Conventional Medical Therapy Research Articles

Medical Management versus PACK-CXL in Dogs with Infectious Keratitis: A Randomized Controlled Trial Protocol.

Simple SummaryInfected corneal ulcers are a common and painful disease, usually caused by bacteria in dogs. Short-nosed dog breeds are predisposed to corneal ulcers. Treatment aims to eliminate bacteria, stop the enzymatic tissue melting process in the cornea, and allow for normal healing to resume. Success of treatment largely depends on the effectivity of the applied medications, possibly including antibiotics. In the context of globally growing antibiotic resistance, non-antibiotic-based treatment alternatives are desirable. Photoactivated Chromophore for Keratitis-Corneal Cross-linking (PACK-CXL) reduces enzymatic tissue melting and damages multiple targets within microorganisms, resulting in corneal stabilization and non-antibiotic-based elimination of bacteria. A confirmatory clinical study providing unbiased evidence of PACK-CXL effectiveness in dogs is currently lacking. We therefore aim to conduct such a study and determine whether PACK-CXL is a viable alternative to conventional state-of-the-art medical therapy for corneal ulcer treatment in dogs. Here we present the randomized controlled clinical trial study protocol. Registering trials favors sound statistical analysis and prevents publication bias. The trial results will be published after successful trial conclusion.Infectious keratitis is a common and painful disease, usually caused by bacteria in dogs. Brachycephalic breeds are at increased risk. Despite medical therapy, enzymatic corneal melting can lead to ulcer perforation and globe loss. Treatment alternatives are needed due to an increase in antibiotic resistance and growing popularity of brachycephalic dogs. Photoactivated Chromophore for Keratitis-Corneal Cross-linking (PACK-CXL) reduces enzymatic collagenolysis and damages multiple targets within microorganisms, resulting in corneal tissue stabilization and elimination of bacteria, irrespective of their antibiotic resistance status. A randomized controlled trial providing evidence of PACK-CXL effectiveness in dogs is lacking. We aim to determine whether PACK-CXL is a viable alternative to conventional medical therapy for canine infectious keratitis. Two hundred-and-seventy client-owned dogs with presumed infectious keratitis will be allocated to two equally sized treatment groups (PACK-CXL or medical therapy) in a masked, randomized, controlled, multicenter trial in eleven clinics. The primary outcome measure is treatment success defined as complete epithelial closure within 28 days. The sample size is based on a group sequential design with two interim analyses, which will be overseen by a Data Safety and Monitoring Board. Ethical approvals have been obtained. The study protocol is preregistered at preclinicaltrials.eu. Publishing trial protocols improves study reproducibility and reduces publication bias.

Low blood pressure and guideline-directed medical therapy in patients with heart failure with reduced ejection fraction

BackgroundPatients with heart failure (HF) presenting with low blood pressure (BP) have been underrepresented in large-scale clinical trials. We investigated the characteristics and implementation of conventional guideline-directed medical therapy (GDMT; renin-angiotensin system inhibitors and β-blockers) in patients with low BP hospitalized for HF with systolic dysfunction. MethodsConventional GDMT was evaluated by discharge BP among 2043 consecutive patients with HF and left ventricular ejection fraction (LVEF) < 50% in the WET-HF registry. Among the 708 (34.7%) patients with lower discharge BP (≤ 100 mmHg; the lower tertiles), exploratory subgroups included patients with previous HF hospitalization, inotrope use, New York Heart Association (NYHA) III–IV class, and lower estimated glomerular filtration rate (eGFR) and LVEF (lower than median value). We evaluated the risk-adjusted association between GDMT implementation and 2-year adverse events (all-cause mortality or HF rehospitalization). ResultsAmong the 2043 patients (age 74 [63–82] years), the median systolic BP was 108 (98–120) mmHg. Among patients with lower BP, GDMT prescription rate was 62.7%, and GDMT use was associated with decreased adverse events (HR:0.74, 95%CI:0.58–0.94). GDMT prescription rates were lower among higher-NYHA class and lower-eGFR subgroups compared with their reference subgroups, and directionally similar outcomes were noted in all subgroups (favoring GDMT use); however, this association was somewhat attenuated in the lower-eGFR group (HR:0.87, 95%CI:0.64–1.17). ConclusionsConventional GDMT use was associated with decreased adverse outcomes in most patients with HF compounded by systolic dysfunction and low BP, albeit caution is warranted in patients with renal dysfunction.

