Cardiology cathlab-based management of thrombotic carotid stenoses in acute ischaemic stroke: tools, techniques, local stroke unit collaboration, challenges and patient outcomes

Background

Shortage of endovascular operators able to deliver thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis) in managing stroke mechanistic pathologies such as AFib (pharmacology/ablation) or PFO (diagnosis/closure).

Purpose

To present accumulating experience en route to a full interventional stroke service on the basis of a cardiac cathlab and local multi-specialty collaboration.

Methods

Withn the PARADIGM-EXTEND (symptomatic and increased-stroke-risk asymptomatic carotid stenosis) all-comer study we have treated, on an emergent basis, 21 patients (15 men, age 58–83 years, median 68 years) with AIS caused by severe carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service.

Results

All lesions (100%) were thrombotic (mobile thrombus - 29%; one was a thrombotic total occusion). Proximal neuroprotection (flow reversal using a CCA±ECA balloon) with thrombus aspiration was used in 19/21 patients (90.5%; in ICA total thrombotic occlusion TigerTrieverXL was used). In 2 patients proximal system use was unfeasible. All cases were done under ACT control and using, consistent with the PARADIGM-EXTEND protocol, the MicroNET-covered embolic prevention stent system (CGuard) that was routinely optimized with large balloons/high pressures.

There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases. Embolism-to-infarct territory was 0% and embolism-to-new territory was 0%. Vascular access closure device use was 76%. A 30-day good clinical outcome (mRS of 0–2) rate was 95.2%. One patient with thrombotic near-occlusion, in whom crescendo stroke episodes superimposing the baseline late presentation event necessitated treatment, had a haemorrhagic stroke transformation on day 2 that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred.

Conclusion

Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for AMI have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS. Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy. Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services, including thrombectomy, in the cardiology cathlab.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): John Paul II Hospital in Krakow and Jagiellonian University

Leonurus sibiricus root extracts decrease airway remodeling markers expression in fibroblasts

Bronchial asthma is believed to be provoked by the interaction between airway inflammation and remodeling. Airway remodeling is a complex and poorly understood process, and controlling it appears key for halting the progression of asthma and other obstructive lung diseases. Plants synthesize a number of valuable compounds as constitutive products and as secondary metabolites, many of which have curative properties. The aim of this study was to evaluate the anti-remodeling properties of extracts from transformed and transgenic Leonurus sibiricus roots with transformed L. sibiricus roots extract with transcriptional factor AtPAP1 overexpression (AtPAP1). Two fibroblast cell lines, Wistar Institute-38 (WI-38) and human fetal lung fibroblast (HFL1), were incubated with extracts from transformed L. sibiricus roots (TR) and roots with transcriptional factor AtPAP1 over-expression (AtPAP1 TR). Additionally, remodeling conditions were induced in the cultures with rhinovirus 16 (HRV16). The expressions of metalloproteinase 9 (MMP)-9, tissue inhibitor of metalloproteinases 1 (TIMP-1), arginase I and transforming growth factor (TGF)-β were determined by quantitative polymerase chain reaction (qPCR) and immunoblotting methods. AtPAP1 TR decreased arginase I and MMP-9 expression with no effect on TIMP-1 or TGF-β mRNA expression. This extract also inhibited HRV16-induced expression of arginase I, MMP-9 and TGF-β in both cell lines (P < 0·05) Our study shows for the first time to our knowledge, that transformed AtPAP1 TR extract from L. sibiricus root may affect the remodeling process. Its effect can be attributed an increased amount of phenolic acids such as: chlorogenic acid, caffeic acid or ferulic acid and demonstrates the value of biotechnology in medicinal research.

DFTB+, a software package for efficient approximate density functional theory based atomistic simulations

DFTB+ is a versatile community developed open source software package offering fast and efficient methods for carrying out atomistic quantum mechanical simulations. By implementing various methods approximating density functional theory (DFT), such as the density functional based tight binding (DFTB) and the extended tight binding method, it enables simulations of large systems and long timescales with reasonable accuracy while being considerably faster for typical simulations than the respective ab initio methods. Based on the DFTB framework, it additionally offers approximated versions of various DFT extensions including hybrid functionals, time dependent formalism for treating excited systems, electron transport using non-equilibrium Green's functions, and many more. DFTB+ can be used as a user-friendly standalone application in addition to being embedded into other software packages as a library or acting as a calculation-server accessed by socket communication. We give an overview of the recently developed capabilities of the DFTB+ code, demonstrating with a few use case examples, discuss the strengths and weaknesses of the various features, and also discuss on-going developments and possible future perspectives.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Additionality and permanence standards in California's Forest Offset Protocol: A review of project and program level implications

