Contemporary Management of Isolated Ostial Side Branch Disease: An Evidence-based Approach to Medina 001 Bifurcations

The optimal management of bifurcation lesions has received significant interest in recent years and remains a matter of debate among the interventional cardiology community. Bifurcation lesions are encountered in approximately 21% of percutaneous coronary intervention procedures and are associated with an increased risk of major adverse cardiac events. The Medina classification has been developed in an attempt to standardise the terminology when describing bifurcation lesions. The focus of this article is on the management of the Medina 0,0,1 lesion (‘Medina 001’), an uncommon lesion encountered in <5% of all bifurcations. Technical considerations, management options and interventional techniques relating to the Medina 001 lesion are discussed. In addition, current published data supporting the various proposed interventional treatment strategies are examined in an attempt to delineate an evidence-based approach to this uncommon lesion

Intensification of Solvent Extraction in an Additively Manufactured Microfluidic Separator

Solvent extraction is an integral chemical and biochemical separation process that is drastically intensified in microfluidic systems. A novel high-throughput micro-separator was additively manufactured for the intensification of liquid–liquid separation. The micro-posts array within the flow plate generated a capillary pressure gradient on the non-wetting organic phase, enabling continuous, membrane-free, and density-independent phase separation. The device was integrated with an upstream micromixer for aqueous isobutanol extraction, allowing equilibrium extraction levels within 0.25 s. By capitalizing on the high depth-to-width aspect ratio of binder jetting, hydraulic pressure drops were substantially reduced, avoiding a detrimental effect on separation observed in current micro-separators. This novel architecture also enabled the rare ability to separate both “slug flow” and the highly effective but challenging “dispersed droplet flow”. Near-complete separation of the aqueous and organic phases was attained at flow rates up to 15 ml/min, under interfacial tensions of 48.9 and 10.9 mN/m, and aqueous:organic inlet flow ratios of 1:1 and 2:1. Separation performance deteriorated at 20 ml/min due to an increase of velocity gradients near the outlets, leading the wetting aqueous phase to exit from the organic outlet. Owing to its simplicity, manufacturing merits, and robust separation performance, this device addresses key requirements for achieving industrial-level throughputs using a “scale-up via number-up” approach

NeBula: Team CoSTAR's robotic autonomy solution that won phase II of DARPA Subterranean Challenge

This paper presents and discusses algorithms, hardware, and software architecture developed by the TEAM CoSTAR (Collaborative SubTerranean Autonomous Robots), competing in the DARPA Subterranean Challenge. Specifically, it presents the techniques utilized within the Tunnel (2019) and Urban (2020) competitions, where CoSTAR achieved second and first place, respectively. We also discuss CoSTAR¿s demonstrations in Martian-analog surface and subsurface (lava tubes) exploration. The paper introduces our autonomy solution, referred to as NeBula (Networked Belief-aware Perceptual Autonomy). NeBula is an uncertainty-aware framework that aims at enabling resilient and modular autonomy solutions by performing reasoning and decision making in the belief space (space of probability distributions over the robot and world states). We discuss various components of the NeBula framework, including (i) geometric and semantic environment mapping, (ii) a multi-modal positioning system, (iii) traversability analysis and local planning, (iv) global motion planning and exploration behavior, (v) risk-aware mission planning, (vi) networking and decentralized reasoning, and (vii) learning-enabled adaptation. We discuss the performance of NeBula on several robot types (e.g., wheeled, legged, flying), in various environments. We discuss the specific results and lessons learned from fielding this solution in the challenging courses of the DARPA Subterranean Challenge competition.The work is partially supported by the Jet Propulsion Laboratory, California Institute of Technology, under a contract with the National Aeronautics and Space Administration (80NM0018D0004), and Defense Advanced Research Projects Agency (DARPA)

Performance of the 2019 EULAR/ACR classification criteria for systemic lupus erythematosus in early disease, across sexes and ethnicities.

