Suboptimal Preparation Research Articles

Effectiveness Evaluation of the Student Research Proposal Presentation Program at Scientific Writing Course

Higher education increasingly emphasizes the importance of developing students' academic and professional abilities, including scientific communication and presentation skills. The research proposal presentation program is a strategic initiative in responding to these needs, but challenges in its implementation still exist. Evaluate the effectiveness of student research proposal presentation programs in the Scientific Writing course at UNINDRA and identify strengths and weaknesses in the delivery of material and student argumentation structure. Evaluative research involves collecting data from the results of presentation evaluations, feedback from lecturers or other participants, and assessing the quality of presentations. Qualitative and quantitative data analysis techniques were used, with thematic analysis techniques to identify patterns or themes in participant feedback and evaluation. The evaluation showed that the research proposal presentation program provided significant benefits for lecturers and students. However, there are challenges in the learning process due to inadequate support in CPMK and material distribution. The high lecturer-student ratio also hinders the implementation of the ideal presentation. Internal obstacles such as lack of courage and suboptimal preparation of presentation materials also affect the quality of presentations. The need for adjustments in the preparation of the curriculum and teaching methods, including aligning the CPMK with the CPL and ensuring that the plan for the presentation of research proposals is included in the RPS. It is necessary to provide adequate time and improvement of presentation equipment to improve the quality of presentation and feedback. Better integration between CPMK and CPL will create a globally competitive generation of academics and professionals. Thus, this program can be more effective in achieving higher education goals in developing students' academic and professional abilities.

A validated in-house assay for HIV drug resistance mutation surveillance from dried blood spot specimens

Despite increasing scale-up of antiretroviral therapy (ART) coverage, challenges related to adherence and HIV drug resistance (HIVDR) remain. The high cost of HIVDR surveillance is a persistent challenge with implementation in resource-constrained settings. Dried blood spot (DBS) specimens have been demonstrated to be a feasible alternative to plasma or serum for HIVDR genotyping and are more suitable for lower resource settings. There is a need for affordable HIVDR genotyping assays which can amplify HIV-1 sequences from DBS specimens, particularly those with low viral loads, at a low cost. Here, we present an in-house assay capable of reliably amplifying HIV-1 protease and partial reverse transcriptase genes from DBS specimens, which covers the complete World Health Organization 2009 list of drug resistance mutations under surveillance. DBS specimens were prepared using whole blood spiked with HIV-1 at concentrations of 10,000, 5000, 1000, and 500 copies/mL (n=30 for each concentration). Specimens were tested in triplicate. A two-step approach was used consisting of cDNA synthesis followed by nested PCR. The limit of detection of the assay was calculated to be approximately 5000 (95% CI: 3200–10,700) copies/mL for the protease gene and 3600 (95% CI: 2200–10,000) copies/mL for reverse transcriptase. The assay was observed to be most sensitive with higher viral load specimens (97.8% [95% CI: 92.2–99.7]) for both protease and reverse transcriptase at 10,000 copies/mL with performance decreasing with the use of specimens with lower viral loads (46.7% [36.1–57.5] and 60.0% [49.1–70.2] at 500 copies/mL for protease and reverse transcriptase, respectively). Ultimately, this assay presents a promising opportunity for use in resource-constrained settings. Future work should involve validation under field conditions including sub-optimal storage conditions and preparation of DBS with fingerprick blood in order to accurately reflect real-world collection scenarios.

Pathologic maternal and neonatal outcomes associated with programmed embryo transfer: potential etiologies and strategies for prevention.