Patients with inflammatory bowel disease at risk of sub-optimal outcomes report poorer biopsychosocial functioning than controls: data from two cross-sectional surveys

ABSTRACT Inflammatory bowel disease (IBD) is a chronic gastrointestinal disorder. Standard treatment focuses on reducing the inflammatory burden, however, not all patients respond adequately to conventional medical therapy. These patients, referred to as Patients at Risk of Suboptimal Outcomes (PARSO), have not been studied collectively. The present study aimed to understand the biopsychosocial characteristics of patients with IBD at risk of sub-optimal outcomes for targeted multi-disciplinary treatment to encourage optimal outcomes. Two cross-sectional online surveys, including 760 PARSO and 208 control (non-PARSO) participants, were conducted and their data combined. Biopsychosocial factors included quality of life, pain, disease activity, wellbeing, fatigue, stress, social support, and sleep difficulties. Results suggest that active disease, quality of life, stress, social support, sleep difficulties, fatigue, wellbeing, smoking status, IBD subtype, and pain are significantly associated with membership in a subgroup of PARSO. We also used logistic regression to explore variables associated with the total likelihood of PARSO status. Overall, the model predicted the at-risk status to a substantial degree (R 2 −2ll = .41, x2 = 401.53, p < .001). Younger age in years, female sex, Crohn’s disease, and greater measured and subjective disease activity significantly increased the likelihood of participants being identified as PARSO; OR CI95% = 0.96 (0.95, 0.97); OR CI95% = 4.46 (2.95, 6.71); OR CI95% = 1.58 (1.05, 2.37); OR CI95% = 3.52 (2.18, 5.69); OR CI95% = 45.99 (14.11, 149.89). A biopsychosocial and personalised approach to IBD care might be necessary to support those at risk of suboptimal outcomes in achieving better long-term wellbeing.

Predictors of in-hospital mortality due to heart failure hospitalisation and trends of guideline-directed medical therapy usage

Abstract Background The burden of heart failure (HF) is immense, from reducing quality of life (QoL) to increasing mortality risks and additional financial implications. The risk of adverse outcomes get higher with each HF hospitalisation (HFH). Purpose To look at predictors of in-hospital mortality outcomes during HFH and the prescription trends in conventional guideline-directed medical therapy (GDMT) for HF. Methods Retrospective analyses were performed for 7405 HFH cases admitted to our cardiology institution from 2009 to 2018, diagnosed based on the signs and symptoms of heart failure with NTProBNP≥300 at presentation. Results Most patients that required HFH were aged &amp;lt;65 years (53.5%), were males (72.8%) and had more diabetes mellitus (66%) and hypertension (75.1%). There were fewer other co-morbidities such as coronary artery disease (CAD) (26.9%), renal insufficiency (33.8%), atrial fibrillation (Afib) (23.9%), dyslipidaemia (40.3%), prior stroke/transient ischaemic attack (TIA) (5.6%), chronic obstructive pulmonary disease (11.6%), current/ex-smokers (45.5%). Most had presenting systolic blood pressure (SBP) &amp;gt;100 mmHg (88.8%), presenting heart rate ≥70 bpm (78.6%) and were in heart failure with reduced ejection fraction (HFrEF) &amp;lt;40% (74.8%). At presentation for HFH, 31.2% had 3 GDMTs (GDMT III) (angiotensin converting enzyme inhibitor / angiotensin receptor blocker / angiotensin receptor neprilysin inhibitor + beta blocker + mineralocorticoid receptor antagonist), 37% had either 2 GDMTs (GDMT II), 25% had only 1 GDMT (GDMT I), while 6.8% had none. The average in-hospital mortality rate was 5.2%. Independent predictors associated with increased in-hospital mortality were males, renal insufficiency, Afib, prior stroke/TIA, SBP ≤100 mmHg, serum sodium &amp;lt;135 mmol/L, uric acid ≥529 μmol/L, NTProBNP ≥6590, inpatient procedures i.e. dialysis, mechanical ventilation and cardiopulmonary resuscitation (CPR). Independent predictors associated with reduced inpatient mortality were hypertension, inpatient cardiac diagnostic procedures and presence of GDMT I, GDMT II and GDMT III at presentation (Figure 1). Throughout the 10 years, the proportion of GDMT prescription were similar; GDMT I (19.1–28.7%), GDMT II (35.1–41.6%), GDMT III (25.2–37.3%). The proportion of GDMT III across the CKD group stages were never more than 50% (Figure 2). Conclusion There remains significant in-hospital mortality risk for HFH. While some of these predictors are not modifiable, others are, especially when it comes to GDMT prescriptions. GDMTs provide better prognosis in patients living with HF. There are growing evidence that simultaneous / rapid sequence initiation of GDMTs are more beneficial than the conventional step wise approach. The analysis findings of GDMT proportions at presentation of HFH and also in the CKD group stages meant that many patients are still receiving suboptimal care for their HF and this clinician inertia mentality has got to change. Funding Acknowledgement Type of funding sources: None.

