Interventional Cardiology Research Articles

Identifying the Role of Flow-Mediated Dilatation Assessment in Acute Coronary Syndromes: A Systematic Review.

In the context of the global burden of cardiovascular disease, the development of novel, patient-targeted diagnostic and therapeutic strategies is of paramount importance. Acute coronary syndromes (ACS) comprise a subset of cardiovascular disease, with constantly increasing prevalence requiring urgent attention. Flow-mediated dilatation (FMD), a noninvasive method for the evaluation of endothelial function, has been previously implemented in patients with ACS. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in order to identify all relevant studies assessing the implementation of FMD among patients with ACS. Our review reflects an effort to present all available data regarding the role of FMD to date, a valuable noninvasive and easy accessible diagnostic tool, in the prognosis of patients with ACS. FMD evaluation in patients with ACS reveals a decline in values, indicative of the presence of endothelial function among this distinct patient group. FMD has also been used to assess the response to various treatments, as well as to predict major adverse cardiovascular events. Dynamic responses to interventions highlights its potential in the evolving field of interventional cardiology.

Does Artificial Intelligence Change How We Design User Interfaces? A Case Study from Representatives in the Medical Device Industry

Intravascular ultrasound (IVUS) is an imaging technique that allows interventional cardiologists (ICs) to capture and visually display images of blood vessels during Percutaneous Coronary Interventions (PCI). IVUS images allow ICs to: (i) evaluate the type and characteristics of lesions present, (ii) assess the appropriate intervention, (iii) determine the size of the stent or balloon to be used if they were needed, and (iv) examine if the intervention was successful. The size of the stent or balloon is determined by identifying, and then measuring, the diameters of vessel or lumen borders at the treatment locations. Identification of vessel borders is a manual time-consuming process that is rigorous to accomplish. Alternatively, a machine learning model that automatically identifies and measures the lumen and vessel borders of IVUS images was developed. This industry case study shows how the HFE team lead the UI design process to incorporate this automation into the existing UI.

Consensus of the National Heart Center in collaboration With the Saudi Arabian Cardiac Interventional Society on the Clinical Use of Intracoronary Imaging.

Studies show that intracoronary imaging (ICI)-guided PCI is associated with a significantly lower risk of stroke, Q-wave myocardial infarction, and death compared to angiography-guided PCI in the management of acute coronary syndromes, complex coronary lesions and left-main interventions. Despite these well-established clinical benefits, the utilization of ICI-guided PCI in Saudi Arabia remains suboptimal. The National Heart Center (NHC) and the Saudi Arabian Cardiac Interventional Society (SACIS) gathered national experts to develop a consensus document on how to integrate ICI-guided PCI in routine clinical practice in Saudi Arabia. The consensus was based on the nominal group technique, whereby a committee of interventional cardiologists affiliated with the NHS and SACIS developed and discussed a number of statements on the clinical use of intracoronary imaging based on a systematic review of the literature. A total of 17 statements were discussed in light of scientific evidence and agreed upon. Initiatives to improve operator skills when it comes to image acquisition and interpretation are crucial in the incorporation of ICI-imaging guided PCI in Saudi Arabia. Local data on reference diameters and measurements and epidemiological data on Saudi patients being treated in catheterization laboratories are necessary. Herein, we provide the first national consensus on the use of ICI-guided PCI in Saudi Arabia. We anticipate that this document contributes to a more optimal and integrative use of ICI-guided PCI in the Kingdom.

Academic productivity and content from social media influencers in vascular surgery compared to complementary specialties

