The role of structured inpatient lipid protocols in optimizing non-statin lipid lowering therapy: a review and single-center experience

Dyslipidemia is a leading contributor to atherosclerotic cardiovascular disease (ASCVD). There has been a significant improvement in the treatment of dyslipidemia in the past 10 years with the development of new pharmacotherapies. The intent of this review is help enhance clinicians understanding of non-statin lipid lowering therapies in accordance with the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway on the Role of Non-statin Therapies for LDL-Cholesterol Lowering. We also present a single-center experience implementing a systematic inpatient protocol for lipid lowering therapy for secondary prevention of ASCVD.

The practice of social protection policies in China: a systematic review on how left-behind children's mental health can be optimised

AIMS

By discussing the mental health challenges faced by left-behind children, this article recommends or comments on existing social protection policies that can affect left-behind children's mental health at the micro-, meso- and macro-levels to holistically understand how a range of parties can jointly socially include left-behind children, a process which is conducive to the latter's mental health development.

METHODS

J.H. carried out a systematic review by searching through the English bibliographical databases Google Scholar, Web of Science and Scopus, in addition to Chinese bibliographic databases CNKI, Wanfang Data and VIP Chinese Science and Technology Periodicals. Here J.H. searched for the words ('social protection' OR 'socially protected') AND ('mental health' OR 'psychological wellbeing' OR 'mental problems' OR 'psychological problems') AND ('left-behind children' OR 'LBC' OR 'leftover children') AND ('China' OR 'Chinese'). Publication dates of the search results were limited to between 2010 and 2022.

RESULTS

One of the primary problems encountered by left-behind children is their inadequate home supervision. A further study indicates that parental migration serves as a crucial risk factor for child depression. State-level provision of insurance programmes helps curtail these children's encounters of mental health challenges. Moreover, an improvement in family and school protection is essential when optimising the protection system for left-behind rural Chinese children from poor villages. It is necessary for upper-level government units to re-structure their lower-level counterparts to improve the local administration. This allows lower-level government units to exploit preferential policies, refine relevant regulations and policies on child protection, and facilitate the establishment of social organisations where local policies can be successfully implemented to socially include and protect left-behind children in villages.

CONCLUSIONS

At the meso-level, community environment construction should be emphasised. At macro- and meso-levels, government authorities and social organisations should encourage the marketisation of hiring professional surrogate parents. At the micro-level, migrant parents should proactively take an initiative to contact their left-behind children via telecommunications.

Mechanical aspiration thrombectomy using the penumbra CAT RX system for patients presenting with acute coronary syndrome

Patient undergoing PCI can have distal embolization and microvascular obstruction despite normalization of epicardial blood flow. Aspiration thrombectomy has been studied previously to reduce infarct size, but prior methods of aspiration thrombectomy were associated with increased risk of stroke and is currently recommended as a bailout strategy. Penumbra CAT RX has been recently approved for aspiration thrombectomy, we evaluated the catheter's use in an academic cardiac catheterization lab. Patients undergoing cardiac catherization at an academic medical center who had deployment of the Penumbra CAT RX from 2017 through 2020 were included in the case series. TIMI flow pre and post procedure were determined by individual operator. Endpoints included 30-day cardiovascular death and post-procedural stroke. The Penumbra CAT RX catheter was used in a total of 34 patients, with 71% STEMI, 23% NSTEMI, 3% UA, and 3% new onset heart failure. TIMI 3 flow was achieved in 88% of cases. There were no cases of 30-day cardiovascular death or post procedural stroke. Aspiration thrombectomy continues to have clinical benefit in modern cardiac catherization laboratories with use in select cases. The Penumbra CAT RX appears to be safe and highly effective at thrombus removal in the acute setting without increased stroke risk as seen with manual aspiration thrombectomy.

Report of ventricular fibrillation in a 44-year-old man using kratom

Kratom is an unregulated kappa-opioid receptor agonist available for order on the internet that is used as a remedy for chronic pain. We present a case of a middle-aged man who suffered a cardiac arrest in the setting of kratom ingestion.