Medicinal plants and diabetes: An ethnopharmacological studyin Brazilian Northeast

Despite access to conventional medical therapies, the use of complementary medicine is increasing in many communities. The present study aimed to evaluate the popular knowledge of medicinal plants used to treat diabetes and its co-morbidities, in four rural communities in the municipality of Vitória de Santo Antão, in the Brazilian State of Pernambuco. The relative importance of a particular medicinal plant was calculated based on the percentage of mentions (IR%). The similarity between the communities was quantified using the Sørensen index (Ss).Interviews were conducted with 141 patients, of these, 83 reported use of medicinal plants as an alternative treatment. Overall there were 186 mentions, covering 61 ethnospecies. In relation to IR%, Mentha × villosa presented the highest value.Knowing the factors that influence selection of medicinal plants sheds light on the mechanisms through which patterns of use develop and this may help to preserve this knowledge.

Safety Considerations for Natural Products Commonly Used By Patients with Allergic Disease

Natural products are a category of Complementary and Alternative Medicine that includes medicinal plants, vitamins, and dietary supplements. These products are often utilized by patients with allergies in conjunction with, or as an alternative to, their conventional medical therapies. Despite the wide use of these modalities, many clinicians often have limited knowledge and training in their use. It is important for health care providers to know the safety and risks of these products that their patients may use. This Clinical Commentary reviews the side effects and adverse reactions of several natural products commonly used by patients with allergies and gives an overview of the U.S. Food and Drug Administration requirements for manufacturing, advertising and distribution.

Local pulmonary administration of factor VIIa (rFVIIa) in massive pulmonary haemorrhage in post-operative cardiac infant.

Diffuse pulmonary haemorrhage is an ominous condition that has a high paediatric mortality rate. Recombinant activated factor VIIa (rFVIIa) is a powerful haemostatic agent which has been used intravenously in life-threatening haemorrhage in variety of conditions in which conventional medical or surgical therapy are unsuccessful. We report off-label successful use of endotracheal rFVIIa for massive life-threatening respiratory haemorrhage following aspiration and cardiopulmonary resuscitation in a 3-month-old infant who was anticoagulated with enoxaparin following corrective cardiac surgery with other comorbidities. Off-label administration of endotracheal rFVIIa permitted rapid safe control of massive pulmonary haemorrhage and prevented further detrimental decline in respiratory function with satisfactory outcome.

