Unsuccessful Attempts Research Articles

ULTRASOUND IN THE ETIOLOGICAL ASSESSMENT OF EMBRYONIC IMPLANTATION FAILURES AT THE FERTILIA MEDICAL CLINIC IN BAMAKO

Recurrent implantation failure refers to failure to achieve a clinical pregnancy after the transfer of at least four embryos in at least three fresh or frozen cycles in a woman under 40 years of age. Implantation failure can be a consequence of embryonic or uterine factors. Thorough investigations must be necessary to determine whether there is an embryonic or uterine cause. Various uterine pathologies, including fibroids, endometrial lesions, polyps, congenital anomalies and intrauterine adhesions, vascular parameters should be explored by ultrasound to aid in the diagnosis of the causes of embryo implantation failures [1]. Aims: - To describe the sonographic lesions likely to explain embryo implantation failures. - To determine the correlation between ultrasound lesions detected during our study and embryo implantation failures. Subjects And Methods: This was a cross-sectional, descriptive study concerning 165 women collected between January 2016 and January 2022 at the Fertilia medical clinic in Bamako. The study population consisted of consenting women in whom at least three unsuccessful attempts to transfer good quality fresh or frozen embryos were made. All of our patients underwent a biological assessment, but our study focused on the contribution of ultrasound. Ultrasounds were performed by endocavitary and suprapubic route with General Electric Voluson E8, Vivid 3 and Logic9 devices. Results: 165 women were recruited into our. The average age was 38 years with extremes ranging from 23 to 52 years. 86 patients or 52% were between 30 and 40 years old. 94 patients or 57% had made at least three unsuccessful attempts to transfer good quality embryos. 139 patients or 84.24% had at least one ultrasound anomaly. The most common pathologies were adenomyosis (30.3%), endometritis (13.94%), hydrosalpinx (4.24%), a high pulsatility index (12.12%), the presence of notch in one or both uterine arteries (7.27 %), polymyomatous uterus (26%), congenital malformation (1.21%), polyp (4.85%). Conclusion: Repeated embryo implantation failures are partly due to the embryo and partly to the uterus or its annexes. Ultrasound is a tool of choice in developing countries such as ours to diagnose the causes of these implantation failures and to allow infertile couples to procreate. We were able to highlight the relationships that exist between abnormalities detected on ultrasound and repeated embryo implantation failures.

The nonlinearity of pupil diameter fluctuations in an insight task as criteria for detecting children who solve the problem from those who do not.

Insights, characterized by sudden discoveries following unsuccessful problem-solving attempts, are fascinating phenomena. Dynamic systems perspectives argue that insight arises from self-organizing perceptual and motor processes. Entropy and fractal scaling are potential markers for emerging new and effective solutions. This study investigated whether specific features associated with self-organization in dynamical systems can distinguish between individuals who succeed and those who fail in solving insight tasks. To achieve this, we analyzed pupillary diameter fluctuations of children aged 6 to 12 during the 8-coin task, a well-established insight task. The participants were divided into two groups: successful (n = 24) and unsuccessful (n = 43) task completion. Entropy, determinism, recurrence ratio, and the β scaling exponent were estimated using Recurrence Quantification and Power Spectrum Density analyses. The results indicated that the solver group exhibited more significant uncertainty and lower predictability in pupillary diameter fluctuations before finding the solution. Recurrence Quantification Analysis revealed changes that went unnoticed by mean and standard deviation measures. However, the β scaling exponent did not differentiate between the two groups. These findings suggest that entropy and determinism in pupillary diameter fluctuations can identify early differences in problem-solving success. Further research is needed to determine the exclusive role of perceptual and motor activity in generating insights and investigate these results' generalizability to other tasks and populations.

THE DIAGNOSTIC ACCURACY OF INTRAOPERATIVE SYNOVIAL FLUID CALPROTECTIN IN SUSPECTED LOW-GRADE PERIPROSTHETIC HIP JOINT INFECTIONS

