Aim: To evaluate risk factors associated with nocturia in patients with obstructive sleep apnea syndrome (OSAS). Materials and Methods: Patients diagnosed with OSAS by polysomnography (PSG) and over eighteen years old evaluated retrospectively between January and December 2019. The number of nocturia episodes was assessed in the 3-day bladder diary. We analyzed age, gender, body mass index (BMI), apnea-hypopnea index (AHI) scores and severity, hypertension, diabetes mellitus, smoking, heart diseases in all patients. Results: A total of 124 patients with the mean age of 49.9±11.6 years (range 25–81 years) was included in the study. Ninety-two (75.8%) patients had nocturia. The mean nocturia episode of patients with nocturia was 2.41.3. To determine the factors that affect the risk of nocturia, logistic regression analysis was performed. The results revealed that patient age and BMI were found as the most effective risk factors determining nocturia (p<0.05). The odds of patient age were 1.06 (95% CI 1.01-1.11, p=0.010) times higher for patients with nocturia. Every 1 unit increase in BMI increased the risk of nocturia by 1.12. 48 patients with nocturia underwent continuous positive airway pressure (CPAP) therapy or surgical treatment. The mean nocturia epi¬sodes of these patients were 2.3±1.4 before treatment and were 1.7±2.2 after treatment. There was a significant decrease in terms of nocturia episodes (p=0.032). Although there was a significant increase in the total daily urine volume after treatment, there was a statistically decrease in total night-time urine volume at night (p=0.016 and p=0.024, respectively). Conclusion Age and BMI were risk factors associated with nocturia in patients with OSAS.
Asthma is a disease characterized by reversible bronchoconstriction, but some subjects develop fixed airflow obstruction (FAO). Subjects with FAO present more asthma symptoms and may have increased sedentary behavior; however, the effect of FAO on aerobic fitness and physical activity levels (PAL) remains poorly understood. Aim: To compare adolescents with asthma and FAO and adolescents with asthma without FAO in terms of aerobic fitness, PAL, muscle strength, and health-related quality of life (HRQoL). Methods: This cross-sectional study included adolescents with asthma, both sexes, and aged 12 to 18 years. They were divided into 2 groups: FAO and non-FAO groups. The adolescents were diagnosed with asthma in accordance with the Global Initiative for Asthma guidelines and underwent optimal pharmacological treatment for at least 12 months. FAO was diagnosed when FEV1/FVC ratio was below the lower limit of normal range after optimal treatment. Aerobic fitness, PAL, peripheral and respiratory muscle strength, and HRQoL were evaluated. Results: No significant differences were observed between FAO and non-FAO groups regarding the peak oxygen uptake (34.6±8.5 vs. 36.0±8.4 mLO2/min/kg), sedentary time (578±126 vs. 563±90 min/day), upper limb muscle strength (29.1±5.9 vs. 28.1±5.7 kgf), lower limb muscle strength (42.8±8.6 vs. 47.6±9.6 kgf), or HRQoL (5.1±1.3 vs. 4.7±1.4 score) (p>0.05). However, the FAO group exhibited a higher maximal expiratory pressure than did the non-FAO group (111.5±15.5 vs. 101.5±15.0 cmH2O, respectively). Conclusion: Our results suggest that FAO does not impair aerobic fitness, PAL, peripheral muscle strength, or HRQoL in adolescents with asthma. Furthermore, adolescents with asthma were physically deconditioned.
Introduction: The Lung Clearance Index (LCI) derived from the multiple-breath washout test (MBW), is both feasible and sensitive to early lung disease detection in young children with cystic fibrosis and asthma. The utility of LCI has not been studied in children with sickle cell disease (SCD). We hypothesized that children with SCD, with or without asthma or airway hyper reactivity (AHR), would have an elevated LCI compared to healthy controls. Methods: Children with SCD from a single center between the ages of 6-18 years were studied at baseline health and completed MBW, spirometry, plethysmography and blood draws for serum markers. Results were compared to healthy controls of similar race, age and gender. Results: Control subjects (n=35) had a significantly higher daytime oxygen saturation level, weight and body mass index (BMI) but not height compared to subjects with SCD (n=34). Total Lung Capacity(TLC) z-scores were significantly higher in the healthy controls compared to those with SCD (0.87 (1.13), 0.02 (1.27), p=0.005) while differences in Forced Expiratory Volume in 1 second (FEV1) z-scores approached significance (0.26 (0.97), -0.22 (1.09), p=0.055). There was no significant difference in LCI among the comparison groups (7.29 (0.72), 7.40 (0.69), p=0.514). Conclusion: LCI did not differentiate SCD from healthy controls in children between the ages of 6 and 18 years at baseline health. TLC may be an important pulmonary function measure to follow longitudinally in the pediatric SCD population.
