Recognition and management of hemolysis following transcatheter aortic valve replacement in a patient with chronic kidney disease

A 79-year-old female with chronic kidney disease (CKD) and transthoracic aortic valve replacement presented with exertional dyspnea and was found to have hemolysis due to moderate paravalvular leak. Balloon dilatation resolved symptoms and anemia. Detecting hemolysis related to paravalvular leak is challenging due to CKD, possibly leading to bone marrow suppression.

Impact of low skeletal muscle mass on postoperative complications in head and neck cancer patients undergoing free flap reconstructive surgery - A systematic review and meta-analysis

Low skeletal muscle mass is emerging as an adverse predictive and prognostic factor in cancer patients. The use of this parameter as a risk factor for complications after surgery is not currently used in clinical practice. This meta-analysis aims to assess the association of low skeletal muscle mass defined by radiological criteria and complications after reconstructive microsurgery in head and neck cancer patients. A systematic review for articles was performed using the PubMed, EMBASE database and by manual search. Articles that assessed low skeletal muscle mass and its impact on postoperative complications in head and neck cancer patients undergoing free flap surgery were selected. Pooled estimates of postoperative outcome data were calculated by extracting the odds ratio (OR) and 95% confidence interval (CI). The search strategy returned with 6 studies meeting the inclusion criteria. A total of 1082 patients were analyzed. The prevalence of low skeletal muscle mass between studies ranged from 24.6% to 61.5%. The meta-analysis showed an OR for complications after surgery of 2.42 (95% CI 1.53-3.32, p = 0.00). The study therefore concludes that skeletal muscle mass is an independent risk factor for postoperative complications in head and neck cancer reconstructive surgery patients. This argues for implementing screening for low skeletal muscle in preoperative management to optimize surgical decision making.

Effect of surfactant concentration on the evaporation-driven deposition of carbon nanotubes: from coffee-ring effect to strain sensing

Carbon nanotubes (CNTs) as electrically conductive materials are of great importance in the fabrication of flexible electronic devices and wearable sensors. In this regard, the evaporation-driven self-assembly of CNTs has attracted increasing attention. CNT-based applications are mostly concerned with the alignment of CNTs and the density of CNT films. In the present work, we focus on the latter by trying to achieve an optimal evaporation-driven deposition with the densest CNT ring. Although surfactants are used for effective dispersion and colloidal stabilization of CNTs in the aqueous phase, their excessive usage induces Marangoni eddies in the evaporating sessile droplets, leading to poor ring depositions. Thus, there is an optimum surfactant concentration that contributes to CNTs deagglomeration and results in the densest ring-like deposition with relatively high thickness. We report that this optimum concentration for sodium dodecyl sulfate (SDS) as a surfactant can be approximately considered as much as the concentration of multi-walled carbon nanotubes (MWCNTs) as the colloidal nanoparticles. Optimal depositions show the lowest electrical resistances for each CNT concentration, making them suitable for electronic applications. We also propose the multiple depositions method in which a new droplet is printed after the complete evaporation of the previous droplet. This method can lead to denser rings with a higher conductivity using lower concentrations of CNTs. Lastly, we fabricate strain sensors based on the optimal evaporation-driven deposition of CNTs which show higher gauge factors than the commercial strain gauges, corroborating the applicability of our method.

Treatment of open-angle glaucoma and ocular hypertension with preservative-free tafluprost/timolol fixed-dose combination therapy: 6 case reports and clinical outcomes

Background

Treatment of open angle glaucoma (OAG) and/or ocular hypertension (OHT) focuses on achievement of target intraocular pressure (IOP), with the objective of slowing disease progression. However, ocular surface health is an important consideration in the optimization of treatment. We report 6 patient cases in which enhanced IOP control was achieved following appropriate management of ocular surface inflammation and a therapeutic switch to the preservative-free (PF) tafluprost (0.0015%)/timolol (0.5%) fixed-dose combination (FC).

