China has developed convalescent plasma to treat patients who are infected with COVID-19 patients and treatment effect is positive. There are some experiences worthy of our share in convalescent plasma collection and infusion. We successfully applied of the technique to therapy a COVID-19 patient in Hubei province, China.

A 59-year-old male with a history of unstable angina was diagnosed with a myocardial bridge of the left anterior descending artery (LAD) and apical variant hypertrophic cardiomyopathy (AHCM). He underwent unroofing of the myocardial bridge and a left ventricular apical myectomy. Intraoperatively, epicardial ultrasound was used to identify the myocardial bridge with systolic compression of the LAD and confirm resolution of this compression postoperatively. Furthermore, epicardial ultrasound was used for guiding the degree of apical resection of the decompressed heart. This novel use of intraoperative epicardial ultrasound can help guide surgeons preoperatively and confirm results immediately after an operation.

Pyoderma Gangrenosum could mimic early postoperative sternal wound infection. Steroids therapy is the only method of treatment recognizing the fact that steroids can lead to immunosuppression and inhibits healing after major surgery.

Rationale, aims, and objectives: Lean and Six Sigma methodologies are set of principles aimed at improving organizations through restructuring processes, and via identification and elimination of steps that do not add value for the consumer and result in wasted time, resources and expenses. Owing to its multifaceted nature and high impact on patient health and recovery, as well as its significant financial impact, the operating room (OR) environment is an obvious substrate for Lean and Six Sigma implementation. In this review, we aim to prioritize the most effective and reproducible optimization Lean and Six Sigma tool and to raise awareness among healthcare professionals about the current experience of Lean and Six Sigma utilization in the daily work routine in the OR. Methods: A computerized search from inception up to June 2019 of the online electronic databases PubMed and Google Scholar was performed. Studies investigating Lean or Six Sigma interventions considering various OR aspects were examined. Results: Most of the studies originated in the USA and demonstrated Value Stream Mapping (VSM) as the most common practiced optimization technique followed by the Define, Measure, Analyze, Improve, Control (DMAIC) tool. These methods provided the most effective sole tools for promoting positive changes in the work environment. Conclusions: Lean and Six Sigma implementation in the OR was found to be associated with improved safety and quality of care, reduced waiting times, increased patient satisfaction and cost reduction. We suggest that the implementation of a synergized approach, combining VSM and DMAIC tools, in the routine workflow may lead to a positive impact on productivity and efficiency, regardless of the scale or type of surgical procedures performed.

The brain is the most cholesterol rich organ in the body containing about 25% of the body’s free cholesterol. Cholesterol cannot pass the blood brain barrier and be imported or exported directly, instead it is synthesised in situ and metabolised to oxysterols, oxidised forms of cholesterol, which can pass the blood brain barrier. 24S-Hydroxycholesterol is the dominant oxysterol in brain after parturition but during development a myriad of other oxysterols are produced which persist as minor oxysterols after birth. During both development and in later life, oxysterols and other sterols interact with a variety of different receptors, including nuclear receptors e.g. liver X receptors; membrane bound G protein-coupled receptors e.g. smoothened; the endoplasmic reticulum resident proteins e.g. INSIG (insulin induced gene), or the cholesterol sensing protein SCAP (SREBP cleavage activating protein); and the ligand-gated ion channel N-methyl-D-aspartate receptors found in nerve cells. In this review we summaries the different oxysterols (neuro-oxysterol) and sterols (neuro-sterols) found in the central nervous system whose biological activity is transmitted via these different classes of protein receptors.

A discrete wrist-worn transdermal alcohol monitoring device, the BACtrack® Skyn™, was evaluated in a subject over three drinking sessions. The relationship between transdermal alcohol concentration (TAC) and breath alcohol concentration (BrAC) was evaluated. The relationship amongst contemporaneous TAC/BrAC measurements revealed an R2 of 0.65, while the relationship in the 45-minute post-drinking phase revealed an R2 of 0.89. Results obtained show promise for its use. Further research is needed with many subjects in real-world drinking situations.

Predicting the behavior of overland flow with analytical solutions to the kinematic wave equation is appealing due to its relative ease of implementation. Such simple solutions, however, have largely been constrained to applications on simple planar hillslopes. This study presents analytical solutions to the kinematic wave equation for hillslopes with modest topographic curvature that causes divergence or convergence of runoff flowpaths. The solution averages flow depths along changing hillslope contours whose lengths vary according hillslope width function, and results in a one-dimensional approximation to the two-dimensional flow field. The solutions are tested against both two-dimensional numerical solutions to the kinematic wave equation (in ParFlow) and against experiments that use rainfall simulation on machined hillslopes with defined curvature properties. Excellent agreement between numerical, experimental and analytical solutions is found in all cases. The solutions show that curvature drives large changes in maximum flow rate qmax and time of concentration tc, predictions frequently used in engineering hydrologic design and analysis.