Since 2007, African swine fever virus (ASFV) has spread to countries in Europe, Asia and Oceania, and has caused devastating impacts on pigs and the pork industry. Transmission can be direct or indirect, and epidemiologic scenarios have been described in which spread occurs between free-living and domestic pigs. The purpose of this scoping review was to identify primary research in which authors made statements to support ASFV transmission between free-living and domestic pigs and assess the circumstances in which transmission events occurred. A search was conducted in five bibliographic databases and the grey literature. Two reviewers (from a team of ten) independently screened each record and charted data (demographics of the pig populations, their husbandry [domestic pigs] and habitat [free-living pigs], the spatial and temporal distribution of ASF, the occurrence or burden of ASF in the populations, and whether ticks were present in the geographic range of the pig populations). Data synthesis included statistics and a narrative summary. From 1,349 records screened, data were charted from 46 individual studies published from 1985 to 2020. Outbreak investigations revealed that whilst poor biosecurity of domestic pig operations was often reported, direct contact resulting in transmission between free-living and domestic pigs was rarely reported. Studies in which quantitative associations were made generally found that spread within populations was more important than spread between populations, although this was not always the case, particularly when domestic pigs were free-ranging. We conclude that there is limited evidence that transmission of ASFV between free-living and domestic pigs is an important feature of ASF epidemiology, especially in the current ASF epidemic in Europe and the Russian Federation. If ASFV elimination cannot be achieved in free-living pigs, compartmentalisation of free-living and domestic pig populations via biosecurity strategies could be used to support trade of domestic pigs.
Atrial fibrillation (AF) is the most common cardiac arrhythmia and often occurs with heart failure (HF) . AF prevalence increases with increasing severity of HF: for instance its prevalence ranges from 5 percent in patients with New York Heart Association (NYHA) functional class I HF to 40 percent in patients with NYHA class IV HF . Its presence with HF plays a significant prognostic role and increases morbidity and mortality. Heart Failure with reduced ejection fraction (HFrEF) is associated with cardiac arrhythmias . HFrEF is also one of the indications for Cardiac resynchronization therapy (CRT) placement . Therefore, many patients undergoing CRT implantation will concomitantly have HF and AF. As the benefit from CRT in HF patients has been established, the data on patients with both HF and AF is limited, because patients with atrial arrhythmias were excluded from most of the major CRT trials, such as CARE-HF and COMPANION . However, a number of observational studies and small randomized clinical trials suggest a benefit from CRT in AF and HF patients such as a CRT-mediated ejection fraction (EF) increase [6, 7]. Other studies showed a high non-response rate in patients with AF as compared to those in sinus rhythm (SR) . Thus, it is important to determine whether CRT has a beneficial role in these patients to decide on adding an atrial lead at the time of CRT implantation especially in patients with longstanding-persistent AF.In their published study, Ziegelhoeffer et al. investigated the outcomes of CRT placement with an atrial lead in patients with HF and AF. This was done by conducting a retrospective analysis of all patients with AF who received CRT for HF at the Kerckhoff Heart Center since June 2004 and were observed until July 2018- completing a 5-year follow-up. The authors identified 328 patients and divided them into 3 subgroups: paroxysmal (px) AF, persistent (ps) AF, and longstanding-persistent (lp) AF, with all patients receiving the same standard operative management. During the observation period, the authors analyzed the rhythm course of the patients, cardiac parameters (NYHA class, MR, LVEF, left atrial diameter) and performed a subgroup analysis for patients who received an atrial lead. The study showed that all groups had a high rate of sinus rate (SR) conversion and rhythm maintenance at 1 and 5 years. Specifically, the patients who received an atrial lead among the lp AF group were shown to have a stable EF, less pronounced left ventricular end-systolic diameter (LVESD) and left ventricular end diastolic diameter (LVEDD) and lower mitral regurgitation (MR) rates at one year follow-up as compared to the group without atrial lead placement. Moreover, the results of the lp group were similar to the ps-AF