Main Interventions Research Articles

Transjugular intrahepatic portosystemic shunt, local thrombaspiration, and lysis for management of fulminant portomesenteric thrombosis and atraumatic splenic rupture due to vector-vaccine-induced thrombotic thrombocytopenia: a case report

IntroductionRecombinant adenoviral vector vaccines against severe acute respiratory syndrome coronavirus 2 have been observed to be associated with vaccine-induced immune thrombotic thrombocytopenia. Though vaccine-induced immune thrombotic thrombocytopenia is a rare complication after vaccination with recombinant adenoviral vector vaccines, it can lead to severe complications. In vaccine-induced immune thrombotic thrombocytopenia, the vector vaccine induces heparin-independent production of platelet factor 4 autoantibodies, resulting in platelet activation and aggregation. Therefore, patients suffering from vaccine-induced immune thrombotic thrombocytopenia particularly present with signs of arterial or venous thrombosis, often at atypical sites, but also signs of bleeding due to disseminated intravascular coagulation and severe thrombocytopenia. We describe herein a rare case of fulminant portomesenteric thrombosis and atraumatic splenic rupture due to vaccine-induced immune thrombotic thrombocytopenia.Case summary (main symptoms and therapeutic interventions)This case report presents the diagnosis and treatment of a healthy 29-year-old male Caucasian patient suffering from an extended portomesenteric thrombosis associated with atraumatic splenic rupture due to vaccine-induced immune thrombotic thrombocytopenia after the first dose of an adenoviral vector vaccine against severe acute respiratory syndrome coronavirus 2 [ChAdOx1 nCoV-19 (AZD1222)]. Therapeutic management of vaccine-induced immune thrombotic thrombocytopenia initially focused on systemic anticoagulation avoiding heparin and the application of steroids and intravenous immune globulins as per the recommendations of international societies of hematology and hemostaseology. Owing to the atraumatic splenic rupture and extended portomesenteric thrombosis, successful management of this case required splenectomy with additional placement of a transjugular intrahepatic portosystemic shunt to perform local thrombaspiration, plus repeated local lysis to reconstitute hepatopetal blood flow.ConclusionThe complexity and wide spectrum of the clinical picture in patients suffering from vaccine-induced immune thrombotic thrombocytopenia demand an early interdisciplinary diagnostic and therapeutic approach. Severe cases of portomesenteric thrombosis in vaccine-induced immune thrombotic thrombocytopenia, refractory to conservative management, may require additional placement of a transjugular intrahepatic portosystemic shunt, thrombaspiration, thrombolysis, and surgical intervention for effective management.

Left Ventricular Support for Unprotected Left Main Coronary Artery Interventions (The Dayton Heart and Vascular Impella Registry).

Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function <40% (17% vs. 2%;P < 0.025). In a selected group of patients with LM disease, unsupported PCI appears to be a feasible and safe procedure. In high-risk patients, the use of Impella 2.5 appears to be superior to IABP in LM PCI resulting in favorable short-term outcomes.

