Tissue plasminogen activator dose and pulmonary artery pressure reduction in catheter directed thrombolysis of submassive pulmonary embolism.

PURPOSE:The purpose of this study is to assess the incremental effect of tissue plasminogen activator (t-PA) dose on pulmonary artery pressure (PAP) and bleeding during catheter directed thrombolysis (CDT) of submassive pulmonary embolism (PE). MATERIALS AND METHODS:Records of 46 consecutive patients (25 men, 21 women, mean age 55±14 y) who underwent CDT for submassive PE between September 2009 and February 2017 were retrospectively reviewed. Mean t-PA rate was 0.7±0.3 mg/h. PAP was measured at baseline and daily until CDT termination. Mixed-effects regression modeling was performed of repeated PAP measures in individual patients. Bleeding events were classified by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) and t-PA dose at onset. RESULTS:Mean t-PA dose was 43.0±30.0 mg over 61.9± 28.8 h. Mean systolic PAP decreased from 51.7±15.5 mmHg at baseline to 35.6±12.7 mmHg at CDT termination (p<0.001). Mixed-effects regression revealed a linear decrease in systolic PAP over time (β = -0.37 (SE = 0.05), p<0.001) with reduction in mean systolic PAP to 44.8±1.9 mmHg at 12 mg t-PA/20 h, 39.5±2.0 mmHg at 24 mg t-PA/40 h, and 34.9±2.1 mmHg at 36 mg/60 h. No severe, one moderate, and 8 mild bleeding events occurred; bleeding onset was more frequent at ≤24 mg t-PA (p <0.001). One patient expired from cardiopulmonary arrest after 16 h of CDT (15.4 mg t-PA); no additional intra-procedural fatalities occurred. CONCLUSION:Increased total t-PA dose and CDT duration were associated with greater PAP reduction without increased bleeding events

Esophagopulmonary fistula causing pulmonary arterial pseudoaneurysms and massive hemoptysis.

An esophagopulmonary fistula (EPF) may occur in patients with esophageal carcinoma and result in pulmonary abscess formation. Lung abscesses may in turn cause pulmonary artery (PA) pseudoaneurysms and life-threatening hemoptysis. We report a 59-year-old man with past medical history of metastatic distal esophageal adenocarcinoma who presented with fever, cough, and massive hemoptysis. Imaging evaluation demonstrated an EPF, associated lung abscess, and PA pseudoaneurysms. The presented case illustrates that embolization of PA pseudoaneurysms to prevent bleeding, and endoscopic esophageal covered stent graft placement to divert esophageal contents from the abscess, may facilitate a favorable outcome

Arterial-portal fistula treated with hepatic arterial embolization and portal venous aneurysm stent-graft exclusion complicated by type 2 endoleak.

Intrahepatic arterioportal fistulas may be complicated by portal hypertension. An associated portal venous aneurysm (PVA) may impinge upon adjacent structures or rupture. We present a 65-year-old man with an intrahepatic Intrahepatic arterioportal fistula and 6.4 × 5.8 cm right portal vein aneurysm extending within 0.4 cm of the hepatic margin, associated with pain concerning for impending rupture. The PVA was refractory to transarterial embolization due to recruitment of arterial collaterals. Therefore, it was additionally excluded from the portal vein with a 12 mm × 9.5 cm venous stent graft. Although endovascular therapy thrombosed the aneurysm and improved symptoms, it was complicated by a type 2 endoleak into the PVA

Risk-reducing early salpingectomy and delayed oophorectomy as a two-staged alternative for primary prevention of ovarian cancer in women at increased risk: a commentary.

This is the peer reviewed version of the following article: Gaba, F. , Piek, J. , Menon, U. and Manchanda, R. (2019), Risk reducing early salpingectomy and delayed oophorectomy as a two staged alternative for primary prevention of ovarian cancer in increased risk women: a commentary. BJOG: Int J Obstet Gy. Accepted Author Manuscript. doi:10.1111/1471-0528.15651, which has been published in final form at https://doi.org/10.1111/1471-0528.15651. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Version

Physical modelling of lime stabilisation in soft soils around deep excavations

Bored concrete piles have been used widely on commercial developments in London for about the last 50 years. The life of a commercial building is between 25 – 30 years and, as each building is demolished and rebuilt, the piles from the previous buildings remain in the ground causing obstruct ions to the new foundations. This paper describes a preliminary study to explore the viability of sheet piled foundations as a genuine alternative to cast in situ concrete piles and all of the complications inherent in their construction and the obstruction they create to subsequent foundations. If it is possible to u se steel piles as foundations they can be easily removed, recycled and will not cause obstructions for future developments. However, individual sheet piles have relatively low capacity when axially loaded and it is therefore necessary to consider a sheet p ile grou p in conjunction with a pilecap, which can be considered a hybrid foundation; a combination of shallow (pilecap) and deep (sheet pile). A short series of centrifuge tests is reported in which model sheet pile groups in over - consolidated clay were l oaded axially whilst vertical displacements were measured. Equivalent cast in place piles were similarly tested alongside the sheet pile groups by way of comparison