In the first of two companion papers, we comprehensively reviewed the recent evidence in the primary literature, which addressed the increased prevalence of hypertensive disorders of pregnancy, late-onset or term preeclampsia, fetal overgrowth, postterm birth, and placenta accreta in women conceiving by in vitro fertilization. The preponderance of evidence implicated frozen embryo transfer cycles and, specifically, those employing programmed endometrial preparations, in the higher risk for these adverse maternal and neonatal pregnancy outcomes. Based upon this critical appraisal of the primary literature, we formulate potential etiologies and suggest strategies for prevention in the second article. Comprehensive review of primary literature. Presupposing significant overlap of these apparently diverse pathological pregnancy outcomes within subjects who conceive by programmed autologous FET cycles, shared etiologies may be at play. One plausible but clearly provocative explanation is that aberrant decidualization arising from suboptimal endometrial preparation causes greater than normal trophoblast invasion and myometrial spiral artery remodeling. Thus, overly robust placentation produces larger placentas and fetuses that, in turn, lead to overcrowding of villi within the confines of the uterine cavity which encroach upon intervillous spaces precipitating placental ischemia, oxidative and syncytiotrophoblast stress, and, ultimately, late-onset or term preeclampsia. The absence of circulating corpus luteal factors like relaxin in most programmed cycles might further compromise decidualization and exacerbate the maternal endothelial response to deleterious circulating placental products like soluble fms-like tyrosine kinase-1 that mediate disease manifestations. An alternative, but not mutually exclusive, determinant might be a thinner endometrium frequently associated with programmed endometrial preparations, which could conspire with dysregulated decidualization to elicit greater than normal trophoblast invasion and myometrial spiral artery remodeling. In extreme cases, placenta accreta could conceivably arise. Though lower uterine artery resistance and pulsatility indices observed during early pregnancy in programmed embryo transfer cycles are consistent with this initiating event, quantitative analyses of trophoblast invasion and myometrial spiral artery remodeling required to validate the hypothesis have not yet been conducted. Endometrial preparation that is not optimal, absent circulating corpus luteal factors, or a combination thereof are attractive etiologies; however, the requisite investigations to prove them have yet to be undertaken. Presuming that in ongoing RCTs, some or all adverse pregnancy outcomes associated with programmed autologous FET are circumvented or mitigated by employing natural or stimulated cycles instead, then for women who can conceive using these regimens, they would be preferable. For the 15% or so of women who require programmed FET, additional research as suggested in this review is needed to elucidate the responsible mechanisms and develop preventative strategies.

#249 : Spotlight on the Artefacts in Next Generation Sequencing in PGT-A: Possible Reason for High Mosaicism Reporting

Background and Aims: Advancement in Next Generation Sequencing (NGS) has led to the extensive utilization of Preimplantation Genetic testing for Aneuploidy. But one challenge, in reporting of aligned short read sequencing data, is the ability to discriminate between embryonic NGS profiles with genuine pathological copy number variations (CNVs) from artefacts arising from erroneous DNA amplification/library preparation. Do technical errors in VeriSeq-NGS lead to artefacts in CNV charts resulting in falsely increased reporting of chromosomal mosaicism? Method: After ethical clearance and informed consent, patients [Formula: see text] 35 years, [Formula: see text]1 implantation failures and severe male factor infertility underwent PGT-A. Those with aneuploid embryos on TE biopsy, donated their embryos for research in year 2022. The DNA extraction and amplification was carried out using Sureplex-DNA amplification system. The libraries were prepared using VeriSeqTM-PGS Library Preparation kit. A total of 24 libraries were pooled, denatured and subjected to NGS using Illumina MiSeq system. CNV visualization and analysis for each sample was carried out using BlueFuse Multi Software (Illumina, USA). The aneuploid whole blastocyst were subjected to the same protocol. Results: NGS profiles generated from the aneuploid whole blastocysts, were manually analyzed for CNVs and for any common genomic artifacts. The quality control was performed using Illumina-Quality Control requirements and only samples satisfying these requirements were used for analysis in the study. Common artifacts were identified affecting chromosome 7,11,16 and 19. Out of 22 blastocysts, NGS profiles of 21 blastocysts had artifact at chromosome 19, and 15 had artifacts at chromosome 7,11,16. These artifacts may be introduced during whole genome amplification and/or suboptimal NGS library preparation or is inherent weakness of the VeriSeq-NGS kit. Conclusion: The four commonly occurring artefacts involved chromosome 7,11,16 and 19, which could be introduced during steps of whole genome amplification or library preparation. The awareness of these artefacts is important to reduce the false positive/inconclusive rate.