Pre-operative definitive diagnosis of infection in painful total hip arthroplasty (THA) is not always easy to be established, making the intra-operative decision-making process crucial in management of revision hip surgery. Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJIs.From November 2020 to December 2022, 105 patients with painful primary THA were treated with revision THA in 3 orthopaedic departments. Pre-operatively, 23 were considered infected and treated with two-stage revision THA. The remaining 82 were likely infected according to the 2019 EBJIS criteria. The suspicion of low-grade infection was based on clinical (rest and/or night pain), laboratory (CRP, ESR, WBC – normal or slightly elevated) and radiological evaluation (loosening). Hip aspiration under CT imaging was performed in these cases and 34 of them yielded positive culture and were treated with two-stage revision. Aspiration was ineffective in the remaining 48 cases (33 negative, 15 unsuccessful attempts). Intra-operatively, calprotectin was measured with lateral flow immunoassay test in these patients. Cases with calprotectin levels ≥ 50 mg/L were treated with 2-stage revision THA; otherwise, they were considered not-infected and one-stage revision was performed. Synovial fluid and tissue samples were collected for analysis. Implants were sent for sonication fluid cultures.Calprotectin was positive (≥ 50 mg/L) in 27 cases and negative in 21 cases. There was 1 false negative case with positive tissue cultures. Out of the 27 positive cases, 25 had positive tissue cultures and sonication. However, 2 cases with high calprotectin levels (>200 mg/L) were not infected. The false positive result was attributed to severe metallosis. Calprotectin sensitivity was 96.2%, specificity 90.9%, PPV 92.6%, NPV 95.2%, AUC 0.935.The results of this ongoing study indicate that calprotectin seems to be a valuable tool in facilitating the intra-operative decision-making process in cases that low-grade infection is suspected and diagnosis cannot be established pre-operatively.

P-730 Detection of mitochondrial reversal following meiotic spindle transfer: a finding of importance for mitochondrial replacement therapies used for the purpose of avoiding mtDNA disease transmission

Abstract Study question Following transfer of the meiotic spindle from a patient’s oocyte into an enucleated donor oocyte, do relative levels of patient and donor mtDNA remain stable? Summary answer mtDNA transferred along with the patient’s spindle typically remain at a low level. However, disproportionate expansion of the patient’s mtDNA can occur in some cases. What is known already Mitochondrial DNA disorders are caused by mutations in the mitochondrial genome, disrupting ATP production. They have few treatment options and no cure. All mitochondria are derived from the oocyte, therefore mtDNA disorders are maternally inherited. It has been proposed that disease transmission could be avoided if female mtDNA mutation carriers underwent meiotic spindle transfer (MST), removing the chromosomes (on the spindle) from an affected oocyte and transferring them into the healthy cytoplasm of a donor oocyte. However, research using embryonic stem cells has suggested that the small population of mitochondria transferred along with the spindle can sometimes undergo dramatic expansion. Study design, size, duration 25 infertile couples were enrolled in a prospective pilot study evaluating MST as a treatment for infertility. The female participants had a mean age of 37.2, and an average of 6.4 previous unsuccessful IVF cycles (range 3-11) characterised by extremely poor embryo development and without any previous pregnancy. Importantly, none of the patients were carriers of a mtDNA disorder. Oocyte donors with previous successful IVF outcomes were matched with patients according to standard practice. Participants/materials, setting, methods Metaphase-II-spindles from patient oocytes were transferred into enucleated donor oocytes. Reconstructed oocytes underwent ICSI and the resulting embryos were transferred at the blastocyst stage. Mitochondrial genomes were sequenced to identify polymorphisms differing between the patient and oocyte donor. These variations were quantified in the embryos (blastocyst biopsies), during pregnancy (amniocentesis), in newborns (cord blood, cord tissue, urine), at 3-6 months and at one year (saliva, urine, blood), revealing the relative amounts of each mitochondrial type. Main results and the role of chance This MST pilot study resulted in the birth of six children, indicating that the procedure is compatible with the production of viable embryos, capable of producing healthy live births. The patient’s mtDNA was shown to represent <1% of the total in all blastocysts produced, confirming that MST is highly reproducible and that relatively few mitochondria are transferred along with the spindle. For five of the six children, the proportion of the total mtDNA attributable to the patient appeared to be stable, remaining at very low levels in all of the samples from later developmental stages. However, in one child the small quantity of mtDNA transferred along with the spindle increased disproportionately with respect to the mtDNA of the oocyte donor, ultimately representing 30-60% of the total at birth, depending on the tissue tested. The precise timing of the expansion of one type of mtDNA at the expense of the other is not known but occurred sometime between the blastocyst stage and birth. By the time of birth, the levels of donor and patient mtDNA appeared to have stabilised (no further increases were seen at 6 months and one year). All of the children born remain developmentally normal and healthy. Limitations, reasons for caution After using MST, several pregnancies were achieved for patients with a long history of unsuccessful IVF attempts, associated with poor oocyte quality and a failure to produce blastocysts. However, this small pilot study lacked the controls necessary for a definitive evaluation of MST as a tool for infertility treatment. Wider implications of the findings All children born following MST were healthy. However, our results clearly demonstrate that a substantial degree of mtDNA ‘reversal’ is possible. Consequently, mitochondrial replacement therapies used for avoidance of mtDNA disorders might not always be successful, even when initial levels of mutant mtDNA in reconstructed oocytes are very low. Trial registration number ISRCTN11455145