SARS-CoV-2 has been shown to bind the host cell ACE2 receptor through its spike protein receptor binding domain (RBD), required for its entry into the host cells. We have screened phytocompounds from a medicinal herb, Tinospora cordifolia, for their capacities to interrupt the viral RBD and host ACE2 interactions. We employed molecular docking to screen phytocompounds in T. cordifolia against the ACE2-RBD complex, performed molecular dynamics (MD) simulation, and estimated the electrostatic component of binding free energy. ‘Tinocordiside’ docked very well at the center of the interface of AEC2-RBD complex, and was found to be well stabilized during MD simulation. Tinocordiside incorporation significantly decreased electrostatic component of binding free energies of ACE2-RBD complex (23.5 and 17.10 kcal/mol in the trajectories without or with the ligand, respectively). It indicates that such an interruption of electrostatic interactions between the RBD and ACE2 would weaken or block COVID-19 entry and its subsequent infectivity. We postulate that natural phytochemicals like Tinocordiside could be the viable options for controlling COVID-19 contagion and its entry into host cells.

BackgroundHypofractionated radiotherapy is the current standard for adjuvant radiotherapy across many centres. Further hypofractionation may be possible but remains to be investigated in non-caucasian populations with more advanced disease, with a higher proportion of patients requiring mastectomy as well as tumour bed boost. We are reporting the design of randomized controlled trial testing the hypothesis that a one week (5 fractions) regimen of radiotherapy will be non-inferior to a standard three week (15 fractions) schedule. MethodsWe describe a multicenter, randomized controlled trial recruiting patients at large academic centres across India. Patients without distant metastases who merit adjuvant radiotherapy will be eligible for inclusion in the study. Patients in the control arm will receive adjuvant radiotherapy to the breast or chest wall (with/without regional nodes) to a dose of 40 Gy / 15 fractions / 3 weeks, while those in the experimental arm will receive a dose of 26 Gy / 5 fractions / 1 week (to the same volume). Use of a simultaneous integrated boost (dose of 8 Gy and 6 Gy respectively) is allowed in patients who have undergone breast conservation. A sample size of 2100 patients provides an 80% power to detect a non-inferiority of 3% in the 5-year locoregional recurrence rate with a one-sided type I error of 2.5%, assuming that the locoregional recurrence rate in the control arm is 5% at 5 years (corresponding to a hazard ratio of 1.63). Patients will be recruited over a period of 5 years, and followed up for a further 5 years thereafter. Discussion If a five-fraction regimen of breast cancer is proven to be non-inferior, this will result in a  significant improvement in the access to radiotherapy, as well as reduced costs of treatment. The trial gives an opportunity to standardize and quality assure radiotherapy practices across the nation at the same time. Along with the results of the FAST Forward trial, the safety of this intervention in advanced node-positive disease requiring regional nodal radiation will be established.Trial Registration The trial has been registered at the Clinical Trial Registry of India (CTRI) vide registration number: CTRI/2018/12/016816 as well as the clinical trial.gov website at NCT03788213. The HYPORT Adjuvant Trial group is presented in the section \ref{author-details}.

This study was conducted to determine the most effective cell disruption method and oil extraction solvent on the microalgae Neochloris oleoabundans. The three methods, either individually or combinatorial, were as integrated enzymatic hydrolysis (E) by cellulase (1, 2, 3 and 4%, v/w) and Flavourzyme (0.5, 1, 1.5 and 2% v/w); ultrasonication (U) (20 KHz and 100% spin with 20 and 40 amplitudes for 3, 8 and 13 min); and homogenization (H) (7200, 11200 and 15600 rpm for 3 min). For oil extraction, the three solvents tested were water, ethanol and methanol. The most effective method for cell disruption (as judged by quantity of subsequently extracted oil) was the integrated E+H method, followed by the integrated E+U, respectively. The fatty acids C16:0, C18:1 and C18:2 were the main constituents of extracted oil. Methanol was the most effective solvent, extracting 6.44%, 19.66% and 20.54% of fatty acids. Furthermore, in terms of biodiesel characterization, the iodic index and cetane number of the extracted oil were as 63.15 and 73.84 in ethanol, 95.33 and 62.59 in methanol and 67.66 and 76.31 in water. Therefore, the most effective method was to use the E+H method for cell disruption followed by methanol as the suitable solvent for oil extraction.