Developing a Data Integrated COVID-19 Tracking System for Decision-Making and Public Use

Introduction

The unprecedented COVID-19 pandemic unveiled a strong need for advanced and informative surveillance tools. The Centre for Health Informatics (CHI) at the University of Calgary took action to develop a surveillance dashboard, which would facilitate the education of the public, and answer critical questions posed by local and national government.

Objectives

The objective of this study was to create an interactive method of surveillance, or a “COVID-19 Tracker” for Canadian use. The Tracker offers user-friendly graphics characterizing various aspects of the current pandemic (e.g. case count, testing, hospitalizations, and policy interventions).

Methods

Six publicly available data sources were used, and were selected based on the frequency of updates, accuracy and types of data, and data presentation. The datasets have different levels of granularity for different provinces, which limits the information that we are able to show. Additionally, some datasets have missing entries, for which the “last observation carried forward” method was used. The website was created and hosted online, with a backend server, which is updated on a daily basis. The Tracker development followed an iterative process, as new figures were added to meet the changing needs of policy-makers.

Results

The resulting Tracker is a dashboard that visualizes real-time data, along with policy interventions from various countries, via user-friendly graphs with a hover option that reveals detailed information. The interactive features allow the user to customize the figures by jurisdiction, country/region, and the type of data shown. Data is displayed at the national and provincial level, as well as by health regions.

Conclusion

The COVID-19 Tracker offers real-time, detailed, and interactive visualizations that have the potential to shape crucial decision-making and inform Albertans and Canadians of the current pandemic.

Abstract 347: Can Radiation Exposure in the Catheterization Lab be Controlled With an Increasing Frequency of Complex and High Risk Procedures?

Background: Radiation [stochastic and deterministic] exposes patients and providers that must be balanced against the benefits achieved. Data derived from high exposure events has resulted in a goal of ALARA [as low as reasonably achievable] with concerns at 50 mSv [single event], 100 mSV [proximate exposures], 400 mSv [lifetime exposure]. Cath lab patients may receive high radiation as a consequence of high risk/ complex procedures, obesity, prior PCI/CABG and lesion complexity [ESRD, calcified, CTO], structural disease, supported interventions. Initiatives to reduce radiation exposure include: procedure staging, collimation, mapping, decrease fluoro frame rates and cine run number/length.

Procedure: Radiation of patients with invasive procedures in 2018 and 2019 with high exposure stochastic risk [Dose Area Product ≥20,000 μGy* m 2 ( 200 Gy*cm 2 ) or Skin Dose deterministic risk > 5 Gray were analyzed for associations and compared. Effective dose [0.23 mSy/Gy*m 2 ] provides a lifetime risk of fatal cancer related to radiation.

Results: Interventional volume increased from 1431 to 1547 PCI. The number and frequency of high DAP exposures decreased [237 to 161] and for 10 of 11 high volume operators; there was no decrease in high Skin Dose cases [83 versus 119]. Associations with high DAP rates: Surgical turndowns [14/161; 9%], high risk/complex procedures (e.g. rotablator [42/161; 26.1%], CTOs [27/161; 16.8%]), Obesity [100/161; 62%; Morbid Obesity 31/161; 19%]. Single vessel PCI patients comprised 41/161; 25.5% of high exposures with 10/41 [24% having a prior CABG]. Single event Dose Area Products were as high as 167,235 μGy* m 2 [effective dose 368 mSv; lifetime risk of fatal cancer 0.92%]; repeat procedures [up to 5 returns/ year with cumulative doses 10/161 in the 100-200 mSv range [1:200 -1:400 lifetime fatal cancer risk]. 36 of the 161 patients were ≤ 60 years old. Despite Skin Doses as high as 14 Gray no skin sequelae occurred. Operators varied in the frequency of high radiation procedures [highest volume 56/268; 21%; all others 105/1547; 8%], influenced by patient selection and procedure, but also by technical variables [e.g. fluoro verus cine, frame rate, collimation].