Case presentation

Six patient cases, aged 48–74 years, presented with OAG or OHT. Each patient had signs and symptoms of ocular surface disease (OSD). Cases 1–3 were each receiving maximal medical therapy for OAG; regimens comprising prostaglandin analogue (PGA), β-blocker, carbonic anhydrase inhibitor (CAI) and α-2 agonist agents (including treatments containing preservative agent). Cases 1 and 2 reported IOP values ≥23 mmHg in each eye, and wide IOP fluctuations were identified when reviewing patient data concerning case 3 (11–20 mmHg). Maximal therapy was ceased and PF tafluprost/timolol FC was initiated, after which the signs and symptoms of OSD were improved and IOP was reduced (≤18 mmHg for cases 1–3) and stabilized. Cases 4 and 5 were diagnosed with OAG and case 6 had OHT. Each had symptoms and signs of OSD and were treated with a preserved PGA monotherapy (latanoprost 0.005% or bimatoprost 0.03%). At presentation, IOP was 24 mmHg in both eyes (case 4), ≥18 mmHg (case 5) and ≥ 22 mmHg (case 6). Following a switch to the PF tafluprost/timolol FC, OSD symptoms were improved and IOP was 14 mmHg (both eyes; case 4), ≤14 mmHg (case 5) and 16 mmHg (both eyes; case 6).

Conclusions

In addition to IOP-lowering efficacy, approaches to the management of OAG and OHT should consider the impact of treatment tolerability and the susceptibility of these patients to OSD. The presence of ocular surface inflammation appears to be detrimental to adherence and therefore to the effectiveness of topical medications. Addressing OSD through the use of PF FC formations, such as the PF tafluprost/timolol FC, reduces exposure to potentially toxic agents and facilitates improvements in IOP control.

Postoperative Imaging Appearance of Iliac Crest Free Flaps Used for Palatomaxillary Reconstructions

The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Capture-free deactivation of CTCs in the bloodstream; a metastasis suppression method by electrostatic stimulation of the peripheral blood

While limited investigations have been reported on CTC elimination and its profits, recently, some new works were reported on detection followed by the destruction of CTCs. Limitations and complications of CTC capturing procedures have highly reduced the chance of selective destruction of CTCs in the bloodstream in the therapeutic guidelines of the patients. Here, we selectively deactivated the invasive function of CTCs during their circulation in the bloodstream by exposing the whole blood to pure positive electrostatic charge stimulation (PPECS). Our treatment suppressed pulmonary metastasis and extended the survival of the mice had been intravenously injected by electrostatically deactivated 4T1 breast cancer CTCs. Moreover, the number of cancerous lung nodules was drastically reduced in the mice injected by treated CTCs in comparison with the non-treated cohort. Evaluating the side effect of the PPECS on the blood components revealed no major effect on the functional properties of the white blood cells, and just a negligible fraction (∼10%) was damaged during this process. This approach does not need any capturing or targeting of CTCs from the blood as it is focused on perturbing the electrical function of negatively-charged tumor cells after being exposed to positive electrostatic charges. Taken together, continuous in-vivo deactivation of CTCs by PPECS with no requirement to complicated capturing protocols may improve the survival of cancer patients.

Low skeletal muscle mass is a strong predictive factor for surgical complications and a prognostic factor in oral cancer patients undergoing mandibular reconstruction with a free fibula flap

BACKGROUND

Fibula free flaps (FFF) are effective in accomplishing successful reconstruction for segmental defects of the mandible. Potential risk factors for FFF complications have been described in previous research, e.g. age, comorbidity and smoking. Low skeletal muscle mass (SMM) has shown to be an emerging predictive factor for complications and prognostic factor for survival in head and neck cancer. This study aims to identify the predictive and prognostic value of low SMM for surgical FFF related complications, postoperative complications and survival in patients who underwent mandibular reconstruction with FFF after oral cavity cancer resection.

MATERIALS AND METHODS

A retrospective study was performed between 2002 and 2018. Pre-treatment SMM was measured at the level of the third cervical vertebra and converted to SMM at the level of the third lumbar vertebra (L3). SMM at the level of L3 was corrected for squared height. Low SMM was defined as a lumbar skeletal muscle index (LSMI) below 43.2 cm²/m².

RESULTS

78 patients were included, of which 48 (61.5%) had low SMM. Low SMM was associated with an increased risk of FFF related complications (HR 4.3; p = 0.02) and severe postoperative complications (Clavien-Dindo grade III-IV) (HR 4.0; p = 0.02). In addition low SMM was a prognosticator for overall survival (HR 2.4; p = 0.02) independent of age at time of operation, ACE-27 score and TNM stage.

CONCLUSION

Low SMM is a strong predictive factor for FFF reconstruction complications and other postoperative complications in patients undergoing FFF reconstruction of the mandible. Low SMM is also prognostic for decreased overall survival.