A Novel Metabolism-Related Gene Signature for Predicting the Prognosis of HBV-Infected Hepatocellular Carcinoma

Metabolic reprogramming is one of the crucial hallmarks of cancer. Hepatocellular carcinoma (HCC) resulting from hepatitis B has various altered metabolic features. However, the impact of such alterations on the tumor microenvironment (TME) and immunotherapy efficacy is still unclear. Here, a prognostic signature of metabolism-related gene (MRG) composition was constructed, and the immune profile of different subgroups and potential response to immunotherapy were described. Based on the HCC gene dataset, we used weighted gene coexpression network analysis for identifying MRGs linked to hepatitis B. An MRG prognostic index (MRGPI) with two genes, ATIC and KIF2C, was constructed using Cox regression analysis, an independent prognostic factor. In addition, the model was validated using the GEO dataset. The immune profile and prediction of HCC response to immunotherapy in different subgroups were analyzed using CIBERSORT and TIDE. Based on the outcomes, the distributions of memory B cells, monocytes, resting mast cells, and M0 macrophages in TME were different with a greater benefit of immunotherapy in the low MRGPI risk group. In addition, the MRGPI risk groups showed substantial differences in sensitivity to conventional drug therapy. This study concludes that MRGPI is an effective biomarker for predicting the prognoses of patients with HCC resulting from hepatitis B virus infections and determining the efficacy of immunotherapy and conventional medical therapy.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS)

BackgroundUrologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response.MethodsUCPPS patients (240) ages 18–70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief.DiscussionEmpirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine.Trial RegistrationClinicaltrials.gov NCT05127616. Registered on 9/19/21.

Novel combination of multi-walled carbon nanotubes and gold nanocomposite for photothermal therapy in human breast cancer model

Despite current medical advancements, the resistance of malignant tumours to conventional medical therapies highlights the need for innovative therapeutic techniques. Numerous studies have focused on the promising application of nanomaterials in recent years. Nanoparticles (NPs) are used to treat cancer. Plasmonic photothermal therapy (PPTT) is a cancer-ablation technique in which photon energy is rapidly converted into heat by some radiative and non-radiative events. Gold NPs (Au-NPs) and carbon nanotubes (CNTs) are plasmonic NPs with excellent thermal conductivity and their near-infrared (NIR) absorbance has several interesting qualities. Additionally, CNTs could penetrate cells. In this study, Au-NPs were used to fabricate multi-walled CNTs (MWCNTs), which could boost its efficacy in cancer treatment in accordance with PPTT. Transmission electron microscopy, field-emission scanning electron microscopy (FESEM), atomic force microscopy and FTIR were used to examine the MWCNTs made from walnut shell. Au-NPs were explored using green chemistry and MWCNT-COOAu, MWCNT-COO and MWCNT-Au were examined by Raman, EDX and FESEM techniques. The effect of MWCNT-COOAu, MWCNT-COO and MWCNT-Au at various concentrations (3.12, 6.25, 12.5 and 25 µg/mL) and irradiation time intervals (30, 60, 90 and 120 sec) by using NIR laser under λ = 1064 nm and P = 3 W on the breast cancer cell line (MCF7) was investigated. The highest temperatures for MWCNT-COO, MWCNT-COOAu and MWCNT-Au were determined to be 44.1 °C, 46 °C and 46.9 °C, respectively, which produced 61.66 %, 72 % and 85.3 % cytotoxicity, respectively, in MCF7 cell line at a concentration of 25 µg/mL and an irradiation period of 120 sec. The treatment of MCF7 cell line by photothermal therapy was found to be in a concentration- and time-dependent manner.