ObjectiveSocial media (SoMe) plays a growing role in disseminating scientific information to health care professionals, patients, and the public. This study analyzes the influence of vascular care providers on Twitter (now X), comparing top influencers across specialties and exploring the connection between social media impact and academic productivity. MethodsA text search of Twitter bios in 2022 identified all United States-based users who self-identify as vascular surgeons (VSs), cardiothoracic surgeons (CTSs), interventional cardiologists (ICs), or interventional radiologists (IRs). The top 100 influencers in each specialty were selected based on number of followers. Social Authority (SA) was also used to evaluate Twitter influence. Standardized internet searches and publicly available data were used to obtain H-index, publication number, university affiliation, and professorship. The Twitter API was used to generate a tweet archive of each user’s last 3200 tweets, and specialty-related hashtags and mentions were compared. ResultsWe identified 8321 Twitter handles of users across four specialties, of which 1489 were included for analysis: VS (n = 310), CTS (n = 152), IC (n = 672), and IR (n = 355). Of the top 100 influencers ranked by follower count, most CTS (72%) and VS (67%) users were academically affiliated. Top VS influencers had a higher SA compared with CTS influencers (48 ± 6.0 vs 38 ± 11.4; P < .001) but lower SA than IC influencers (55 ± 6.4; P < .001). VSs also had fewer followers per user than ICs (1606 ± 1338 vs 4420 ± 7415; P < .001), but not CTSs or IRs. Among academically affiliated Twitter users, VSs had similar H-indices (19 ± 16), publications per user (88 ± 106), and citations per user (2547 ± 5182) as ICs, CTSs, and IRs (P > .050 for all). Academic rank was similar across specialties (P = .99), with most users representing assistant professors (30%-44%). A total of 1,063,419 of the most recent tweets from all users were analyzed. Forty-seven of the top 100 most tweeted handles belonged to individual IC accounts, and included international physicians and those who did not self-identify as ICs based on their bio text. Only six of the top 100 most tweeted handles were VSs. Over 20,000 unique hash tags were identified in the tweet archive. Of the top 100 most tweeted hashtags, 21 contained general cardiology subject matter, 16 related to IC-specific subject matter, eight pertained to VS-specific subject matter, and 12 were disease-specific hashtags that are treated by multiple specialties. ConclusionsWhen compared with complimentary specialists, VSs have lower SoMe influence than ICs, but similar influence as CTSs and IRs. VSs should engage with complimentary specialists to increase their SoMe reach and enhance the dissemination of vascular surgery-related content.

An In-depth Analysis of the Adverse Effects of Ionizing Radiation Exposure on Cardiac Catheterization Staffs.

Diagnostic and interventional angiograms are instrumental in the multidisciplinary approach to CAD management, enabling accurate diagnosis and effective targeted treatments that significantly enhance patient care and cardiovascular outcomes. However, cath lab staff, including interventional cardiologists, is consistently exposed to ionizing radiation, which poses inherent health risks. Radiation exposure in the cath lab primarily results from the use of fluoroscopy and cineangiography during diagnostic and interventional procedures. Understanding these risks and implementing effective radiation protection measurements are imperative to ensure the well-being of healthcare professionals while delivering high-quality cardiac care. Prolonged and repeated exposure can lead to both deterministic and stochastic effects. Deterministic effects, such as skin erythema and tissue damage, are more likely to occur at high radiation doses. Interventional cardiologists and staff may experience these effects when safety measures are not rigorously followed. In fact, while ionizing radiation is essential in the practice of radiation cardiology ward, cath lab staff faces inherent risks from radiation exposure. Stochastic effects, on the other hand, are characterized by a probabilistic relationship between radiation exposure and the likelihood of harm. These effects include the increased risk of cancer, particularly for those with long-term exposure. Interventional cardiologists, due to their frequent presence in the cath lab, face a higher lifetime cumulative radiation dose, potentially elevating their cancer risk. Protective measures, including the use of lead aprons, thyroid shields, and radiation monitoring devices, play a crucial role in reducing radiation exposure for cath lab personnel. Adherence to strict dose optimization protocols, such as minimizing fluoroscopy time and maximizing distance from the radiation source, is also essential in mitigating these risks. Ongoing research and advancements in radiation safety technology are essential in further for minimizing the adverse effects of ionizing radiation in the cath lab.

The Impact of Artificial Intelligence on Internal Medicine Physicians: A Survey of Procedural and Non-procedural Specialties.

