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Background Pulmonary vein (PV) reconnection is the main cause of atrial fibrillation (AF) recurrence. This study aimed to examine the effect of first‐pass PV isolation (PVI) on PV reconnection frequency during the procedure and on AF ablation outcomes. Methods This retrospective study included 446 patients with drug‐refractory AF (370 men, aged 64 ± 10 years) who underwent initial PVI using an open‐irrigated contact force catheter between January 2015 and October 2016. We investigated the effect of first‐pass PVI on PV reconnection during spontaneous PV reconnection and dormant conduction after an adenosine triphosphate challenge. Results First‐pass PVI was achieved in 69% (617/892) of ipsilateral PVs, of which we observed PV reconnection during the procedure in 134 (22%) PVs. This value was significantly lower than that observed in those without first‐pass PVI (50%, 138/275) (P, The 2‐year AF recurrence‐free rate was significantly higher in the first‐pass group than in the other group (75% vs. 59%, log‐rank P = 0.032). Absence of first‐pass PVI was associated with a higher frequency of spontaneous PV reconnection and dormant conduction and poor ablation outcomes. First‐pass isolation may be a useful marker for better PVI durability.

Although a left atrial posterior wall isolation (LAPWI) in addition to a pulmonary vein isolation is a well-accepted option for persistent atrial fibrillation (AF), a complete isolation can be challenging. This study aimed to evaluate the performance of a modified ablation index (AI) (AI/bipolar voltage along the ablation line) for predicting a durable LAPWI. The study included 55 consecutive patients, aged 65 ± 11 years, who underwent an electroanatomic mapping-guided LAPWI of AF. The association between the gaps (first-pass LAPWI failure and/or acute LAPW reconnections), voltage amplitude along the roof and floor lines, and thickness of the LAPW was investigated. Gaps occurred in 22 patients (40%) and in 26 (8%) of the 330 line segments. Gaps were associated with a relatively high bipolar voltage (3.38 ± 1.83 vs. 1.70 ± 1.12 mV, P

Introduction Successful pulmonary vein isolation (PVI) for atrial fibrillation (AF) depends on the formation of durable transmural lesions. Recently, novel indices have emerged to guide lesion delivery. The aim of the systematic review of literature was to determine AF recurrence following ablation guided by indices incorporating force, power and time, and compare acute procedural outcomes and 12-month AF recurrence with ablation guided by contact force (CF) guided only. Methods PubMed, EMBASE, and Web of Science Core Collection databases were searched on 27 January 2020 using the keywords; catheter ablation, ablation index (AI), lesion size index (LSI), contact force, atrial fibrillation. Results After exclusions, seven studies were included in the analysis. AI-guided catheter ablation was associated with a 91% (n=5, 0.91 95% CI; 0.88–0.93) and 80% (n=5, 0.80, 95% CI; 0.77–0.84) freedom from AF at 12 months with and without the use of anti-arhythmic drugs respectively. As compared to CF guided ablation, AI-guided catheter ablation was associated with a 49% increase in successful first pass isolation (n=3; RR: 1.49, 95% CI; 1.38, 1.61), a 50% decrease in number of acute reconnections (n=4; RR: 0.50, 95% CI; 0.39–0.65) and a 22% (n=4, RR: 1.22, 95% CI; 1.10–1.35) increase in AF freedom without anti-arrhythmic drugs at 12 months. Conclusions Radiofrequency ablation guided by AI was associated with higher successful first pass isolation and lower rates of acute reconnection which translates to greater freedom from AF at 12 months [CRD42019131469].

Background and purpose First pass effect (FPE) is defined as achieving modified treatment in cerebral infarction (mTICI) grade 2c/3 reperfusion from the first pass and is associated with more favorable outcomes. We aimed to compare FPE and non-FPE using a large database and further compare first-pass mTICI 2b with multiple passes mTICI 3. Methods A retrospective cohort study of acute ischemic stroke patients who received mechanical thrombectomy at a high-volume center was performed. Baseline characteristics and outcomes including rates of discharge and 90-day functional independence (modified Rankin Scale ≤2), mortality, symptomatic, and asymptomatic intracerebral hemorrhage were compared. Results Of the 637 patients included, 294 achieved FPE; 161 patients had multiple passes mTICI 3 and 36 had first pass mTICI 2b. Propensity-score matching resulted in 211 matched pairs for FPE vs non-FPE, and 30 matched pairs for multiple passes mTICI 3 vs first pass mTICI 2b. The FPE group had significantly more instances of discharge (33.6% vs 19.4%, p = 0.001) and 90-day functional independence (51.7% vs 40.8%, p = 0.032), and lower rates of mortality (18.0% vs 27.5%, p = 0.027) compared to non-FPE. There was no significant difference between first pass mTICI 2b and multiple passes mTICI 3 concerning any studied outcomes. Conclusions First pass mTICI 2c/3 is safer and is associated with higher rates of functional independence. We did not observe a significant difference between first pass mTICI 2b and multiple passes mTICI 3. The limitations of this study prevent us from drawing conclusions related to the difference between them and calls for future large-scale studies to explore that further.

