-based and one academic medical center in the Omaha, NE., Patients: 7,967 adults hospitalized with sepsis., Interventions: None., Measurements and Main Results: Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate., Conclusions: Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.

Background: Robotic percutaneous coronary intervention (R-PCI) has been shown to benefit the operator but has not shown any significant benefit to the patient. We sought to compare a large cohort of R-PCI to traditional percutaneous coronary intervention (PCI) procedures performed at a tertiary care center in the same time frame., Methods: A total of 996 consecutive patients referred for PCI between December 2017 and March 2019 were studied, of which 310 (31.1%) patients were selected to undergo R-PCI and 686 (68.9%) patients underwent traditional PCI. The coprimary study outcome measures were air kerma, dose-area product, fluoroscopy time, volume of contrast, and total procedural time. Caliper propensity-matching technique was used (caliper, 0.05) to match each R-PCI patient to the nearest traditional PCI patient without replacement., Results: Air kerma (mGy; median [interquartile range]; P ; 884 [537-1398] versus 1110 [699-1498]; P =0.002) and dose-area product (cGycm 2 ; 4734 [2695-7746] versus 5746 [3751-7833]; P =0.003) were significantly lower in the R-PCI group. There was no difference in fluoroscopy time (minutes; 5.51 [3.53-8.31] versus 5.48 [3.31-9.37]; P =0.936) and contrast volume (mL; 130 [103-170] versus 140 [100-180]; P =0.905). Total procedural time (minutes) was significantly higher in the R-PCI group (27 [21-40] versus 37 [27-50]; P <0.0005)., Conclusions: R-PCI is associated with a significant decrease in radiation exposure to the patient with no increase in fluoroscopy time, as well as contrast utilization, and a minor increase in procedure duration compared with traditional PCI.

Transradial access has increased in utilization and has been shown to be superior compared with transfemoral access. Although infrequent, several transradial access site-related complications occur. By understanding potential mechanisms related to these complications, several prevention and treatment strategies can be implemented to mitigate adverse outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Compared with adults, children may be at greater risk of medication errors and potential adverse effects. The American Academy of Pediatrics recommends developing mechanisms for proactively identifying patients at risk for medication-related adverse events and failed reconciliation. This study's primary purpose was to evaluate pediatric patients admitted to identify risk factors requiring pharmacist intervention during medication reconciliation (MedRec)., Methods: This prospective study included pediatric patients admitted during the study time frame until the target population of 500 patient encounters was achieved. During each admission, pharmacy staff completed a medication history, after which a pediatric pharmacist completed a MedRec, as is standard hospital practice. The primary outcome was identification of factors for high-risk transitions of care during pediatric admissions based on the need for pharmacist interventions during the MedRec process., Results: In total, 331 interventions were made for 127 patients (median 2; range, 1-12). Of the 331 interventions, 196 (59.2%) were classified as being of moderate or significant severity. Although patients with at least 2 home medications were significantly more likely to require any intervention (p < 0.0001), patients with 5 or more home medications were more likely to have a significant intervention., Conclusion: Identifying patients with home medications could allow for focused efforts to intervene. Also, patients admitted to the PICU or those with cardiology- or endocrinology-related diagnoses should be prioritized for MedRec process, because of the likelihood of requiring multiple home medications. This strategy should be tailored to individual pediatric institutions based on internal quality control assessments and available resources., Competing Interests: Disclosure The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. Dr Nolt has had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis., (Copyright Pediatric Pharmacy Association. All rights reserved. For permissions, mhelms@pediatricpharmacy.org 2020.)

Background: Robotic-assisted percutaneous coronary intervention (R-PCI) has been successfully employed in the United States since 2011. Performing R-PCI from a remote location has never been reported but if feasible would extend availability of treatment to many patients with coronary artery disease (CAD) who would otherwise go without., Objective: To assess the feasibility of remote tele-R-PCI with the operator 20 miles away from the patients., Methods: Five patients with single, type A coronary artery lesions treatable by PCI consented to participate. The primary endpoint was procedural success with no major adverse cardiac events (MACE) before discharge. Procedural success was defined as achieving < 10% diametric stenosis of the occluded target vessel utilizing tele-R-PCI balloon angioplasty and stent deployment (CorPath GRX®, Corindus Vascular Robotics, USA) without converting to in-lab manual PCI by an on-site standby team. Procedural, angiographic, and safety data were collected as were questionnaire scores from the remote operator evaluating the robot-network composite, image clarity, and overall confidence in the procedure., Results: The primary endpoint was achieved in 100% of patients. No procedural complications or adverse events occurred, and all patients were discharged the following day without MACE. The operator scores were favorable with the operators rating the procedure as equivalent to an in-lab procedure., Conclusions: Performing long distance tele-R-PCI in patients with CAD is feasible with predictably successful outcomes if reliable network connectivity and local cardiac catheterization facilities are available., (© 2019 Published by Elsevier Ltd.)

