Bigeminy and the bifid papillary muscle

Various structural anomalies of the left ventricular papillary muscles have been observed in recent years. Many of these have been linked to electrocardiographic aberrations

Burning issues in the prevention of heart failure

Chronic heart failure is common, debilitating, and often the culmination of pervasive cardiovascular insults that systematically undermine the heart’s circulatory capacity and invoke counterproductive neuro-hormonal compensatory changes. Prevention of chronic heart failure therefore requires minimising the impact of traditional cardiovascular risk factors with incisive treatment of hypertension and type 2 diabetes mellitus (T2DM) and prompt lifestyle interventions for smoking, lack of exercise, obesity and hypercholesterolemia. This review is narrative, with selected emphasis on major studies, rather than structured on a specific clinical question, and should be read as such

The canonical effect in statistical models for relativistic heavy ion collisions

Enforcing exact conservation laws instead of average ones in statistical thermal models for relativistic heavy ion reactions gives raise to so called canonical effect, which can be used to explain some enhancement effects when going from elementary (e.g. pp) or small (pA) systems towards large AA systems. We review the recently developed method for computation of canonical statistical thermodynamics, and give an insight when this is needed in analysis of experimental data.Comment: 4 pages, 3 figures. Talk given in Strangeness in Quark Matter, Frankfurt am Main 2001. Submitted to J. Phys. G: Nucl. Part. Phy

Determination of the critical stages of processing and tolerance limits for Harmonia axyridis for ‘ladybug taint’ in wine

'Ladybug taint’ (LBT) has recently been reported in some wines from North America, and is associated with 2-isopropyl-3-methoxypyrazine (IPMP), produced by Harmonia axyridis Pallas (the Multicolored Asian Lady Beetle - MALB) when they are incorporated into the winemaking process. It is not known when IPMP is transferred from MALB (e.g. in the vineyard onto grapes or during must processing) nor what minimum MALB densities are required for production of LBT in the final wines. This study sought to clarify these issues through a series of three trials. In the first, MALB were added to 'Riesling' grapes or must at different stages of processing (harvest, crush/destem, pressing or directly to juice), and the resultant wines were analysed chemically and by paired-comparison sensory difference tests.The presence of MALB during processing had minimal effect on the basic composition and spectral properties of the wine. Concentrations of IPMP were < 5 ng·l-1 for all wines except those produced after the direct addition of MALB to the juice (10.3 ng·l-1). Sensorially, control wines (no added MALB) could be differentiated from wines made after MALB were added at crushing/destemming (at 3 beetles per kg grapes), whole bunch pressing and when added directly into the juice, but not when MALB were added and subsequently removed from a simulated harvest treatment or when added during crushing/destemming at 0.3 beetles per kg grapes. In trials 2 and 3, sensory detection thresholds for LBT were determined for white and red wines produced with known densities of MALB. Estimates of ‘tolerance limits’ in the vineyard were then calculated using regression models, and correspond to 1530 and 1260 beetles per t grapes for white and red wines respectively. However, given the range of grape and wine processing options available to producers, many of which are not accounted for in this study, we recommend that a more conservative limit of 200-400 beetles per t grapes may be appropriate. These results should assist in directing appropriate interventions in the vineyard/winery, and provide baseline targets for reducing MALB density to avoid development of LBT.

Structural Causes of Right Bundle Branch Block—Time for a Closer Look?

Right bundle branch block is an electrocardiographic phenomenon with specific criteria

Effects of tranexamic acid on surgical, traumatic and obstetric bleeding: a critical analysis of the evidence from randomised trials using systematic reviews and meta-analytic techniques