The New Noir: Race, Identity, and Diaspora in Black Suburbia

Most Black people in the United States now live in the suburbs. To some this may be surprising. Suburban development in the postwar period has usually been understood as a history of the formation of entirely white communities that segregated themselves spatially, legally, and socially with the aid of local and federal administrations from the majority-minority cities they often orbited. But the crabgrass frontier that suburban historian Kenneth Jackson described in the mid-1980s was always more porous than it appeared. To date, scholars of Black suburbanization since Jackson have focused primarily on the “complex role of race and class for Black people” in suburban spaces (p. 5). Books like Living with Racism (1996) and Black Picket Fences (1999) have demonstrated the extent to which Black Americans who made it through the wringer of social mobility in the United States experienced the social and economic benefits of suburbia unevenly and irregularly. For them, white picket fences and green lawns did not translate to the stereotypical expectations of class stability and safety. They also have examined the ways in which Black Americans negotiated racial identity, racism, and the culture of class in these spaces.Orly Clerge's ethnographic study, The New Noir, heads in a different direction. It takes into consideration the fact that “since the passage of the 1965 Immigration Act, the flow of hundreds of thousands of Black immigrants from the Caribbean and Africa have transformed Black mobility and cultural geography” (p. 7). The New Noir expands our understanding of immigration, the Black middle class, and suburban culture through an exploration of the development of what Clerge has termed the “Black diasporic suburbs” (p. 2). To understand “the localized identities and practices of the Black middle class in the twenty-first century,” Clerge saliently argues that we must break the mold of the nation state and “use a more global and comparative perspective” that considers international histories of race, migration, and politics (p. 13). In doing so, Clerge reconfigures the boundaries of the literature on the Black middle class by exploring how diaspora and migration shaped the ways in which members of the transnational Black middle class in New York City negotiated racial identity and class formation.The introduction lays out the stakes of the book, particularly focusing on consumption practices and the culture of food. Clerge focuses on seemingly quotidian tasks and activities that provide a window into the “cultural worlds of [the] multiethnic Black middle class” (p. 5) A trip to the local store, she points out, “is an opportunity to see the multiplicity of regional and national culture that animate suburbia” (p. 3). The second and third chapters take the reader through the historiographies of migration and place through the lens of suburban placemaking and Black Atlantic world diasporas. They explore how cross-national racial formations and migrations shaped trans-geographical journeys of “Black Americans, Haitians, and Jamaicans from slavery to the middle class.”Chapter 4 examines the cultural economies of the Black middle class and the importance of inter/intragroup differences created by successive waves of migration to make sense of the “structure and culture of class” in diasporic Black suburbs. The next chapter builds on the ideas of the previous one to examine the experiences of being a first-generation member of the Black middle class. Her interviewees articulated class origin stories of “downward, lateral, and upward mobility.” The final two chapters unpack the meanings of “race, nationality, and regionality” for the Black middle class through an exploration of how residents of these places, individually and collectively, understood and negotiated racial identity. Chapter 6 outlines Clerge's term “racial consciousness spectrum,” which is a “framework for categorizing interethnic and intraethnic racial identities and practices.” While sociologists often claim that middle-class Black immigrants “distance themselves from Black identities,” this chapter challenges that argument by analyzing the “diversity of definition and performances of Blackness” among residents of the diaspora suburbs. Chapter 7 investigates the “centrality of nationality and regionality in the lived experiences” of “Black Americans, Haitians, and Jamaicans” in the workplace, neighborhood, and at home. Finally, the conclusion, “Mustard Seeds,” rehashes the main interventions of the book and provides a strong agenda for future researchers to look into how “suburban Black millennials,” both immigrants and those born in the states, negotiate race and class in the twenty-first century.

Intravascular imaging and drug-coated balloons forunprotected left main percutaneous coronary interventions: Questions with a predictable or unpredictable answer? Author's reply.

Intravascular imaging and drug-coated balloons forunprotected left main percutaneous coronary interventions: Questions with a predictable or unpredictable answer? Author's reply.

Medication Errors in Intensive Care Units: An Umbrella Review of Control Measures.

Medication errors are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” Such errors account for 30 to 50 percent of all errors in health care. The literature is replete with systematic reviews of medication errors, with a considerable number of studies focusing on systems and strategies to prevent errors in intensive care units, where these errors occur more frequently; however, to date, there appears to be no study that encapsulates and analyzes the various strategies. The aim of this study is to identify the main strategies and interventions for preventing medication errors in intensive care units through an umbrella review. The search was conducted on the following databases: PubMed, CINAHL, PsycInfo, Embase, and Scopus; it was completed in November 2020. Seven systematic reviews were included in this review, with a total of 47 studies selected. All reviews aimed to evaluate the effectiveness of a single intervention or a combination of interventions and strategies to prevent and reduce medication errors. Analysis of the results that emerged identified two macro-areas for the prevention of medication errors: systems and processes. In addition, the findings highlight the importance of adopting an integrated system of interventions in order to protect the system from harm and contain the negative consequences of errors.

Myocardial regeneration protocols towards the routine clinical scenario: An unseemly path from bench to bedside.