In view of hemorrhagic and prothrombotic tendencies, ST-segment elevation myocardial infarction (STEMI) patients with chronic hematologic malignancies (CHM) are felt to be at a higher risk and hence denied standard reperfusion strategies. In-hospital outcomes of CHM patients presenting with STEMI are unclear. The Nationwide Inpatient Sample data files from 2003 to 2014 were used to extract adult patients who presented with a primary diagnosis of STEMI. Patients who had a diagnosis of CHM defined as chronic myelogenous leukemia, chronic lymphocytic leukemia, essential thrombocythemia, polycythemia vera, chronic monocytic leukemia, and multiple myeloma were identified. The primary study outcome measure was in-hospital mortality. Inverse probability weighting-adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality. Of 2,715,807 STEMI patients included in the final analyses, 11,974 (0.4%) patients had a diagnosis of CHM. Patients with CHM were significantly older, had a higher prevalence of co-morbidities, and had a significantly higher unadjusted in-hospital mortality (14.9% vs 9.0%; p <0.001). After adjusting for co-morbidities, CHM did not independently predict a higher in-hospital mortality (odds ratio = 1.02, 95% confidence interval = 0.96 to 1.09; p = 0.461). In patients with CHM who presented with STEMI, percutaneous coronary intervention was found to be associated with a significant reduction in in-hospital mortality (odds ratio = 0.22, 95% confidence interval = 0.18 to 0.27; p <0.001) (c-statistic = 0.81). In conclusion, CHM patients presenting with STEMI should be treated with similar treatment strategies as those without CHM, including revascularization if indicated, as there appears to be a sizable outcome advantage with this approach., (Copyright © 2019. Published by Elsevier Inc.)

The spectrum of conditions affecting the penile skin is varied and ranges from simple, benign dermatoses to premalignant and malignant conditions. Anogenital malignancies and premalignancies are an important personal/public health problem due to their effects on individuals' physical, mental, and sexual health. Furthermore, due to their etiological association with human papillomavirus infection, anogenital malignancies, and premalignancies constitute an immense public health burden. Bowen's disease, Bowenoid papulosis, and erythroplasia of Queyrat are the most widely seen premalignancies of anogenital region and are all forms of squamous intraepithelial neoplasia. Histopathologically, these conditions share identical histologic features of squamous cell carcinoma in situ , but their clinical features differ. In this article, we explore the common precancerous states that can lead to penile carcinoma., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Indian Journal of Sexually Transmitted Diseases and AIDS.)

Objectives: To gain insight into current practice of transradial angiography and intervention in the United States and around the world., Background: Transradial access (TRA) has grown worldwide. In a prior survey, there was significant practice variation and there was minimal US participation which limited the generalizability to US operators., Methods: We used an internet-based survey software program to solicit input from practicing interventional cardiologists from the United States and around the world. US operators were compared with outside the United States (OUS) operators and respondent-level comparisons were made with the prior survey to assess for temporal changes in practice., Results: Between August 2016 and January 1, 2017, 125 interventional cardiologists completed the survey representing 91 countries with the United States having 449 (39.9%) respondents. Preprocedure, noninvasive testing for collateral circulation is used more commonly in the United States (54.1%) than around the world (26.6%) but its use has decreased since 2010. In the US, 48.8% of operators never use ultrasound and 92.6% of OUS operators never use it; only 4.4% overall use ultrasound in >50% of cases. Use of bivalirudin has decreased in the US and OUS. Nearly, 30% of operators do not assess for radial artery patency following hemostasis. US respondents used TRA less commonly for primary PCI for STEMI than their global counterparts., Conclusions: There is wide variation in how TRA procedures are performed including relatively low rates of adherence to practices that are known to improve outcomes. Further education aimed at increasing use of best practices will impact patient outcomes., (© 2018 Wiley Periodicals, Inc.)

Objectives: Data on next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) are limited. This study investigated the feasibility and safety of NDD as a first-line option (the very-early discharge [VED] strategy) compared with the early-discharge (ED) strategy (2-3 days as a first-line option) after TAVR., Methods: We reviewed 611 consecutive patients who had minimalist TAVR (transfemoral approach under conscious sedation) and no in-hospital mortality; a total of 418 patients underwent ED strategy (since December 2013) and 193 patients underwent VED strategy (as part of a hospital initiative to reduce length of stay, since August 2016). NDD in the VED strategy was performed with heart team consensus in patients without significant complications. The primary outcome was a composite of 30-day all-cause mortality/rehospitalization., Results: Sixty-five patients (33.7%) in the VED strategy and 10 patients (2.4%) in the ED strategy were discharged the next day (P<.001). NDD patients had received balloon-expandable (n = 30) or self-expanding valves (n = 45) and showed a similar primary outcome rate compared with non-NDD patients. After adjustment using propensity score matching (172 pairs), post-TAVR length of stay was significantly shorter in the VED group (3.2 ± 3.1 days) than in the ED group (3.5 ± 2.7 days; P<.01). The primary outcome did not differ between the two groups (7.0% vs 11.6%; P=.14), with comparable 30-day mortality rate (1.2% vs 2.3%; P=.68) and rehospitalization rate (5.8% vs 11.1%; P=.08)., Conclusions: Utilization of NDD as a first-line option after minimalist TAVR is feasible and safe, and leads to further reduction in length of stay compared with an ED strategy.