Results of the IAEA supported national end-to-end audit of the IMRT technique in Poland

The dosimetry audit services were established in Poland in 1991, since then new audits have been introduced. The recently developed IAEA audit methodology for IMRT H&N treatments was tested nationally. Anthropomorphic SHANE phantom (CIRS) was used to perform measurements in 8 hospitals which voluntarily participated in the study. Each participant had to complete successfully pre-visit activities to take part in an onsite visit. During the visit, auditors together with the local staff, did a CT scan using local protocol, recalculated the plan and verified all the relevant parameters and performed measurements with an ionization chamber and films in SHANE. The adoption of IAEA methodology to the national circumstances was done with no major issues. Participants plans were verified and the results of ionization chamber were all within the 5 % tolerance limit for PTV (max 4,5%) and 7 % for OAR (max 5,3%). Film global gamma results (3 %, 3 mm, 90 % acceptance limit) were within 91,5–99,7% range. The IAEA established acceptance criteria which were achievable for most tests except for CTtoRED conversion curve. The locally performed study allowed establishing new limits. The audit gave interesting results and showed that the procedure is very thorough and capable to identify issues related with suboptimal treatment preparation and delivery. The new limits for CTtoRED conversion curve were adopted for national study. Such an audit gives an opportunity to verify the quality of locally implemented procedures and should be available for Polish hospitals on a daily basis.

Early-to-Intermediate Clinical and Radiographic Outcomes of the Vantage Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: The Vantage total ankle arthroplasty (TAA) features a design based on careful study of arthritic ankles and current ankle biomechanics, with theoretical advantages of a vertically-oriented tibial fixation and a fully congruent talar dome bone-implant interface. In this design-team, single-institution investigation, we report early-to-intermediate term clinical and radiographic outcomes, implant survivorship, and complications of the Vantage TAA. Methods: We retrospectively reviewed prospectively collected data for 278 consecutive patients undergoing Vantage fixed-bearing TAA. Ankles with coronal plane deformity > 25 degrees and suspected poor bone quality were prospectively excluded. Prospectively collected data includes: PROMIS, SF-36, SMFA, VAS and AOFAS hindfoot-ankle scores. Using previously published and commonly accepted evaluation methods, independent radiographic analysis, performed by a non-design surgeon investigator, included pre-operative, 1-year, and most recent follow-up assessments of 2-plane alignment, component position, and the bone- implant interface. A non-design surgeon investigator with dedicated training in statistics performed the statistical analysis using descriptive statistics to report PROM and radiographic measures and Kaplan-Meier survivorship analysis. Results: Mean patient age was 64.8yrs (range:33-86), 44.2% were female, and mean follow-up was 3.1yrs (2.0-5.5). Mean preoperative and postoperative PROMs were as following: PROMIS-Depression 50.3+/-4.2 and 45.6+/-9.8, PROMIS-Physical Function 39.0+/-3.4 and 45.0+/-7.8, SF-36 total score 55.8+/-15.3 and 73.2+/-20.0, SMFA-Function 29.0+/-13.5 and 15.9+/-5.4, VAS 15.8+/-24.8 and 3.1+/-10.1, and AOFAS hindfoot-ankle 46.3+/-16.5 and 81.1+/-16.3 (Table 1). Radiographic lucency at the bone- implant interface was noted in 33 (18.5%) TAAs at final follow-up; 20 (11.2%) were progressive. Lucency was almost exclusive to the tibial component. Implant survivorship was 99.6% [98.9-100.0] at 1-year and 93.3% [88.7-98.2] at the 5-year mark (Table 2, Figure 1). We identified suboptimal bone preparation, initial component alignment and/or component position in all 11 implant failures (Table 3). Conclusion: At early-to-intermediate followup, we observed favorable clinical outcomes, radiographic results and implant survivorship for the fixed-bearing Vantage TAA, especially with optimal bone preparation and component position. Tibial component lucency remains a concern and warrants further investigation. Suboptimal bone preparation, initial component alignment and/or component position was observed in all implant failures.