Evolution of large area TiS2-TiO2 heterostructures and S-doped TiO2 nano-sheets on titanium foils

We report a novel and facile method to synthesize sulfur-doped titanium oxide sheets and realize TiS2-TiO2 heterostructures by means of a sequential sulfurization and oxidation step in a dual-zone chemical vapor deposition furnace. The inclusion of chlorine and argon gases during the growth of such titanium-based compounds plays a critical role in the formation of desired geometries and crystalline structures. These heterostructures possess nano-whisker and nanosheet configurations, controlled by adjusting the growth parameters such as temperature, carrier gas and the sequencing between different steps of the growth. The evolution of these complex heterostructures has been investigated using Raman spectroscopy and EDS characterization. The presence of chlorine gas during the growth results in local TiS2 formation as well as faceted growth of TiO2 nanosheets through anatase to rutile phase change prohibition. The electron microscopy (TEM) images and diffraction pattern (SAED) characterization reveal the crystallinity and layered nature of grown structures, further demonstrating the 2D characteristics of S-doped nanosheets. The evolution of TiO2 on TiS2 heterostructures has also has been verified using XPS analysis. These highly featured nanostructures are suitable candidates to enhance the photocatalytic behavior of TiO2 nanostructures.

Application of Bayes' to the prediction of referral decisions made by specialist optometrists in relation to chronic open angle glaucoma

PURPOSE

To determine the accuracy of a Bayesian learning scheme (Bayes') applied to the prediction of clinical decisions made by specialist optometrists in relation to the referral refinement of chronic open angle glaucoma.

METHODS

This cross-sectional observational study involved collection of data from the worst affected or right eyes of a consecutive sample of cases (n = 1,006) referred into the West Kent Clinical Commissioning Group Community Ophthalmology Team (COT) by high street optometrists. Multilevel classification of each case was based on race, sex, age, family history of chronic open angle glaucoma, reason for referral, Goldmann Applanation Tonometry (intraocular pressure and interocular asymmetry), optic nerve head assessment (vertical size, cup disc ratio and interocular asymmetry), central corneal thickness and visual field analysis (Hodapp-Parrish-Anderson classification). Randomised stratified tenfold cross-validation was applied to determine the accuracy of Bayes' by comparing its output to the clinical decisions of three COT specialist optometrists; namely, the decision to discharge, follow-up or refer each case.

RESULTS

Outcomes of cross-validation, expressed as means and standard deviations, showed that the accuracy of Bayes' was high (95%, 2.0%) but that it falsely discharged (3.4%, 1.6%) or referred (3.1%, 1.5%) some cases.

CONCLUSIONS

The results indicate that Bayes' has the potential to augment the decisions of specialist optometrists.

Long-term efficacy and visual acuity following transscleral diode laser photocoagulation in cases of refractory and non-refractory glaucoma

AIMS

Transscleral diode laser cyclophotocoagulation (TSCP) is widely accepted in the treatment of refractory glaucoma especially in eyes with poor vision. However, until recently, there has been a reluctance to extend its use to eyes with good visual acuity (VA). The aims of this study were to evaluate the long-term efficacy and safety of TSCP for a range of glaucoma conditions, with particular emphasis on post-treatment VA in seeing eyes.

METHODS

A retrospective analysis of case notes of 74 treated eyes was conducted over a period of 4-30 months (mean 12.5 months).

RESULTS

Mean (SD) intraocular pressure (IOP) was reduced by 43% from 40.3 (6.7) to 21.1 mmHg (5.4) at the final index visit. Of all patients, 58% had a reduction in glaucoma drops and all discontinued oral Acetazolamide; 9% experienced complications. Mean VA was preserved in the subgroups with good vision, although 3/23 (13%) patients with primary open-angle glaucoma (POAG) lost vision due to cataract and glaucoma progression. There were no cases of hypotony (IOP<or=5 mmHg) or phthisis and only one eye required re-treatment.

CONCLUSIONS

TSCP is highly effective and safe for various types of glaucoma, and its use can be extended to eyes with good vision.