Conclusions: Despite efforts, radiation exposure remains a concern, aggravated by the need for increasingly high risk, structural heart, and supported interventional procedures. Opportunities for improvement include: lab upgrade to improve imaging in progress, increase staging [CABG , multivessel PCI patients], limit runs/ frame rates, increase mapping, optimize collimation. Lifetime fatal cancer risk is higher in younger than older patients with similar exposures due to both the latency period for cancer development and the likelihood of repeat radiation exposure. Efforts are underway to limit and track the cumulative radiation exposure of patients.

Scombroid Fish Poisoning Leading to Vasospastic Angina: A Rare Etiology of Chest Pain

Chest pain is commonly reported in emergency departments, and a thorough clinical history is important in distinguishing the etiology. This case highlights Kounis syndrome, a histamine-mediated coronary vasospasm leading to myocardial injury, due to scombroid fish poisoning. (Level of Difficulty: Beginner.)

Abstract 143: Spoke and Hub or Moat and Castle, Evolving Referral Patterns

Objective: Stony Brook University Renaissance Medical School and University Hospital [UH] is a tertiary care hospital in Sufflolk County, NY, an area covering 912 square miles [86 miles in length and maximum width of 26 miles] and serving a population of 1.5 million. UH coordinates STEMI calls of the 94 voluntary ambulance services covering the county. The county geography has made coverage for emergent interventional procedures challenging. UH, until relatively recently had one of two cath labs (now 7) and the only CT surgical program (now 3) in the county. Independent cath labs (and 2 CTS programs) have been set up at Community hospitals to provide 7 x 24 interventional service, changes that may modify the traditional "Hub with Spokes" referral pattern for STEMI. Opposing this centrifugal force has been the increasing consolidation of health care hospital networks. We examined the effects of these changes on STEMI referrals and overall volume at UH and a Cath capable community hospital between 2014- 2017.

Procedure: We examined the effects of changes in emergency cath lab availability on STEMI referrals and overall volume at UH and a Cath capable community hospital [BMH] between 2014- 2017.

Results: In 2014 of 167 STEMI calls 76 [45.5%] were referred to UH and 49 [29.3%] BMH. 2015 had 209 calls, 109 [52.2%] were referred to UH and 53 [25.4%] BMH. 2016 had 205 calls, 89 [43.4%] referred to UH and 53 [25.9%] BMH. 2017 had 247 calls, 101 [40.9%] referred to UH and 47 [19.0%] BMH. Ambulance company patterns of referral remained relatively stable despite an increase in local hospital availability. 34 ambulance companies brought patients to UH and 17 to BMH in 2014; 28 brought pts to UH and 19 to BMH in 2017. Ambulance companies continued to serve multiple hospitals throughout the monitored period. Total volume at UH remained little effected by changing practice guidelines or referral patterns: 2014: 2194 cath and 1329 PCI [total 3523]; 2015: 2371 cath and 1502 PCI [total 3873]; 2016: 2336 cath and 1578 PCI [total 3914]; 2017: 2367 cath and 1516 PCI [total 3883]. At UH, private [reflecting community hospital referrals] and staff physician utilization of the Cath lab also remained relatively unchanged in the studied period.

Conclusions: Increased availability of 24 x 7 cath lab availability has resulted in a modest relative decline in referrals, more pronounced at the community hospital. Despite this, overall volume and therefore demand remains preserved. The increasing development of hospital networks and hospital based emergency ambulance services has not yet had a major impact on services, changing our "Hub with Spokes" to a "Castle and Moat", but will continue to be closely observed.