Background There is paucity of literature documenting the intubation characteristics using ancillary protective gears innovated during pandemic times. We conducted a simulation based pilot study to compare the intubation characteristics with the use of intubation box (IB) and plastic sheet (PS) using both direct laryngoscope and videolaryngoscope. Methods It was a prospective simulation based trial involving sixteen senior residents as participants. Each resident performed six intubations, three using macintosh laryngoscope and 3 with videolaryngoscope each using intubation box, plastic sheet and without any ancillary equipment respectively. Time taken to intubation was recorded as primary outcome. First pass success rate, overall success rate, laryngoscopic view, ease of intubation and any breach in personal protective gear were the secondary outcomes. Results The mean time to intubation with DL without ancillary equipment, with PS and with IB was [11 (3.2) Vs 18.9 (6.7) Vs 15.94 (6.7), p = 0.0001] sec respectively, while with VL was [15.1 (7.5) Vs 25.2 (13.5) Vs 23.3 (11.4), p = 0.010] sec respectively. Pairwise comparison showed no difference between PS and IB with either DL or VL. There was statistically significant difference in the ease of intubation between DL and VL without any ancillary equipment (p = 0.018), with PS (p Conclusions Use of ancillary equipment prolonged the intubation time with both DL and VL, however increased difficulty in maneuvering the tube was faced with VL. This warrants aggressive simulation based training with both the VL and ancillary equipment before using them in clinical practice and testing them in the real world scenario.

Surgeon providers and billing professionals use Current Procedural Terminology (CPT) codes to specify patient treatment and associated charges. In the present study, coding discrepancies between surgeons' first pass coding and employed coders' final codes were investigated. A total of 500 patients over 3 months were retrospectively analyzed for coding discrepancies. To quantify the impact of change, codes with the most accumulated discrepancies were studied and change to annual relative value unit (RVU) was determined. Final submission of codes to billing demonstrated a 161% increase in total codes by the professional coders, versus original surgeon-derived codes (1594 vs 987 CPT codes). The most common source of change between the surgeon and coder was the addition of distinct codes by the billing professional (270 patients, 54.51%). These results demonstrate the existence of coding discrepancies. Future investigation will evaluate the communication between surgeons and billing professionals.

With the greatly increased popularity of segmented in vitro fertilization and frozen embryo transfers, progesterone replacement strategies in programmed cycles are being reexamined. Bidirectionality and the limited capacity of the uterine first pass provide an explanation for disconnects between the endometrial and serum levels when either vaginal or intramuscular progesterone is used alone. Whereas monotherapy departs from the physiology of spontaneous pregnancies, combined therapy provides physiologic replacement while minimizing the number of injections.

Background and study aims The poor flexibility of large-bore EUS needles often leads to technical failure when sampling from the duodenum. The aim of this study was to evaluate the technical and diagnostic performances of a new Menghini tip 19G nitinol EUS needle for sampling pancreatic solid lesions in the head and uncinate process. Patients and methods This was a European prospective multicenter single-arm study. A maximum of four passes were allowed. In case of failure, different needles were permitted. Results We included 75 patients (51 % males) with lesions in the head (n = 68; 91 %) and uncinate process (n = 7; 9 %) (mean size: 33 ± 12 mm; number of passes: 1.8 ± 0.9). Technical success was seen in 71 of 75 (94.7 %). Diagnostic rates were 89.3 % (67/75) and 94.4 % (67/71) in the intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. In the eight cases with failure, diagnosis was obtained with another needle (n = 4), from another lesion (n = 3) or with follow-up (n = 1). A histological sample was obtained in 64 patients (ITT 85.3 % and PP 90 %) and immunohistochemistry was successfully performed in 13 of 15 lesions in which it was required. No differences between rapid on-site evaluation (ROSE) and non-ROSE groups were observed regarding diagnostic success (87.5 % vs 91 %, P = 0.582) and diagnosis at the first pass (70 % vs 81 %, P = 0.289). Number of passes was lower in the ROSE group (1.4 + 0.9 vs 2.2 + 0.7, P Conclusions The new nitinol Menghini tip 19G EUS needle showed high technical diagnostic success in safely sampling solid lesions in the head and uncinate process of the pancreas.