Artificial intelligence (AI) is increasingly being integrated into various aspects of healthcare, including internal medicine. However, the impact of AI on physicians across different internal medicine specialties remains unclear. This study assesses AI's adoption, utilization, and perceived impact among procedural and non-procedural internal medicine physicians. A comprehensive survey questionnaire was designed to cover current AI use, perceived impact on diagnostic accuracy, treatment decisions, patient outcomes, challenges, ethical concerns, and future expectations. The survey was distributed to a diverse sample of internal medicine physicians across various specialties, including procedural (e.g., interventional cardiology, gastroenterology) and non-procedural (e.g., endocrinology, rheumatology) fields.Responses were analyzed using descriptive statistics, chi-square tests, t-tests, and logistic regression. The survey received responses from 22 internal medicine physicians, with 64% (n=14) representing procedural specialties and 36% (n=8) representing non-procedural specialties. Sixty-eight percent (n=15) of respondents reported using AI tools in their practice, with higher adoption rates among procedural specialties (n=11,79%) compared to non-procedural specialties (n=4, 50%). Surveyed physicians reported that AI improved diagnostic accuracy (n=12, 80%), treatment decisions (n=10, 67%), and patient outcomes (n=13, 87%). However, 55% (n=12) of respondents expressed concerns about the interpretability and transparency of AI algorithms. Non-procedural specialists were more likely to perceive AI as a threat to their job security (n=3, 38%) than procedural specialists (n=3, 21%). The most common challenges to AI adoption were lack of training (n=16, 73%), cost (n=13, 59%), and data privacy concerns (n=11, 50%). This study assesses the perceived impact of AI on internal medicine physicians, highlighting the differences between procedural and non-procedural specialties. The findings underscore the need for specialty-specific considerations in developing and implementing AI tools. While AI can potentially improve diagnostic accuracy, treatment decisions, and patient outcomes, addressing challenges such as lack of training, cost, and data privacy concerns is crucial for widespread adoption. Moreover, the study emphasizes the importance of ensuring the interpretability and transparency of AI algorithms to foster trust among physicians. As AI continues to evolve, it is essential to engage internal medicine physicians across specialties in the development process to create AI tools that effectively complement their expertise and improve patient care. Further research should focus on developing best practices for AI integration in internal medicine and evaluating the long-term impact on patient outcomes and healthcare systems.

What Is Needed to Encourage Women to Choose Careers in Interventional Cardiology

What Is Needed to Encourage Women to Choose Careers in Interventional Cardiology

Spanish cardiac catheterization and coronary intervention registry. 33rd official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2023)

Introduction and objectivesThis article presents the 2023 activity report of the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC). MethodsAll interventional cardiology laboratories in Spain were invited to participate in an online survey. Data analysis was carried out by an external company and subsequently reviewed and presented by the members of the ACI-SEC board. ResultsA total of 119 hospitals participated. The number of diagnostic studies decreased by 1.8%, while the number of percutaneous coronary interventions (PCI) showed a slight increase. There was a reduction in the number of stents used and an increase in the use of drug-coated balloons. The use of intracoronary diagnostic techniques remained stable. For the first time, data on PCI guided by intracoronary imaging was reported, showing a 10% usage rate in Spain. Techniques for plaque modification continued to grow. Primary PCI increased, becoming the predominant treatment for myocardial infarction (97%). Noncoronary structural procedures continued their upward trend. Notably, the number of left atrial appendage closures, patent foramen ovale closures, and tricuspid valve interventions grew in 2023. There was also a significant increase in interventions for acute pulmonary embolism. ConclusionsThe 2023 Spanish cardiac catheterization and coronary intervention registry indicates a stabilization in coronary interventions, together with an increase in complexity. There was consistent growth in procedures for both valvular and nonvalvular structural heart diseases.

Radiation Exposure and Protection for (Assumed) Pregnant Interventional Cardiologists and Electrophysiologists

Radiation Exposure and Protection for (Assumed) Pregnant Interventional Cardiologists and Electrophysiologists

Intervención dirigida por catéter en la embolia aguda de pulmón. Posicionamiento SEC-Asociación de Cardiología Intervencionista/SEC-Asociación de Cardiopatía Isquémica y Cuidados Agudos Cardiovasculares/SEC-GT Hipertensión Pulmonar