Homoeopathy as an add-on treatment for schizophrenia - A case series

Introduction: Schizophrenia is a complex, progressive and severe mental disorder characterised by distortions in thinking, perception, emotions, language, sense of self and behaviour. Conventional medication and cognitive behaviour therapy are used in the treatment of schizophrenia. Homoeopathy can also offer promising results in schizophrenia as evident from the previous studies. Case Summary: Five patients reported at the outpatient department of National Homoeopathy Research Institute in Mental Health, Kerala, India, with symptoms of schizophrenia were treated with individualised homoeopathic medicine as an add-on therapy to conventional medicines. Assessment of the patients was done using three scales: Positive and Negative Syndrome Scale, brief psychiatric rating scale and Glasgow Anti-psychotics Side-effects Scale. Possible causal attribution of changes was explicitly depicted by Modified Naranjo Criteria. All five patients showed improvement as evident from the assessment scales. These cases show the positive role of homoeopathic treatment in schizophrenia, reducing the psychotic symptoms and reinstating the insight of the patient and also tapering the conventional medication. To bring out further robust evidence of homoeopathy in schizophrenia, extensive research studies are required.

IGST Combined with Conventional Drug Therapy and TCM Therapy for Treatment of Bilateral Vestibular Hypofunction.

Objective To investigate the effects of intensive gaze stability training (IGST) combined with conventional drug therapy and traditional Chinese medicine (TCM) therapy on hearing recovery and quality of life (QOL) in patients with bilateral vestibular dysfunction. Materials and Methods A total of 120 patients with bilateral vestibular dysfunction admitted to our hospital from January 2019 to January 2020 were recruited and assigned to group A (n = 60) and group B (n = 60) based on the order of admission. Group B received conventional medication and TCM therapy, and group A received IGST plus conventional medication and TCM therapy. The serum biochemical indexes, blood rheology indexes, symptoms disappearance time, hearing recovery time, pure-tone hearing threshold, vestibular symptom index (VSI), and QOL of the two groups were compared. Results The serum biochemical indexes and blood rheology indexes in group A were lower than those in group B after treatment (P < 0.001). Patients in group A had a shorter time lapse before symptoms disappearance and hearing recovery than those in group B (P < 0.001). Group A had lower results of the pure-tone hearing threshold (P < 0.001) and of VSI (P < 0.05) than group B. Patients in group A had higher QOL scores than those in group B after treatment (P < 0.001). Conclusion IGST plus conventional drug therapy effectively improves the serum biochemical indexes and blood rheological indexes of patients with bilateral vestibular hypofunction, accelerates their hearing recovery process, and alleviates their clinical symptoms, thereby improving their QOL, which shows good potential in clinical application.

Evaluating the Level of Serum IL-23 in Brucellosis Infection by ELISA and Investigating its Relationship in Cases with Failure to Respond to Treatment.

Brucella is belonging to the small immobile gram-negative spore-lacking cocco-bacilli bacteria family that grows in an aerobic environment, it is known as a zoonosis infection named brucellosis. This study was designed to investigate serum values of IL-23 in patient with brucellosis and investigate its relationship with cases with failure to respond to conventional medical therapy. A total of 372 individuals were divided into 2 groups (n=186) as follows: Group A comprising 186 infected participants with brucella (7-80 years-old), these people had not received antibiotics for at least 6 months ago. Group B including the healthy participants. All the participants in both groups were in the same age range. 5 ml blood samples were obtained from the participants intravenously (without anticoagulation substance). The serum level of IL-23 was investigated by ELISA diagnostic kit. The recorded data showed that the levels of IL-23 in the serum samples obtained from group A (143.64 Pg/ml) significantly (P<0.001) increased compared with this value in group B (23.14 Pg/ml). Based on the recorded data in the forms completed by all the participants at the day 0 of the experiment, 44 out of 186 individuals in group A, had experienced Brucellosis attack 2-3 times in spite of receiving medical prescriptions. A hypothesis about the possible immune system disorders in these participants lead us to did the re-sampling following drug administration. Results illustrated failure to respond to conventional medical therapy in patients with low level of serum IL-23.

Safety, efficacy, and patient selection of ripasudil in patients with uncontrolled glaucoma with maximum conventional medical therapy.