BACKGROUND First-pass success is the successful intubation on the first attempt. It is the desired goal of emergency intubation and failure to achieve it may increase the risk of adverse effects. With failure of first pass intubation, life-threatening complications occur, commonly in critically ill patients. The aim of this study is to determine the association between the success of first-pass intubation and frequency of adverse events during endotracheal intubation. METHODS A cross sectional analytical study was done in a tertiary care hospital between October 2016 and October 2017. 100 failed first-pass intubation cases and 100 successful first-pass intubation cases were evaluated for factors associated with failed first-pass intubation and frequency of adverse events following intubation. RESULTS The groups were matched with respect to gender, induction agent use, fentanyl use and type of laryngoscope used. Mean age in failed first-pass intubation group was 5.61 years higher than subjects in successful first-pass intubation group (P = 0.016). Proportion of subjects with difficult airway was 19 % in failed first-pass intubation group and 3 % in successful first-pass intubation (P < 0.001). Failed first-pass intubation cases had higher frequency of adverse events like oesophageal intubation (9 % vs. 0 %), aspiration (7 % vs. 1 %), cuff leakage (2 % vs. 0 %) and hypotension (7 % vs. 1 %) compared to successful first-pass intubation cases. CONCLUSIONS The frequency of adverse events was high in failed first-pass intubation. Older age and presence of difficult airway were factors significantly associated with failed first-pass intubation. KEYWORDS First Pass Intubation, First-Pass Success, Adverse Events, Emergency Department, Failed First Attempt, Endotracheal Intubation

Flange wrinkling will occur when the dual-metal sheet is formed to a certain degree in conventional spinning, leading to forming failure, so it is necessary to study the flange wrinkling defects. In order to predict and avoid the flange wrinkling, a theoretical model for calculating the forming limit was proposed according to the energy method. Additionally, experiments and numerical simulations were conducted to study the wrinkling and verify the established model. Based on the above analytical model, forming limit diagrams of flange wrinkling in the first-pass conventional spinning were given, and the effects of roller feed rate (f), blank thickness (t), the thickness ratio (λ) of each layer on the flange wrinkling of dual-metal sheets were further analyzed. It is concluded that increasing the roller feed rate and reducing the thickness of the dual-metal sheet will cause the flange to be more prone to instability and wrinkles. And analytical results are consistent with numerical and experimental results. Considering that the finite element (FE) model is difficult to set up, the theoretical method provides guidance for the selection of process parameters to avoid wrinkling defects.

The study was carried out in 80 patients admitted in ICU and OT at IGMC Shimla. Patients were divided into 2 groups:- group A (short axis) and group B(long axis) of 40 patients each. Internal jugular vein cannulation was done under USG guidance using the two techniques. We were successfully able to cannulate all the patients. We obtained vascular access with higher first pass success and less number of needle passes using short axis approach compared to long axis. Keywords: internal jugular vein cannulation, USG guided approach, short axis versus long axis technique, Central vein catheterization

This manuscript reviews the literature for all in silico, ex vivo, in vitro, in vivo and clinical studies of high-power short-duration (HPSD) radiofrequency (RF) ablations. It reviews the biophysics of RF energy delivery applicable to HPSD and the use of surrogate endpoints to guide the duration of HPSD ablations. In silico modeling shows that a variety of settings in power, contact force and RF duration can result in the same surrogate endpoint value of ablation index and several HPSD combinations produce lesion volumes similar to a low-power long-duration (LPLD) RF application. HPSD lesions are broader with more endocardial effect and are slightly shallower but still transmural. The first 10 s of RF application is most important for lesion formation with diminishing effect beyond 20 s. The ideal contact force is 10-20 g with only a small effect beyond 30 g. In vitro and in vivo models confirm that HPSD makes transmural lesions that are often broader and shallower, and with proper settings, result in fewer steam pops than LPLD. One randomized trial shows better outcomes with HPSD and validates lesion size index as a surrogate endpoint. Clinical studies of HPSD using comparator groups of LPLD ablations uniformly show shorter procedure times and shorter total RF energy delivery for HPSD. HPSD generally has a higher first pass vein isolation rate and a lower acute vein reconnection rate than LPLD. Although not dramatically different from LPLD, long-term freedom from atrial fibrillation and complication rates seem slightly better with HPSD.