P-792 The effect of subendometrial injection of autologous platelet rich plasma (PRP) guided by hysteroscopy in recurrent implantation failure patients - A pilot study

Abstract Study question Does the subendometrial injection of autologous platelet-rich plasma (PRP) guided by hysteroscopy achieve successful pregnancy outcome in recurrent implantation failure patients? Summary answer In this study we observed that subendometrial injection of autologous PRP is associated with higher implantation rates in recurrent implantation failure patients. What is known already The key success factors in IVF are to have a good endometrium lining and vascularity for successful implantation. These two factors directly affect the pregnancy outcomes of IVF. Although several approaches have been attempted to address these factors including estrogen treatment, aspirin, sildenafil, vitamin E, Granulocyte-Colony Stimulating Factor (G-CSF), there is no efficient method described. Additionally, some cases do not show a response to the medical treatment. In those cases, specifically, in previously failed IVF patients autologous Platelet Rich Plasma (PRP) injection into the sub-endometrial cavity with an ovum pick up needle has been preferred, as confirmed by literature. Study design, size, duration An open label, single center study. Total 130 women were selected for hysteroscopic instillation of PRP, all patients have previous unsuccessful IVF attempts in our clinic or were referred to our clinic. Study participants are of age 23 to 49 years. Study began in July 2020 and was completed in December 2022. Participants/materials, setting, methods 2 ml of autologous PRP was instilled in the junctional zone using a wallace needle through the hysteroscope's operating channel to inject the PRP beneath the superficial endometrium from day 6-14 of menstrual cycle. FET preparation was started from Day 2/3 of next menstrual cycle using 6 mg/daily estradiol hemihydrate (EV Active Tab CORONA Remedies). Main results and the role of chance Women who received hysteroscopic instillation of PRP in the sub-endometrial junction had higher pregnancy rates (82/130 [63.07%] (P-value = <0.05). In the subsequent cycle monitored to day 15, Endometrial thickness (ET) was 7 mm or thicker in 90 of 130 patients [69.23%] (P-value = <0.05) and 6-7 mm in 8 of 130 patients [6.15%]. Endometrial thickness did not improve in 32 of 130 patients [24.61%] and remained below 6 mm. Subendometrial blood flow increased significantly in 92 of 130 patients [70.76%] (P-value = <0.05). The mean increase in ET was 1.5 to 2 mm. The instillation of PRP caused no side effects and was well tolerated by all patients. In 47 patients (36.15%) we did not achieve clinical pregnancy while 1 had a biochemical pregnancy Based on paired ‘t’ test, it is concluded that there is statistically significant improvement in ET, vascularity and successful pregnancy outcome after PRP instillation. Limitations, reasons for caution Little is known about the best dosage and time for the instillation of PRP in endometrium. The importance of standard yet simple techniques and a highly repeatable protocol for clinical use is deciding factor which yet to finalize. It involves invasive procedure so may cause infections and anesthesia related complications. Wider implications of the findings Although PRP has still not gained universal acceptance in previously failed IVF patients for a variety of reasons, emerging evidences suggests that PRP could be an effective option compared to conventional approach especially, in patients with thin endometrium, advanced maternal age and primary ovarian insufficiency. Trial registration number Not applicable

Informatively cross-correlation aspects of unsuccessful attempts at assisted reproductive technologies