group, although the latter had a lower number of participants (n=4) without initial implantation of the atrial lead. The authors attributed the improvement in cardiac function and SR conversion to CRT and the implantation of an additional atrial lead.Although some studies showed that CRT therapy reduced secondary MR in HF [9, 10], this study additionally suggests that CRT with an atrial lead was associated with improved myocardial function and improvement of interventricular conduction delay triggering cardiac remodeling in patients with HF and AF. Although the results showed better cardiac function in the subgroup analysis of the patients with an additional atrial lead, these results were reported as percentages with no level of significance specified, hence statistical significance of the difference in the described parameters (such as LVESD, LVEDD) could not be determined. Further investigation via prospective studies is needed with larger sample size in the future to further support the results of the study especially that it was done in a single center and had a relatively small sample size.References:1. Chung MK, Refaat M, Shen WK, et al. Atrial Fibrillation: JACC Council Perspectives. J Am Coll Cardiol. Apr 2020; 75 (14): 1689-1713.2. Maisel, W.H. and L.W. Stevenson, Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol, 2003. 91 (6a): p. 2d-8d.3. AlJaroudi WA, Refaat MM, Habib RH, et al. Effect of Angiotensin Converting Enzyme Inhibitors and Receptor Blockers on Appropriate Implantable Cardiac Defibrillator Shock: Insights from the GRADE Multicenter Registry. Am J Cardiol Apr 2015; 115 (7): 115(7):924-31.4. Yancy, C.W., et al., 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 2013. 62 (16): p. e147-239.5. Cleland, J.G., et al., The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med, 2005.352 (15): p. 1539-49.6. Leclercq, C., et al., Comparative effects of permanent biventricular and right-univentricular pacing in heart failure patients with chronic atrial fibrillation. Eur Heart J, 2002. 23 (22): p. 1780-7.7. Upadhyay, G.A., et al., Cardiac resynchronization in patients with atrial fibrillation: a meta-analysis of prospective cohort studies. J Am Coll Cardiol, 2008. 52 (15): p. 1239-46.8. Wilton, S.B., et al., Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: a systematic review and meta-analysis. Heart Rhythm, 2011. 8 (7): p. 1088-94.9. van Bommel, R.J., et al., Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk. Circulation, 2011.124 (8): p. 912-9.10. Breithardt, O.A., et al., Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol, 2003. 41 (5): p. 765-70.
Particle selectivity plays an important role in clarifying sediment transport processes in vegetative filter strips (VFS). 10-m long grass strips at slopes of 5○ and 15○were subjected to a series of silt-laden inflows experiments with different particle sizes to investigate the sediment transport and its response to overland flow hydraulics. The inflow sediments came from local soil, river-bed sand, and mixed, with median particle size d50 of 39.9, 207.9, and 77.4 μm, respectively. Three independent repeated experiments were carried for each treatment. The results show that when the sediment trapping lasted for a certain length of time, the re-entrainment of some small-sized particles was greater than the deposition; that is, negative deposition occurred, which was not erosion of the original soil. Negative deposition of particles is mainly determined by the particle diameter. The coarser the inflow sediment particles and/or the steeper the slope, the coarser the particles can be negatively deposited. Deposited sediment causes the VFS bed surface to become smooth and hydraulic resistance decrease exponentially. Stream power P is more suitable than shear stress τ of overland flow to be used to describe the process of sediment particle transport in VFS. The relationship between P and d50 of outflow sediment is very consistent with the form of power function with a constant term. These results are helpful to understand the physical process of sediment transport on vegetation hillslopes.
ABSTRACT: Objective To investigate the Aneurysmal of the left sinus of Valsalva, and to improve the understanding of the disease and the level of diagnosis and treatment. Methods This article mainly reports a case of huge Aneurysmal of the left sinus of Valsalva patients treated with surgical treatment. Results After surgery, the prognosis of the case was good. Conclusion Aneurysmal of the left sinus of Valsalva has low incidence，which is rare in clinical with no clinical specific symptoms leading to difficulty in early detection. The appropriate surgical method should be considered to the patient condition, to prevent the tumor rupture and the death of patients.