Background First-pass efficacy (FPE) is an established marker of technical and clinical efficacy among mechanical thrombectomy (MT) techniques. It is unclear what the optimal approach is in achieving FPE. We present a single-center experience comparing rates of FPE among 2 MT techniques and evaluate the potential predictors of FPE among other outcomes. Methods A single-center retrospective analysis was carried out of patients with consecutive large-vessel occlusion strokes (LVOS) of anterior circulation from September 2015 to April 2019 who underwent MT and for whom data were available on the status of FPE. Four MT techniques were identified: ADAPT (a direct first-pass aspiration), SrADAPT (stent retriever with aspiration), SRBG (stent retriever with balloon guide catheter), and STRAP (stent retriever-aspiration and proximal flow arrest). The primary outcome was FPE and secondary outcomes included the rate of successful reperfusion. Results Among 226 patients with LVOS of the anterior circulation who underwent MT, data were available for 164 on FPE for the 4 MT techniques. SRBG was the most prevalent technique. No significant difference was found in rates of FPE among the 4 MT techniques (P = 0.332). No independent predictors of FPE were identified on multivariable analysis. STRAP had the highest rate of successful reperfusion compared with the other techniques (P = 0.049) and was the only independent predictor of that outcome (P = 0.027). Conclusions Among patients with LVOS of the anterior circulation, the rate of FPE did not differ among the 4 MT techniques. There were no predictors of FPE among the studied variables. STRAP was the only predictor of successful reperfusion.

Background/Aims Recently, a three-plane symmetric needle with Franseen geometry was developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). In this retrospective study, tissue acquisition per pass was compared between 22-gauge Franseen FNB and standard fine needle aspiration (FNA) needles in patients with solid pancreatic lesions. Methods Consecutive patients who underwent EUS-FNA or EUS-FNB for solid pancreatic lesions between October 2014 and March 2018 were retrospectively studied. The tissue acquisition rate and the diagnostic performance per session, per pass, and at first pass were compared. Results A total of 663 passes (300 by the FNB needle and 363 by the standard FNA needle) were performed in 154 patients (71 FNB and 83 FNA). The tissue acquisition rate per session and at first pass in the FNB and FNA groups was 100% and 95% (p=0.13) and 87% and 69% (p=0.007), respectively. The multivariate analysis revealed that among the patients, EUS-FNB (odds ratio, 3.07; p=0.01) was associated with a higher first-pass tissue acquisition rate. While the tissue acquisition rate reached a plateau after the 4th pass with FNA, it reached a plateau after the 2nd pass with FNB. Among the 129 malignant cases, the histological tissue acquisition rate per session was similar (100% and 94%), but the sensitivity by histology alone per session was higher for FNB than for FNA (93% and 73%, p

BackgroundFirst-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children.MethodsWe performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS.ResultsIntubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen.ConclusionsPlacement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.

Introduction: Different results are described after atrial fibrillation ablation and multiples predictors of recurrence are well established. Objective: Evaluate and analyze if first-pass isolation effect (FPI) during first atrial fibrillation (AF) ablation with high-power short-duration (HPSD) comparing to low-power long-duration (LPLD) can impact on late outcome. Methods: Observational, retrospective study, 144 patients submitted to HPSD and LPLD ablation. HPSD: 71 patients, 50 (70.42%) males, mean age 59.73 years, 52 (73.24%) hypertension, 44 (61.97%) obstructive apnea, 23 (32.39%) arterial disease, 20 (28.17%) diabetes, and 10(14.08%) stroke. CHADS2VASC2 2.57. CT: 73 patients, 50 (68.49%) males, mean age 60.7 years, 53 (72.60%) hypertension, 41 (56.16%) obstructive apnea, 28 (38.36%) arterial disease, 14 (19.17%) diabetes and 8 (10.96%) stroke. CHAD2SVASC2 2.22. Results: Recurrence occurred in 33 patients (22.92%) at 12 months follow-up, HPSD with 9 patients and LPLD with 24 patients. Higher rate of bilateral FPI were observed in HPSD patients with 62 of 71 patients comparing to 17 of 73 patients in LPLD (P < 0.00001). At the end of study 62 (87.32%) of 71 HPSD patients were in sinus rhythm comparing to 49 (67.12%) of 73 patients in LPLD (P 0.0039). Conclusion: HPSD ablation produced higher rates of FPI comparing to LPLD. HPSD compared to LPLD showed a superiority in maintaining sinus rhythm at 12 months. At patients submitted to HPSD protocol ablation, FPI could predict higher rate of sinus rhythm at 12 months follow-up.

Background:While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day.Methods:We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables.Results:The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037).Discussion:After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Marginal-restraint mandrel-free spinning is an advanced technology for manufacturing ellipsoidal heads with large diameter-thickness ratios. The effects of spinning parameters on the forming accuracy of ellipsoidal heads have been studied, and optimized spinning parameters have been obtained. The microstructure evolution of a workpiece is usually very complicated in the spinning process. In this work, the influence of spinning parameters on the microstructures of two-pass spun ellipsoidal heads is studied. It is found that the forming angle and feed rate of the first pass, angle between passes, and feed rate of the second pass significantly affect the microstructures. Meanwhile, the evolution rule of the microstructures near the inner and outer surfaces of the spun parts is almost consistent. A large forming angle, large angle between passes, or large feed rate of the second pass are beneficial to obtain uniform microstructures. A small or large feed rate of the first pass reduces the microstructure uniformity. To improve the microstructure uniformity between the inner and outer surfaces, the optimized spinning parameters are determined.