A key component of California's cap-and-trade program is the use of carbon offsets as compliance instruments for reducing statewide GHG emissions. Under this program, offsets are tradable credits representing real, verifiable, quantifiable, enforceable, permanent, and additional reductions or removals of GHG emissions. This paper focuses on the permanence and additionality standards for offset credits as defined and operationalized in California's Compliance Offset Protocol for U.S. Forest Projects. Drawing on a review of the protocol, interviews, current offset projects, and existing literature, we discuss how additionality and permanence standards relate to project participation and overall program effectiveness. Specifically, we provide an overview of offset credits as compliance instruments in California's cap-and-trade program, the timeline for a forest offset project, and the factors shaping participation in offset projects. We then discuss the implications of permanence and additionality at both the project and program levels. Largely consistent with previous work, we find that stringent standards for permanent and additional project activities can present barriers to participation, but also, that there may be a trade-off between project quality and quantity (i.e. levels of participation) when considering overall program effectiveness. We summarize what this implies for California's forest offset program and provide suggestions for improvements in light of potential program diffusion and policy learning.

Templating the 3D structure of conducting polymers with self-assembling peptides

Polymerization of pre-assembled peptide–thiophene monomers produced electrically conductive gels with fibrous, porous structures.

Biocompatibility of electrospun human albumin: a pilot study

Albumin is rarely used for electrospinning because it does not form fibres in its native globular form. This paper presents a novel method for electrospinning human albumin from a solution containing pharmaceutical grade protein and 25% polyethylene oxide (PEO) used as the fibre-forming agent. After spontaneous cross-linking at body temperature, with no further chemicals added, the fibres become insoluble and the excess PEO can be washed out. Albumin deposited along the fibres retains its native characteristics, such as its non-adhesiveness to cells and its susceptibility for degradation by macrophages. To demonstrate this we evaluated the mechanical properties, biocompatibility and biodegradability of this novel product. After subcutaneous implantation in mice, albumin mats were completely resorbable within six days and elicited only a limited local inflammatory response. In vitro, the mats suppressed cell attachment and migration. As this product is inexpensive, produced from human pharmaceutical grade albumin without chemical modifications, retains its native protein properties and fulfils the specific requirements for anti-adhesive dressings, its clinical use can be expedited. We believe that it could specifically be used when treating paediatric patients with epidermolysis bullosa, in whom non-healing wounds occur after minor hand injuries which lead to rapid adhesions and devastating contractures.

Electrospinning of poly(lactic acid)/polyhedral oligomeric silsesquioxane nanocomposites and their potential in chondrogenic tissue regeneration

The study was conducted to evaluate the cytocompatibility and hydrolytic degradability of the new poly(lactic acid)/polyethylene glycol-polyhedral oligomeric silsesquioxane (peg-POSS/PLLA) nanocomposite as potential material for cartilage regeneration. PLLA scaffolds containing 0 to 5% of peg-POSS were fabricated by electrospinning. Human mesenchymal stem cells (hMSC's) were cultured in vitro to evaluate the cytocompatibility of the new nanocomposite material. Hydrolytic degradation studies were also carried out to analyze the mass loss rate of the nanocomposites through time. The addition of the peg-POSS to the PLLA did not affect the processability of the nanocomposite by electrospinning. It was also observed that peg-POSS did not show any relevant change in fibers morphology, concluding that it was well dispersed. However, addition of peg-POSS caused noticeable decrease in mean fiber diameter, which made the specific surface area of the scaffold to rise. hMSC's were able to attach, to proliferate, and to differentiate into chondrocytes in a similar way onto the different types of electrospun peg-POSS/PLLA and pure PLLA scaffolds, showing that the peg-POSS as nano-additive does not exhibit any cytotoxicity. The hydrolytic degradation rate of the material was lower when peg-POSS was added, showing a higher durability of the nanocomposites through time. Results demonstrate that the addition of peg-POSS to the PLLA scaffolds does not affect its cytocompatibility to obtain hyaline cartilage from hMSC's.

Non-curative gastrectomy for metastatic gastric cancer: rationale and long-term outcome in multicenter settings

BACKGROUND

Metastatic gastric cancer remains a significant problem as the majority of Western patients are diagnosed with disseminated disease and no routine therapeutic regimen is accepted in such cases.

METHODS

A cohort of 3141 patients with gastric cancer operated between 1990 and 2005 was evaluated using a multicenter data set held by the Polish Gastric Cancer Study Group to determine potential risks and benefits of non-curative gastrectomy for metastatic disease. Additionally, parameters of Quality of Life (QoL) were evaluated prospectively in 140 patients undergoing gastrectomy using the QLQ-C30 questionnaire.