Process analytical technology (PAT) has been defined by the Food and Drug Administration (FDA) as a system for designing, analyzing, and controlling manufacturing through timely measurements to ensure final product quality. Based on quality-by-design (QbD) principles, real-time or near-real-time data monitoring is essential for timely control of critical quality attributes (CQAs) to keep the process in a state of control. To facilitate next-generation continuous bioprocessing, deployment of PAT tools for real-time monitoring is integral for process understanding and control. Real-time monitoring and control of CQAs is essential to keep the process within the design space and align with the guiding principles of QbD. The contents of this manuscript are pertinent to the online/at-line monitoring of upstream titer and downstream product quality with timely process control. We demonstrated that a UPLC system interfaced with a process sample manager (UPLC-PSM) can be utilized to measure titer and CQAs directly from bioreactors and downstream unit operations, respectively. We established online titer measurements from fed-batch and perfusion-based alternating tangential flow (ATF) bioreactors as well as product quality assessments of downstream operations for real-time peak collection. This integrated, fully automated system for online data monitoring with feedback control is designed to achieve desired product quality.
Regular treatment of DKA patients includes rapid and large amount of fluids supply, which is not feasible in DKA patients associated with Uremia because of being urineless and prone to heart failure of these patinets. Our results indicated that continuous renal replacement therapy (CRRT) is a better alternative.
Acetylene, an important petrochemical feedstock, is the starting chemical to produce many polymer products. Separating C2H2 from its by-product mixtures is still an energy-consuming process and remains challenging. Here, we present a metal-organic framework[Zn2(bpy)(btec)], with a desirable pore geometry and highly stable framework, which demonstrated a high separation performance of C2H2 from simulated mixtures. With the desirable pore dimension and hydrogen bonding sites, Zn2(bpy)(btec) shows by far the both highest C2H2/CO2 and C2H2/CO2 uptake ratios, very high adsorption selectivities and moderately C2H2 uptake of 93.5 cm3•cm−3 under 298 K and 1 atm. Not only straightforwardly produced high purity of C2H4, but also recovered high purity of C2H2 (>98%) in the regeneration process (>92% recovery). More notably, Zn2(bpy)(btec) can be straightforwardly synthesized at a large scale under environmentally friendly conditions, and its good water/chemical stability, thermostability, and cyclic stability highlight the promise of this molecular sieving material for industrial C2H2 separation.
The application of nanostructured lipid carrier (NLC) in UV filters encapsulation was found to enhance its safe use. In this work, kenaf seed oil-NLC (KSO-NLC) co-loaded with UV filters encapsulated was used as an active ingredient in α-tocopherol cream to develop a photoprotective prototype. It was then subjected to further analysis to determine the physical properties storage stability and cytotoxicity. The ratio of KSO-NLC to α-tocopherol cream was optimised based on the SPF value using UV transmittance analyser. The physical properties of the samples were analysed and the amount of α-tocopherol was quantified by ultra-high performance liquid chromatography (UHPLC). The optimised sample was then evaluated for in vitro antioxidant activities using DPPH and ABTS assays. Meanwhile, in vitro cytotoxicity was studied on normal human dermal fibroblast (NHDF) cell line using MTT and CCK-8 assays. The sample produced by KSO-NLC to α-tocopherol cream in ratio 1:2 (N3) showed SPF value > 50. Besides, the samples showed microbial stability and sustainable α-tocopherol content upon 12 weeks of storage. The cytotoxicity evaluation of N3 and α-tocopherol cream (N5) showed > 100 % cell proliferation indicated there is no side effect on the cell growth, yet it triggered the cell proliferation with the presence of bioactive compounds. Overall, the results herein gathered are very promising towards the development of new green cosmetic formulations with the utilisation of KSO-NLC and palm-based α-tocopherol cream.