Pulmonary embolism (PE) is the leading cause of hospital death and the third most frequent cause of cardiovascular mortality. Traditionally, treatment options have included anticoagulation, thrombolysis, or surgery; however, catheter-directed interventions (CDI), including catheter-directed thrombolysis and aspiration thrombectomy, have been developed for patients with intermediate- or high-risk PE. These techniques can rapidly improve right ventricular function, hemodynamic status, and mortality in some patients, although there is a lack of evidence from randomized controlled trials. This document, prepared by the Interventional Cardiology Association, the Association of Ischemic Heart Disease and Acute Cardiovascular Care, and the Working Group on Pulmonary Hypertension of the Spanish Society of Cardiology (SEC), reviews the current recommendations and available evidence on the management of PE. It emphasizes the importance of rapid response teams, risk stratification, and early patient monitoring in identifying candidates for reperfusion. Based on existing clinical evidence on CDI, the document discusses various clinical scenarios and provides guidance on patient selection, particularly in situations of uncertainty due to insufficient evidence. Lastly, it describes periprocedural support, highlighting the necessary multidisciplinary approach to improve outcomes and reduce morbidity and mortality in patients with PE.

Evaluation of radiation dose to the lens in interventional cardiology physicians before and after dose limit regulation changes.

In response to the International Commission on Radiological Protection, which lowered the lens equivalent dose limit, Japan lowered the lens dose limit from 150 mSv y-1to 100 mSv/5 years and 50 mSv y-1, with this new rule taking effect on 1 April 2021. DOSIRIS®is a dosimeter that can accurately measure lens dose. Herein, we investigated lens dose in interventional cardiology physicians 1 year before and after the reduction of the lens dose limit using a neck dosimeter and lens dosimeter measurements. With an increase in the number of cases, both personal dose equivalent at 0.07 mm depth [Hp(0.07), neck dosimeter] and personal dose equivalent at 3 mm depth [Hp(3), lens dosimeter] increased for most of the physicians. The Hp(3) of the lens considering the shielding effect of the Pb glasses using lens dosimeter exceeded 20 mSv y-1for two of the 14 physicians. Protection from radiation dose will become even more important in the future, as these two physicians may experience radiation dose exceeding 100 mSv/5 years. The average dose per procedure increased, but not significantly. There was a strong correlation between the neck dosimeter and lens dosimeter scores, although there was no significant change before and after the lens dose limit was lowered. This correlation was particularly strong for physicians who primarily treated patients. As such, it is possible to infer accurate lens doses from neck doses in physicians who primarily perform diagnostics. However, it is desirable to use a dosimeter that can directly measure Hp(3) because of the high lens dose.

Percutaneous Valvular and Structural Heart Disease Interventions. 2024 Core Curriculum of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC.

The percutaneous treatment of structural, valvular, and non-valvular heart disease (SHD) is rapidly evolving. The Core Curriculum (CC) proposed by the EAPCI describes the knowledge, skills, and attitudes that define competency levels required by newly trained SHD interventional cardiologists (IC) and provides guidance for training centres. SHD ICs are cardiologists who have received complete interventional cardiology training. They are multidisciplinary team specialists who manage adult SHD patients from diagnosis to follow-up and perform percutaneous procedures in this area. They are competent in interpreting advanced imaging techniques and master planning software. The SHD ICs are expected to be proficient in the aortic, mitral, and tricuspid areas. They may have selective skills in either the aortic area or mitral/tricuspid areas. In this case, they must still have common transversal competencies in the aortic, mitral, and tricuspid areas. Additional SHD domain competencies are optional. Completing dedicated SHD training, aiming for full aortic, mitral, and tricuspid competencies, requires at least 18 months. For full training in the aortic area, with basic competencies in mitral/tricuspid areas, the training can be reduced to 1 year. The same is true for training in the mitral/tricuspid area, with competencies in the aortic area. The SHD IC CC promotes excellence and homogeneous training across Europe and is the cornerstone of future certifications and patient protection. It may be a reference for future CC for national associations and other SHD specialities, including imaging and cardiac surgery.

Comparative transcatheter occlusion of patent ductus arteriosus: multicenter collaborative study across pediatric and veterinary cardiology centers