Traditional Acupuncture for Reflex Sympathetic Dystrophy: A Randomised, Sham-Controlled, Double-Blind Trial

Acupuncture has been suggested as helpful in reflex sympathetic dystrophy (RSD), but no controlled study has yet been published. The hypothesis of this randomised, double-blind, sham-controlled trial, therefore, was that traditional Chinese acupuncture improves subjective as well as objective signs in this condition. Patients were included when suffering from clinically and scintigraphically confirmed acute RSD of the upper or lower limb, with a history between one and four months. They were randomly assigned to either traditional acupuncture (group A) or sham acupuncture (group S). Treatments were applied five times a week for three weeks, each session lasting for 30 minutes. Both groups received identical standard treatments in addition. The primary outcome variable had been pre-defined to be pain, as measured by visual analogue scale assessed before each treatment. Subjective success was also recorded by the patients on a rating scale. Due to force of circumstances, only 14 patients were entered into the study, therefore no test statistics could be performed and the data was evaluated descriptively. At baseline, pain was almost identical in both groups. During the course of the study, patients in group A demonstrated a more pronounced reduction of pain: 28.6% ± 1.9 vs 17.9% ± 2.4 (Mean ± SEM). Similarly, subjective success was rated to favour traditional acupuncture. It is concluded that acupuncture may be useful in the management of pain in patients with acute RSD, but that the present results are not conclusive. Larger, rigorous studies are required to answer the question.

[Synchronous multifocal laryngeal squamous carcinoma a case report]

An aged female complained intermittent hoarse 10 years, without swallowing and breathing difficulties. A month ago, this patient's voice hoarse became worse, she also had sore throat and pharyngeal foreign body sensation at the same time. There are visible lesions on the right side of the vocal cords, anterior commissure and on the left side of the ventricular bands. Laryngeal CT: the right side of the vocal cords has increased thickness, and hyper density with mild enhancement.

Comparison of Standard Catheters Versus Radial Artery-Specific Catheter in Patients Who Underwent Coronary Angiography Through Transradial Access

In this prospective, randomized controlled study, we aim to compare the performance outcomes of standard catheters with the radial artery-specific catheter. Over the past decade, transradial cardiac catheterization has gained widespread popularity because of its low complication rates compared with transfemoral access. Operators have the choice of using either standard catheters (used for both transfemoral and transradial approach, with need for separate catheter use for either right or left coronary artery engagement) or a dedicated radial artery catheter, which is specifically designed to engage both coronary arteries through radial artery access. A total of 110 consecutive patients who underwent coronary angiography at our institution from March 2015 to April 2015 were prospectively randomized to either radial artery-specific Tiger catheter (5Fr; Terumo Interventional Systems, Somerset, New Jersey) versus standard Judkins left and right catheters (5Fr R4, L4; Cordis Corporation, Miami, Florida). The end points of the study included fluoroscopy time, dose-area product, contrast volume used, and total procedure time for the coronary angiography. A total of 57 patients (52%) were randomized to radial artery-specific catheter and 53 (48%) to the standard catheter. Tiger catheter was associated with significantly lower fluoroscopy time (184 ± 91 vs 238 ± 131 seconds, p = 0.015), which was statistically significant. Other outcome measures such as dose-area product (2,882.4 ± 1,471.2 vs 3,524.6 ± 2,111.7 Gy·cm(2), p = 0.07), total contrast volume (48.1 ± 16.1 vs 53.4 ± 18.5 ml, p = 0.114), and total procedure time (337 ± 382 vs 434 ± 137 seconds, p = 0.085) were also lower in single-catheter group, but it did not reach statistical significance. A total of 8 patients (14%) were crossed over from radial-specific catheter arm to standard catheter arm because of substandard image quality and difficulty in coronary engagement. Six patients had to be switched to femoral access (3 in each group) secondary to radial artery spasm. In conclusion, the radial artery-specific catheter was shown to have significantly lower fluoroscopy times but higher failure rates compared with the standard catheters.