SummaryHeart failure secondary to cardiomyocyte loss and/or dysfunction is the number one killer worldwide. The field of myocardial regeneration with its far-reaching primary goal of cardiac remuscularization and its hard-to-accomplish translation from bench to bedside, has been filled with ups and downs, steps forward and steps backward, controversies galore and, unfortunately, scientific scandals. Despite the present morass in which cardiac remuscularization is stuck in, the search for clinically effective regenerative approaches remains keenly active. Starting with a concise overview of the still highly debated regenerative capacity of the adult mammalian heart, we focus on the main interventions, that have reached or are close to clinical use, critically discussing key findings, successes, and failures. Finally, some promising and innovative approaches for myocardial repair/regeneration still at the pre-clinical stage are discussed to offer a holistic view on the future of myocardial repair/regeneration for the prevention/management of heart failure in the clinical scenario.FundingThis research was funded by Grants from the Ministry of University and Research PRIN2015 2015ZTT5KB_004; PRIN2017NKB2N4_005; PON-AIM – 1829805-2.

964 MOUTHCARE MATTERS: QI PROJECT TO IMPROVE ORAL HEALTH IN ELDERLY HOSPITAL INPATIENTS

Abstract Background A quality improvement (QI) project completed over four months on an elderly-care ward comprising 34 inpatients in a UK district general hospital. The QI team comprised the ward Foundation Year 1 (FY1) and Consultant, with Nursing staff consultation. Introduction There is evidence that oral-health in elderly people deteriorates with hospitalisation (Terezakis et al. J Clin Periodontol. 2011;38(7):628–636). Poor oral-health is associated with increased incidence of hospital-acquired infections and reduced oral intake (Kaneoka et al. Infect Control Hosp Epidemiol. 2015;36(8):899–906; Poisson et al. Gerodontology. 2016;33(2):61–168). We had no data on oral-health among our hospital inpatients, nor on nursing measures to maintain or improve it. We aimed to collect baseline data and implement ward-based improvements to oral-health assessment and care. Method Interventions were identified using a ‘drivers-for-change’ flow-diagram: main interventions were introduction of a mouthcare proforma (for nurse-led assessment of patient oral-health and documentation of mouthcare given), ensuring availability of mouthcare products and providing relevant ward-staff education. Two ‘Plan-Do-Study-Act’ cycles were completed; intervention implementation was staggered two-monthly, following evaluation of preceding changes’ impact. Data to measure impact of changes was collected two-monthly by the FY1 on patient oral-health (subjectively scored with assessment tool), rate of proforma completion and patient-reported completion of routine mouthcare. Results Over the four-month period, there were significant improvements to rates of oral-health assessment (proforma completion increased by 86%), completion of routine mouthcare (increased by 32%), and overall patient oral-health: proportion of ‘good’ or ‘excellent’ oral-health scores increased from 21% to 66%. We aim to deliver further ward-based education to maintain progress. Conclusion These interventions are simple, low-cost and could be implemented across many elderly-care wards. Wider adoption would improve mouthcare across larger patient-numbers, with potential benefit to both patient experience and morbidity. Ongoing education and integration of the proforma into existing ward ‘patient-care-bundles’ will promote sustained improvement.

COVID-19 waves: variant dynamics and control

The waves of COVID-19 infections driven by its variants continue to nullify the success we achieved through efficacious vaccines, social restrictions, testing and quarantine policies. This paper models the two major variants-driven waves by two sets of susceptible-infected-quarantined-recovered-vaccinated-deceased coupled dynamics that are modulated by the three main interventions: vaccination, quarantine and restrictions. This SI^2Q^2R^2VD system is used to demonstrate that the second major novel coronavirus wave in the US is caused by the delta variant and the corresponding rapid surge in infectious cases is driven by the unvaccinated pool of the populace. Next, a feedback control based planned vaccination strategy is derived and is shown to be able to suppress the surge in infections effectively.