(Non)fungibility of socio-cultural capital for rural-based students in South African universities

The number of university students coming from rural areas has significantly increased in South Africa in the last two decades. While this is a positive sign of inclusive social growth and development, the fact that 70% of South African universities are still located in urban areas creates challenges for a number of these students. This is also compounded by the fact that most rural schools in South Africa offer sub-optimal preparation for post-school activities. As such, the first barrier for most of these students is negotiating various levels of access to higher education (HE), using forms of social and cultural capital that may be incommensurate with urban-based HE institutions. Using an in-depth review of literature on the subject of rural education, transition to higher education, student success and reflections on the professional experience of the authors in student support services in higher education. This study argues that since most South African universities are “urban enclaves”, students from rural areas take time to adapt and accumulate relevant socio-cultural capital to enable them to thrive and succeed. The transition of students from rural schools to urban-based universities is a socio-cultural as much as it is an epistemological mobility. As such, this “troubled transition” of rural students can be ameliorated through a trans-sectoral or transdisciplinary transitional intervention to simultaneously enable epistemological access and create commensurate socio-cultural capital. However, previous interventions on student transition have been generic and lacked the nuanced intersectional analysis of rurality on student access and success.Transdisciplinary contribution: The study proposes a trans-sectoral or transdisciplinary transitional space in which education institutions (basic and HE) collaborate with government and non-state partners to ensure sufficient and effective transition, especially for rural school learners.

Dual-Energy CT Evaluation of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is a potentially life-threatening condition accounting for more than 300 000 annual hospitalizations. Multidetector abdominopelvic CT angiography is commonly used in the evaluation of patients with GI bleeding. Given that many patients with severe overt GI bleeding are unlikely to tolerate bowel preparation, and inpatient colonoscopy is frequently limited by suboptimal preparation obscuring mucosal visibility, CT angiography is recommended as a first-line diagnostic test in patients with severe hematochezia to localize a source of bleeding. Assessment of these patients with conventional single-energy CT systems typically requires the performance of a noncontrast series followed by imaging during multiple postcontrast phases. Dual-energy CT (DECT) offers several potential advantages for performing these examinations. DECT may eliminate the need for a noncontrast acquisition by allowing the creation of virtual noncontrast (VNC) images from contrast-enhanced data, affording significant radiation dose reduction while maintaining diagnostic accuracy. VNC images can help radiologists to differentiate active bleeding, hyperattenuating enteric contents, hematomas, and enhancing masses. Additional postprocessing techniques such as low-kiloelectron voltage virtual monoenergetic images, iodine maps, and iodine overlay images can increase the conspicuity of contrast material extravasation and improve the visibility of subtle causes of GI bleeding, thereby increasing diagnostic confidence and assisting with problem solving. GI bleeding can also be diagnosed with routine single-phase DECT scans by constructing VNC images and iodine maps. Radiologists should also be aware of the potential pitfalls and limitations of DECT. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Drug-coated balloon strategy following orbital atherectomy for calcified coronary artery compared with drug-eluting stent: One-year outcomes and optical coherence tomography assessment.