In this study, heterogeneous silica-based catalyst was prepared from rice husk using a facile method for transesterification of palm fatty acid distillate (PFAD) into biodiesel. Huskcatacid and Huskcatbase were characterized using scanning electron microscopy (SEM), Energy Dispersive X-ray (EDX), Brunauer-Emmett-Teller (BET) surface area and pore size analysis. Results showed that Huskcatacid was efficiently employed in esterification of PFAD to afford 91.6% ester in 1:1 (PFAD:MeOH) and 5 wt% catalyst, followed by transesterification in 1:1 (oil: MeOH) using Huskcatbase (1 wt%) to produce 97.5% biodiesel in 30 min, with high percentage of methyl palmitate (34.43%) and methyl oleate (57.86%). Both Huskcatacid and Huskcatbase have high porosity (2.726 x 10-3 cm3/g and 4.985 x 10-3 cm3/g) and surface area (7.362 m2/g and 14.493 m2/g), respectively, which offer efficient esterification, easy glycerol separation and reusability up to three times to afford biodiesel ranging from 90-97% yield. The biodiesel obtained was applied on Megatech®-Mark III engine and demonstrated a proportional increased of torque (ɽ) with the B100 biodiesel loading. Rice husk demonstrated a good potential as solid support heterogeneous catalysts and feedstock for value-added products, which also assists to overcome agricultural waste management issues.

Biodiversity and community assembly are central topics in ecological studies, and mountains present natural laboratories for studying these issues. Most previous studies have focused on biodiversity hotspots and tropical regions, and relevant research in the middle and high latitudes is relatively limited. We hypothesized that species dispersion and habitat filtering simultaneously might drive the assembly of the current plant community in temperate region mountains. We studied the plant community of the Kunlun Mountains, an independent physical geographic unit located in northwest China on the northern edge of the Qinghai-Tibetan Plateau. We integrated measures of species distribution, geological history, and phylogeography, and analyzed the taxonomic richness, phylogenetic diversity, and phylogenetic community structure of the current plant community in the area. The distribution patterns of 1,911 seed plants showed that species were distributed mainly in the eastern and the southeastern parts of the Kunlun Mountains, which were considered as conservation targets for biodiversity. Similarities of genera and species strongly indicated that mass species migrations exist among the Kunlun Mountains and adjacent biodiversity hotspots. This indicated that the current patterns of species diversity were from species recolonization, and the plant species of the Kunlun Mountains originated primarily from the Hengduan Mountains which are a biodiversity hotspot. The net relatedness index (NRI) indicated that 17 of the 28 communities were phylogenetic clustering, and the others were phylogenetic dispersion. The nearest taxon index (NTI) indicated that 27 of the 28 communities were phylogenetic clustering, and the phylogenetic community structure of Banma County was the only example of overdispersion. By combining the standard effect size phylogenetic diversity (SES-PD) with the two indexes, we showed that species recolonization was likely to be an important evolutionary process affecting the assembly of current plant communities, and that habitat filtering may have drove the ecological processes of these communities.

Introduction Erectile Dysfunction (ED) is common in older age and in diabetes (DM). Phosphodiesterase type 5-inhibitors (PDE5-is) are the first-line for ED. We investigated how type of diabetes and age of males affects the PDE5-i use in the primary care setting. Methods 2018-19 general practice level quantity of all PDE5-i agents were taken from the GP Prescribing Data set in England. The variation in outcomes across practices was examined across one year, and for the same practice against the previous year. Results We included 5,761 larger practices supporting 25.8million men of whom 4.2million≥65 years old. Of these, 1.4million had T2DM, with 0.8million of these>65. 137,000 people had T1DM. 28.8million tablets of PDE5-i were prescribed within the 12 months (2018-19) period in 3.7million prescriptions (7.7 tablets/prescription), at total costs of £15.8million (£0.55/tablet). The NHS ED limit of 1 tablet/user/week suggests that 540,000 males are being prescribed a PDE5-i at a cost of £29/year each. With approximately 30,000 GPs practising, this is equivalent to one GP providing 2.5 prescriptions/week to overall 18 males. There was a 3x variation between the highest decile of practices (2.6 tablets/male/year) and lowest decile (0.96 tablets/male/year). The statistical model captured 14% of this variation and showed T1DM males were the largest users, while men age<65 with T2DM were being prescribed 4 times as much as non-DM. Those T2DM>65 were prescribed 80% of the non-DM amount. Conclusion There is wide variation in use of PDE5-is. With only 14% variance capture, other factors including wide variation in patient awareness, prescribing rules of local health providers, and recognition of the importance of male sexual health by GP prescribers might have significant impact.