The objective: increase of efficiency of assisted reproductive technologies (ART) on the basis of lead through cross-correlation analysis them ineffective attempts. Materials and methods. A basic group was selected with the womanish factors of infertility (100 matrimonial pair with unsuccessful attempts of ART in anamnesis). Thus the following sub-groups were selected in a basic group: pipe peritoneal infertility; endocrine infertility; endometriosis and united factors of infertility. The group comparison was made by 50 women without violations of fertility. For these women, the normal structure of the endometrium was confirmed. The complex conducted research included clinical, endocrinology, and morphological. Results. The presence of feed-backs of moderate force found between the positive effect of and presence in anamnesis of appendectomy (r=- 0,41), tubectomy (r=-0,37), to the syndrome of polycystic ovaries (r=-0,32), myomectomy (r=-0,35) and laparotomy (r=0,32). The Opposite found the positive copulas of a factor of the offensive of pregnancy after in vitro fertilization with a presence in anamnesis of such patients of information about laparoscopy (r=0,38) and separate diagnostic scraping off (r=0,30). Analyzing the results of ART with the conducted treatment, the frequency of coagulation of hearths of the endometrium for patients with the negative result of in vitro fertilization was 28,2%, more than 2 times, exceeding the proper value in the sub-group of patients with the positive result of ART. The estimation of intercommunication of the positive effect of assisted reproductive technologies with a hormonal factor routined the presence of positive connections of moderate force with the concentrations of hormones of follicle-stimulating hormone (r=0,42), prolactin (r=0,39) and to thetriiodo-thyronine (r=0,31). The connection of the offensive of pregnancy with the level of estradiol was reliable, however weak (r=0,28). Also weak was the connection of the positive effect of ART with the level of receptors of the endometrium to progesterone in the stroma of endometrium (r=0,23), however many correlations with all other indexes of receptors of the endometrium to the steroid hormones were lines, and moderate force: with the receptors of endometrium to progesterone in an epithelium - r=0,42, receptors of endometrium to the estradiol in stroma - r=0,32, receptors to the estradiol in the epithelium of endometrium of r=0,40. Conclusion. The principal reasons for unsuccessful attempts of ART are protracted infertility, repeated operative interferences on the organs of the small pelvis, a large number of endometrial operations, the presence of endometriosis, and a high infectious index. Except for it, protracted and unsuccessful treatment of infertility in itself is a negative factor that strengthens present violations. These factors of risk are instrumental in derangement adaptation-homoeostatic backlogs of organisms, synchronization inflammation, strengthening anatomical-and-functional defects of the genesis system, that, in the same queue, reduces the genesial potential of patients and instrumental in the unsuccessful attempts of ART. Conducted a cross-correlation analysis routined the substantial role of dishormonal violations and pathology of endometrium in the unsuccessful attempts of ART. The got results must be taken into account in the development of an algorithm for an increase of the efficiency of ART.

Internet gaming addiction among children and adolescents with non-suicidal self-Injury: A network perspective

BackgroundInternet gaming addiction is a growing global concern and mental health burden. Currently, no study has examined Internet gaming addiction among individuals with non-suicidal self-injury (NSSI). This study aims to examine the epidemiology, correlates, and network structure of Internet gaming addiction among children and adolescents with NSSI in China. MethodsThis was a cross-sectional study conducted in Guangdong Mental Health Center, China, from Dec 2019 to Dec 2021. The 13-item Chinese Internet gaming addiction scale, SAS, SDS, and UCLA loneliness scale were adopted to evaluate patient's internet gaming addiction, anxiety, depression and loneliness. Univariate analyses, multivariate logistic regression, and network analysis were conducted. ResultsA total of 110 children and adolescents with NSSI behaviors participated in the study, and 45 (40.9%) of them reported Internet gaming addiction. Multivariate logistic regression analysis revealed that male participants (OR = 6.047, P = 0.001) and those living on campus (OR = 2.677, P = 0.039) were more likely to suffer from Internet gaming addiction. Network analysis revealed that item1 (‘Always thinking about online games when not playing’), item6 (‘Clearly aware of the dangers of online games but fail to stop’), and item3 (‘Moody / anxious / agitated / angry while not playing’) were core symptoms for the identification of Internet gaming addiction, while item9 (‘loss of interest’), and item13 (‘deceiving’) were the least influential symptoms in the network. ConclusionsInternet gaming addiction was prevalent among children and adolescents with NSSI. ‘Preoccupation’, ‘Unsuccessful attempts to control playing’, and ‘Withdrawal’ were of key importance for identifying Internet gaming addiction. Ongoing clinical care and targeted interventions to address these symptoms (e.g., strengthening self-control) may be important for reducing the risk of Internet gaming addiction in children and adolescents with NSSI.

What is aChallenging Clot? : ADELPHI Consensus Statement from the CLOTS 7.0 Summit.

Predicting achallenging clot when performing mechanical thrombectomy in acute stroke can be difficult. One reason for this difficulty is alack of agreement on how to precisely define these clots. We explored the opinions of stroke thrombectomy and clot research experts regarding challenging clots, defined as difficult to recanalize clots by endovascular approaches, and clot/patient features that may be indicative of such clots. Amodified DELPHI technique was used before and during the CLOTS 7.0 Summit, which included experts in thrombectomy and clot research from different specialties. The first round included open-ended questions and the second and final rounds each consisted of 30closed-ended questions, 29on various clinical and clot features, and 1on number of passes before switching techniques. Consensus was defined as agreement ≥ 50%. Features with consensus and rated ≥ 3out of 4on the certainty scale were included in the definition of achallenging clot. Three DELPHI rounds were performed. Panelists achieved consensus on 16/30 questions, of which 8were rated 3or 4on the certainty scale, namely white-colored clots (mean certainty score3.1), calcified clots under histology(3.7) and imaging(3.7), stiff clots(3.0), sticky/adherent clots(3.1), hard clots(3.1), difficult to pass clots(3.1) and clots that are resistant to pulling(3.0). Most panelists considered switching endovascular treatment (EVT) techniques after 2-3 unsuccessful attempts. This DELPHI consensus identified 8distinct features of achallenging clot. The varying degree of certainty amongst the panelists emphasizes the need for more pragmatic studies to enable accurate apriori identification of such occlusions prior to EVT.