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. While recent studies reported the efficacy of orbital atherectomy (OA) combined with DES for calcified lesion, the effectiveness of drug-coated balloon (DCB) following OA has not been fully elucidated. Between June 2018 and June 2021, 135 patients who received PCI for calcified de novo coronary lesions with OA were enrolled and divided into two groups; OA followed by DCB (n = 43) if the target lesion achieved acceptable preparation, or second- or third-generation DESs (n = 92) if the target lesion showed suboptimal preparation between June 2018 and June 2021. All patients underwent PCI with optical coherence tomography (OCT) imaging. The primary endpoint was 1-year major adverse cardiac event (MACE), that was a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization. Mean age was 73 years and 82% was male. In OCT analysis, maximum calcium plaque was thicker (median: 1050 µm [interquartile range (IQR): 945-1175 µm] vs. 960 µm [808-1100 µm], p = 0.017), calcification arc tended to larger (median: 265° [IQR: 209-360°] vs. 222° [162-305°], p = 0.058) in patients with DCB than in DES, and the postprocedure minimum lumen area was smaller in DCB compared with minimum stent area in DES (median: 3.83 mm2 [IQR: 3.30-4.52 mm2 ] vs. 4.86 mm2 [4.05-5.82 mm2 ], p < 0.001). However, 1 year MACE free rate was not significantly different between 2 groups (90.3% in DCB vs. 96.6% in DES, log-rank p = 0.136). In the subgroup analysis of 14 patients who underwent follow-up OCT imaging, late lumen area loss was lower in patients with DCB than DES, despite lower lesion expansion rate in DCB than DES. In calcified coronary artery disease, DCB alone strategy (if acceptable lesion preparation was performed with OA) was feasible compared with DES following OA with respect to 1-year clinical outcomes. Our finding indicated using DCB with OA might be reduce late lumen area loss for severe calcified lesion.

Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature

Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.

Coronary Intravascular Lithotripsy in a Tight Circumferential Calcified Lesion in the Presence of Haematoma Extending into Left Main Coronary Artery After Rotational Atherectomy.

Calcified disease increases procedural challenges and is associated with worse outcomes in percutaneous coronary intervention. Coronary intravascular lithotripsy is a new balloon-based modality for treating calcified disease with deep circumferential calcification. Its main benefit is simplicity and safety compared to atherectomy. However, atherectomy remains the modality of choice in balloon-uncrossable lesions. More than one modality is often needed for treatment of calcified disease. The authors present a case of a balloon-uncrossable calcified ostial left circumflex lesion which was first treated with rotational atherectomy. However, there was haematoma formation in the ostial circumflex extending into left main coronary artery, together with suboptimal preparation of calcified disease. Intravascular coronary lithotripsy was then used to successfully prepare the calcified lesion for stenting without causing extension of the haematoma.

Illuminating the Artefacts of NGS Seen in PGT-A &amp; PGT-SR

Background: Advancements in next generation sequencing (NGS) based genomics over the past 10 years have allowed the routine adoption of preimplantation genetic testing for aneuploidy (PGT-A), and/or segmental rearrangements (PGT-SR) of [Formula: see text]10Mb 1 in the assisted reproductive technology (ART) clinic. However, one challenge remains within the assessment of aligned short read sequencing data, in the ability to discriminate between embryonic profiles with genuine pathological copy number variations (CNVs) from artefacts arising from erroneous DNA amplification or library preparation. Aim: To identify the common artefacts seen in next generation sequencing (NGS) based PGT to reduce inconclusive or false positive results. Method: NGS profiles generated from biopsied human embryonic trophectoderm cells were manually analysed for common genomic artefacts. Following trophectoderm biopsy within a clinical ART cycle, cell samples underwent DNA amplification (Illumina SureplexTM DNA amplification system), sequencing (VeriSeqTM PGS kit on the MiSeq[Formula: see text] System, and bioinformatic data analysis (Bluefuse Multi v4.4, Illumina). Results: Common artefacts were identified affecting chromosomes 7, 11, and 19. Artefacts imitated small CNVs typically displaying a [Formula: see text]50% increase in centromeric sequence counts on chromosomes 7 and 11, and a global increase of sequence counts of [Formula: see text]40% across the entire chromosome 19 (except at the centromere, presenting as diploid). Interestingly a technical repeat of the library preparation and sequencing of the original DNA template somewhat normalised these artefacts. Conclusion: The study found three commonly occurring artefacts involving chromosomes 7, 11, and 19 artificially introduced during suboptimal NGS library preparation. Importantly these artefacts may be normalised through technical repeat of library preparation and sequencing. The awareness of these artefacts may reduce false positive and/or inconclusive results, increasing clinical embryonic utilisation following PGT.