Funder: American College of Rheumatology Research and Education Foundation; FundRef: http://dx.doi.org/10.13039/100000960Funder: National Institute of Arthritis and Musculoskeletal and Skin Diseases; FundRef: http://dx.doi.org/10.13039/100000069Funder: European League Against Rheumatism; FundRef: http://dx.doi.org/10.13039/501100008741OBJECTIVES: The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 Classification Criteria for systemic lupus erythematosus (SLE) have been validated with high sensitivity and specificity. We evaluated the performance of the new criteria with regard to disease duration, sex and race/ethnicity, and compared its performance against the Systemic Lupus International Collaborating Clinics (SLICC) 2012 and ACR 1982/1997 criteria. METHODS: Twenty-one SLE centres from 16 countries submitted SLE cases and mimicking controls to form the validation cohort. The sensitivity and specificity of the EULAR/ACR 2019, SLICC 2012 and ACR 1982/1997 criteria were evaluated. RESULTS: The cohort consisted of female (n=1098), male (n=172), Asian (n=118), black (n=68), Hispanic (n=124) and white (n=941) patients; with an SLE duration of 1 to <3 years (n=196) and ≥5 years (n=879). Among patients with 1 to <3 years disease duration, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 81%). The EULAR/ACR criteria performed well in men (sensitivity 93%, specificity 96%) and women (sensitivity 97%, specificity 94%). Among women, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 83%) and better specificity than the SLICC criteria (94% vs 82%). Among white patients, the EULAR/ACR criteria had better sensitivity than the ACR criteria (95% vs 83%) and better specificity than the SLICC criteria (94% vs 83%). The EULAR/ACR criteria performed well among black patients (sensitivity of 98%, specificity 100%), and had better sensitivity than the ACR criteria among Hispanic patients (100% vs 86%) and Asian patients (97% vs 77%). CONCLUSIONS: The EULAR/ACR 2019 criteria perform well among patients with early disease, men, women, white, black, Hispanic and Asian patients. These criteria have superior sensitivity than the ACR criteria and/or superior specificity than the SLICC criteria across many subgroups

European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance.

BACKGROUND/OBJECTIVES: The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 classification criteria for systemic lupus erythematosus system showed high specificity, while attaining also high sensitivity. We hereby analysed the performance of the individual criteria items and their contribution to the overall performance of the criteria. METHODS: We combined the EULAR/ACR derivation and validation cohorts for a total of 1197 systemic lupus erythematosus (SLE) and n=1074 non-SLE patients with a variety of conditions mimicking SLE, such as other autoimmune diseases, and calculated the sensitivity and specificity for antinuclear antibodies (ANA) and the 23 specific criteria items. We also tested performance omitting the EULAR/ACR criteria attribution rule, which defines that items are only counted if not more likely explained by a cause other than SLE. RESULTS: Positive ANA, the new entry criterion, was 99.5% sensitive, but only 19.4% specific, against a non-SLE population that included other inflammatory rheumatic, infectious, malignant and metabolic diseases. The specific criteria items were highly variable in sensitivity (from 0.42% for delirium and 1.84% for psychosis to 75.6% for antibodies to double-stranded DNA), but their specificity was uniformly high, with low C3 or C4 (83.0%) and leucopenia 80% for all items, explaining the higher overall specificity of the criteria set

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Chronic total occlusions — Current techniques and future directions

Chronic total occlusions (CTOs) of coronary arteries represent a common and significant challenge to interventional cardiology. Medical therapy is often regarded as an adequate long term strategy in the management of these lesions with surgical intervention for refractory symptoms. Extensive collateralisation is used as a marker of distal coronary perfusion, further reinforcing non-invasive strategies. This together with relatively low percutaneous success rates outside of specialised centres has meant that rates of percutaneous intervention have remained low. Increasing evidence suggests that CTOs are not a benign entity. Further, symptom control and quality of life improve significantly with successful percutaneous revascularisation. Both factors have reignited interest in percutaneous modalities. The Japanese have been pioneers in the field of CTO intervention although their success rates have been difficult to replicate. New techniques and equipment developed in North America offer an alternative to the Japanese approach. These techniques focus on time, radiation and contrast minimisation. This review will assess the histopathology of CTO and shifting paradigms in CTO treatment strategies