Context: Vitiligo is an autoimmune pigmentary disorder characterized by localized or generalized depigmentation of the skin. It is associated with significant stigma and has impact on patient's quality of life (QoL) and psychological wellbeing., Aims: To see the variance in QoL and level of depression in vitiligo patients with extent of vitiligo., Materials and Methods: Vitiligo patients aged ≥18 years attending OPD were included in the study. Impairment in QoL was assessed by administering DLQI (Dermatology Life Quality Index) and VIS22 (Vitiligo Impact Scale22). Depression was assessed by administering QIDSSR16 (Quick Inventory of Depressive Symptomatology). The Vitiligo Area Scoring Index (VASI) was calculated based on clinical examination., Results: One hundred and fifty patients enrolled. Most common age group was 18-30 years. Mean DLQI, VIS22, QIDSSR16 scores were 7.02, 16.37, 5.87, respectively. QoL was affected to some extent in 85.3% and 86.7% according to the DLQI and VIS22, respectively. Depression was seen in 44%., Coclusion: Young patients showed higher impairment in QoL and also higher levels of depression. It would be useful to offer psychiatric consult and counseling in addition to specific treatment., Competing Interests: There are no conflicts of interest.

Competing Interests: There are no conflicts of interest.

Objectives: The study sought to evaluate whether prophylactic ipsilateral ulnar artery compression during radial artery hemostasis could reduce the risk of radial artery occlusion (RAO)., Background: RAO after transradial access (TRA) is a structural complication of TRA. It limits future ipsilateral TRA and may cause transient pain. Maintaining radial artery flow during hemostasis reduces the incidence of acute RAO. Ipsilateral ulnar compression increases radial artery flow and could impact the incidence of RAO., Methods: Three thousand patients undergoing diagnostic cardiac catheterization using TRA were randomized to receive either standard patent hemostasis protocol (Group I) or prophylactic ipsilateral ulnar compression in addition to patent hemostasis (Group II). Using plethysmography, radial artery patency was evaluated at the time of removal of the compression device as well as 24 h and 30 days after the procedure. The primary study endpoint was 30-day RAO., Results: The primary endpoint, 30-day RAO, was significantly reduced in patients with patent hemostasis and prophylactic ulnar compression compared with standard patent hemostasis (0.9% vs. 3.0%; p = 0.0001). Baseline patient and procedural characteristics were similar between the 2 groups. RAO was significantly reduced by prophylactic ulnar compression at all time intervals (p < 0.0001)., Conclusions: Prophylactic ipsilateral ulnar compression during radial artery hemostasis is an effective, simple, and inexpensive technique that lowers the risk of RAO after TRA., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Right heart catheter advancement from right atrium (RA) to right ventricle (RV) is frequently difficult in patients with large and geometrically deformed RAs. We describe a simple technique, using no additional equipment, that significantly improves the probability of successful passage of right heart catheter from RA to RV.

Background: The choice of drug-eluting stent in the treatment of patients with diabetes mellitus and coronary artery disease who are undergoing percutaneous coronary intervention (PCI) has been debated. Previous studies comparing paclitaxel-eluting stents with stents eluting rapamycin (now called sirolimus) or its analogues (everolimus or zotarolimus) have produced contradictory results, ranging from equivalence between stent types to superiority of everolimus-eluting stents., Methods: We randomly assigned 1830 patients with diabetes mellitus and coronary artery disease who were undergoing PCI to receive either a paclitaxel-eluting stent or an everolimus-eluting stent. We used a noninferiority trial design with a noninferiority margin of 4 percentage points for the upper boundary of the 95% confidence interval of the risk difference. The primary end point was target-vessel failure, which was defined as a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization at the 1-year follow-up., Results: At 1 year, paclitaxel-eluting stents did not meet the criterion for noninferiority to everolimus-eluting stents with respect to the primary end point (rate of target-vessel failure, 5.6% vs. 2.9%; risk difference, 2.7 percentage points [95% confidence interval, 0.8 to 4.5]; relative risk, 1.89 [95% confidence interval, 1.20 to 2.99]; P=0.38 for noninferiority). There was a significantly higher 1-year rate in the paclitaxel-eluting stent group than in the everolimus-eluting stent group of target-vessel failure (P=0.005), spontaneous myocardial infarction (3.2% vs. 1.2%, P=0.004), stent thrombosis (2.1% vs. 0.4%, P=0.002), target-vessel revascularization (3.4% vs. 1.2%, P=0.002), and target-lesion revascularization (3.4% vs. 1.2%, P=0.002)., Conclusions: In patients with diabetes mellitus and coronary artery disease undergoing PCI, paclitaxel-eluting stents were not shown to be noninferior to everolimus-eluting stents, and they resulted in higher rates of target-vessel failure, myocardial infarction, stent thrombosis, and target-vessel revascularization at 1 year. (Funded by Boston Scientific; TUXEDO-India Clinical Trials Registry-India number, CTRI/2011/06/001830).