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

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

Federal government relief programs for grain farmers: rewards for the late adjusters?

Non-Peer ReviewedThe Canadian Federal Government has introduced several major ad hoc relief programs for prairie farmers in the last fifty years, in response to various agricultural crises. Each of these programs has rewarded late adjusters – farmers who contributed to the crises by not responding appropriately to market or environmental conditions. Early adjusters who quickly and innovatively responded have been treated indifferently or penalized by the programs. The 1941 Wheat Acreage Reduction (WAR) program and 1970 Lower Inventory for Tomorrow (LIFT) favoured farmers who grew large acreages of wheat in the preceding years despite high levels of Canadian and world wheat stocks. Farmers who had cut production or diversified received less program money than the late adjusters. The Special Canadian Grains Program (SCGP) of 1986, introduced to offset low world prices in traditional crops, made no payments to special crop producers in its first year. Producers who cultivated below average quality land in a township or who planted traditional rotations regardless of, sometimes in spite of, climatic conditions in 1988 received much of the benefit of the Canadian Crop Drought Assistance Program (CCDAP). The 1989 Permanent Cover Program of the Canada-Saskatchewan Agreement on Soil Conservation will reward, at least in part, late adjusters who brought marginal land under cultivation, some as recently as July 1987, without regard for environmental consequences. Throughout the last fifty years, the delivery quota system, based on the number of acres farmed, has encouraged extensive farming techniques and the cultivation of marginal land. Farmers who practiced annual cultivation of export crops may have maximized short run economic returns given the combined economic and policy signals which were received. Farmers who have tried to farm according to the best long-term agronomic practices have not been rewarded through policy initiatives. Ad hoc programs which have tried to move producers away from traditional prairie crops and cultivation methods, especially wheat production, often have been poorly designed, underfunded and limited in scope. Fundamental federal government policies for Prairie agriculture, including the Homestead Act, the Land Survey, and the Crow Rate/Western Grain Transportation Act (WGTA) have consistently pushed Prairie land use in a single direction, encouraging annual cultivation and the production of grain, especially wheat, for export at the expense of most other types of agricultural production. A precarious cyclical economy has been one result, especially in Saskatchewan. Deterioration of a significant portion of the land base has been another. The provincial land assessment and property taxation system may have institutionalized this land degradation. The "Wheat is King" tradition is still alive and well on the prairies and in the minds of policy planners. Wheat will remain a major crop. However, governments which are serious about diversification in Prairie agriculture must begin to reward early adjusters – those who innovate and respond appropriately to markets and the physical environment. Federal Government legislation for the prairie region should be enabling, not disabling legislation

Superclustering with the Atacama Cosmology Telescope and Dark Energy Survey. I. Evidence for Thermal Energy Anisotropy Using Oriented Stacking

The cosmic web contains filamentary structure on a wide range of scales. On the largest scales, superclustering aligns multiple galaxy clusters along intercluster bridges, visible through their thermal Sunyaev-Zel'dovich signal in the cosmic microwave background. We demonstrate a new, flexible method to analyze the hot gas signal from multiscale extended structures. We use a Compton y-map from the Atacama Cosmology Telescope (ACT) stacked on redMaPPer cluster positions from the optical Dark Energy Survey (DES). Cutout images from the y-map are oriented with large-scale structure information from DES galaxy data such that the superclustering signal is aligned before being overlaid. We find evidence of an extended quadrupole moment of the stacked y signal at the 3.5σ level, demonstrating that the large-scale thermal energy surrounding galaxy clusters is anisotropically distributed. We compare our ACT × DES results with the Buzzard simulations, finding broad agreement. Using simulations, we highlight the promise of this novel technique for constraining the evolution of anisotropic, non-Gaussian structure using future combinations of microwave and optical surveys. © 2022. The Author(s). Published by the American Astronomical Society

90Y Radioembolization for Hepatic Malignancy in Patients with Previous Biliary Intervention: Multicenter Analysis of Hepatobiliary Infections

PurposeTo determine the frequency of hepatobiliary infections after transarterial radioembolization (TARE) with yttrium 90 (90Y) in patients with liver malignancy and a history of biliary intervention.Materials and MethodsFor this retrospective study, records of all consecutive patients with liver malignancy and history of biliary intervention treated with TARE at 14 centers between 2005 and 2015 were reviewed. Data regarding liver function, 90Y dosimetry, antibiotic prophylaxis, and bowel preparation prophylaxis were collected. Primary outcome was development of hepatobiliary infection.ResultsOne hundred twenty-six patients (84 men, 42 women; mean age, 68.8 years) with primary (n = 39) or metastatic (n = 87) liver malignancy and history of biliary intervention underwent 180 procedures with glass (92 procedures) or resin (88 procedures) microspheres. Hepatobiliary infections (liver abscesses in nine patients, cholangitis in five patients) developed in 10 of the 126 patients (7.9%) after 11 of the 180 procedures (6.1%; nine of those procedures were performed with glass microspheres). All patients required hospitalization (median stay, 12 days; range, 2–113 days). Ten patients required percutaneous abscess drainage, three patients underwent endoscopic stent placement and stone removal, and one patient needed insertion of percutaneous biliary drains. Infections resolved in five patients, four patients died (two from infection and two from cancer progression while infection was being treated), and one patient continued to receive suppressive antibiotics. Use of glass microspheres (P = .02), previous liver resection or ablation (P = .02), and younger age (P = .003) were independently predictive of higher infection risk.ConclusionInfectious complications such as liver abscess and cholangitis are uncommon but serious complications of transarterial radioembolization with 90Y in patients with liver malignancy and a history of biliary intervention.© RSNA, 2018Online supplemental material is available for this article