The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children.

Our study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department. We conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models. Proceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization-by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7). Emergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.

CHRONIC OSTEOMYELITIS: BEWARE OF PRE-REFERRAL CULTURES

Materials & MethodsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures.ResultsWe reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year.60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation.Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation.ConclusionsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires early referral to a specialist Orthoplastic unit. Less than half of organisms cultured pre-operatively reflect the causative organisms cultured intra-operatively with 52% of these infections being polymicrobial.After initial treatment, 8% of patients will require a further combination of extended antibiotic therapy and surgery to eradicate infection.

Venous blood point-of-care testing (POCT) for paramedics in urgent and emergency care: protocol for a single-site feasibility study (POCTPara).

The COVID-19 pandemic placed the UK healthcare system under unprecedented pressure, and recovery will require whole-system investment in innovative, flexible and pragmatic solutions. Positioned at the heart of the healthcare system, ambulance services have been tasked with addressing avoidable hospital conveyance and reducing unnecessary emergency department and hospital attendances through the delivery of care closer to home. Having begun to implement models of care intended to increase 'see and treat' opportunities through greater numbers of senior clinical decision makers, emphasis has now been placed upon the use of remote clinical diagnostic tools and near-patient or point-of-care testing (POCT) to aid clinical decision making. In terms of POCT of blood samples obtained from patients in the pre-hospital setting, there is a paucity of evidence beyond its utility for measuring lactate and troponin in acute presentations such as sepsis, trauma and myocardial infarction, although potential exists for the analysis of a much wider panel of analytes beyond these isolated biomarkers. In addition, there is a relative dearth of evidence in respect of the practicalities of using POCT analysers in the pre-hospital setting. This single-site feasibility study aims to understand whether it is practical to use POCT for the analysis of patients' blood samples in the urgent and emergency care pre-hospital setting, through descriptive data of POCT application and through qualitative focus group interviews of advanced practitioners (specialist paramedics) to inform the feasibility and design of a larger study. The primary outcome measure is focus group data measuring the experiences and perceived self-reported impact by specialist paramedics. Secondary outcome measures are number and type of cartridges used, number of successful and unsuccessful attempts in using the POCT analyser, length of time on scene, specialist paramedic recruitment and retention, number of patients who receive POCT, descriptive data of safe conveyance, patient demographics and presentations where POCT is applied and data quality. The study results will inform the design of a main trial if indicated.

Failed Successive Attempts at Medical Abortion of A 26 Weeks Intrauterine Fetal Death and The Discovery of Rudimentary Horn Pregnancy

We report a case of primigravida at 26 weeks of pregnancy with intrauterine fetal death (IUFD) on ultrasound who underwent repeated unsuccessful attempts at medical induction of abortion until exploratory laparotomy with right intact rudimentary horn removal was undertaken with nonviable female fetus . This is an example of unicornuate uterus with rudimentary horn pregnancy (RHP) which has an overall incidence of 1 in 1, 50000 to 1 in 76000 and stresses the understanding of the sonographic appearance of early pregnancy within the rudimentary horn of unicounuate uterine configuration being imperative for appropriate and timely clinical management. In Conclusion: Rudimentary horn pregnancy (RHP) must be kept as strong clinical suspicion if there is no response to repeated failed attempts at the induction of abortion.