Aim: Asian patients are known to be more prone to bleeding complications than patients of other ethnicities. Therefore, there are possibilities of other risk factors that should be given special consideration for dosage adjustment in this specific ethnic group. This study aimed to investigate the risk factors for bleeding complications in Asian patients under appropriate edoxaban dosage regimens. Methods: Data on patients taking proper dosages, based on the Lixiana package insert, were analyzed. Univariate and multivariable analyses were conducted to evaluate associations between risk factors and bleeding outcomes. Subgroup analysis was performed on high-risk patients for bleeding complications whose edoxaban dose was reduced according to the package insert. Results: A total of 346 patients were included. Among them, 32 patients experienced bleeding complications. Patients with either weights of less than or equal to 60 kg and with cancer showed around 3.3- and 3.4-fold increased risk of bleeding complications compared to heavier patients ( > 60 kg) and those without cancer, respectively. In subgroup analysis with high-risk patients who took low-dose edoxaban (15 mg and 30 mg), weights of less than or equal to 60 kg remained a significant factor for bleeding outcomes. Conclusion: This study showed that weights of less than or equal to 60 kg and the presence of cancers could affect bleeding complications which occurred despite proper edoxaban treatment in Asian patients. Therefore, more strict dosage guideline could be considered in populations with high proportions of Asian ethnicities.
Idiopathic ventricular arrhythmias (VA) is defined as premature ventricular complexes (PVCs) or ventricular tachycardias (VT) that occur in the absence of structural heart disease. Endocardial radiofrequency (RF) ablation is often curative for idiopathic VA. The success of the procedure depends on the ability to localize the abnormal foci accurately. These arrhythmias typical originate from the right ventricular outflow tract (RVOT), specifically from the superior septal aspect, but can also originate from the left ventricular outflow tract (LVOT) and the coronary cusps.1 The QRS electrocardiogram (ECG) characteristics have been helpful in patients with VAs, patient with accessory pathways and patients who have pacemakers.2 VAs originating from the RVOT have typical ECG findings with a left bundle branch block (LBBB) morphology and an inferior axis.3In the current issue of the Journal of Cardiovascular Electrophysiology, Hisazaki et al. describe five patients with idiopathic VA suggestive of RVOT origin and who required ablation in the left-sided outflow tract (OT) in addition to the initial ablation in the RVOT for cure to be achieved. Patients exhibited monomorphic, LBBB QRS pattern with an inferior axis on ECG, consistent with the morphology of VAs originating from the RVOT. Interestingly, all patients had a common distinct ECG pattern: qs or rs (r ≤ 5 mm) pattern in lead I, Q wave ratio[aVL/aVR]>1, and dominant S-waves in leads V1 and V2. Mapping of the right ventricle demonstrated early local activation time during the VA in the posterior portion of the RVOT, matching the QRS morphology obtained during pacemapping. Despite RF energy delivery to the RV, the VAs recurred shortly after ablation in four patients and had no effect at all in one patient. A change in the QRS morphology was noted on the ECG that had never been observed before the procedure. The new patterns were suggestive of left-sided OT origin: the second VAs exhibited an increase in the Q wave ratio [aVL/aVR] and R wave amplitude in lead V1, decrease in the S wave amplitude in lead V1, and a counterclockwise rotation of the precordial R-wave transition. Early activation of the second VA could not be found in the RVOT, and the earliest activation time after mapping the LV was found to be relatively late. Real-time intracardiac echocardiography and 3D mapping systems were used to determine the location immediately contralateral to the initial ablation site in the RVOT. Energy was then delivered to that site which successfully eliminated the second VA. The authors postulated that the second VAs shared the same origins as the first VAs, and the change in QRS morphology is likely attributed to a change in the exit point or in the pathway from the origin to the exit point. The authors further explained that the VAs originated from an intramural area of the superior basal LV surrounded by the RVOT, LVOT and the transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV).A limitation of this study is that GCV-AIV ablation was not attempted; however, the authors’ approach is safer and was successful in eliminating VA. Another limitation is that left-sided OT mapping was not initially performed. Nevertheless, given the ECG characteristics, local activation time, and mapping, it was appropriate to attempt a RVOT site ablation.Overall, the authors should be commended for their effort to describe in detail patients with idiopathic VAs that required ablation in the left-sided OT following ablation in the RVOT. Although change in QRS morphology after ablation has been previously described, the authors were the first to describe the ECG patterns of these patients.4–7 The results of this study have important clinical implications. First, the authors have demonstrated the importance of anatomical approach from the left-sided OT for cure to be achieved. Second, insight into the location of the origin of the VA may be helpful to physicians managing patients with VAs from the RVOT. Finally, continuous monitoring of the ECG during ablation for a change in QRS morphology should be considered to identify patients who will require further ablation. We have summarized in Table 1 important ECG characteristics indicative VA of specific origins, based on the findings of this study and previous studies in the literature.3,8–15