Introduction/ObjectiveTranscatheter therapeutics have revolutionized treatment of patent ductus arteriosus (PDA). Greater understanding of corrective interventions across species can advance best practices, protocols, and outcomes while minimizing adverse events. The objective of this study was to describe characteristics and outcomes in children and dogs undergoing transcatheter PDA occlusion. Animals, Materials and MethodsThis was a multicenter, retrospective cohort study from two pediatric and three veterinary centers. Demographics, procedural characteristics, and outcomes were assessed. ResultsData included 202 children and 106 dogs treated from July 2019 to June 2021. Forty-five (23%) children and 19 (18%) dogs had congestive heart failure prior to catheterization. Transvenous and transarterial approaches for deployment were most used in children and dogs, respectively. All children had percutaneous vascular access compared to 17 (16%) dogs. Intraprocedural anticoagulation was standard for children (100% of 165 reported), but not for dogs (2/103). The median (interquartile range) pulmonary ostium diameter in children was 2.2 mm (1.5–3.0 mm) and 3.0 mm (2.0–4.2 mm) in dogs when all body sizes were considered (P<0.001). Amplatzer™ Duct Occluder was most commonly used in children (64/202, 32%); the Amplatz® Canine Duct Occluder was used in dogs (96/100, 96%). Closure was manual compression in all children, whereas vessel ligation was most used in dogs (74/104, 73%). Successful device deployment was achieved in 197 (98%) children and 98 (93%) dogs (P=0.03). Major reasons for failure included device embolization in six (2.9%) children and PDA morphology concerns in four (3.8%) dogs. ConclusionsTranscatheter PDA occlusion is successful in children and dogs. Study data might be useful for optimizing transcatheter therapeutics and animal models for interventional cardiology.

Ionizing Radiation Exposure at Interventional Cardiology Practices in Bangladesh

Ionizing Radiation Exposure at Interventional Cardiology Practices in Bangladesh

Same-day discharge coronary interventions: How to succeed?

Percutaneous coronary interventions(PCI) are the cornerstone of treatment in patients with coronary artery disease, generating substantial costs for the healthcare system. Considerable improvement in PCI technique, stent technology and antiplatelet therapy led to a complication rate of <5%, a success rate of >95% and lack of routine cardiothoracic surgical support. Thereby, the concept of same-day discharge following PCI has been proposed due to comparable efficacy, safety, and socioeconomic benefits to inpatient PCI. Although single-vessel disease was the primary indication for outpatient (OP) PCI, more complex scenarios such as multivessel disease, left main disease and chronic total occlusions were shown to be feasible and safe in OP setting as well. Currently available data shows that OP PCI leads to cost optimization, increased PCI center capacity, decrease in nosocomial infections rate and increased patient satisfaction, along with good clinical outcomes. Although OP PCI seems promising in a subset of well-prepared and compliant patients without severe comorbidities, there are some challenges to overcome before its routine implementation. To prevent unnecessary hospitalizations and unsafe same-day discharges, interventional cardiology teams should be trained to perform reliable risk-benefit assessments. Standardized forms should be created to obtain informed consent and instruct OP PCI patients and their relatives about postprocedural management. Here, we summarize the available data on OP and inpatient PCI outcomes, discuss the opportunities and challenges of OP PCI and propose a periprocedural patient management checklist, with the goal of facilitating OP PCI implementation in interventional cardiology centers.

Half-dose ticagrelor versus standard-dose clopidogrel in a dual antiplatelet regimen for stent-assisted coiling or flow diversion of unruptured intracranial aneurysms: a cohort study

BackgroundIntracranial hemorrhage is the major safety concern of standard-dose ticagrelor (90 mg twice daily) based dual antiplatelet therapy (DAPT). The bleeding avoidance strategy through dose de-escalation has been investigated in...

Analysis of interventional cardiological risk in emergency aid: Indications and procedures

Introduction: Interventional cardiology procedures require special preparation recommended in the form of a protocol for each service. It is understood that the need for this is an advance for the ICHS, mainly because anxiety and fear accompany patients. Objetives: The aim of this study is to carry out an up-to-date literature review on information about hemodynamics and interventional cardiology services. Material and Methods: The methodology used was a literature review. The health terminologies consulted in the Health Sciences descriptors (DeCS/BIREME) were used; information on Hemodynamics and Interventional Cardiology services. Results and Discussions: Hemodynamics and interventional cardiology is an area of cardiology that diagnoses and treats diseases of the heart and blood vessels using catheters. The Hemodynamics service is responsible for performing cardiac catheterization for the diagnosis and treatment of heart disease. The department performs the procedure on adults and children. Many patients are referred to the interventional cardiologist after an assessment with the clinical cardiologist. However, some go to the emergency department first because they have symptoms that could be considered serious, such as chest pain or even because they are already having a heart attack. Conclusions: Through procedures such as catheterization, angioplasty, intracoronary ultrasound, among others, interventional cardiology is a procedure without cuts, which allows patients to recover quickly. In this case, it can be used both to treat coronary artery disease, such as angina and heart attacks, as well as structural heart disease, such as problems with heart valves like severe aortic stenosis.