MODERN METHODS OF TREATING PATIENTS WITH DISEASES OF THE BILIARY TRACT COMPLICATED BY MECHANICAL JAUNDICE

Summary. Introduction. Treatment of patients with diseases of the biliary tract complicated by jaundice remains an urgent problem in abdominal surgery. The development of mechanical jaundice (MJ) is observed in 15–40 % of patients with gallstone disease complicated by choledocholithiasis. MJ of malignant etiology occurs in 40–67 % of patients.
 Aim. To study the results of the use of minimally invasive surgical interventions in patients with diseases of the biliary tract complicated by mechanical jaundice.
 Materials and methods. The object of the study were 56 patients with biliary tract complicated by MJ who were being treated in the State Institution “Zaycev V.T. Institute of general and emergency surgery of the National academy of medical sciences of Ukraine”. The first group included 34 patients with non-neoplastic diseases of the biliary tract, complicated by MJ, the second group included 22 patients with cholangiocarcinoma.
 Results. In subgroup 1A, 15 (41.1 %) patients underwent antegrade endobiliary interventions for the purpose of biliary decompression, in subgroup 1B 19 (55.9 %) patients had unsuccessful attempts at retrograde biliary decompression. The second stage of surgical treatment consisted of reconstructive and restorative operations or combined interventions from antegrade and retrograde approaches. Using antegrade endobiliary interventions, we managed to reduce the development of complications of biliary decompression, compared to patients who had an unsuccessful attempt at endoscopic treatment from 15 (78.9 %) to 1 (6.67 %), as well as reduce the number of complications after reconstructive and restorative operations from 10 (52.6 %) to 1 (6.67 %) and the fatality rate from 2 (10.5 %) to 1 (6.67 %).
 After successfully performed biliary decompression, 11 (50 %) patients underwent reconstructive and restorative surgical interventions, which were included in the 2A subgroup. The remaining 11 (50 %) patients, who made up the 2B subgroup, underwent similar surgical interventions without prior biliary decompression. In patients of the 2A subgroup, the performance of antegrade endobiliary intervention allowed to reduce the number of postoperative complications by 9.1 % and mortality by 9.1 % in comparison with the patients of the 2B subgroup.
 Conclusions. Thus, antegrade endobiliary interventions are an alternative method of treatment of diseases of the biliary tract complicated by MJ. Antegrade endobiliary interventions reduced the number of complications after reconstructive operations from 27.3 % to 18.2 %, the mortality rate from 18.2 % to 9.1 %. Antegrade endobiliary interventions for benign diseases of the biliary tract and improved minimally invasive methods of treatment of “endoscopic difficult” forms of choledocholithiasis reduced the number of complications of biliary decompression compared to patients in whom endoscopic decompression was ineffective from 78.9 % to 6.67 %, as well as reduced the level of postoperative complications after reconstructive treatment from 52.6 % to 6.67 % and mortality from 10.5 % to 6.67 %.

The struggle to get a PhD: the collaborative autoethnographic accounts of two ‘journeymen’

ABSTRACT The PhD is the ultimate indicator of academic excellence. The journey is familiar to most University academics and is a journey the majority have successfully completed. Yet, just as it is said history is written by the victors, so most accounts written about doing a PhD, are written by those who have succeeded, not by ‘journeymen’, such as the narrators of this account. There is a need for narrative accounts that both acknowledge the difficulty of the journey and also show how some candidates have battled, to achieve their PhDs. Such stories have the power to inspire those who may be struggling on their own PhD journeys. Academics can share these accounts with their own PhD students and thus hopefully improve completion rates and change practice. The authors of this narrative have adopted a collaborative autoethnographic approach to their PhD journeys. The parallel narratives are in four interdependent sections. The narratives start with both authors’ unsuccessful attempts to get a PhD and end with how they, after completing their PhDs, started collaborating on research. From the authors’ first attempts, their respective PhD journeys took 20 to 30 years to come to completion. The accounts show that personality features such as resilience, motivation and grit, as well as the appearance of supervisors and partners i.e. allies of help at the right time can make the difference between success and failure. Both, now in their sixties, they are looking forward to many more exciting years of joint research.

Characterizing Physical Interactions between Male and Female Mosquitoes (Aedes aegypti) in Relation to Female Receptivity and Insemination Outcomes Using a Hydrophobic Fluorescent Dye.

Aedes aegypti, the yellow fever mosquito, presents a major threat to human health across the globe as a vector of disease-causing pathogens. Females of this species generally mate only once. From this single mating event, the female stores sufficient sperm to fertilize the multiple clutches of eggs produced during her lifetime. Mating causes dramatic changes in the female's behavior and physiology, including a lifetime suppression of her mating receptivity. Female rejection behaviors include male avoidance, abdominal twisting, wing-flicking, kicking, and not opening vaginal plates or extruding the ovipositor. Many of these events occur on a scale that is too miniscule or fast to see by eye, so high-resolution videography has been used to observe these behaviors instead. However, videography can be labor intensive, require specialized equipment, and often requires restrained animals. We used an efficient, low-cost method to record physical contact between males and females during attempted and successful mating, determined by recording spermathecal filling after dissection. A hydrophobic oil-based fluorescent dye can be applied to the abdominal tip of one animal and can be subsequently transferred to the genitalia of animals of the opposite sex when genital contact occurs. Our data indicate that male mosquitoes make high levels of contact with both receptive and unreceptive females and that males attempt to mate with more females than they successfully inseminate. Female mosquitoes with disrupted remating suppression mate with and produce offspring from multiple males, transferring dye to each. These data suggest that physical copulatory interactions occur independently of the female's receptivity to mate and that many of these interactions represent unsuccessful mating attempts that do not result in insemination.