Morphology and location of restenosis following bare metal coronary stenting

Restenosis following bare metal coronary stenting is common. The location and characteristics of restenotic lesions in patients who have undergone coronary stent implantation is not well described. The purpose of this study was to determine the location, type and temporal distribution of stent-related restenosis. We reviewed the clinical and angiographic characteristics of 203 consecutive patients with stent-related restenosis undergoing a repeat clinically-indicated coronary angiogram, 30 days to 1 year after the index procedure. All lesions within 10 mm of the proximal and distal margins of the stent were included in the analysis. An angiographic classification was developed based on lesion location. Class I lesions were those occurring within the stent, and Class II comprised those lesions occurring within 10 mm of the proximal and distal stent edge. We classified a total of 234 stent-related restenosis lesions. Class I lesions were found in 52% of patients, and Class II in 48%. Three-fifths of the patients who developed new lesions at a stent edge presented 1-3 months following the initial procedure, which was significantly earlier than other lesion types (p < 0.001). A substantial number of patients undergoing repeat angiography after stent placement have lesions proximate, but peripheral, to the stent. This may limit the effectiveness of stent-based efforts to reduce restenosis. The time interval between coronary stenting and symptom recurrence appears to vary according to lesion location.

Digital imaging of the optic nerve head: monoscopic and stereoscopic analysis

AIMS

To compare monoscopic and stereoscopic assessment of the optic disc using novel software for the digital stereoscopic analysis of optic disc stereopairs.

METHODS

Software was developed for the stereoscopic display of digital optic disc images using an interlaced display method. Neuroretinal rim width was determined at 10 degree intervals around the optic disc using a custom (stereoscopic) cursor whose depth was adjusted to that of Elschnig's rim. Measurements were taken, first viewing the disc monoscopically and at a separate sitting, stereoscopically.

RESULTS

Measurements were made in 35 eyes from 35 patients (1260 estimates for each observer) using three observers. The mean cup to disc ratio (CDR) ranged from 0.57 to 0.66 (SD 0.13-0.14) for monoscopic viewing compared with 0.64 to 0.69 (SD 0.12-0.14) for stereoscopic viewing. Stereoscopic assessments gave higher CDRs in temporal, superior, nasal, and inferior aspects of the optic disc (p<0.001, Mann-Whitney U test). Agreement between observers in estimating CDR was high for monoscopic assessment (intraclass correlation coefficient 0.74 (CI 0.72 to 0.76) increasing to 0.80 (0.78 to 0.82) for stereoscopic assessment.

CONCLUSION

Digital stereoscopic optic disc assessment provides lower estimates of neuroretinal rim width and higher levels of interobserver agreement compared with monoscopic assessments.

Discrimination of glaucomatous optic neuropathy by digital stereoscopic analysis

PURPOSE

To evaluate the diagnostic power of a novel digital stereoscopic imaging system in the diagnosis of glaucomatous optic neuropathy.

DESIGN

Prospective cross-sectional analysis of the diagnostic accuracy of digital stereoscopic optic disc analysis in the diagnosis of glaucomatous optic neuropathy exhibiting mild to moderate field loss.

PARTICIPANTS

Fifty-two patients with open-angle glaucoma and 54 normal individuals were recruited. The presence of a reproducible visual field loss characteristic of glaucoma was used as the reference standard for the presence of glaucoma independent of the optic nerve head appearance. Patients were excluded if the optic disc, fundus, or visual field indicated other disease. One eye from each patient and individual was included in the study, the eye with the least field loss and a randomly designated normal eye, respectively.

METHODS

Simultaneous stereoscopic optic disc photography was performed on each specified eye. Three experienced observers viewed the resultant stereoscopic image of each nerve head using a Z screen, recorded a subjective clinical diagnosis, and undertook digital stereoscopic planimetry. Separate linear regression analysis was performed, post hoc, from the planimetric results for each observer of the logarithm of neuroretinal rim (NRR) against optic disc area derived from each normal eye. Eyes with NRR areas below the 95th prediction interval of the normal cohort were then classified as glaucomatous.

MAIN OUTCOME MEASURES

Sensitivity and specificity for the detection of glaucomatous optic neuropathy.

RESULTS

With subjective stereoscopic analysis, sensitivity for glaucoma detection among the 3 observers was 80.8%, 76.9%, and 90.4%, with respective specificities of 94.4%, 79.6%, and 79.6%. Regression analysis of the NRR in 30 degrees segments gave sensitivities between 69.2% and 80.8% and specificities between 83.3% and 90.7%. A combination of the subjective and quantitative analysis did not significantly improve discrimination.