RESULTS

Gastrectomy was carried out in 2258 patients. Distant organ metastases were diagnosed in 951 patients, 415 of which underwent non-curative gastrectomy. The overall mortality rates were significantly higher in patients undergoing non-resectional surgery (10%) than either curative (3%, P < 0.001) or non-curative (4%, P = 0.002) gastrectomy. The overall median survival in patients with metastatic disease was significantly higher for non-curative gastrectomy (10.6 months, 95% confidence interval (CI) 9.3-11.9) than for non-resective operations (4.4 months, 95% CI 4.0 to 4.8, P < 0.001). The hazard ratio of death in patients subject to non-resectional surgery compared to those treated by gastrectomy was 2.923 (95% CI 2.473 to 3.454, P < 0.001). A gradual impairment in QoL parameters was found over 12 months after non-curative resections but changes did not reach statistical significance and individual parameters were similar to gastrectomy without distant metastases.

CONCLUSION

Non-curative gastrectomy for metastatic gastric cancer is associated with significantly better survival compared to non-resective surgery and does not impair quality of life.

Window effect of temperature on carbachol-induced theta-like activity recorded in hippocampal formation in vitro

The effect of different temperatures of ACSF (18-42 degrees C) on carbachol (CCH)-induced field potentials were examined in the present study. Two hundred and thirty one experiments were performed on hippocampal formation slices maintained in a gas-liquid interface chamber. All slices were perfused with 50 microM CCH. A recording electrode was positioned in the region of CA3c pyramidal cells. The experiments gave two main findings. First, in a presence of continuous cholinergic stimulation the temperature of the bathing medium per se determined the rate of synchronization of the field potentials and pattern of EEG activity recorded. Second, within the temperature range from 33 degrees to 37 degrees C a window effect of temperature on CCH-induced theta-like activity (TLA) was noted: in this temperature range all slices tested responded only with one pattern of EEG activity-TLA. The results are discussed in light of temperature effects on hippocampal neuronal networks.

[Use of trans-slice technique for microencephalographic examinations in vitro]

The present paper reviews the experimental data concerning the use of trans-slice preparation technique in investigation of theta-like activity generation in the limbic cortex. Specific aspects of the technical arrangement of the hippocampal formation and entorhinal cortex microelectroencephalographic registration were emphasized.

Analysis of drug transport kinetics in multidrug-resistant cells: implications for drug action

Multidrug resistance (MDR) in model systems is known to be conferred by two different integral proteins--the 170-kDa P-glycoprotein (P-gp) and the 190-kDa multidrug resistance-associated protein (MRP1)--that pump drugs out of MDR cells. The intracellular level of a drug, which influences the drug's cytotoxic effect, is a function of the amount of drug transported inside the cell (influx) and the amount of drug expelled from the cell (efflux). One possible pharmacological approach to overcoming drug resistance is the use of specific inhibitors that enhance the cytotoxicity of known antineoplastic agents. Many compounds have been proven to be very efficient in inhibiting P-gp activity, but only some of them can inhibit MRP1. However, the clinical results obtained so far by this approach have been rather disappointing. The other likely approach is based on the design and synthesis of new non-cross-resistant drugs whose physicochemical properties favor the uptake of such drug by resistant cells. Our recent studies have shown that whereas the P-gp- and MRP1-mediated efflux of different anthracycline-based drugs may not differ considerably, their kinetics of uptake do. Thus, the high uptake of drug by cells may lead to concentrations at the cellular target site high enough to achieve the needed cytotoxicity against MDR cells. Therefore, increased drug lipophilicity might be one factor in improving drug cytotoxicity in MDR cells. In vitro studies have shown that idarubicin, an analogue of daunorub cin, is more effective than daunorubicin and doxorubicin against MDR tumor cell lines and that this increased effectiveness is related in part to the increased lipophilicity of idarubicin. Other studies have also confirmed the strong impact of lipophilicity on the uptake and retention of anthracyclines in MDR cells.

In vitro recorded theta-like activity in the limbic cortex: comparison with spontaneous theta and epileptiform discharges

The generation of EEG theta rhythm in the mammalian limbic cortex is a prime example of rhythmic activity that involves central mechanisms of oscillations and synchrony. This EEG pattern has been extensively studied since 1938, when Jüng and Kornmüller (1938) demonstrated the first theta recordings in the hippocampal formation of rabbits. In 1986 in collaboration with Drs. B.H. Bland, S.H. Roth and B.M. MacIver we demonstrated for the first time that bath perfusion of hippocampal slices with the cholinergic agonist, carbachol, resulted in theta-like oscillations. Since this initial demonstration of in vitro theta-like activity, we have carried out a number of experiments in an attempt to answer the basic question: what are the similarities between cholinergic-induced in vitro theta-like activity and theta rhythm which naturally occurs in the in vivo preparation. Thus far, our studies have provided strong evidence that theta-like activity recorded in vitro shares many of the physiological and pharmacological properties of theta rhythm observed in vivo. The question whether in vitro theta-like oscillations reflect features of epileptiform activity is also addressed in this review.