Li‐rich layered Mn‐based oxide (LMO) cathode materials, with the formation of Li2MnO3, have attracted much attention due to their potential in various applications with high energy density. However, these cathode materials for Lithium‐ion batteries still suffer from drawbacks such as poor rate capability and voltage decay, which makes further investigation vital and rational. Here, the doping strategy is employed to investigate the effect of TM = Ti, Cu, and Zn on Li2Mn0.5TM0.5O3 cathode materials for improving electrochemical performances of Li2MnO3. Electrochemical properties such as voltage, electrical conductivity, safety, structural stability, and kinetics and mechanism of Li‐ion diffusion are evaluated and compared. All doped cathodes decrease the voltage reduction and improve the electrical conductivity coefficient in comparison with LMO. Doping Cu notably increases the electrical conductivity of LMO by 77%. Ti doping exhibits the potential to increase the maximum voltage of LMO and structural stability. Doping Zn and Cu elements can delay the oxygen loss significantly, which leads to a higher life cycle and safety. In addition, doping Zn is expected to have a higher Li‐ion diffusion coefficient due to its low energy barrier and partial charge of oxygen atoms in its cathode structure. This first‐principle study of doping effects of TM = Ti, Cu, and Zn with α = 0.5 in Li2Mn0.5TMαO3 may be a useful leading study for further investigation into the synthesis of lithium‐rich materials with enhanced electrochemical performance.
Pulmonary Vein Isolation (PVI) remains the cornerstone for catheter ablation for atrial fibrillation (AF). Achieving durable PVI safely with Radiofrequency Catheter Ablation (RFCA) has proven challenging until recently, even with the use of Contact Force (CF) sensing catheters and electroanatomical mapping1. Ablation success rates improve markedly, including in persistent AF, when permanent PVI can be achieved1,2, which only underscores the critical role of the Pulmonary Veins (PV) in AF arrhythmogenesis.Historically, the only way to assess PVI durability has been through invasive electrophysiology study, with all its associated risk, inconvenience, and costs. This price appears particularly galling to pay if the PVs are found to be isolated at repeat study, as is now becoming increasingly common3. Multiple randomised studies have failed to show additional benefit from ablating extra-PV structures4,5, and the best outcomes following repeat AF ablation procedures are restricted to those where PV reconnection is identified and treated6. As such, there remains a pressing need for a non-invasive tool that can accurately assess PVI durability, and ideally, the size and location of residual gaps. As Magnetic Resonance Imaging (MRI) has increasingly been shown capable of delineating atrial scar, there is much anticipation that it may serve this important purpose7.RFCA and Cryoballoon ablation (CBA) are by far the most common modalities used for PVI, and there is remarkable equivalence in their clinical results8. However, the handling of the two technologies in the catheter laboratory is very different, and ultrahigh density mapping has shown important differences in the number and location of chronic gaps between the two9. The use of MRI in characterizing these differences has not been well described so far.In this issue of the journal, Kurose and colleagues present a small but elegant study10, in which 30 consecutive patients who underwent PVI (18 with CBA, 12 with RFCA) were assessed by LGE-MRI two months later, where lesion width and visual gap(s) around each vein were assessed. The RF applications were delivered using a CF sensing catheter, with a target lesion size index (LSI) of 5, and an inter-lesion distance of <6mm. They found that the mean lesion width on MRI was significantly wider in the CBA group (8.1±2.2 mm) as compared to the RFCA group (6.3±2.2 mm), p=0.032. However, there were more visual gaps seen in the CBA group, especially in the bottom segments of the two inferior veins. In the RFCA group, gaps were seen most often seen in the left posterior segments where the target LSI value could not be achieved because of esopheageal temperature rise. Furthermore, the number of gaps visualised on MRI was linked to freedom from AF at 12 months; receiver operating characteristic curve analysis suggested a cut off value of less than 5 visual gaps per patient as being predictive of a good outcome.The authors deserve to be congratulated for their study, which builds on their previous work where LGE-MRI was used to compare chronic lesions between CBA and RFCA with non-CF sensing catheters11. It is notable that whilst the lesion width in their previous study was also significantly greater in the CBA group