BACKGROUND Surgical, traumatic and obstetric bleeding are important causes of mortality and morbidity. The antifibrinolytic drug, tranexamic acid (TXA), inhibits clot breakdown and may have a role in the management of excessive bleeding. AIM: Evaluate the evidence from randomised trials for the effects of TXA in patients with surgical bleeding, traumatic bleeding, and for preventing postpartum haemorrhage (PPH). METHODS: Using systematic reviews and meta-analytic techniques, evaluate the evidence from randomised trials to: i) quantify the effects of TXA for surgical bleeding; ii) investigate the quality of trials of TXA for surgical bleeding; iii) to quantify the effects of TXA for traumatic bleeding; iv) estimate the number of avoidable trauma deaths by the routine use of TXA; v) quantify the effects of TXA for preventing PPH; and vi) propose a trial of TXA for preventing PPH. RESULTS: A systematic review including 129 trials involving 10,488 patients suggests that TXA reduces bleeding in surgical patients by about one third, although its effect on death and thromboembolic events is uncertain. Evidence that TXA reduces surgical bleeding has been available for many years, although, poor methodological quality of trials may mean that it is unreliable. There is reliable evidence that TXA reduces death due to bleeding in trauma patients. This evidence originates from a large, high quality randomised trial in 20,211 patients. If TXA was given to all patients soon (<3 hours) after injury over 100,000 deaths could be prevented every year. A systematic review including 26 trials involving 4191 women suggests that there is no reliable evidence for the effects of TXA for preventing PPH. The trials are poor quality and contain serious flaws. The proposed WOMAN-2 trial of TXA for preventing PPH in 10,000 women with anaemia aims to resolve the uncertainties. CONCLUSIONS: Most trials assessing the effect of TXA for surgical bleeding and for preventing PPH are small and poor quality. Although together they provide promising evidence that TXA reduces bleeding, further evidence from large trials at low risk of bias is required to determine reliably the effects of TXA for these indications. There is reliable evidence that TXA reduces the risk of death in trauma patients and no further trials are required. Instead, dissemination of the evidence and implementation of TXA into trauma protocols worldwide, should be a priority. Although there is no evidence from randomised trials that it increases risk, the effect of TXA on thromboembolic events remains uncertain

The effectiveness and safety of antifibrinolytics in patients with acute intracranial haemorrhage: statistical analysis plan for an individual patient data meta-analysis

Introduction: The Antifibrinolytic Trialists Collaboration aims to increase knowledge about the effectiveness and safety of antifibrinolytic treatment by conducting individual patient data (IPD) meta-analyses of randomised trials. This article presents the statistical analysis plan for an IPD meta-analysis of the effects of antifibrinolytics for acute intracranial haemorrhage. Methods: The protocol for the IPD meta-analysis has been registered with PROSPERO (CRD42016052155). We will conduct an individual patient data meta-analysis of randomised controlled trials with 1000 patients or more assessing the effects of antifibrinolytics in acute intracranial haemorrhage. We will assess the effect on two co-primary outcomes: 1) death in hospital at end of trial follow-up, and 2) death in hospital or dependency at end of trial follow-up. The co-primary outcomes will be limited to patients treated within three hours of injury or stroke onset. We will report treatment effects using odds ratios and 95% confidence intervals. We use logistic regression models to examine how the effect of antifibrinolytics vary by time to treatment, severity of intracranial bleeding, and age. We will also examine the effect of antifibrinolytics on secondary outcomes including death, dependency, vascular occlusive events, seizures, and neurological outcomes. Secondary outcomes will be assessed in all patients irrespective of time of treatment. All analyses will be conducted on an intention-to-treat basis. Conclusions: This IPD meta-analysis will examine important clinical questions about the effects of antifibrinolytic treatment in patients with intracranial haemorrhage that cannot be answered using aggregate data. With IPD we can examine how effects vary by time to treatment, bleeding severity, and age, to gain better understanding of the balance of benefit and harms on which to base recommendations for practice

Non-operatively managed small to medium-sized subscapularis tendon tears: MRI evaluation with a minimum of 5 years follow-up

Background Isolated or combined subscapularis (SSC) tendon tears are frequently found in patients with shoulder pain. The purpose of this study was to evaluate the structural changes associated with SSC tear in a consecutive series of patients with nonoperatively treated small size to midsize SSC tendon tears using magnetic resonance imaging (MRI). Methods In this retrospective case series, all patients with an isolated or combined SSC tendon tear treated nonoperatively between 1999 and 2019 were identified from our MRI and clinical databases. Twenty-one patients with a mean age of 52.6 years (range 26.6-64.8, standard deviation 9.3) with a second MRI scan at a minimum of 5 years of follow-up were enrolled. The mean follow-up was 8.6 years (range 5.6-12.6, standard deviation 1.8). Initial and last follow-up MRI scans were used to determine concomitant cuff lesions, size of the SSC tear, fatty infiltration of the SSC muscle, and biceps pathology. Results Five patients had an isolated SSC lesion; 7 patients had a concomitant tear of the supraspinatus, and 9 patients had a supraspinatus and anterior infraspinatus tendon tear. At diagnosis, 14 patients had a type 1 SSC lesion as classified by Lafosse et al, 4 patients had type 2, and 3 patients had type 3 lesions. Nineteen patients (90%) were found to have an SSC tear progression of at least one Lafosse grade (P < .001); however, no tear had progressed to an irreparable type lesion (defined as Lafosse type 5). In addition, the size of SSC tendon tears increased significantly from 75 mm2 to 228 mm2 (P < .001). At the final MRI scan, the grading of fatty infiltration increased by 1 grade in 4 cases and by 2 grades in 4 cases (P = .042). At the final follow-up, in eight patients, the condition of the long head of biceps tendon was unchanged from the initial MRI; in nine patients, there was a newly subluxated biceps tendon, and in 6 patients, there was a newly ruptured long head of biceps tendon (P < .001). Conclusion After a mean of 8.6 years, almost all nonoperatively treated SSC tendon tears had increased in size, but only one-third showed additional progression of muscle fatty degeneration on MRI scan. None of the SSC lesions became irreparable during the observation period

Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease.