CONCLUSIONS

The subjective analysis of digital stereoscopic images provides a useful method for the discrimination of normal and glaucomatous optic nerves. Planimetric analysis does not significantly improve the diagnostic precision of this technique.

Movement detection threshold and ocular hypertension

PURPOSE

To determine whether patients with ocular hypertension (OH) have elevated oscillatory movement displacement thresholds (OMDT) indicative of early neural damage.

METHODS

Evidence of early neural loss was sought using OMDT. The OMDT of 29 normotensive individuals were compared with those obtained from 44 untreated age-matched OH eyes (20 male, 24 female).

RESULTS

A mean OMDT at 15 sec arc at 40 years of age was obtained in normotensive individuals, the age trend increasing by about 4 sec arc per decade. About one-third of all ocular hypertensives (13 cases; 6 male, 7 female), who were dismissed without treatment, exhibited abnormal OMDT. An equal proportion of abnormal thresholds were observed in individuals in each decade, although the age trend diverges from that established for normotensives with increasing age. Mean OMDT for ocular hypertensives (37.1 sec arc) were significantly different (t = 2.7, p < 0.007) from the mean obtained from normotensives (22.2 sec arc).

CONCLUSION

The results emphasise the need for more rigorous differentiation of OH using psychophysical techniques indicating early neural damage.

Ultraviolet radiation-blocking characteristics of contact lenses: relevance to eye protection for psoralen-sensitised patients

Nine brands of contact lens marketed as "UV protective" were tested for ultraviolet (UV) transmission in order to assess potential suitability for psoralen-sensitised patients. UV-transmission characteristics of hydrated lenses was tested with a Bentham monochromator spectro-radiometer system. All lenses showed minimal transmission loss in the visible band. The performance of the nine lenses was uniform for ultraviolet B radiation with negligible transmission, but showed variation in transmission for ultraviolet A radiation. None of the lenses complied with UV-transmission criteria used previously to assess UV-blocking spectacles. Only two lenses had UV-blocking characteristics which came close to the arbitrary criteria used. The performance of ordinary soft and hard lenses was very similar, with negligible blocking of UV radiation. None of the nine contact lenses marketed as "UV protective" excluded sufficient UVA to comply with criteria in current use to assess UV protection in spectacles for psoralen-sensitised patients. However, the improved UV-blocking characteristics of contact lenses identified in this paper compared to previous studies suggests that such a contact lens will soon become available. Meanwhile, contact lens-wearing systemically sensitised PUVA patients should continue to wear approved spectacles for eye protection whilst photosensitised with psoralen.

Serum lipase and amylase ratio in acute alcoholic and nonalcoholic pancreatitis by using Dupont ACA discrete clinical analyzer

This work involves a retrospective analysis of serum amylase, lipase, and lipase/amylase ratio in alcoholic and nonalcoholic patients diagnosed with acute pancreatitis. The purpose of this study was to test the reliability of the Dupont ACA method with respect to the lipase/amylase ratio as a discriminator, for the etiology of pancreatitis. Thirty-six consecutive patients with the diagnosis of acute pancreatitis were studied. These patients were divided in two groups. Group I consisted of 11 patients who had presumed acute alcoholic pancreatitis. In group II, 19 patients had acute biliary pancreatitis, including two with necrcotizing pancreatitis and abscess formation secondary to cholilathiasis, five cases were idiopathic in nature, and one was thought to be medication induced (hydrochlorothiazide). In all cases, the Dupont ACA discrete clinical analyzer was used to determine serum levels of amylase and lipase. Concerning the lipase/amylase ratio, the geometric mean ratio for group I was 0.32 (range: 0.11-0.86) and for group II the mean ratio was 0.22 (range: 0.04-0.93). With P > 0.1, the difference between geometric mean ratios was not statistically significant. This study reveals that the lipase/amylase ratio would not have been a good indicator of alcoholic vs nonalcoholic acute pancreatitis. Although there was no significant statistical difference between geometric means, this study does show a significant difference in the number of individuals with serum amylase > 2000 IU/dl in nonalcoholic acute pancreatitis patients (8/25 showed levels above 2000 IU/dl) when compared to alcoholic acute pancreatitis patients (0/11 showed levels above 2000 IU/dl). Chi-square analysis between < 2000 IU/dl and > 2000 IU/dl for the nonalcoholic vs the alcoholic groups yielded a P value of 0.03.