A119 ACUTE DIVERTICULITIS &amp; CONCURRENT DIVERTICULAR BLEED: A RARE CLINICAL ENTITY

AimsColonic diverticula are mostly asymptomatic incidental findings on cross sectional imaging or colonoscopy. In the setting of known diverticulosis, complications like diverticulitis and diverticular bleeding occur in only 4% and 1% of patients respectively. It is unusual to see both complications expressed in the same patient and moreover, rare to see them expressed concurrently. We report a case of concurrent diverticulitis with diverticular bleed and expand on the clinical course.MethodsCase reportResultsA 73-year old was diagnosed with sigmoid diverticulitis based on her clinical presentation and an abdominal CT scan. She was discharged home on oral antibiotics but presented a week later with painless rectal bleeding. In view of the ongoing diverticulitis, a colonoscopy was not pursued although it is the typical procedure of choice to manage active gastrointestinal bleeding. A CT scan was recommended as the alternate initial investigation, which revealed active colonic bleeding in the region of the hepatic flexure immediately adjacent to a diverticulum. A subsequent CT angiogram identified the middle colic artery to be the responsible blood supply to the region and embolization coils were deployed within this vessel in an attempt to achieve hemostasis.Despite vascular intervention the patient continued to bleed and resuscitation with blood products was insufficient. A repeat CT scan ruled out any areas of colonic ischemia as well as any further active areas of extravasation. A decision was made to proceed with a total colectomy to provide definitive treatment of the diverticular disease and manage the bleeding. An urgent intraoperative colonoscopy was attempted but quickly abandoned due to suboptimal preparation and ongoing bleeding obscuring the view. The patient underwent a total colectomy with ileorectal anastomosis. On pathology there was extensive diverticulosis of the ascending and the sigmoid colon with diverticulitis and diverticular abscess cavities within the sigmoid colon.ConclusionsDiverticulitis and diverticular bleed are thought to be unrelated complications of diverticulosis involving distinct physiologic pathways (Figure 1). Although diverticular bleed may occur in patients with a history of prior diverticulitis, concurrent presentation of these two entities is extremely rare. In addition, diverticular bleed is mostly self-limiting. While endoscopic and vascular embolization are established treatment options, colectomy is rare for the management of diverticular bleeding.We report a rare case of concurrent diverticulitis and lower GI bleeding. The presence of the sigmoid diverticulitis made interventional radiology a relatively safer option over endoscopy, which is the typical first line diagnostic and interventional procedure. Ongoing bleeding led to total colectomy and provided the patient with a definitive cure for her diverticular disease. Funding AgenciesNone

Combined Coronary Orbital Atherectomy and Intravascular Lithotripsy for the Treatment of Severely Calcified Coronary Stenoses: The First Case Series.

Severely calcified coronary stenoses remain a significant challenge during contemporary percutaneous coronary intervention (PCI), often requiring advanced therapies to circumvent suboptimal lesion preparation and major adverse cardiac events (MACEs). Recent reports suggest combined coronary atherectomy and intravascular lithotripsy (IVL) may achieve superior preparation of severely calcified coronary stenoses during PCI. We sought to evaluate the safety and utility of combined orbital atherectomy (OA) and IVL for the modification of coronary artery calcification (CAC) prior to drug-eluting stent (DES) implantation in PCI. We performed a retrospective review of all patients who underwent coronary OA and IVL within a single PCI procedure at our institution. The primary outcome was procedural success, defined as successful DES implantation with a residual percent diameter stenosis of <30% and Thrombolysis in Myocardial Infarction (TIMI) 3 flow following PCI without occurrence of in-hospital MACE (cardiac death, myocardial infarction, or target-vessel revascularization). MACE was additionally assessed at 30 days post intervention. Eight patients underwent combined coronary OA and IVL within a single PCI procedure. The mean percent diameter stenosis prior to intervention was 80.5 ± 8.3%, with a mean calcific arc of 338 ± 42°. Procedural success was achieved in 7 of 8 cases (87.5%). Both in-hospital and 30-day MACE rates were 0%. We report the safe and effective use of combined coronary OA and IVL for the preparation of severely calcified coronary stenoses during PCI. Through their distinct yet complementary mechanisms of action, the combined use of these therapies may achieve superior preparation of severely calcified coronary stenoses during PCI.