Change in P wave morphology after convergent atrial fibrillation ablation

Convergent atrial fibrillation ablation involves extensive epicardial as well as endocardial ablation of the left atrium. We examined whether it changes the morphology of the surface P wave. We reviewed electrocardiograms of 29 patients who underwent convergent ablation for atrial fibrillation. In leads V₁, II and III, we measured P wave duration, area and amplitude before ablation, and at 1, 3 and 6 months from ablation.

After ablation, there were no significant changes in P wave amplitude, area, or duration in leads II and III. There was a significant reduction in the area of the terminal negative deflection of the P wave in V₁ from 0.38 mm² to 0.13 mm² (p = 0.03). There is also an acute increase in the amplitude and duration of the positive component of the P wave in V₁ followed by a reduction in both by 6 months. Before ablation, 62.5% of the patients had biphasic P waves in V₁. In 6 months, only 39.2% of them had biphasic P waves.

Hybrid ablation causes a reduction of the terminal negative deflection of the P wave in V₁ as well as temporal changes in the duration and amplitude of the positive component of the P wave in V₁. This likely reflects the reduced electrical contribution of the posterior left atrium after ablation as well as anatomical and autonomic remodeling. Recognition of this altered sinus P wave morphology is useful in the diagnosis of atrial arrhythmias in this patient population.

Correlation between pericardial, mediastinal, and intrathoracic fat volumes with the presence and severity of coronary artery disease, metabolic syndrome, and cardiac risk factors

AIMS

To investigate the association of pericardial, mediastinal, and intrathoracic fat volumes with the presence and severity of coronary artery disease (CAD), metabolic syndrome (MS), and cardiac risk factors (CRFs).

METHODS AND RESULTS

Two hundred and sixteen consecutive patients who underwent cardiac magnetic resonance (CMR) imaging and had a coronary angiogram within 12 months of the CMR were studied. Fat volume was measured by drawing region of interest curves, from short-axis cine views from base to apex and from a four-chamber cine view. Pericardial fat, mediastinal fat, intrathoracic fat (addition of pericardial and mediastinal fat volumes), and fat ratio (pericardial fat/mediastinal fat) were analysed for their association with the presence and severity of CAD (determined based on the Duke CAD Jeopardy Score), MS, CRFs, and death or myocardial infarction on follow-up. Pericardial fat volume was significantly greater in patients with CAD when compared with those without CAD [38.3 ± 25.1 vs. 31.9 ± 21.4 cm(3) (P = 0.04)]. A correlation between the severity of CAD and fat volume was found for pericardial fat (β = 1, P < 0.01), mediastinal fat (β = 1, P = 0.03), intrathoracic fat (β = 2, P = 0.01), and fat ratio (β = 0.005, P = 0.01). These correlations persisted for all four thoracic fat measurements even after performing a stepwise linear regression analysis for relevant risk factors. Patients with MS had significantly greater mediastinal and intrathoracic fat volumes when compared with those without MS [126 ± 33.5 vs. 106 ± 30.1 cm(3) (P < 0.01) and 165 ± 54.9 vs. 140 ± 52 cm(3) (P < 0.01), respectively]. However, there was no significant difference in pericardial fat, mediastinal fat, intrathoracic fat, or fat ratio between patients with or without myocardial infarction during the follow-up [33.6 ± 22.1 vs. 35.7 ± 23.8 cm(3) (P = 0.67); 115 ± 26.2 vs. 114 ± 33.8 cm(3) (P = 0.84); 149 ± 44.7 vs. 150 ± 55.7 cm(3) (P = 0.95); and 0.27 ± 0.15 vs. 0.28 ± 0.14 (P = 0.70), respectively]. There was no significant difference in pericardial fat, mediastinal fat, intrathoracic fat, or fat ratio between patients who were alive compared with those who died during follow-up [36.6 ± 26.6 vs. 35.3 ± 23.2 cm(3) (P = 0.76); 114 ± 40.2 vs. 114 ± 31.4 cm(3) (P = 0.95); 150 ± 64.7 vs. 149 ± 52.5 cm(3) (P = 0.92); and 0.29 ± 0.15 vs. 0.28 ± 0.14 (P = 0.85), respectively].