Gender Disparities in Japanese Interventional Cardiology: Outcomes of Female Operators in Percutaneous Coronary Interventions

BackgroundGender disparity remains a significant global concern in interventional cardiology, and there is a lack of extensive research examining the outcomes of percutaneous coronary interventions (PCIs) performed by female interventionalists. ObjectivesThe aim of this study was to examine the practice patterns and outcomes of PCIs conducted by female interventionalists in Japan. MethodsThis retrospective observational study analyzed data from the Japanese Percutaneous Coronary Intervention registry between January 2019 and December 2021. The primary endpoint was in-hospital mortality and the secondary endpoint was the success rate of PCIs. ResultsA total of 447 female operators (7.3% of all operators) performed 35,211 PCIs (5.3%) during the study period. Female doctors treated a higher percentage of patients with ST-segment elevation myocardial infarction compared with their male counterparts (20.2% vs 17.7%; P = 0.001), whereas male doctors were more likely to perform PCIs for left main disease (4.9% vs 5.9%; P < 0.001) and lesions treated with rotational atherectomy (3.5% vs 4.9%; P < 0.001). The success rate of PCIs was higher for female interventionalists (97.8% vs 97.2%; P < 0.001). After conducting a risk-adjusted analysis, we found no significant difference in in-hospital mortality (adjusted OR: 0.896; 95% CI: 0.78-1.03; P = 0.12), or procedural complications associated with the operator's gender. ConclusionsOverall, female operators exhibited outcomes similar to their male counterparts in terms of adjusted procedural outcomes, and higher crude success rate in certain subgroups. These findings emphasize gender disparities and stress the need to increase gender diversity in interventional cardiology.

Real time eye dose reduction in fluoroscopy with auditory and visual feedback dosimeter through swine model experiments

This paper proposes measurement and reduction of eye dose in real time for the physician and the assistant performing fluoroscopy guided arterial puncture. Eye dose rates were measured for 30 fluoroscopy-guided punctures of bilateral femoral arteries in pigs. Fifteen fluoroscopy-guided punctures were performed using real time radiation dosimeter without auditory and visual feedback and other fifteen punctures were done using real time radiation dosimeter with visual and auditory feedback worn on forehead by an interventional cardiologist having experience of more than 10 years. The mean radiation dose rate for eyes of physician during arterial puncturing with real time radiation dosimeter with auditory feedback was 0.07 mSv/h (n = 15) whereas it was 0.18 mSv/h (n = 15) without visual and auditory feedback. The percentage of reduction with the device was 61% for eyes. In case of assistant the reduction was 33% for eyes (n = 15). The real time visual and auditory feedback dosimeter has reduced the eye dose rate of the physician and assistant and also helped him staying away from the X-ray source. Real time radiation dosimeters can be an effective tool to measure and reduce the dose to the eyes. The radiation eye dose rate for physician and assistant was significantly reduced by using real time radiation dosimeter with visual and auditory feedback. The real time radiation dosimeter not only helps in measuring but also help in minimizing the radiation dose rate for the physician and assistant in real time.

Limericks for Myocardial Recovery and Regeneration.

Limericks are an easy, casual, and entertaining way to have fun with the English language. Creating them can be an engaging pastime to assist in memorizing important anatomic relationships necessary for being an interventional cardiologist or simply an intellectual exercise that provides respite after a hectic day in the cardiac catheterization laboratory, surgical suite, outpatient clinic, or intensive care unit. Interest in this form of poetry often dates back to when we, as children, were taught the simplistic rhyming pattern of a traditional limerick or learned one during adolescence. As we age, our limericks often became more humorous, personal, and bawdy. That evolution is the beauty of this poetic form. For this edition of Poet's Pen, we invited Dr. Marshall S. Flam, a noted dabbler in the limerick world, to pen "Limericks for Myocardial Recovery and Regeneration" to accompany the theme of this issue.