Purpose:Ripasudil hydrochloride hydrate (0.4%) is the first Rho-associated protein kinase (ROCK) inhibitor eye drop that lowers intraocular pressure (IOP) by increasing conventional aqueous outflow through the trabecular meshwork and Schlemm’s canal. We aimed to evaluate the safety and efficacy of ripasudil in patients using the maximum topical anti-glaucoma medications and with uncontrolled IOP.Methods:In our prospective interventional study, we enrolled 27 eligible and consenting patients (46 eyes) who presented to us between January 2021 and June 2021. Ripasudil 0.4% was added as adjunctive therapy to the ongoing glaucoma treatment. On follow-up visits at 7 days, 15 days, 1 month, 2 months, and 3 months, the visual acuity, IOP with applanation tonometer, anterior segment, and fundus were evaluated. The IOP before and after the use of ripasudil eye drops was compared by paired t-test.Results:Among the 27 patients, 18 were males and 9 were females. A statistically significant reduction in IOP was noted at all time durations (P < 0.00001) with the maximum reduction at 3 months with all patients achieving their target IOP. No patient developed any side effects necessitating the omission of ripasudil. The most common adverse event noted was conjunctival hyperemia (22 patients), which was mild and transient.Conclusion:Ripasudil showed additional IOP-lowering effect with other antiglaucoma medications and exhibited no significant side effects.

First-Line Catheter Ablation of Monomorphic Ventricular Tachycardia in Cardiomyopathy Concurrent With Defibrillator Implantation: The PAUSE-SCD Randomized Trial.

Catheter ablation as first-line therapy for ventricular tachycardia (VT) at the time of implantable cardioverter defibrillator (ICD) implantation has not been adopted into clinical guidelines. Also, there is an unmet clinical need to prospectively examine the role of VT ablation in patients with nonischemic cardiomyopathy, an increasingly prevalent population that is referred for advanced therapies globally. We conducted an international, multicenter, randomized controlled trial enrolling 180 patients with cardiomyopathy and monomorphic VT with an indication for ICD implantation to assess the role of early, first-line ablation therapy. A total of 121 patients were randomly assigned (1:1) to ablation plus an ICD versus conventional medical therapy plus an ICD. Patients who refused ICD (n=47) were followed in a prospective registry after stand-alone ablation treatment. The primary outcome was a composite end point of VT recurrence, cardiovascular hospitalization, or death. Randomly assigned patients had a mean age of 55 years (interquartile range, 46-64) and left ventricular ejection fraction of 40% (interquartile range, 30%-49%); 81% were male. The underlying heart disease was ischemic cardiomyopathy in 35%, nonischemic cardiomyopathy in 30%, and arrhythmogenic cardiomyopathy in 35%. Ablation was performed a median of 2 days before ICD implantation (interquartile range, 5 days before to 14 days after). At 31 months, the primary outcome occurred in 49.3% of the ablation group and 65.5% in the control group (hazard ratio, 0.58 [95% CI, 0.35-0.96]; P=0.04). The observed difference was driven by a reduction in VT recurrence in the ablation arm (hazard ratio, 0.51 [95%CI, 0.29-0.90]; P=0.02). A statistically significant reduction in both ICD shocks (10.0% versus 24.6%; P=0.03) and antitachycardia pacing (16.2% versus 32.8%; P=0.04) was observed in patients who underwent ablation compared with control. No differences in cardiovascular hospitalization (32.0% versus. 33.7%; hazard ratio, 0.82 [95% CI, 0.43-1.56]; P=0.55) or mortality (8.9% versus 8.8%; hazard ratio, 1.40 [95% CI, 0.38-5.22]; P=0.62]) were observed. Ablation-related complications occurred in 8.3% of patients. Among patients with cardiomyopathy of varied causes, early catheter ablation performed at the time of ICD implantation significantly reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. These findings were driven by a reduction in ICD therapies. URL: https://www. gov; Unique identifier: NCT02848781.