Starbursts versus Truncated Star Formation in Nearby Clusters of Galaxies

We present long-slit spectroscopy, B and R bandpass imaging, and 21 cm observations of a sample of early-type galaxies in nearby clusters which are known to be either in a star-forming phase or to have had star formation which recently terminated. From the long-slit spectra, obtained with the Blanco 4-m telescope, we find that emission lines in the star-forming cluster galaxies are significantly more centrally concentrated than in a sample of field galaxies. The broadband imaging reveals that two currently star-forming early-type galaxies in the Pegasus I cluster have blue nuclei, again indicating that recent star formation has been concentrated. In contrast, the two galaxies for which star formation has already ended show no central color gradient. The Pegasus I galaxy with the most evident signs of ongoing star formation (NGC7648), exhibits signatures of a tidal encounter. Neutral hydrogen observations of that galaxy with the Arecibo radiotelescope reveal the presence of ~4 x 10^8 solar masses of HI. Arecibo observations of other current or recent star-forming early-type galaxies in Pegasus I indicate smaller amounts of gas in one of them, and only upper limits in others.Comment: to be published in Astronomical Journa

Systematic review of acceptability, cardiovascular, neurological, bone health and HRT outcomes following risk reducing surgery in BRCA carriers

© 2020 Primary surgical prevention in the form of risk-reducing salpingo-oophorectomy (RRSO) is the most effective option and the gold standard for ovarian cancer (OC) risk-reduction, particularly given the absence of an effective national OC screening programme. However, premenopausal RRSO leads to premature surgical menopause with detrimental long-term health sequelae particularly in women who do not/are unable to take hormone replacement therapy (HRT). HRT uptake in women undergoing pre-menopausal oophorectomy appears low and is dependent on informed counselling, the safety of HRT and efficacy in mitigating the health sequelae of premature menopause. Acceptance of a central role for the fallopian tube in OC etiopathogenesis, coupled with the detrimental consequences of premature menopause, has led to the attractive proposal of early-salpingectomy with delayed oophorectomy as an alternative OC surgical prevention strategy in premenopausal women who have completed childbearing but decline or wish to delay RRSO. The successful implementation of risk reducing surgery for OC prevention depends on the acceptability of surgery to both, recipients (e.g. BRCA1/BRCA2 carriers) and intervention deliverers (healthcare professionals/researchers). Acceptability is also informed by an understanding of health outcomes following risk reducing surgery and the safety of HRT. It is therefore vital to understand the effects of surgery on important health outcomes such as cardiovascular health, neurological function and bone health. We present a comprehensive review of acceptability, the selected health outcomes mentioned above and HRT safety following risk reducing surgery

Population Based Testing for Primary Prevention: A Systematic Review

Working paperThe current clinical model for genetic-testing is based on clinical-criteria/family-history(FH) and a pre-defined mutation probability threshold.  It requires people to develop cancer before identifying unaffected individuals in the family to target prevention. This process is inefficient, resource intense and misses >50% of individuals/mutation carriers at risk. Population genetic-testing can overcome these limitations. It is technically feasible to test populations on a large scale; genetic-testing costs are falling and the acceptability/awareness is rising. MEDLINE/EMBASE/Pubmed/CINAHL/PsychINFO databases were searched using a free-text and MeSH terms; reference lists of publications retrieved screened; additionally web-based platforms, Google, and clinical-trial registries were searched. Quality of studies were evaluated using appropriate check-lists. A number of studies have evaluated population-based BRCA-testing in the Jewish-population. This has been found to be acceptable, feasible, clinically-effective, safe, associated with high satisfaction rates and extremely cost-effective. Data support change in guidelines to population-based BRCA-testing in the Jewish-population. Population panel-testing for BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 gene mutations is the most cost-effective genetic-testing strategy in general-population women and can prevent thousands more breast/ovarian cancers than current clinical-criteria based approaches. A few ongoing studies are evaluating population-based genetic-testing for multiple cancer susceptibility genes in the general-population but more implementation studies are needed. A future population-testing programme could also target other chronic diseases

A commentary on population genetic testing for primary prevention: changing landscape and the need to change paradigm

BRCA1/BRCA2 genes were discovered in early 1990s and clinical testing for these has been available since the mid-1990s. National Institute of Health and Care Excellence (NICE) and other international guidelines recommend genetic-testing at a ~10% probability threshold of carrying a BRCA-mutation. A detailed three generation family-history (FH) of cancer is used within complex mathematical models (e.g. BOADICEA, BRCAPRO, Manchester-Scoring-System) or through standardized clinical-criteria to identify individuals who fulfil this probability threshold and can be offered genetic-testing. Identification of unaffected carriers is important given the high risk of cancer in these women and the effective options available for clinical management which can reduce cancer risk, improve outcomes and minimise burden of disease. This article is protected by copyright. All rights reserved

Subcutaneous Plasmacytoma Metastasis Precipitated by Tunneled Central Venous Catheter Insertion

Extramedullary plasmacytomas are tumors of monoclonal plasma cells arising within soft tissue that uncommonly occur in multiple myeloma patients. While sporadic development of these tumors at cutaneous trauma sites, including venous catheter access sites, has been reported, interventional radiologists seldom encounter this disease. Herein, we describe a case of metastatic subcutaneous plasmacytoma precipitated by tunneled central venous catheter insertion in a male patient undergoing stem cell therapy for treatment of multiple myeloma. In addition, we review the identification, diagnostic pitfalls, pathogenesis, and treatment of this rare entity