Objective The Solitaire Platinum 4×40 mm stent retriever contains radiopaque markers with a long length. We evaluated the effect of Solitaire Platinum 4×40 mm stent retriever in Solumbra technique thrombectomy, and compared it with shorter Solitaire stent retrievers. Methods A total of 70 patients who underwent Solumbra technique thrombectomy with equal diameter (4 mm) and different length (40 vs. 20 mm) Solitaire stent retrievers were divided into two groups : the Solitaire Platinum 4×40 mm stent (4×40) group and the Solitaire FR 4×20 mm stent or Solitaire Platinum 4×20 mm stent (4×20) group. The clinical outcomes, Thrombolysis in Cerebral Infarction score, the first pass reperfusion status, and complications were evaluated and compared between the two groups. Multivariate analysis was performed to evaluate the predictive factors for reperfusion and complete reperfusion from the first pass. Results Higher first-pass reperfusion and complete reperfusion were achieved in the 4×40 group (68.0% and 48.0%) than in the 4×20 group (46.7% and 33.3%; p=0.004 and 0.007, respectively). In multivariate analysis, radiopaque device and longer stent retriever were correlated with first-pass reperfusion (p=0.014 and 0.008, respectively) and first-pass complete reperfusion (p=0.022 and 0.012, respectively). Conclusion Our study demonstrated the usefulness of the Solitaire Platinum 4×40 mm stent retriever, which led to higher firstpass reperfusion and complete reperfusion rates than the Solitaire FR 4×20 mm stent or the Solitaire Platinum 4×20 mm stent, especially in Solumbra technique thrombectomy.

Background Video-laryngoscopy has proven valuable in management and training of difficult airways. We evaluate the Yann tube, a novel bi-directional articulable endotracheal tube and video stylet combination, together with video-laryngoscopy in a simulation setting to determine if it improves management and education of difficult airways. Methods We evaluated the Yann tube (with video-laryngoscopy) against direct and video-laryngoscopy alone across four simulated airway scenarios, and measured time and attempts to successful intubation, percentage-of-glottic-opening (POGO) score, and Cormack-Lehane grading. Afterward, we surveyed participant subjective experiences. Results There were 32 participants of varying experience. Pharyngeal obstruction was the only airway scenario where the Yann tube was significantly slower than video-laryngoscopy alone (37s vs 27s; p Conclusions Although the Yann tube did not significantly improve successful first pass intubation, it did not significantly take longer to perform, and improved airway visualization in certain difficult airway scenarios. The use of simulation also enhanced education and understanding of airway anatomy for novice intubators.

BackgroundClot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion.MethodsClot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis.ResultsAmong all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034).ConclusionsClot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.

Background The NeVa™ thrombectomy device (Vesalio LLC, Nashville, USA) has been reported to succeed in large vessel occlusion thrombectomy in animal, in-vitro, and clinical studies. Designed with Drop Zone technology, a closed distal tip, and strong expansive radial force, the device demonstrated particular efficiency in resistant “white” thrombi in preclinical research. Our goal is to determine the safety and performance of this novel stent retriever on first-pass rates and overall recanalization. Methods The Interventional Neurology Database is a prospectively maintained database of anterior and posterior circulation stroke thrombectomy cases. We retrospectively analyzed cases where the NeVa™ thrombectomy device was used as the first-line treatment strategy. Data collection occurred between January 2019 and January 2020. First-pass recanalization, final recanalization, 90-day functional outcome, complication, and bleeding rates are reported. Results One hundred eighteen patients were treated with the NeVa™ thrombectomy device. The mean patient age was 69 ± 14 years, the median baseline National Institutes of Health Stroke Scale was 14, and the median initial Alberta Stroke Program Early Computed Tomography score was 8. The median time from groin puncture to successful recanalization was 29 min (interquartile range (IQR): 20–40). First-pass recanalization rates were 56.8% (modified treatment in cerebral infarction (mTICI) 2b/3) and 44.9% (mTICI 2c/3). Final successful recanalization rate was 95.8% (thrombolysis in cerebral infarction 2b/3). Favorable functional outcome (modified Rankin Scale 0–2) was 53% in the “first-pass” subgroup and 42.4% in the total patient population. The median number of passes to achieve the final recanalization score was 1 (IQR 1–2). The rate of embolization into new territory was 1.7%. Four patients (3.3%) had symptomatic hemorrhage. Conclusions In our experience, the NeVa™ device demonstrated high first-pass and overall recanalization rates along with a good safety profile.