CONCLUSION

Our study confirms an association between pericardial fat volume with the presence and severity of CAD. Furthermore, an association between mediastinal and intrathoracic fat volumes with MS was found.

An avulsed radial artery with a high take-off

A 63-year-old female was diagnosed with severe aortic stenosis, who underwent a diagnostic coronary angiography via transradial approach prior an aortic-valve replacement. After imaging the left coronary system, entrapment of the diagnostic catheter was encountered as a result of spasm of the radial artery. An arteriogram of the arm revealed an anatomical variation in the radial artery (high take-off). Several attempts to remove the entrapped catheter resulted in avulsion of the artery, which was managed successfully with coil embolization. To our knowledge, no such complication has been reported.

Henoch Schonlein Purpura in children: clinical analysis of 120 cases

BACKGROUND

Henoch Schonlein Purpura (HSP) is a systemic vasculitic disease which is common in children. It is very important to understand the clinical features of this disease for doctors and nurses.

OBJECTIVES

To study the clinical characteristics of HSP in children.

METHODS

Collect the clinical data of the HSP children, and analyze the clinical characteristics of these HSP patients.

RESULTS

The ratio of M:F was 1.9:1. The mean age was 6.6 ± 1.6 years. The typical onset seasons were spring, winter and autumn. Infection and food allergy were the main etiological factors. The first symptom was skin purpura and these purpura mainly concentrated the lower extremities and buttocks. The dominant digestive clinical features were abdominal pains and vomiting. The knee joint and ankle joint were most frequently affected. The typical kidney symptoms were microscopic hematuria and albuminuria. An increased ESR was reported in 68 patients (56.7%). Serum C3 decreased in 13 cases (10.8%). ASO titer was higher in 57 children (47.5%).

CONCLUSION

There were gender, season and area differences for the HSP patients. The etiological factors were diverse. HSP patients could have various clinical symptoms and rare complications.

Imbalance of interleukin-18 and interleukin-18 binding protein in children with Henoch-Schönlein purpura

The balance between interleukin-18 (IL-18) and its endogenous antagonist, IL-18 binding protein (IL-18BP), was evaluated in children with Henoch-Schönlein purpura (HSP). Plasma IL-18 and IL-18BP levels and peripheral blood mononuclear cell IL-18 mRNA expression were significantly higher in patients with active HSP (n = 30) than in healthy controls (n = 20); IL-18BP mRNA expression was similar in active HSP and controls. Plasma levels and mRNA expression of IL-18 and IL-18BP in patients in remission (n = 19) were similar to those in controls. The ratios of IL-18 / IL-18BP plasma levels and IL-18 / IL-18BP mRNA levels in active HSP were significantly higher than in patients in remission and healthy controls. Thus, adequate IL-18BP to block the proinflammatory activity of IL-18 may not be present in active HSP and regulation of the IL-18 / IL-18BP balance might provide a potential therapeutic strategy.

[The detection of laryngeal carcinoma-associated antigens in tissue and serum using three mixed monoclonal antibodies against laryngeal cancer]

Laryngeal carcinoma-associated antigens in tissue and serum of patients with laryngeal carcinoma and normal adults were detected by using ABC and ELISA methods. The results showed that the positive rate rised from 80-86.6% to 97.7% by applying mixed monoclonal antibodies compared with single monoclonal antibody against laryngeal cancer. It was also found that the level of laryngeal carcinoma-associated antigens was much higher in serum of laryngeal carcinoma group than that of control group. The statistic difference was very significant (P < 0.01). The level was different with clinical types, stages and increased in line with the tumor growth. So it was suggested that the mixed monoclonal antibodies were sensitive and specific, which was considered as a useful tumor marker for diagnosis, monitoring clinial course and judging prognosis of patient with laryngeal carcinoma.