The Prediction of Inadequate Colon Capsule Cleansing: A Cohort Selection Guided by CC-CLEAR

Introduction: In order to optimize the rate of adequate cleansing in colon capsule, it may be important to identify risk factors that can predict a suboptimal colon preparation. Aim:To define predictive factors for inadequate bowel preparation in colon capsule, according to CC-CLEAR (Colon Capsule CLEansing Assessment and Report). Methods: Retrospective, single center, cohort study. Patients’ demographics, data, and quality of bowel preparation, according to CC-CLEAR, were collected retrospectively. A univariate analysis tested the association between covariables and the outcome, inadequate cleansing. The statistically significant variables were included in multivariable logistic binary regression, and a receiver operating characteristic curve (ROC) assessment was performed. Results: We included 167 consecutive colon capsules. Sixty-eight percent (n = 114) of patients were female, with a mean age of 64 years. The main indication for colon capsule was previous incomplete colonoscopy, in 158 patients (94.6%). The colon capsules cleansing was graded as good or excellent in 96 patients (57.5%) and as inadequate in 71 (42.5%), according to CC-CLEAR. The variables inadequate previous colon cleansing (OR adjusted 41.72 [95% CI 12.57–138.57], p value < 0.001); chronic laxative (OR adjusted 4.86 [95% CI 1.08–21.79], p value = 0.039); antidepressant (OR adjusted 5.00 [95% CI 1.65–15.16], p value = 0.004), and impaired mobility (OR adjusted 5.54 [95% CI 1.17–26.31], p value = 0.031) were independently associated with the outcome inadequate cleansing, after adjusting for confoundment. The model presented an excellent discriminative power towards the outcome variable (AUC ROC 0.937 [CI 95% 0.899–0.975], p value < 0.001). Conclusion: A previous inadequate colon cleansing, the use of chronic laxative and antidepressant, or impaired mobility are predictors of inadequate colon capsule cleansing, as assessed by the CC-CLEAR. These 4 predictors come together as a model enabling an accurate categorization of the patients at major risk of inadequate bowel preparation for capsule colonoscopy, with an excellent discriminative power and performance, which seems useful for the selection of patients for tailored optimization of the colon cleansing protocol.

Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices.

BackgroundPatients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end‐of‐life experience with patients with destination therapy LVADs can help identify key opportunities for improving care.Methods and ResultsWe conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end‐of‐life care, and were analyzed using a 2‐step team‐based inductive approach to coding and analysis. Six themes pertaining to end‐of‐life experiences were derived: (1) timing end‐of‐life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end‐of‐life preparation and decision‐making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end‐of‐life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal.ConclusionsThis study revealed 6 unique aspects of end‐of‐life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team‐based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD‐specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.

The role of fine-needle aspiration biopsy and post-operative histology in the evaluation of thyroid nodules