Abstract This study estimated the annual economic burden of bovine and human brucellosis in Adjumani District, Uganda in the year 2016 as extension of a larger study that determined seroprevalence and risk factors for brucellosis in cattle and humans. Semi-structured questionnaires were administered to 25 households with Brucella seropositive cattle herds and 14 households with at least one Brucella seropositive person in order to capture economic burden in cattle and humans respectively. Data were analyzed using MS Excel 2007. In cattle, the total economic burden was estimated as a sum of costs associated with mortality of Brucella seropositive cows that abort and cost of morbidity of brucellosis among the cattle population. In humans, brucellosis burden was quantified in Disability Adjusted Life Years (DALYs) and monetary cost of human brucellosis episode. The total bovine brucellosis economic burden was estimated at UGX 2,692,809,443 (745,930.41). The economic burden associated with mortality of Brucella seropositive cows after abortion was UGX 23,488,155. Burden associated with morbidity was UGX 2,669,321,288 (USD 739,424) per year for the district cattle herd (131,282 cattle). The value of calves lost from abortion and perinatal mortality and milk lost from non-aborted seropositive cows accounted for 47% and 3.3% respectively of the total burden. The burden of human brucellosis was estimated at 887 DALYs, average monetary cost of human brucellosis episode was UGX 760,590 (USD 210.7) Out of which indirect cost (attributed to 14 days of lost income from not working), direct medical expenses (diagnostics, consultation and drugs), direct non-medical expenses (transport and food consumed) incurred by a human brucellosis patient amounted to 55.5% (117USD), 11.84% (USD 24.94) and 32.7% (USD 68.9), respectively. One Health approach is recommended for management of brucellosis in livestock and humans in the district. Key words; Brucellosis, economic burden

Natural enemies have been implicated as agents of negative density dependence (NDD) in tropical forests, but their relative contributions to NDD and thus the maintenance of diversity are largely unknown. We assessed the influence of natural enemies on density-dependent interactions among tropical seedlings, monitoring survival and relative growth rates in plots that excluded fungal pathogens, insects, small mammals, or large mammals. Only fungal pathogens caused density dependent mortality, and their exclusion reduced species diversity. Insects reduced relative growth rates when stem density was high, but because this was not driven by conspecific density, insects had little effect on species diversity. Mammals did not cause NDD interactions. We conclude that both fungal pathogens and insects drive NDD interactions among seedlings. Even so, only fungal pathogens increased species diversity, and consequently contribute critically to the structure of tropical tree communities.

Recent observations suggest that COVID-19 causes an “atypical” form of acute respiratory distress syndrome with impaired pulmonary circulation and enhanced thromboembolism. In this letter we have proposed that the interaction between erythrocytes and endothelial cells may have a crucial role in pathogenesis of COVID-19. Acknowledging this interaction suggests new targets for transnational research during the pandemic.

1. Trees are characterised by the large number of seeds they produce. Although most of those seeds will never germinate, plenty will. Of those which germinate, many die young, and eventually only a minute fraction will grow to adult stage and reproduce. Is this just a random process? Do variations in germination and survival at very young stages rely on variations in adaptations to microgeographic heterogeneity? and do these processes matter at all in determining tree species distribution and abundance? 2. We have studied these questions with the Neotropical Symphonia syngameon. In the Guiana shield, Symphonia are represented by at least two sympatric taxa or ecotypes, Symphonia globulifera found almost exclusively in bottomlands, and a yet undescribed more generalist taxon/ecotype, Symphonia sp1. A reciprocal transplantation experiment (510 seeds, 16 conditions) was set-up and followed over the course of 6 years to evaluate the survival and performance of individuals from different ecotypes and provenances. 3. Germination, survival, growth, and herbivory showed signs of local adaptation, with some combinations of ecotypes and provenances growing faster and surviving better in their own habitat or provenance region. S. globulifera was strongly penalised when planted outside its home habitat but showed the fastest growth rates when planted in its home habitat, suggesting it’s a specialist of a high-risk high-gain strategy. Conversely, S. sp1 behaved as a generalist, performing well in a variety of environments. 4. Synthesis: The differential performance of seeds and seedlings in the different habitats matches the known distribution of both ecotypes, indicating that environmental filtering at the very early stages can be a key determinant of tree species distributions, even at the microgeographic level and among very closely related taxa. Furthermore, such differential performance also contributes to explain, in part, the maintenance of the different ecotypes in the Symphonia syngameon living in intimate sympatry despite occasional gene flow.