E-33 | Transcatheter MitraClip Device Therapy in Patients with Cardiogenic Shock: A Meta-analysis of Single Arm Studies

Moderate-to-severe mitral regurgitation (MR) is present in up to 10% of patients with cardiogenic shock (CS). Patients with CS and concomitant MR have a guarded prognosis with conventional medical therapy alone. The purpose of this study was to explore outcomes of MitraClip device repair of severe MR in this high-risk patient population with shock.

Conventional medical therapy in heart failure patients eligible for the PARADIGM-HF, DAPA-HF, and SHIFT trials

BackgroundRecent trials on novel heart failure (HF) treatments (angiotensin receptor-neprilysin inhibitor, sodium-glucose cotransporter 2 inhibitor, and ivabradine) emphasize the use of conventional medical therapy (angiotensin-converting enzyme inhibitors, beta-blockers [BB], and mineral corticosteroid receptor antagonists). We aimed to evaluate the prescription rate of conventional medical therapy and its association with long-term outcomes in patients eligible for recent trials. MethodsWe examined 1295 consecutive patients with HF with reduced ejection fraction (HFrEF) from a multicenter registry (WET-HF registry). We assessed conventional medical therapy implementation among patients meeting the PARADIGM-HF/DAPA-HF and SHIFT enrollment criteria. We also examined the association between conventional medical therapy use and long-term outcomes within each enrollment criterion. ResultsOverall, 62.2% and 35.3% of HFrEF patients met the enrollment criteria of the PARADIGM-HF/DAPA-HF and SHIFT trials. Only 33.9% and 31.9% received full conventional medical therapy within each patient subset. Notably, 84.2% of patients who met the SHIFT enrollment criteria were on BB, and only 23.0% and 4.4% were on ≥50% or the full recommended dose, respectively. Implementation of full conventional medical therapy use was associated with lower 2-year mortality and HF readmission rates in the PARADIGM-HF/ DAPA-HF eligible group (HR 0.68, 95% CI 0.50–0.92). The use of BB at ≥50% of the recommended dose was associated with lower 2-year mortality and HF readmission rates in the SHIFT-eligible group (HR 0.50, 95% CI 0.30–0.84). ConclusionsConventional medical therapy was underutilized among patients eligible for novel trials within a Japanese HF registry. Further efforts to optimize conventional medical therapy are needed.

Efficacy of homoeopathic LM potency in psoriasis: A case report

Introduction: Psoriasis is a prevalent, genetically determined, inflammatory skin disorder of unknown cause marked by well-demarcated, raised, red scaling patches that preferentially locate to the extensor surfaces in its most common form [1]. It is a chronic, non-communicable, painful, disfiguring, and disabling disease for which there is currently no cure in conventional method of treatment and is associated with a significant negative impact on the patient's quality of life. However, sin the conventional medical system, topical and systemic therapies, as well as phototherapy, are available [2]. Homoeopathic medicines have been found to be effective in treating such cases. We aim to report here a case treated with homoeopathic constitutional medicine with photographic evidences. This case study suggests that homoeopathic individualized constitutional medicine prescribed on the basis of totality of symptoms could be a promising treatment option for the patients suffering from psoriasis.Case summary: A 17 year old female patient presented with the symptoms of widespread red, thick, hard scaly eruptions from last 4 years. Clinically it was diagnosed as psoriasis. Individualized homoeopathic medicine was prescribed which showed a positive role in the treatment of psoriasis. Modified Naranjo criteria were used to show causal attribution of changes in her condition to homoeopathic treatment. Future observational studies and randomized control trials are suggested to ascertain the efficacy of homoeopathy in the cases of psoriasis.