than the RFCA group, the mean number of gaps in the RFCA group was higher. This suggests that the modern technique of delivering LSI-guided contiguous RFCA lesions has resulted in a material improvement in PVI durability, something that is borne out in clinical studies too3.Some limitations of the work should be mentioned. Patients were not randomised to RFCA or CBA; rather, patients undergoing CBA were pre-selected with those with left common PV or large PVs excluded. The ablation technique used for CBA was unusual in that the use of RFCA was allowed if PVI could not be achieved after a single 3-minute freeze. This low bar for defining CBA failure led to as many as 3 patients out of 25 being excluded from the study. Many readers will feel that the mean procedural times of 129 minutes and fluoroscopy times of 39 minutes for CBA are much longer than what is the norm today. They may also find the RF powers used in this study unusual; only 30W was used on the anterior wall, and 20-25W on the posterior wall, which was reduced even further if esophageal temperature rise was observed. The field is moving towards using higher power short duration (HPSD) RF applications, and as HPSD lesions have been shown to be wider12, it is possible that the gaps on the posterior wall identified in this study may not have been present had HPSD applications been used. Finally, the definition of visual gap on MRI used in this study, a non-LGE site larger than 4 mm, almost certainly overestimated the number of true gaps. For instance, the authors observed at least one visual gap in each of the 16 segments around the PVs in more than 10% CB patients; this is at odds with data obtained with ultrahigh density mapping9, and also with the good clinical outcomes reported here. Future research should look at correlating these MRI-visualised gaps with actual gaps seen on repeat electrophysiological study, so that the clinical significance of these can be better defined.What can we take away from this study? Firstly, the use of MRI to assess post-ablation scar is now a reality in many labs, allowing assessment of PVI durability to help decide whether or not to offer a repeat procedure to a patient with AF recurrence. Secondly, the evolution of the RFCA technique to include target lesion indices and inter-lesion distance has made RFCA at least as effective as CBA in achieving durable PVI. Finally, this is an area ripe for further research, and we look forward to similarly valuable contributions from Kurose and colleagues in the future.
The current COVID-19 global pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) of probable bat origin, has highlighted the ongoing need for a One Health response to emerging zoonotic disease events, which are significantly increasing over time. Understanding the human-animal interface and its relevance to disease transmission remains a critical control point for many emerging zoonoses. Determination of the susceptibility of various animal species to infection with SARS-CoV-2 and the role of animals in the epidemiology of the disease will be critical to informing appropriate human and veterinary public health responses to this pandemic. A scoping literature review was conducted to collect, evaluate and present the available research evidence regarding SARS-CoV-2 infections in animals. Experimental studies have successfully demonstrated SARS-CoV-2 infection and transmission in cats, ferrets, hamsters, bats and non-human primates under experimental settings. Dogs appear to have limited susceptibility to SARS-CoV-2, while other domestic species including pigs and poultry do not appear susceptible. Naturally occurring SARS-CoV-2 infections in animals appear uncommon, with 14 pets, 8 captive big cats and an unreported number of farmed mink testing positive to date. Infections typically appear asymptomatic in dogs, while clinical signs of respiratory and/or gastrointestinal disease tend to be mild to moderate in felines, and severe to fatal in mink. Most animal cases have been infected by close contact with COVID-19 patients. In domestic settings, viral transmission is self-limiting, however in high density animal environments there can be sustained between-animal transmission. To date, two potential cases of animal-to-human transmission are being investigated, on infected mink farms. Given the millions of COVID-19 cases worldwide and ongoing potential for further zoonotic and anthroponotic viral transmission, further research and surveillance activities are needed to definitively determine the role of animals in community transmission of SARS-CoV-2.
In the context of the current COVID-19 pandemic, what are the lessons clinical pharmacology could learn to improve our teaching practice and involvement in research and ethics committees to make sure we are better prepared for the next emergency. Is there something in the light of the hydroxychloroquine hype that we as clinical pharmacologists or our professional societies could have done better? We propose updating the way we teach about drug development, rules and ethics of off-label prescribing and critical appraisal of primary sources when guidelines and top-level evidence are not available. Clinical pharmacology should play a leading role in the future re-definition of processes and guidelines for emergencies such as the one we faced in 2020.