Tracheostomy managment and tube weaning within a framework of dysphagia intervention

Persistent dysphagia is amajor predictor of prolonged ventilation weaning and unsuccessful attempts at decannulation. Due to the high incidence of dysphagia in tracheotomized patients, tracheal cannula management and dysphagia treatment must be coordinated. Acentral element of tracheal cannula management in dysphagia treatment is the establishment of physiological airflow. This enables voluntary clearing functions, such as coughing and throat clearing and significantly reduces aspiration. Adistinction is made between spontaneous and staged decannulation pathways with expansion of cuff unblocking times and occlusion training. Other therapeutic measures include secretion and saliva management, cough function training with improvement of strength and sensitivity, pharyngeal electrical stimulation, adaptation of tracheal tubes to optimize respiratory and swallowing function, control and treatment of airway stenosis, and standardization of processes for quality assurance.

Feasibility of Direct Intercostal and Lumbar Artery Revascularization to Prevent Spinal Cord Ischemia Associated with Endovascular Thoracoabdominal Aortic Repair

Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) is still a devastating complication following endovascular thoracoabdominal aortic repairs. Current preventive strategies such as staged repair, temporary sac perfusion, hemodynamic management, and spinal drainage, focus on augmentation of spinal perfusion through collateral networks. Novel strategies to preserve key intercostal/lumbar arteries have been described including endovascular incorporation of fenestrations/branches and extra-anatomic bypass. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVAR). A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Among 318 patients who underwent FBEVAR during the study period, 12 patients were included in the study. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in eight patients and supraceliac coverage >10 cm was required in four. Nine patients received endovascular incorporation (Fig 1), including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (1/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene and saphenous vein (Fig 2). Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic cerebral spinal fluid drain was placed in nine patients. One patient had unsuccessful drain placement attempts. Two patients who had selective angiography identifying the great anterior radiculomedullary artery, did not undergo drain placement. Total number of target vessels for FBEVAR was 4.2 with a fluoroscopy time 66 ± 31 minutes, and contrast usage of 109 ± 51 mL. There were no in-hospital mortalities. One patient died of intracranial hemorrhage after sustaining a fall from a ladder 32 days after discharge. Tarlov grade II SCI were seen in two patients (one endovascular, one extra-anatomic bypass), which resolved before discharge. At median follow-up of 13 months (range, 13 days to 37 months), three patients had thrombosed intercostal/lumbar branches (one extra-anatomic bypass, two endovascular branches) with no new SCI symptoms. In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing intercostal and lumbar arteries and optimization of revascularization strategies.Fig 2Extra-anatomic, profunda femoris to L1 radicular artery bypass using a composite polytetrafluoroethylene-saphenous vein conduit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P126 RADIOTHERAPY AND THE HEART: IN SEARCH OF ARIANNA‘S THREAD

Abstract Background Radiation therapy (RT) is widely diffused in the treatment of cancer; but it could lead to various negative consequences on the cardiovascular system, even several years after treatment end. They include also valvular heart diseases, arrythmias, coronary artery diseases, heart failure, pericardial diseases, systemic and pulmonary artery diseases. We report an interesting case about RT cardiotoxicity different manifestation occurred in the same patient. Case report: 79 years old patient, history of previous testicular seminoma when he was 54 years old (1997), treated through surgery and RT with betatron (total body cobalt). In 2008 aortic valve replacement with mechanical prothesis; in 2017 first hospitalization for heart failure during atrial fibrillation. In subsequent years, recurring episodes of atrial fibrillation (2 unsuccessful attempts at electrical cardioversion), and heart failure exacerbations with mild reduced ejection fraction, treated through medical therapy improvement. At follow–up echocardiogram (03/19) finding of ejection fraction mild reduced (45%), right sections increased in volumes, tricuspid valve moderate regurgitation. In January 2022, at the last cardiac check–up, he reported worsening dyspnoeic symptoms, and occasional episodes of retrosternal pain in last months. It was performed Coro–TC observing a 60% stenosis at distal tract of right coronary; in addition, patient underwent a transoesophageal echocardiogram which documented further reduction in left ventricle ejection fraction, and worsening tricuspid regurgitation to a severe degree, with anulus dilatation and partial failure of leaflets coaptation, which appeared fibro–elastic; inferior vena cava ectasia, Paps 40–45 mmHg circa. Holter–ECG showed atrial fibrillation for all 24 hours, plus 2000 BEV. The case was discussed in Heart Team, and an indication was placed for Triclip intervention. Discussion Nowadays great achievements of anticancer therapies improved patients’ survival, consequently increased the number of anticancer therapies complications; therefore, an accurate cardiac screening for early diagnosis and effective treatment of CV adverse effects is necessary. Several distinct factors contribute to determine the onset cardiotoxicity insurgence, such as the type of cancer, its anatomical localization; radiation techniques applied, total and fractional radiation doses; patient’s age and his comorbidity and risk factors for cardiovascular diseases.