Relationship between Anaemia, Haemolysis, Inflammation and Haem Oxygenase-1 at Admission with Sepsis: a pilot study

Upregulation of haem oxygenase-1 (HO-1), due to haemolysis and/or inflammation, can lead to impaired immune function. Anaemia is common among sepsis patients, but the consequences of sepsis-associated anaemia are poorly understood. Here, our objective was to determine the prevalence and extent of anaemia, haemolysis, inflammation, and HO-1 induction after early hospital admission. We hypothesised that inflammation- or infection-induced haemolysis contributes to sepsis-associated anaemia and that this will lead to expression of HO-1. In this study, plasma obtained from seventy adult patients within 12 hours of admission to intensive care due to sepsis were analysed for anaemia, haemolysis and inflammatory markers by ELISA and microbead array. The majority (82.6%) of patients were anaemic with evidence of haemolysis (raised haem, haptoglobin, haemopexin, and HO-1 concentrations). Interestingly, concentrations of both haemoglobin and IL-10 were moderately positively correlated with HO-1 concentration (Hb: r = 0.32, p = 0.007; IL-10 r = 0.39, p = 0.0008) whereas HO-1 concentration was weakly negatively correlated with haemopexin (r = -0.23, p = 0.055). Anaemia, while common, was not associated with HO-1 concentration. After adjusting for confounding, HO-1 induction appears to be associated primarily with IL-10 concentration rather than haemolysis. Disease severity at diagnosis was correlated with early plasma IL-10 (r = 0.35, p = 0.003) and HO-1 (r = 0.24, p = 0.048) concentrations. Notably, admission levels of haem, HO-1, and IL-10 were indicators of survival

Superclustering with the Atacama Cosmology Telescope and Dark Energy Survey. I. Evidence for Thermal Energy Anisotropy Using Oriented Stacking

The cosmic web contains filamentary structure on a wide range of scales. On the largest scales, superclustering aligns multiple galaxy clusters along intercluster bridges, visible through their thermal Sunyaev-Zel'dovich signal in the cosmic microwave background. We demonstrate a new, flexible method to analyze the hot gas signal from multiscale extended structures. We use a Compton y-map from the Atacama Cosmology Telescope (ACT) stacked on redMaPPer cluster positions from the optical Dark Energy Survey (DES). Cutout images from the y-map are oriented with large-scale structure information from DES galaxy data such that the superclustering signal is aligned before being overlaid. We find evidence of an extended quadrupole moment of the stacked y signal at the 3.5σ level, demonstrating that the large-scale thermal energy surrounding galaxy clusters is anisotropically distributed. We compare our ACT × DES results with the Buzzard simulations, finding broad agreement. Using simulations, we highlight the promise of this novel technique for constraining the evolution of anisotropic, non-Gaussian structure using future combinations of microwave and optical surveys

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis

Introduction Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. Methods We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. Results We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women. Pregnant women with SARS-CoV-2 infection—as compared with uninfected pregnant women—were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12). Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. Conclusions This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol

Cosmological shocks around galaxy clusters: A coherent investigation with DES, SPT & ACT

We search for signatures of cosmological shocks in gas pressure profiles of galaxy clusters using the cluster catalogs from three surveys: the Dark Energy Survey (DES) Year 3, the South Pole Telescope (SPT) SZ survey, and the Atacama Cosmology Telescope (ACT) data releases 4, 5, and 6, and using thermal Sunyaev-Zeldovich (SZ) maps from SPT and ACT. The combined cluster sample contains around $10^5$ clusters with mass and redshift ranges $10^{13.7} < M_{\rm 200m}/M_\odot < 10^{15.5}$ and $0.1 < z < 2$, and the total sky coverage of the maps is $\approx 15,000 \,\,{\rm deg}^2$. We find a clear pressure deficit at $R/R_{\rm 200m}\approx 1.1$ in SZ profiles around both ACT and SPT clusters, estimated at $6\sigma$ significance, which is qualitatively consistent with a shock-induced thermal non-equilibrium between electrons and ions. The feature is not as clearly determined in profiles around DES clusters. We verify that measurements using SPT or ACT maps are consistent across all scales, including in the deficit feature. The SZ profiles of optically selected and SZ-selected clusters are also consistent for higher mass clusters. Those of less massive, optically selected clusters are suppressed on small scales by factors of 2-5 compared to predictions, and we discuss possible interpretations of this behavior. An oriented stacking of clusters -- where the orientation is inferred from the SZ image, the brightest cluster galaxy, or the surrounding large-scale structure measured using galaxy catalogs -- shows the normalization of the one-halo and two-halo terms vary with orientation. Finally, the location of the pressure deficit feature is statistically consistent with existing estimates of the splashback radius.Comment: [v2]: Version accepted to MNRA