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Complex aortic arch configurations and internal carotid artery (ICA) tortuosity were bad news for carotid artery stenting, but not endarterectomy, according to an MRI substudy of the International Carotid Stenting Study (ICSS).

New ischemic brain lesions on diffusion-weighted MRI after treatment were found in 51% of cases after stenting and 16% of cases after surgery (OR 6.0, 95% CI 2.9-12.4), the paper in the May 2017 issue of Stroke showed.

With carotid artery stenting, Leo Bonati, MD, of University Hospital Basel in Switzerland, and colleagues found age-independent predictors for new brain lesions to be aortic arch configuration type 2 or 3 (OR 2.8, 95% CI 1.1-7.1) and an ICA angle of 60 or higher (OR 4.1, 95% CI 1.7-10.1).

Those whose largest ICA angle was at least 60 had a 12-fold higher risk of strokes during stenting over their peers with smaller ICA angles (OR 11.8, 95% CI 4.1-34.1).

Complex vascular anatomy was not a factor for strokes during surgery. However, aortic arch configuration types 2 and 3 did trend numerically to a higher risk for cerebral ischemia (OR 3.5, 95% CI 0.7-17.1).

Bonati's group suggested that these configurations are associated with increased atherosclerotic burden or represent markers of general vascular risk. Aortic arch type 2 was defined in the study as having at least 1 supra-aortic artery originating between the outer and inner curvature; aortic arch type 3 was for cases where there was at least 1 supra-aortic artery originated below the level of the inner curvature.

"Older age has consistently been shown a risk factor for procedural stroke in carotid artery stenting, but not in carotid endarterectomy," they wrote. "It has been speculated whether the association might be mediated by vascular anatomy."

"Elongation of the aortic arch and supraaortic arteries was found to be more prevalent in elderly patients, possibly leading to more difficulties during the carotid artery stenting procedure," they concluded. "Notably in our analysis, the associations between ICA angulation and aortic arch configuration with cerebral ischemia in the stenting group remained significant after correction for age. Hence, vascular anatomy should be taken into account when selecting the appropriate treatment option for an individual patient, independent of the patient's age."

The ICSS trial randomized 1,700 patients with symptomatic internal carotid artery stenosis to stenting or surgery. Top-line results put stenting recipients at a disadvantage for adverse events.

For this ICSS substudy, the authors included the 184 patients who got magnetic resonance (n=126) or CT angiography (n=58) at baseline on top of brain MRIs before and after treatment.

Bonati and colleagues posed several reasons why it would make sense that complex vascular anatomy has an association with procedural stroke.

"A complex configuration of the aortic arch and the supraaortic arteries increases the technical difficulty of the stent procedure," they wrote. "Repeated attempts to advance the catheter and guidewire may cause endothelial microtrauma or dislodge atherosclerotic plaque and ultimately cause cerebral emboli."

"The protocol of ICSS did not contain detailed precautions against these complications, such as advice on catheter and guidewire handling, limiting guidewire maneuver time between flushing, syringe aspiration and cleansing, concentration of heparin in saline flush, use of constant infusion via infusion ports to stopcocks, etc.," the authors noted.

"We are therefore unable to verify that all possible precautions against thromboembolism were taken," they wrote. "This limitation must be borne in mind when interpreting the results of our study."

Another limitation is the exclusion of patients with extremely unfavorable anatomy for stenting.

"The fact that the ICSS protocol excluded patients with a stenosis that was thought to be unsuitable for stenting because of proximal tortuous anatomy is likely to have limited the number of patients with very unfavorable anatomy," according to Bonati's group. "The full impact of vascular anatomy on carotid artery stenting risk may therefore have been underestimated in this study."

ICSS was funded by several European government and industry grants.

Bonati disclosed serving on scientific advisory boards for Bayer.

2017-04-13T16:00:00-0400

Excerpt from:
Complex Vascular Anatomy Problematic for Carotid Artery Stenting - MedPage Today

Step down. Greys Anatomy's Thursday, April 6, episodesuggested a potential romance between Maggie Pierce (Kelly McCreary) and Jackson Avery (Jesse Williams), which seemed cute at first until fans had the shocking realization that the two are in fact step-siblings. Also, let's not forget that plenty of fans will forever be on Team Japril, so Jackson and Maggie potentially taking things to a new level was troubling for a number of reasons.

Totally Wrong?

During Thursdays episode, Jackson helped Maggie cope with the loss of her mother by showing her photos the dying woman gave him. You and I are kind of like family, he said.