P139 RETURN TO THE ORIGINS: WHEN THE THROMBOLYSIS SAVES THE ANGIOPLASTY

Abstract A 62 year old man arrived in PS for typical chest pain radiating to the jugular and associated with sweating for about three hours. History of arterial hypertension and untreated dyslipidemia, family history of CVD. ECG: sinus rithm at rate of 50 bpm with first degree AVB. Inferior ST elevation in inferior leads and ST depression in V2–V3. Echocardiogram: depressed systolic function (EF 48%) in relation to hypo–akinesia of the mid–basal segments of the inferior–posterior–lateral wall. Diagnosed with STEMI inferior–posterior, was sent to the cath lab to undergo to emergency coronary angiography, with findings of non–significant atheromas on IVA and Cx. Multiple unsuccessful attempts to search for the right coronary artery and failure to visualize the aortography in two complementary projections. During the procedure hemodynamic and electrical instability, worsening angor, marked hypotension and extreme bradycardia up to complete AVB with asystole phases. Inotropics and atropine were started, which proved ineffective, and it was therefore decided to proceed with the implantation of a temporary pacemaker. During the placement, the patient presented cardiac arrest from VF (likely an irritating effect from the passage of the lead through the tricuspid) treated with effective DC–shock. Given the technical difficulties in proceeding with mechanical revascularization and given the patient‘s instability, the decision was made to postpone PCI by attempting systemic thrombolysis. Early efficacy of thrombolysis with disappearance of precordial pain, improvement of echo motion and reduction > 50% of the ST–segment elevation to the rare spontaneous QRS displayed at the transient shutdown of the temporary PM. Subsequent emergence of AF at rate of 116 bpm. Approximately 12 hours after thrombolysis: complete ST resolution in absence of Q waves. AngioTC of the coronaries was performed which showed regularl origin of Cdx from the right coronary sinus but higher up and lateralized to the left, with severe lesion in the first segment. So the patient underwent falicitated PCI with detection of ostio–proximal Cdx thrombotic lesion effectively treated with PTCA and drug–eluting stent placement with good final angiographic result. Control echo: preserved global left ventricular motion (FE 55%), hypokinesia of the basal segment of the inferior wall. The remaining stay decurred without any complications and the patient was discharged with indications for a close follow–up.

C31 NEXT GENERATION MYOCARDITIS

Abstract A 75–year–old overweight man, affected by hypertension, diabetes mellitus and atrial fibrillation since 2020. After 3 unsuccessful attempts of electrical cardioversion it was opted for a strategy of rate control with beta blocker and anticoagulant therapy with Rivaroxaban 20 mg. Following episodes of rectal bleeding; adenocarcinoma of the colon was diagnosed. The patient underwent hemicolectomy and started therapy with Pembrolizumab. The anticoagulant was replaced with Edoxaban 60 mg. In August 2022, he was admitted to the emergency department for severe signs and symptoms of heart failure. On ECG, atrial fibrillation with a heart rate of 90 bpm and non–specific changes in ventricular repolarization. The echocardiogram showed a severe reduction of the ejection fraction (FE 30%), which was not present at previous controls. On blood tests, troponins were negative and BNP increased. The patient underwent coronarography which was negative for significant lesions, and heart failure therapy was prescribed. Three months later the patient came to our cardio–oncology outpatient clinic; we repeated the echocardiogram which showed a recovery of the ejection fraction to 45% and planned a cardiac MRI. Cardiac MRI (CMR) showed global left ventricular hypokinesia (FE 42%) and late subepicardial gadoline enhancement in the basal segment of the inferior wall and transmural in the basal segment of the lateral wall without signs of oedema. Report described as compatible with myocarditis. The case was discussed collegially with radiologists and oncologists, and it was decided to discontinue immunotherapy (ICI). Myocarditis is the most common cardiovascular adverse events of ICI therapy, although it has a very low incidence. Generally, myocarditis related to ICI therapy has a high mortality rate and requires discontinuation of ICI. In addition, CMR may have a lower sensitivity in this setting. There is also a possibility of developing left ventricular dysfunction without associated myocarditis in the absence of increase in cardiac troponin and active myocardial inflammation at CMR. Although our case has been defined as myocarditis, it presents some unclear aspects due in part to the early non–diagnosis as a complication of ICI therapy. Although cancer patients taking ICI has expanded considerably in recent years, the evidence on cardiovascular complications is scarce and unknown to the clinical cardiologist.