Incidence and risk factors of cognitive disorders after urologic endoscopic surgery

IntroductionPostoperative cognitive disorders are an emerging public health problem because of its related socio-economic impact.: Postoperative cognitive disorders are an emerging public health problem because of its related socio-economic impact.ObjectivesTo determine the incidence and risk factors of cognitive disorders after endoscopic resection in urology.MethodsThis is an observational, descriptive and analytical study carried out in the urology department of Sahloul University Hospital during a 3 month period, and enrolling patients scheduled for endoscopic resections. Collected data included socio-demographic characteristics and parameters related to the operative management. Cognitive disorders were assessed by the MOCA Test one day before the intervention, then, during the first postoperative day. Patients developing TURP syndrome were excluded.ResultsDuring the study period, 104 patients were enrolled with a mean age of 67.76 years. The sex ratio was 33.6. Main interventions were transurethral resection of bladder tumor and transurethral resection of the prostate.The incidence of cognitive disorders was 45.2% after endoscopic resection. Main Risk factors in multivariate analysis were age (p &lt;10-3), low educational level (p &lt;0.001), sedentary (p &lt;0.001), smoking (p = 0.029), an age gap with spouse&gt; 10 years (p &lt;0.001), high blood pressure (p &lt;0.001), myocardial infarction (p = 0.005); chronic bronchitis (p = 0.002), sleep disorders (p &lt;0.001), preoperative concentration disturbances (p = 0.005), poor quality of patient information (p &lt;0.05), and the type of anesthesia (p = 0.012).ConclusionsThe incidence of cognitive disorders after urologic endoscopic surgery is considerable. Patients with risk factors require preventive measures, regular screening and optimal management.DisclosureNo significant relationships.

The invasive intracoronary imaging assessment of left main coronary artery disease.

Left main coronary artery disease is associated with an unfavorable prognosis. Evidence-based decision making regardingthe optimal revascularization strategy in patients with left main disease has become a challenge, in view of the recentlypublished data. An improvement in outcomes following left main percutaneous interventions could be achieved by reducingthe rate of repeat target lesion revascularization through stent optimization techniques. In the setting of left main disease, proceduralguidance by intravascular ultrasound or optical coherence tomography is essential for good long-term results, in sucha way that intravascular imaging has gained more of a therapeutic connotation. Besides stent optimization, intracoronary imagingquantifies lesion severity, guides lesion preparation through morphological data, facilitates stent selection through accuratevessel sizing, identifies the landing zones, diagnoses acute vessel wall complications such as stent-related edge dissection orintramural hematoma, and defines procedural success.This review focuses on the two main intracoronary imaging techniques used for diagnostic evaluation and proceduralguidance in left main coronary artery disease: intravascular ultrasound and optical coherence tomography. Based on the mostrecently published data, the review discusses each technique's advantages and pitfalls, and summarizes their indications.

Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: An Evidence-to-Practice Review

Avulsion fractures of the 5th metatarsal bone occur when a portion of the bone is broken or pulled off the rest of the bone. These fractures are often seen in athletes, especially those of a young age. Fractures of the 5th metatarsal bone are more commonly treated non-surgically with immobilization of the foot. There are several different options for immobilization of the foot with no clear result as to which immobilization method is the most effective. The purpose of this evidence to practice review was to summarize a systematic review on comparative outcomes of immobilization interventions on avulsion fractures of the 5th metatarsal. The authors included five studies in this review that compared two intervention methods. The two main interventions compared were short leg casting and splinting of the foot, and the authors reviewed foot function scores and non-union rates of the foot. It was found that foot function scores were greater in the splinting intervention groups, as well as a lower non-union rate of the 5th metatarsal bone. From the results of this systematic review, we recommend the use of a removable splint for avulsion fractures of the 5th metatarsal bone.

Systematic review of antibiotic stewardship interventions for urinary tract infection management in the ambulatory setting