Right Ventricular Dysfunction Is Associated With Increased Mortality In Patients Requiring Veno-venous Extracorporeal Membrane Oxygenation For The Management Of Severe Respiratory Failure In Covid-19 Infection

PurposeRefractory respiratory failure caused by the coronavirus SARS-CoV-2 is associated with a significant mortality rate. Patients unresponsive to conventional medical therapy may benefit from temporary veno-venous extracorporeal membrane oxygenation (VV-ECMO), which provides complete gas exchange while allowing the patient to recover. We sought to investigate the role of right ventricular failure in the outcomes of these patients since clinical and echocardiographic characteristics that predict survival are not yet defined in patients with respiratory failure caused by SARS-CoV-2.MethodsWe performed a single center retrospective cohort study enrolling consecutive patients that required VV-ECMO for the management of refractory respiratory failure between January and December 2020. Seventeen consecutive patients with COVID-19 infection were included in the reported cohort. Demographics, comorbidities, laboratory parameters and echocardiographic features of left and right ventricular (LV/RV) function were compared between patients who survived and those who could not be weaned from VV-ECMO and died.ResultsTen of the 17 patients failed to wean from VV-ECMO and died in the hospital on average 41.5 ± 10.9 days post admission. Seven were successfully decannulated and survived to hospital discharge on average 39.0 ± 19.8 days after admission. There were no significant differences in demographics, comorbidities, laboratory parameters between the groups. LV size and function were also similar. However, moderate to severe RV dysfunction was significantly more frequent in the group of patients who died (8/10, 80%) compared to the survivors (0/7, 0%) (p=0.0017).ConclusionSevere RV dysfunction is associated with increased mortality among patients with severe COVID-19 associated respiratory failure treated with VV-ECMO. Measures to support RV function, including temporary mechanical RV support devices, should be considered for these patients aiming to improve survival.

Outcome Of Patients With Systolic Heart Failure Undergoing Cardiac Sympathetic Denervation For Ventricular Arrhythmia

<h3>Introduction</h3> Cardiac sympathetic denervation (CSD) is a surgical procedure increasingly used for the management of ventricular arrhythmia refractory to conventional medical therapy. Long term outcomes of CSD in patients with systolic heart failure has not been well studied. <h3>Hypothesis</h3> We aim to evaluate the medical comorbidities and outcomes of patients with systolic heart failure who undergo CSD performed as a treatment for ventricular arrhythmia refractory to conventional medical therapy. <h3>Methods</h3> We performed a retrospective analysis of 32 adult patients with ventricular arrhythmia and systolic heart failure who underwent either unilateral or bilateral CSD at the University of Florida from June 1, 2011 to March 31, 2021. Data was analyzed using SAS version 9.4 (SAS Institute, Cary, NC, USA), and unadjusted Kaplan-Meier curves were constructed over one year to evaluate survival over time in patients after CSD. <h3>Results</h3> Of the 32 patients, 28 (88%) were male. The mean age and mean LVEF at the time of CSD were 62 ± 11.6 years and 22 ± 8.2%, respectively. 40.6% of patients had a history of obstructive CAD, defined as at least one major coronary artery with ≥70% luminal stenosis or a history of PCI or CABG. The most common comorbid condition was hypertension (87.5%), followed by atrial arrhythmia (71.9%) and CKD (59.4%). The mean length of survival for all patients after CSD was 613 ± 742 days. At the end of the study period, 16 (50%) patients had died, and the mean time from CSD to death was 290 ± 446 days. The cumulative probability of survival one year after CSD was 71.2% (Figure 1). In a subgroup analysis of patients with and without obstructive CAD, there was a numerical trend towards improved survival in patients without obstructive CAD that was not statistically significant (<i>p</i>=.08). No significant difference in one-year survival was identified when patients were stratified by LVEF ≥20% versus <20% (<i>p</i>=.77). <h3>Conclusions</h3> In this single center retrospective study, CSD for refractory ventricular arrhythmia showed favorable survival (29% one-year cumulative mortality) in patients with systolic heart failure. Interestingly, we noted a trend towards survival in a subgroup of patients without obstructive CAD, and having an LVEF ≥20% did not provide any survival benefit after CSD compared to lower LVEF. The limitations to our study were a small sample size and a lack of follow-up in several patients despite no reported death. This study lays the groundwork for a more in-depth analysis of the potential survival benefits of CSD in patients with systolic heart failure.