[Anti-tobacco education programs for children and youth at different stages of schooling]

Anti-tobacco education programmes for children and youth, developed at the National Research Institute of Mother and Child, are presented. The targets and goals of elaboration and implementation of these programmes are discussed. The four programmes contribute to a continuum of anti-tobacco education from preschool to secondary school. For each programme, the elaborated educational objectives, curriculum structure and methodology are presented. Problems related to evaluation of health promotion programmes are discussed in relation to the requirements of evidence-based medicine. Results of pilot programme implementation are presented. The programmes have been accepted by teachers, pupils and parents and can be implemented in the reformed education system in Poland.

Long-term follow-up in 206 infertility patients with polycystic ovarian syndrome after laparoscopic electrocautery of the ovarian surface

In recent publications we have demonstrated that laparoscopic electrocautery of the ovarian surface (LEOS) is an effective method to reduce serum androgen concentrations, normalizing ovarian cycle length and the ovarian reaction to hormonal stimulation therapy in anovulatory patients with polycystic ovarian disease (PCOD). In this paper we show that these effects are not only temporary. Data from 206 patients undergoing LEOS and monitored for up to 72 months after surgery are evaluated; 145 patients achieved a total of 211 conceptions, giving a pregnancy rate of 70%, with a maximum of four conceptions in one patient. There were 38 early miscarriages (18%) and two late pregnancy losses as well as three ectopic implantations.

[Immunomodulating properties of sera in normal pregnant women]

The purpose of this study was to analyze the immunosuppressive properties of sera of normal pregnant women. Effects of pregnancy sera on the proliferation of mitogen (PHA, Con A, PWM)-induced lymphocytes were examined in healthy primiparas. The sera of normal pregnant women inhibited the proliferation of PHA- and Con A- induced both autologous and allogenic lymphocytes (obtained from nonpregnant and pre-eclamptic women), while remaining neutral towards the proliferation of PWM- induced lymphocytes in comparison with fetal calf serum. The basic immunomodulatory activity of the sera in pregnant women was contained in the heat-stable fraction.

[Subpopulations of t lymphocytes and lymphocyte proliferative activity in normal pregnancy]

T lymphocyte subpopulations (CD3+, CD4+, CD8+) and the lymphocyte proliferative responses to mitogens (PHA, Con A, PWM), in the environment of fetal calf serum (FCS) were examined in 16 normal primigravidas in the third trimester of pregnancy and in 15 healthy nonpregnant women. In normal pregnant women significantly lower absolute and percentage numbers of CD3+ and CD4+ T cells and almost twice reduced CD4+/CD8+ ratio were found, in comparison with nonpregnant subjects. Despite the shifts among particular T lymphocyte subsets in the peripheral blood, non disorders were found in the lymphocyte proliferative responses to mitogens in normal pregnancy.

Plasma concentrations of pepsinogen and corticosteroid in relation to gastric lesions in swine

Plasma pepsinogen and plasma corticosteroid concentrations were found to be unrelated to the presence or severity of gastric lesions in swine. Mean plasma pepsinogen and corticosteroid concentrations were significantly different between collection periods, with significantly higher values occurring during cold weather. Seemingly, plasma pepsinogen and corticosteroid values are neither indicative of susceptibility to, nor of the presence of, gastric erosions or ulcers in swine. However, plasma pepsinogen concentration may be a potential indicator of stress.

Effects of prednisone on gastric secretion and development of stomach lesions in swine

In pigs treated with various doses of prednisone, pathologic changes appeared in the glandular region of the stomach, mainly in the fundic area and rarely and less severely in the cardiac and pyloric mucosae. The characteristic lesion was hemorrhagic gastritis; this was associated with massive gastric hemorrhages in pigs given the larger doses of prednisone. Epithelial changes were found in the esophageal area, but there were no ulcers. In pigs with gastric fistulas, prednisone administered at dose levels of 10 mg/kg of body weight for 8 days produced a significant increase in the volume and the acidity of gastric secretion. Hexosamine output, but not concentration, increased significantly during the treatment period. Change in pepsin secretion was sit significant. Prednisone did not produce an immediate change in gastric secretion--there being a latent period lasting 1 to 2 days before marked changes were observed. After peak changes occurred (3rd or 4th day of treatment), acidity gradually decreased to pretreatment level toward the end of the treatment period. This indicates that although increased acidity may be involved in the development of lesions in the glandular region, other factors probably have a role also in the pathogenesis of steroid-induced stomach lesions in swine.