Dehydration is an important cause of death in patients with Ebola virus disease (EVD). Parenteral fluids are often required in patients with fluid requirements in excess of their oral intake. The peripheral intravenous route is the most commonly used method of parenteral access, but inserting and maintaining an intravenous line can be challenging in the context of EVD. Therefore it is important to consider the advantages and disadvantages of different routes for achieving parenteral access (e.g. intravenous, intraosseous, subcutaneous and intraperitoneal). To compare the reliability, ease of use and speed of insertion of different parenteral access methods. We ran the search on 17 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R) In-Process &amp; Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE(R) and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), CINAHL (EBSCOhost), clinicaltrials.gov and screened reference lists. Randomised controlled trials comparing different parenteral routes for the infusion of fluids or medication. Two review authors examined the titles and abstracts of records obtained by searching the electronic databases to determine eligibility. Two review authors extracted data from the included trials and assessed the risk of bias. Outcome measures of interest were success of insertion; time required for insertion; number of insertion attempts; number of dislodgements; time period with functional access; local site reactions; clinicians' perception of ease of administration; needlestick injury to healthcare workers; patients' discomfort; and mortality. For trials involving the administration of fluids we also collected data on the volume of fluid infused, changes in serum electrolytes and markers of renal function. We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach for the following outcomes: success of insertion, time required for insertion, number of dislodgements, volume of fluid infused and needlestick injuries. We included 17 trials involving 885 participants. Parenteral access was used to infuse fluids in 11 trials and medications in six trials. None of the trials involved patients with EVD. Intravenous and intraosseous access was compared in four trials; intravenous and subcutaneous access in 11; peripheral intravenous and intraperitoneal access in one; saphenous vein cutdown and intraosseous access in one; and intraperitoneal with subcutaneous access in one. All of the trials assessing the intravenous method involved peripheral intravenous access.We judged few trials to be at low risk of bias for any of the assessed domains.Compared to the intraosseous group, patients in the intravenous group were more likely to experience an insertion failure (risk ratio (RR) 3.89, 95% confidence interval (CI) 2.39 to 6.33; n = 242; GRADE rating: low). We did not pool data for time to insertion but estimates from the trials suggest that inserting intravenous access takes longer (GRADE rating: moderate). Clinicians judged the intravenous route to be easier to insert (RR 0.15, 95% CI 0.04 to 0.61; n = 182). A larger volume of fluids was infused via the intravenous route (GRADE rating: moderate). There was no evidence of a difference between the two routes for any other outcomes, including adverse events.Compared to the subcutaneous group, patients in the intravenous group were more likely to experience an insertion failure (RR 14.79, 95% CI 2.87 to 76.08; n = 238; GRADE rating: moderate) and dislodgement of the device (RR 3.78, 95% CI 1.16 to 12.34; n = 67; GRADE rating: low). Clinicians also judged the intravenous route as being more difficult to insert and patients were more likely to be agitated in the intravenous group. Patients in the intravenous group were more likely to develop a local infection and phlebitis, but were less likely to develop erythema, oedema or swelling than those in the subcutaneous group. A larger volume of fluids was infused into patients via the intravenous route. There was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine if the risk of insertion failure differed between the saphenous vein cutdown (SVC) and intraosseous method (RR 4.00, 95% CI 0.51 to 31.13; GRADE rating: low). Insertion using SVC took longer than the intraosseous method (MD 219.60 seconds, 95% CI 135.44 to 303.76; GRADE rating: moderate). There were no data and therefore there was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine the relative effects of intraperitoneal or central intravenous access relative to any other parenteral access method. There are several different ways of achieving parenteral access in patients who are unable meet their fluid requirements with oral intake alone. The quality of the evidence, as assessed using the GRADE criteria, is somewhat limited because of the lack of adequately powered trials at low risk of bias. However, we believe that there is sufficient evidence to draw the following conclusions: if peripheral intravenous access can be achieved easily, this allows infusion of larger volumes of fluid than other routes; but if this is not possible, the intraosseous and subcutaneous routes are viable alternatives. The subcutaneous route may be suitable for patients who are not severely dehydrated but in whom ongoing fluid losses cannot be met by oral intake.A film to accompany this review can be viewed here (http://youtu.be/ArVPzkf93ng)