Förlustanalys av Elnätdistribution i Eskilstuna : En noggrann undersökning av elförluster och dess konsekvenser i ett område i Eskilstuna

This thesis explores the losses occurring in a specific region located in the southern part of Eskilstuna, where ESEM serves as the network owner. The study places particular emphasis on power factor and load factor as key factors. Its objective is to analyze and comprehend the extent of losses in the network and their implications. The results demonstrate that losses in the chosen area of the Eskilstuna network align with prior research and theoretical expectations. Based on calculations, the losses in this network segment amount to approximately 483 MWh per year, corresponding to a cost of approximately 272,000 Swedish Kronor for ESEM in 2022. The method of studies is based on calculations, analyzer, and literature studies to achieve a reliable result. The results show that losses within the selected area of the Eskilstuna network are consistent with previous research and theoretical expectations. Of the total loss, there are some customers who show larger losses compared to the average case. These customers were identified, and a summary analysis was made of their power factor and load factor standard deviation. These losses depend on various factors, such as the existence of reactive power, technical and non-technical losses. Measures to deal with these problems are suggested based on previous research and literature studies. Optimization of transformers, phase compensation and monitoring are some of these measures. This study provides significant insights into power grid losses and proposes potential strategies to mitigate these losses in the examined region. By minimizing such losses, ESEM has the potential to enhance the efficiency of the electrical grid, lower carbon dioxide emissions, and enhance economic outcomes for energy producers, the electricity grid operator, and consumers. For continued progress in the field, further research, and implementation of the proposed measures to streamline the power grid and reduce losses in the future is recommended.Elnätförluster har konsekvenser för miljön, energisystemet och slutanvändarna. När energi går förlorad i elnätet minskar den totala effektiviteten i systemet och ökar belastningen på kraftgenereringen. Detta kan leda till ökade kostnader för energiproducenter och potentiellt högre priser för konsumenterna. Dessutom kan ökade elnätförluster bidra till en ökning av koldioxidutsläppen från kraftverken och därmed ha en negativ miljöpåverkan. Syftet med studien är att undersöka det befintliga elnätet i det utvalda området genom analys av data från mät-elnätavdelningen i ESEM. Metoden för studien är baserad på beräkningar, analyser och litteraturstudier för att uppnå ett pålitligt resultat. Resultaten visar att förluster inom det valda området av Eskilstunanätverket överensstämmer med tidigare forskning och teoretiska förväntningar. Baserat på beräkningar uppgår förlusterna i detta nätsegment till cirka 483 MWh, vilket motsvarar en kostnad på cirka 272 000 svenska kronor för ESEM 2022. Av den totala förlusten finns det vissa kunder som uppvisar större förluster jämfört med genomsnittsfallet. Dessa kunder identifierades, och en översiktsanalys gjordes av deras effektfaktor och standardavvikelse för belastningsfaktorn. Dessa förluster beror på olika faktorer, såsom existensen av reaktiv effekt, tekniska och icke-tekniska förluster. Åtgärder för att hantera dessa problem föreslås baserat på tidigare forskning och litteraturstudier. Optimering av transformatorer, faskompensering och övervakning är några av dessa åtgärder. Denna studie bidrar med viktig kunskap om elnätförluster och identifierar potentiella åtgärder för att minska förlusterna i det studerade området. Genom att minska förlusterna kan man öka elnätets effektivitet, minska koldioxidutsläppen och förbättra ekonomiska aspekter för energiproducenter, elnätägaren och konsumenter. För fortsatta framsteg inom området rekommenderas ytterligare forskning och implementering av de föreslagna åtgärderna för att effektivisera elnätet och minska förlusterna i framtiden