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.MethodsA prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR ResultsA total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR ConclusionsThe impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

Background: To our knowledge, there has been no study comparing intubation characteristics between attending and non-attending emergency physicians in Southeast Asia. We aim to identify whether the use of direct laryngoscopy compared to video laryngoscopy affects first-pass success rates between attending emergency physicians and non-attending emergency physicians. Materials and methods: Retrospective analysis of data from 2009 to 2016 in an existing airway registry managed by an academic Emergency Department in Singapore. Primary outcome was first-pass success intubation rate. Secondary outcome was first-pass success rate for difficult intubations. Difficult intubations were defined as LEMON (Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility) score of more than 1. Results: There were a total of 2909 intubations. Attending emergency physicians conducted 1748 intubations, while non-attending emergency physicians conducted 1161 intubations. The first-pass success rates for AEP were 84.2% and 67.4% for non-attending emergency physicians. Direct laryngoscopy was used in 86.2% of intubation by attending emergency physicians compared to 89.0% in the intubation by non-attending emergency physicians. Also, 7.6% of intubations by the attending emergency physicians were difficult compared to 8.8% by the non-attending emergency physicians (p = 0.25). Logistic regression of the effect of laryngoscopy device on first-pass success in all intubations showed a negative association with video laryngoscopy (odds ratio, 0.70; 95% confidence interval, 0.56–0.88). In the subgroup of difficult intubations, non-attending emergency physicians are 1.54 times (95% confidence interval, 0.53–4.42) as likely to have first-pass success with video laryngoscopy compared to that with direct laryngoscopy. On the contrary, in the subgroup of difficult intubations, attending emergency physicians are 0.90 times (95% confidence interval, 0.38–2.12) as likely to have first-pass success with video laryngoscopy compared to that with direct laryngoscopy. Conclusion: Our study showed that video laryngoscopy has a lower first-pass success rate for all intubations in general. Intubations performed by attending emergency physicians with direct laryngoscopy were associated with a higher first-pass success rate.

Recent treatment approaches of osteoarthritis (OA) face a number of obstacles due to the progressive multitude of pain generators, nociceptive mechanisms, first pass mechanism, less efficacy and compromised safety. The present study was aimed to bring a novel approach for the effective management of OA, by developing sublingual targeted nanovesicles (NVs) bearing tapentadol HCl (TAP), surface modified with chondroitin sulfate (CS). Optimized nontargeted nanovesicle formulation (MB-NV) was developed by an ultrasound method, characterized as spherical in shape, nanometric in size (around 150 nm) with narrow size distribution (polydispersity index0.5), and good entrapment efficiency (around 50%). MB-NV conjugated with CS which was confirmed by IR and

La variabilidad, imprevisibilidad y bajo tanteo del fútbol lo convierten en un sistema dinámico y complejo de analizar donde cada detalle puede ser determinante para el resultado final. Por ello, el principal objetivo de este trabajo es analizar los goles recibidos (N=61) de un equipo de fútbol profesional a partir de variables situacionales, ofensivas y defensivas. Se aplicó la metodología observacional para analizar al Real Betis Balompié (temporada 2017-2018) a partir de una herramienta validada. Fueron utilizadas técnicas de análisis descriptivas y tests de independencia. Los resultados sobre las variables situacionales reflejan que en el ‘intervalo 76-90’ e ir ‘perdiendo’ son factores que provocan el aumento de goles encajados. La forma y zona de pérdida que obtuvieron mayores porcentajes fue ‘Robo’ (36,1%) y ‘Z6’ (19,7%). Del total de goles encajados, el 62,3% fue con 4 o más jugadores propios por delante del balón. Respecto al rival, utiliza pocos pases (

The texture evolution of copper tube manufactured by floating plug drawing process was investigated by Electron Backscatter Diffraction techniques and Visco-Plastic Self-consistent (VPSC) modelling method. The results obtained from experimentation indicate that the initial textures of copper tube transformed sharply after the first pass of the drawing process, and the final textures in the tube consist of Goss {110} and P {110} components. The VPSC model was established in order to study the texture transformation and the activity of slip systems of the tube during the drawing process. Two types of transformation paths were proposed to explain the mechanism of the texture evolution, which has a good agreement with the VPSC simulation results.