A document by İzzet Fidancı. Click on the document to view its contents.

The assessment of left ventricular size is a fundamental component of echocardiography. This is typically performed by measuring the end-diastolic diameter of the left ventricle in the parasternal long-axis image. There are published norms for end-diastolic diameter, as well as thresholds that correspond with mild, moderate and severe left ventricular enlargement. Despite the reliance on end-diastolic diameter to determine left ventricular size, end-diastolic diameter does not always accurately reflect the left ventricular end-diastolic volume. This is especially the case in remodeled ventricles associated with aortic or mitral insufficiency. As left ventricular volumes continue to become easier to obtain, with improved accuracy and reproducibility, when will they become the primary echocardiographic technique for assessing left ventricular size?

Title: Is vestibulodynia a nociplastic pain syndrome? A commentaryAuthor : Filippo Murina, MDAffiliations: Lower Genital Tract Disease Unit, V. Buzzi Hospital–University of the Study of Milan, Milan, ItalyCorresponding Author: Filippo Murina,filippomurina577@gmail.com, Via Castelevetro 24-Milan (Italy). Tel number +300257995464-Fax number +390257995025Author Orcid. Filippo Murina: 0000-0002-9966-6448Running title : Is vestibulodynia nociplastic pain?A recent consensus statement differentiated between persistent vulvar pain of at least 3-month caused by a specific disorder (e.g., inflammatory, neoplastic, traumatic) and vulvodynia, which is vulvar pain without clear identifiable cause.1 The statement suggested using a pain-based system to characterize vulvodynia based on location (localized, generalized, or mixed), situations that elicit the pain (contact, spontaneous, or mixed), temporal pattern (intermittent or constant), and onset (primary or secondary).Vulvodynia is a highly prevalent form of chronic genital pain in women, to such an extent that prevalence studies estimate ranges from 10% to 28% in reproductive-aged women.2, 3 Localized provoked vulvodynia at the vestibule, known as vestibulodynia (VBD), is the most common manifestation of the disease (about 80%).4Women with VBD often describe vulvar pain as a burning, stinging, irritation, rawness, and dyspareunia (difficult or painful intercourse). Most women with VBD described their pain as “hot,” “burning,” or “pricking” and that the vestibular area is sensitive to the touch (e.g. during sexual intercourse or tampon use) and that the pain would be increased by rubbing. The pattern of VBD responses is suggestive of sensory abnormalities in the form of evoked pain (e.g. hyperalgesia or allodynia), suggesting sensitization, an underlying manifestation of neuropathic pain.This is consistent with biopsy studies that have demonstrated increased innervation of the vulvar vestibule and an increase in subepithelial heparinase activity and cytokines that have been linked to neuroinflammatory processes; patients with VBD also experience body changes in sensitivity, suggesting that sensory dysregulation might be involved the expression of this pain condition.5 Furthermore, the discomfort inherent in VBD is always associated with pelvic floor muscle overactivity.6 This prolonged pattern can result in decreased tissue perfusion, muscle dysfunctional overactivity, and the development of myofascial trigger points, resulting in localized or radiating pain and/or intense tenderness. Neuropathic pain and hypertonicity can be considered a multifactorial and complex consequence of maladaptive neuronal plasticity.7 Neuropathic pain is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.8According to this definition, VBD cannot be designated as a neuropathic pain, because a clear and evident lesion or a disease of the somatosensory system has not been identified as the cause of VBD pain. It may be argued that, by excluding VBD from the neuropathic pain syndrome, there is a risk of stigmatizing this group of patients as having a somatization disorder, one without a true and demonstrable abnormality, as opposed to the patients who have a “real” physical illness. The inability of this pain terminology to harmonize with the concepts of neuropathic pain has resulted in the use of other non-defined descriptors of VBD such as “dysfunctional” or “psychosomatic” pain, which not only give no insight into possible mechanisms but also carry implications that may stigmatize patients as only psychologically distressed. The International Association for the Study of Pain recently introduced the new pain descriptor “nociplastic pain,” defined as “pain that arises from altered nociception, despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain,” meant to cover cases not properly covered by neuropathic pain definition.8The descriptor is primarily addressed to patients with chronic pain conditions characterized by evidence of altered nociceptive processing, such as VBD, where altered nociception is clinically documented. Therefore, the new descriptor does not apply to patients reporting pain without hypersensitivity. As such, it is neither a synonym for idiopathic pain nor pain of an unknown origin. A multifactorial aetiology, including infections, hormone disorders, neuroinflammation, atopic disease, gene polymorphisms that interfere with inflammation, and psychogenic factors, has been implicated in the development and maintenance of VBD.8What is becoming increasingly apparent is that VBD is likely not one disease but rather several diseases, in which the common end point is vestibular hypersensitivity and pelvic floor hypertonic dysfunction. In my experience, VBD represents a summation and overlapping of various trigger factors (infections, hormonal disturbances, allergies, genetic aspects, psychological vulnerability, and others) with weight and predominance varying from patient to patient. It is impossible to say whether psychosexual factors are involved in the development or maintenance of VBD or whether they are the consequence of undiagnosed, persistent, and debilitating pain. Pain modulation by psychological factors is one of the most complex problems: in patients with VBD, psycho-neurobiological vulnerability plays a relevant role, and the experience of pain varies depending on the patient’s psychological state.In conclusion, I postulate that VBD results from diverse precipitating and trigger factors that ultimately promote and maintain a nociplastic pain syndrome. I believe these considerations provide the impetus for future work to identify responders of targeted treatments based on various subgroups of VBD.Disclosure of interests . None declared.Contribution to authorship . FM designed and wrote the manuscriptDetails of ethics approval . Ethics approval: N/A.Funding . NoneAcknowledgements . None