Background: Urinary tract infections (UTIs) are common indications for antibiotics in ambulatory setting, and inappropriate use is prevalent. Fluoroquinolones account for 40% of antibiotics prescribed for uncomplicated UTIs, despite clinical guidance against their use as firstline agents. We conducted a systematic review to determine which antibiotic stewardship intervention(s) are effective in improving antibiotic prescribing for UTIs in the ambulatory setting. Methods: Following PRISMA guidelines, English-language literature from 1995 to September 21, 2021, was searched for articles about antimicrobial stewardship, UTI, and ambulatory setting from PubMed, Embase, and Central. Additional articles were identified from authors’ collections and references of pertinent articles. Studies were included if the authors implemented intervention targeting adults 18 years and older in outpatient setting (excluding emergency departments). Interventions were categorized into Guideline Development and Dissemination (GDD), Audit and Feedback, Clinical Decision Support System (CDSS), and Multimodal Interventions. Results: The literature search identified 1,899 papers; 14 papers were included in this review; and 4 additional papers were identified from other sources. The main interventions were GDD in 6 studies, audit and feedback in 3 studies, CDSS in 4 studies, and multimodal interventions in 5 stidues. These studies had heterogeneity of the practice settings and interventions. Moreover, 11 studies targeted primary care, 2 studies targeted urgent care, 1 study targeted both primary and urgent care, 2 studies were conducted in spinal cord injury clinics, and 2 studies were conducted in hospital-wide outpatient sites. Outcomes included (1) statistically significant increase in guideline-concordant antibiotic prescribing in 12 studies (range, 4.6%–246%); (2) statistically significant decrease in fluoroquinolone prescriptions (range, 9.1%–86.3%) in 7 of 9 studies focusing on fluoroquinolones; (3) significant decreases in drug resistance in urine pathogens in 2 studies that evaluated this. Provider education, in conjunction with passive CDSS tools, such as integrating order sets for UTI prescriptions with prefilled instructions into electronic medical records appeared most beneficial. Several studies have investigated negative impact and have found no increase in retreatment rates or worse outcomes. Conclusions: Our systematic literature review identified a limited number of studies with a variety of interventions that improved antibiotic use for UTIs in the ambulatory care setting. Provider education, in conjunction with CDSS tools, can be less time-consuming than audit and feedback and can target a large number of providers and practices. Future studies need to address sustainability over longer periods and should target specialty clinic populations because they have high burden of patients with multidrug-resistant UTI organisms.Funding: NoneDisclosures: None

Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates.

Introduction:Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year.Methods:A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline.Results:We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change.Conclusion:Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.

New tools to improve flu vaccination coverage in patients with risk factors

BackgroundInfluenza vaccination is one of the main interventions to prevent the flu. This study evaluates the impact of automated letter as a method of capturing patients at risk in influenza vaccination campaigns between 2013 and 2017. MethodsThis is a descriptive observational study in Sector I Zaragoza. Data analysis with SPSS and Excel. We studied 173 935 patients (>65 years old or with a risk factor) between 2011 and 2017, comparing the type of catchment used for vaccination. Centre 1 uses postal mail compared to Centre 2 that uses regular information channels. ResultsSignificant differences were observed, with an increase in vaccination in Centre 1 compared to Centre 2 (Centre 1: 29.59%; Centre 2: 19.76%, p < 0.001). Significant differences are found when comparing the vaccination rates in Centre 1 pre-post-intervention (P < 0.001). These differences are also significant when analysing the risk groups: >65 years, asthmatics, patients with COPD, diabetics, and patients with coronary heart disease. 78.3% of the Centre 1's surveys considerade quate the patient catchment via postal mail. ConclusionsSending a letter to those patients at risk of severe complications from influenza is an effective measure to increase influenza vaccination in the primary care setting.

Helminth Infections in Children.

Helminth Infections in Children.

Effectiveness of different types and levels of social distancing measures: a scoping review of global evidence from earlier stage of COVID-19 pandemic

ObjectiveSocial distancing is one of the main non-pharmaceutical interventions used in the control of the COVID-19 pandemic. This scoping review aims to synthesise research findings on the effectiveness of different...

Families Face Pandemic – A Review of Psychological Suggestions and Empirical Findings Regarding the Covid-19 Pandemic

Abstract Aims. Even though child psychology researches related to a pandemic are extensive, the knowledge of practitioners about interventions and practices is still very limited. The complete novelty of such an epidemic situation in Europe, the diversity of terminology and methods are factors that make results hard to interpret. Therefore, the current study aims to give an overview of the psychological literature of the family aspects of the Covid-19 pandemic. Methods. A search was executed in four databases (Science Direct, Medline, Scopus, Google Scholar) using the following keywords: pandemic, Covid 19, family, children, adolescents, anxiety, depression. Our review focuses only on English language literature. Results. The majority of the articles focus on non-pathological phenomena and draws attention to the behavior of healthy populations (increase in internet use, the decline of concentration). Methods were dominated by online surveys. These surveys were mainly constructed ad-hoc and they preferred to address parents. Direct child investigations are underrepresented, but several suggestions were formulated for their optimal functioning. Conclusion:. Researches focusing on psychopathology emphasize the growth in the prevalence of disorders. However, other researches are needed to explore the psychodynamics of the pandemic on the family level. Our study aimed to contribute to the field by summarizing the main findings, suggestions, and interventions hoping that it might be a useful tool for practitioners and reduce the territory of the unknown.