While the moment seemed touching and super flirty at first, fans were quick to point out that the two characters really are family, as Richard Webber (James Pickens Jr.)is Maggie's biological father and Jackson's stepdad.

Japril Forever

Of course, it also goes without saying that many Grey's fans are diehard Japril supporters who were feeling quite optimistic when Jackson and ex April Kepner (Sarah Drew) finally reconnected at a hotel a few episodes ago. The pair have had their relationship tested multiple times and now have a young child together, so plenty of fans want the couple to finally figure things out.

See what fans had to say on Twitter about the unconventional connection from Thursdays episode.

Tell Us: Do you think Jackson and Maggie will hook up?

Greys Anatomy airs on ABC Thursdays at 8 p.m. ET.

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'Grey's Anatomy' Fans' Sex Theory About the Show's Newest Couple Will Disturb You: Read the Tweets! - Us Weekly

The Cleveland Indians (4-4) continue to sputter when it comes to scoring runs as they lost on Tuesday to the Chicago White Sox (3-4), 2-1. Starting pitcher Danny Salazar had a rough start to the game but managed to close strong with an effort that deserved better (6.0 IP, 4 H, 2 ER, 2 BB, 11 K, 106 pitches). Boone Logan, Dan Otero, and Zach McAllister continued the early season dominance from the bullpen with three shutout innings.

The expected offensive fireworks from the Indians have thus far been muted. The Tribe is now 0-for-18 with runners in scoring position (RISP) in their home opening series. Overall, the team is hitting 8-for-61 with 11 walks and 21 strikeouts as they have split the initial two games against the White Sox (.131 batting average, .222 on base percentage). The only run on Wednesday coming on a weak grounding fielders choice to first.

One of the struggling bats has been the prize free agent signee, Edwin Encarnacion. He is a meager 5-for-29 with 12 strikeouts though he does have a double and home run among his few hits (.172/.273/.310). The cleanup hitter has also come up empty when there are runners to knock in as he is now 0-for-7 with two walks with RISP. Tuesdays game was a personal nightmare for Encarnacion as he twice grounded into inning ending double plays with bases loaded and one out. Michael Brantleys 10th inning walk-off heroics bailed him out.

Wednesday would offer a chance for redemption when Lindor stood on third base with the Indians down by a single run in the eighth inning and only one out. A deep sacrifice fly would suffice. Encarnacion struck out, and the last threat would end with a Jose Ramirez ground out.

There is no reason to panic about the slow start, but it is instructive to break down Encarnacions latest RISP opportunity. Here is that at bat in detail.

First Pitch: Foul, 0-1

The at bat was almost over on the first pitch. Reliever Nate Jones left an 89 mile per hour slider hang belt-high over the meat of the plate. Encarnacion took a strong swing and sent it for a ride, but his timing was a bit off as he sliced it foul.

Second Pitch: Ball, 1-1

Lindor was almost able to score again as Jones not only threw a slider in the dirt but well into the left-handed batters box. A fantastic effort by catcher Omar Narvaez of not only blocking it but keeping the ball in front of him was required to keep Lindor on third base.

Third Pitch: Whiff, 1-2

Jones sticks with the slider as his arsenal is almost exclusively sliders and a two-seam fastball that has much more velocity than sinking action. With Encarnacion a fastball hitter, the White Sox have elected to stay away from those similar to the Indians gameplan against him in the 2016 ALCS. The third offering from Jones had better late dropping action compared to his other pitches, which had Encarnacion swinging through air for the whiff.

Fourth Pitch: Foul, 1-2

For the third time in four pitches, Encarnacion almost finds a way to get the job done. Poor luck is encapsulating this plate appearance. Another slider, another belt-high job with no break just like the first pitch. Unlike the first foul ball, mere inches separate this batted ball from finding fair territory. First baseman Jose Abreu gave chase but was not going to catch up to it. The slice was barely enough to stop the Indians from tying the game.

Fifth Pitch: Ball, 2-2

For the only time in this at bat, Jones threw his two-seam fastball. He pitched it belly high in an attempt to entice Encarnacion to swing, but the patient hitter saw it traveling far outside the strike zone.

Sixth Pitch: Whiff, Strikeout

The previous ball might have been a mere setup for the closing pitch. Jones started the path of this pitch on a similar plane to his fifth pitch two-seamer. However, he went back to the slider and got fantastic breaking action from it. There was an initial appearance that it would come back over the plate and Encarnacion (in protection mode with two strikes) committed to his swing. Unfortunately, Jones was able to obtain vertical drop on this offering late, which ended the break towards the plate and made Encarnacion whiff at air to complete the strikeout.