Pericardial cysts are considered rare incidental findings, which are generally asymptomatic in nature. Occasionally, patients may represent with chest discomfort, dyspnea or palpitations. Pericarditis related to a ruptured pericardial cyst has not been previously reported in the literature. Here, we report the case of a 62-year-old male who developed acute pericarditis as a result of a ruptured enlarging pericardial cyst.

Amid the 2020 Coronavirus pandemic, hydroxychloroquine sulfate (brand name Plaquenil or abbreviated HCQ) is being explored as a potential treatment for those affected with Covid-19 disease. Based on a limited in-vitro and anecdotal clinical data, the U.S. Food and Drug Administration (FDA) approved emergency use of hydroxychloroquine sulfate as an off- label medication for hospitalized COVID-19 patients weighing 50kg or more.1 Research Questions: 1. What is the safety profile of hydroxychloroquine sulfate compared to common outpatient medications such as acetaminophen and ibuprofen in terms of major and minor adverse effects? 2. Could hydroxychloroquine sulfate be used as an outpatient medication to treat COVID- 19?

Unexpected Inhibition of Pacing in a Patient with Complete AV Block after Upgrade of a Pacemaker to a Defibrillator: What is the Mechanism?Short Titel: Unexpected inhibition of pacingNicolas Schaerli, MD1, 2; Antonio Madaffari, MD1, 2; Beat Schaer, MD1, 2; Christian Sticherling, MD1,21 Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland2 Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4056 Basel, SwitzerlandDisclosures /Conflict of interest: Nothing to discloseCorresponding author:Christian Sticherling, MDUniversity Hospital Basel, Department of CardiologyPetersgraben 4, 4031 BaselEmail: christian.sticherling@usb.ch

Introduction - Over time, many patients with cardiac implanted devices (CIED) require revision or addition of leads. Predicting patency of the previously implanted vein is important in planning the procedure. The purpose of this study was to examine the accuracy of inspection of the skin overlying a previous CIED implant (usually the shoulder on the implanted side) for prominence of collateral veins, as a predictor of significant venous stenosis or obstruction. Methods - The shoulder area of 38 patients undergoing any procedure related to a previously implanted CIED was inspected by a physician who assigned a ‘collateral score’ of 1-4. Venography was then performed and assessed by two physicians, blinded to the assessment by physical examination. A ‘patency score’ was assigned (1-5). The predictive value of the collateral score for venous patency or any degree of obstruction was assessed. Results - The study included 38 patients. The area under the ROC curve of collateral score as a predictor of any degree of obstruction (patency score>1) was 0.859, indicating excellent correlation. A collateral score of 1.75 yielded a sensitivity of 78.9% and specificity of 88.6% for any degree of venous obstruction. Conclusion - In patients with a previously implanted cardiac device, patency of the implanted vein may be reliably predicted by lack of collateral veins on inspection. Keywords - Pacemaker, implanted device, lead revision, venous patency, physical examination