Asset Price Booms and Macroeconomic Policy: A Risk-Shifting Approach

This paper uses a risk-shifting model to analyze policy responses to asset price booms. We show risk shifting leads to inefficient asset and credit booms in which asset prices can exceed fundamentals. However, the inefficiencies associated with risk shifting arise independently of whether the asset is a bubble. Given evidence of risk shifting, policymakers may not need to determine if assets are bubbles to justify intervention. We then show that some of the main candidate interventions against asset booms have ambiguous welfare implications: tighter monetary policy can mitigate some inefficiencies but at a cost, while leverage restrictions may raise asset prices and lead to more leveraged speculation rather than less. Policy responses are more effective when they disproportionately discourage riskier investments. (JEL D82, E23, E32, E44, E52, G01, G12)

Neuronal Ceroid Lipofuscinosis: The Multifaceted Approach to the Clinical Issues, an Overview.

The main aim of this review is to summarize the current state-of-art in the field of childhood Neuronal Ceroid Lipofuscinosis (NCL), a group of rare neurodegenerative disorders. These are genetic diseases associated with the formation of toxic endo-lysosomal storage. Following a brief historical review of the evolution of NCL definition, a clinically-oriented approach is used describing how the early symptoms and signs affecting motor, visual, cognitive domains, and including seizures, may lead clinicians to a rapid molecular diagnosis, avoiding the long diagnostic odyssey commonly observed. We go on to focus on recent advances in NCL research and summarize contributions to knowledge of the pathogenic mechanisms underlying NCL. We describe the large variety of experimental models which have aided this research, as well as the most recent technological developments which have shed light on the main mechanisms involved in the cellular pathology, such as apoptosis and autophagy. The search for innovative therapies is described. Translation of experimental data into therapeutic approaches is being established for several of the NCLs, and one drug is now commercially available. Lastly, we show the importance of palliative care and symptomatic treatments which are still the main therapeutic interventions.

Determination of Optimal Fluoroscopic Angulations for Left Main Coronary Artery Ostial Interventions: 3-Dimensional Computed Tomography Validation.

Background Current recommendations for the best views for the left main coronary artery (LMCA) ostium intervention are empirical. Objectives To determine the optimal projection to visualize the LMCA ostium using only fluoroscopy. Methods The optimal projection to visualize the LMCA ostium was determined using fluoroscopic images of superimposing the lowest points of the distal ends of two J tipped wires in the noncoronary cusp (NCC) and right coronary cusp (RCC). This was validated independently using 3-dimensional computed tomography (3D-CT) reconstruction. Results Satisfactory images of the overlapping wires in NCC and RCC could be obtained in 90% (45/50). Between the fluoroscopic and the 3D-CT reconstruction approaches, the mean difference for NCC and RCC overlapping at horizontal axes is -1.8 with a 95% limit of agreement between −3.94 and 0.34 (p=0.10) and at vertical axes −1.6 with a 95% limit of agreement between −3.46 and 0.26 (p=0.09); and the mean difference for the optimal projection to visualize the LMCA ostium at horizontal axes is −3.22 with a 95% limit of agreement between -7.26 and 0.81 (p=0.11) and at vertical axes −2.31 with a 95% limit of agreement between −5.83 and 1.21 (p=0.09). The 3D angulation deviation for the optimal projection to visualize the LMCA ostium was 8.5° ± 4.7° when the LMCA ostium faced the NCC-RCC commissure (n = 32) and 22.3° ± 16.0° (p=0.009) when it did not (n = 13). Conclusions The optimal projection for LMCA ostial intervention can be determined using fluoroscopic images of superimposing wires in the NCC and RCC when the LMCA ostium faces the NCC-RCC commissure, as was the case in 71% of the patients studied.