Thyroid nodules present a serious problem, and mostly they do not carry neoplastic characteristics. Thus, they do not need to be surgically treated. The risk of malignancy varies from 5 to 15 %. Steps to diagnose malignancy should include a careful clinical evaluation, laboratory tests, a thyroid ultrasound exam and a fine-needle aspiration biopsy. Fine-needle aspiration biopsy (FNAB) is the most important diagnostic tool in the assessment of thyroid nodules. Today it is considered the gold standard for malignancy diagnosis in thyroid cancer. In this review we evaluate the role of FNAB and post-operative cytology in the evaluation of thyroid nodules. FNA results are classified as diagnostic (satisfactory) or nondiagnostic (unsatisfactory). Unsatisfactory smears (5–10 %) result from hypocellular specimens usually caused by cystic fluid, bloody smears, or suboptimal preparation. Diagnostic smears are conventionally subclassified into benign, indeterminate, or malignant categories. Benign cytology (60–70 %) is negative for malignancy, and includes cysts, colloid nodule, or Hashimoto thyroiditis. Malignant cytology (5 %) is almost always positive for malignancy, and includes primary thyroid tumors or nonthyroid metastatic cancers. Indeterminate or suspicious specimens (10–20 %) include atypical changes, Hurthle cells or follicular neoplasms. The new Bethesda Cytologic Classification has a 6-category classification, subdividing indeterminate further by risk factors. Considering the increasing worldwide incidence of thyroid microadenomas, recently it is recommended to undergo FNAB under ultrasound guidance even in small (&lt; 1cm) nodules if they are correlated with suspicious ultrasonographic features or suspicious neck lymph nodes. FNAB is a cheap and reliable diagnostic tool that can be used in the selection candidates for surgery and pre-operative diagnosis of thyroid carcinomas. It was concluded that FNAB is the gold standard in the evaluation of thyroid nodules and can prevent many unnecessary surgeries. False-negative FNA cytology remains a concern for clinicians treating patients with thyroid nodules. Post-operative histology give the definitive diagnosis and studies confirm that it has a significant discordance between pre-operative cytology and post-operative histology in patients with thyroid nodule. Cytopathologists should strengthen their criteria for the identification of adenomatous hyperplasia, thyroiditis, cystic lesions or suspicious thyroid nodules to avoid misdiagnoses.

Looking ahead of 2021 Tokyo Summer Olympic Games: How Does Humid Heat Affect Endurance Performance? Insight into physiological mechanism and heat-related illness prevention strategies.

The combination of high humidity and ambient temperature of the 2021 Tokyo Summer Olympic Game will undoubtfully result in greater physiological strains and thereby downregulates the endurance performance of athletes. Although many research studies have highlighted that the thermoregulatory strain is greater when the environment is hot and humid, no review articles have addressed the thermoregulatory and performance differences between dry and humid heat and such lack of consensuses in this area will lead to increase the risk of heat-related injuries as well as suboptimal preparation. Furthermore, specific strategies to counteract this stressful environment has not been outlined in the current literature. Therefore, the purposes of this review are: 1) to provide a clear evidence that humid heat is more stressful than dry heat for both male and female athletes and therefore the preparation for the Tokyo Summer Olympic should be environmental specific instead of a one size fits all approach; 2) to highlight why female athletes may be facing a disadvantage when performing a prolonged endurance event under high humidity environment and 3) to highlight the potential interventional strategies to reduce thermal strain in hot-humid environment. The summaries of this review are: both male and female should be aware of the environmental condition in Tokyo as humid heat is more stressful than dry heat; Short-term heat acclimation may not elicit proper thermoregulatory adaptations in hot-humid environment; cold water immersion with proper hydration and some potential per-cooling modalities may be beneficial for both male and female athletes in hot-humid environment.

Airway and Ventilatory Management in a Premature Neonate with Congenital Tracheoesophageal Fistula

Abstract Esophageal atresia/tracheoesophageal fistula (TEF) is a congenital defect that often presents with respiratory distress in neonates. The anatomical defect in the form of connection between the esophagus and the trachea often affects respiratory function. Gastric distention often occurs due to large air leak into the stomach and may lead to respiratory distress. Surgical correction of the anatomical defect will improve the outcome in these patients. Preoperative preparation and intraoperative management is an essential point. Suboptimal preparation may lead to a life-threatening situation intraoperative. Focusing on airway and ventilatory management may help in reducing morbidity and mortality. We report a case of anesthesia management of TEF repair in a premature neonate with a complication during airway and ventilatory management.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit.

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.