Förlustanalys av Elnätdistribution i Eskilstuna : En noggrann undersökning av elförluster och dess konsekvenser i ett område i Eskilstuna

This thesis explores the losses occurring in a specific region located in the southern part of Eskilstuna, where ESEM serves as the network owner. The study places particular emphasis on power factor and load factor as key factors. Its objective is to analyze and comprehend the extent of losses in the network and their implications. The results demonstrate that losses in the chosen area of the Eskilstuna network align with prior research and theoretical expectations. Based on calculations, the losses in this network segment amount to approximately 483 MWh per year, corresponding to a cost of approximately 272,000 Swedish Kronor for ESEM in 2022. The method of studies is based on calculations, analyzer, and literature studies to achieve a reliable result. The results show that losses within the selected area of the Eskilstuna network are consistent with previous research and theoretical expectations. Of the total loss, there are some customers who show larger losses compared to the average case. These customers were identified, and a summary analysis was made of their power factor and load factor standard deviation. These losses depend on various factors, such as the existence of reactive power, technical and non-technical losses. Measures to deal with these problems are suggested based on previous research and literature studies. Optimization of transformers, phase compensation and monitoring are some of these measures. This study provides significant insights into power grid losses and proposes potential strategies to mitigate these losses in the examined region. By minimizing such losses, ESEM has the potential to enhance the efficiency of the electrical grid, lower carbon dioxide emissions, and enhance economic outcomes for energy producers, the electricity grid operator, and consumers. For continued progress in the field, further research, and implementation of the proposed measures to streamline the power grid and reduce losses in the future is recommended.Elnätförluster har konsekvenser för miljön, energisystemet och slutanvändarna. När energi går förlorad i elnätet minskar den totala effektiviteten i systemet och ökar belastningen på kraftgenereringen. Detta kan leda till ökade kostnader för energiproducenter och potentiellt högre priser för konsumenterna. Dessutom kan ökade elnätförluster bidra till en ökning av koldioxidutsläppen från kraftverken och därmed ha en negativ miljöpåverkan. Syftet med studien är att undersöka det befintliga elnätet i det utvalda området genom analys av data från mät-elnätavdelningen i ESEM. Metoden för studien är baserad på beräkningar, analyser och litteraturstudier för att uppnå ett pålitligt resultat. Resultaten visar att förluster inom det valda området av Eskilstunanätverket överensstämmer med tidigare forskning och teoretiska förväntningar. Baserat på beräkningar uppgår förlusterna i detta nätsegment till cirka 483 MWh, vilket motsvarar en kostnad på cirka 272 000 svenska kronor för ESEM 2022. Av den totala förlusten finns det vissa kunder som uppvisar större förluster jämfört med genomsnittsfallet. Dessa kunder identifierades, och en översiktsanalys gjordes av deras effektfaktor och standardavvikelse för belastningsfaktorn. Dessa förluster beror på olika faktorer, såsom existensen av reaktiv effekt, tekniska och icke-tekniska förluster. Åtgärder för att hantera dessa problem föreslås baserat på tidigare forskning och litteraturstudier. Optimering av transformatorer, faskompensering och övervakning är några av dessa åtgärder. Denna studie bidrar med viktig kunskap om elnätförluster och identifierar potentiella åtgärder för att minska förlusterna i det studerade området. Genom att minska förlusterna kan man öka elnätets effektivitet, minska koldioxidutsläppen och förbättra ekonomiska aspekter för energiproducenter, elnätägaren och konsumenter. För fortsatta framsteg inom området rekommenderas ytterligare forskning och implementering av de föreslagna åtgärderna för att effektivisera elnätet och minska förlusterna i framtiden