A first pass workflow for placing cover sequence materials into four broad lithological groups using A-CNK-FM (Al2O3-CaO + Na2O + K2O-Fe2O3+MgO) and A-CN-K (Al2O3-CaO + Na2O-K2O) ternary diagrams in conjunction with the SiO2 vs Al2O3, Fe2O3 and CaO plus the Ca versus Sr XY diagrams has been derived from lithological logging and laboratory whole-rock geochemistry of 2346 samples. These lithological groups include siliciclastics (quartz sands and clays), weathered material, carbonate lithologies (marine limestone, pedogenic carbonate and compositions intermediate between the two end members) and ferruginous lithologies (including ferricrete and ferruginous sediments). Depositional, weathering and groundwater processes influence sample geochemistry during or after the formation of the material and will influence where the sample will plot on the geochemical diagrams used in this study. Geochemical data for discrete lithologies targeted during sampling (e.g. carbonate lithologies) clusters on diagrams used in the geochemical workflow, whereas data from targeted stratigraphic horizons (e.g. basement-cover interface) are more variable. The ability to characterise rock types that are texturally defined using the geochemical workflow is limited. For instance, the geochemistry of diamictite/conglomerate samples is dependent on the matrix versus clast content and composition as well as the source rock and catchment area. This workflow has the potential to be applied in a mineral exploration environment for rapid interpretation of real-time geochemical (e.g. portable XRF) data to gain an understanding of background geochemistry and geochemical signatures that may be related to underlying mineralisation.Key points A workflow for broad lithogeochemcial characterisation of cover sequence materials has been developed. Uses commonly collected major element plus strontium data acquired by laboratory or portable techniques. Categorises materials into siliciclastics, weathered material, carbonate lithologies and ferruginous lithologies. Applications include a mineral exploration environment for interpretation of large geochemical datasets to understand geology and mineralisation vectors. Refereed/Peer-reviewed

Background: There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. Methods: We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. Results: In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. Discussion: For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Acute ischemic stroke (AIS), the result of embolic occlusion of a cerebral artery, is responsible for 87% of the 6.5 million stroke-related deaths each year. Despite improvements from first-generation thrombectomy devices for treating AIS, 80% of eligible stroke patients will either die or suffer a major disability. In order to maximize the number of patients with good outcomes, new AIS therapies need to be developed to achieve complete reperfusion on the first pass. One such therapy that has shown promise experimentally is the application of cyclic aspiration pressure, which led to higher recanalization rates at lower pressure magnitudes. In order to investigate AIS and cyclic aspiration recanalization, an improved computational modeling framework was developed, combining a viscoelastic thromboembolus model with a cohesive zone (CZ) model for the thromboembolus-artery interface. The model was first validated against experimental displacement data of a cyclically aspirated thromboembolus analog. The CZ model parameters, including the addition of a damage accumulation model, were then investigated computationally to determine their individual effects on the thromboembolus and CZ behavior. The relaxation time and the damage model critical opening length were shown to have the greatest effect on the CZ opening and led to increased displacement that accumulated with repeated loading. Additional simulations were performed with parameters relevant to AIS including internal carotid artery dimensions and thromboemboli mechanical properties. In these AIS cases, more upstream CZ opening was observed compared to the thromboembolus analog cases and greater displacement was achieved with the lower-frequency aspiration (0.5 vs 1 Hz).

Background: Mechanical thrombectomy (MT) is an effective treatment for acute cerebral large vessel occlusion (LVO). Complete recanalization of vessels in a single procedure is defined as the first-pass effect (FPE) and is associated with good prognosis. In this study, angiographic clot protruding sign termed the “claw sign,” was examined as candidate preoperative imaging factor for predicting the FPE. Methods: We retrospectively analyzed data from 91 consecutive patients treated for acute LVO in the anterior circulation by MT between January 2014 and December 2019. The claw sign was defined as a thrombus that protruded proximally by more than half of the diameter of the parent artery. Radiological findings such as claw sign, clinical and etiological features, and outcomes were compared between groups with and without successful FPE. Multivariate analysis was conducted to evaluate perioperative factors associated with FPE. Results: FPE was achieved in 26 of 91 (28.6%) patients and the claw sign was observed in 34 of 91 (37.4%) patients. The claw sign was significantly more frequent in the successful FPE group than in the failed FPE group (53.8% vs. 30.8%; P = 0.040). After the multivariate analysis, the claw sign was the only pretreatment parameter that could predict FPE (odds ratio, 2.67; 95% confidence interval, 1.01–7.06; P = 0.047). Conclusion: The claw sign is an angiographic imaging factor that might predict FPE after MT for anterior circulation acute ischemic stroke.

Cavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI depth and ablation parameters on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was p p 420 and > 386, respectively. Among patients with these cut-off values, the first-pass success rate was 89% in the SC and 50% in the DC (p

Gastrointestinal absorption remains indispensable in the systemic delivery of most drugs, even though it presents several challenges that, paradoxically, may also provide opportunities that can be exploited to achieve maximal bioavailability. Drug delivery systems made from nanoparticle carriers and especially, lipid carriers, have the potential to traverse gastrointestinal barriers and deploy in the lymphatic pathway, which aptly, is free from first pass via the liver. Several poorly soluble drugs have presented improved systemic bioavailability when couriered in lipid nanoparticle carriers. In this review, we propose an additional frontier to enhancing the bioavailability of poorly soluble drugs when encapsulated in lipid nano-carriers by imparting muco-adhesion to the particles through application of appropriate polymeric coating to the lipid carrier. The combined effect of gastrointestinal muco-adhesion followed by lymphatic absorption is a promising approach to improving systemic bioavailability of poorly soluble drugs following oral administration. Evidence to the potential of this approach is backed-up by recent studies within the review.

Background It is well-known that antiarrhythmic drugs (AAD) change the electrophysiological properties of the atrium mostly by increasing the atrial refractory period and wavelength for reentry. Frequently, atrial fibrillation (AF) catheter ablation is being performed with AAD interruption. However, the information on the impact of AAD on AF ablation performance is lacking, and AAD interruption is not desirable in highly symptomatic patients with persistent arrhythmia. Purpose We sought to study potential differences in achieving first-pass pulmonary vein isolation (FPI) during AF ablation in patients receiving different classes of ongoing AADs. Methods This was a prospective observational multicenter registry. All centers were invited to participate in the registry voluntarily. Data on demographic, clinical, and procedure characteristics were derived from a web-based system. All catheter ablation procedures were performed according to local practices. A total of 450 patients were enrolled, 408 of them underwent first-time AF ablation. Data on AAD characteristics were available in 350 patients (mean age 61±9 years, 195 (56%) males, 270 (77%) had paroxysmal AF). All patients were divided into three groups: ongoing I class AAD treatment (propafenone, ethacyzin, allapinin, n=76), ongoing II class AAD (beta-blockers, n=60), and ongoing III class AAD (amiodarone, sotalol, n=214). Results Baseline clinical and procedural characteristics between AAD groups are summarized in Table. Patients in the I class AAD group were younger, likely had paroxysmal AF, and a smaller mean left atrial diameter. Procedures in the III class AAD group were performed with a higher median target ablation index on the posterior left atrial wall. But the percentage of first-pass isolation was distributed equally between groups (60%, 68%, 61%, p=0.56). The correlation matrix revealed no significant associations between FPI and clinical and procedural variables (r=0.02–0.09; p>0.05 for all). Conclusion(s) Our real-life multicenter data demonstrate no difference in FPI achievement between patients receiving different AADs. We suggest that highly symptomatic patients may continue pharmacological treatment during AF ablation without compromising acute ablation success. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Higher Education grant (Russian Federation President Grant) Table 1. Clinical and procedural parameter

Background and Aims: Aspiration thrombectomy is an effective method of recanalizing large vessel occlusion (LVO). However, the efficacy of a direct aspiration first-pass technique (ADAPT) for recanalization of LVO of different etiologies is not properly understood.Methods: The prospectively collected database on ADAPT was reviewed retrospectively. We defined two groups of enrolled patients: the embolism-related occlusions (EMB-O) group and the intracranial atherosclerotic stenosis (ICAS)-related occlusion (ICAS-O) group. Baseline characteristics, procedural variables, and post-procedural variables were collected. Multivariate logistic regression analysis was used to identify first-pass recanalization predictors.Results: Of 114 registered patients, 94 were eligible for this study (51 patients in the EMB-O group and 43 patients in the ICAS-O group). Achieving successful reperfusion immediately after direct aspiration was more frequent in the EMB-O group than in the ICAS-O group (64.71 vs. 27.91%, respectively, p = 0.006), with fewer additional rescue treatments needed (35.29 vs. 70.09%, respectively, p = 0.001). The EMB-O group also showed a higher final successful reperfusion rate (96.8 vs. 74.41%, p = 0.006). However, the 90-day good functional outcomes were not affected by the groups. Independent predictors of first-pass success of aspiration included the isolated middle cerebral artery site of occlusion, embolic etiology, and use of larger bore catheters.Conclusions: The efficacy of ADAPT recanalization approach was better in EMB-O than in ICAS-O. In case of embolic etiology and the isolated MCA site of occlusion, using a larger aspiration catheter for direct aspiration thrombectomy may be reasonable.

The arterial input function (AIF) describes the contrast agent input to the myocardium and is required for perfusion quantification ([1][1]). Cardiovascular magnetic resonance quantitative perfusion analysis typically uses the basal left ventricular (LV) blood pool to sample the AIF, despite this