Last Word The 2017 MLB season is still in its infancy. Past Terry Francona Cleveland ballclubs have struggled out of the gate as he has yet to finish an April with a winning record. He has yet to finish a season in Cleveland with a losing record. Encarnacion has also had his share of April struggles as he slashed .239/.303/.394 in April from 2014-2016. He has finished those seasons at .269/.361/.544. The weather will warm, and the bats will warm with it. Until then, the Indians will need to continue to find ways to scrape out wins so that they are in position to trampoline over division rivals who have been surprisingly competitive in the incredibly early stages of the season.

Continued here:
RIP to RISP: Anatomy of an At Bat - Waiting For Next Year

Part I: The Bomb, its contents, and their likely fate

The recent chemical attack inKhan Shaykhun in Syria is alleged by witnesses to have been delivered by an air-dropped bomb. The purpose of this article is to systematically break down a Sarin bomb into its components and analyse what happens to them. This first part addresses the contents of the bomb and how these components interact with the environment.

Whats in an air-dropped Sarin bomb? A Sarin bomb will contain more than just Sarin.

Sarin. The nerve agent Sarin will be in liquid form. However, no chemical reaction makes pure Sarin and no weapon system known to date contained just pure Sarin. Other things are likely to be present in some percentage. They are listed below.

Unreacted Components: It is highly unlikely that any Sarin binary mixing done before loading will be absolutely 100% effective. Bits of unreacted binary components that werent mixed properly, i.e. methylphosphonyl difluoride (DF) and isopropyl alcohol

Hydrogen fluoride (HF) : This results from the DF + isopropyl alcohol reaction. Also results from DF reacting with water. Byproducts: chemicals that are formed by improper DF + alcohol reactions, or are left over in the DF as impurities from earlier stages of production. Degradation products : Sarin, unless made properly, degrades quickly. And Sarin degrades in the presence of moisture. Degradation products are chemicals that result from degradation of the Sarin, such as isopropyl methylphosphonic acid, which in turn degrades to methylphosphonic acid. Additives: Anything additional added, such as acid scavengers and anti-corrosion inhibitors, e.g. hexamine, tributylamine, etc. Also, as some additives are designed to react with the residual HF, the presence of these compounds, e.g. salts, may be present.

Fuze and Bursting charge: Explosive material to make the bomb burst open and create an aerosol. This would include the whole firing chain, with fuzing and several different explosive materials, as well as wiring.

Case material: This is the body of the bomb, including coatings and linings.

Design and Intent of the weapon

US Weteye Sarin Bomb

Non-persistent nerve agents, such as Sarin are used for immediate production of casualties, as their ability to produce contamination is time-limited. As such, Sarin weapons generally function on the principle of producing as much aerosol (a finely divided mist of droplets) as possible. Persistent nerve agents, such as VX, are designed to contaminate terrain and equipment, and cause immediate casualties primarily by skin contact. Therefore, they are often designed to cause dispersal of larger droplets.

How big an explosive charge?

The necessary charge to agent ratio is needed to ensure proper dissemination of the chemical agent contents. A bursting charge that is too small means that too little aerosol is created and you end up with a large pool of liquid or large splashes of Sarin extremely deadly in the immediate vicinity, but not good for causing casualties over a wide area. If the bomb uses too much explosive, much or all of the Sarin is destroyed. Sarin decomposes at higher temperatures. At its boiling point, around 150 deg C, it decomposes rapidly. A large amount of high explosives would easily heat much of the Sarin in a bomb to 150 deg C.

The thickness and structural integrity of the case of the bomb is a key factor in the size of the burster charge, and one of the reasons why air-dropped bombs have a higher ratio of chemical agent to explosive than artillery shells, which, comparatively, have a thicker case. Data on charge to agent ratios for air-dropped bombs is rare, but some information from the old US chemical arsenal has now seeped into the public domain. These charge to agent ratios were fine tuned with extensive field testing at proving grounds and resulted in optimum formation of aerosol. For example, the MC-1 Sarin bomb contained 100kg of Sarin and had a burster charge weighing 6.8 kg, although not all of the 6.8 kg will be explosive weight, i.e. some of that weight will be wire and casing. The US Mk94 bomb held 49kg of Sarin and had a 7.3 kg burster. The Weteye bomb appears to have contained 159 kg of Sarin and had a large bursting charge, around 27 kg, leading one to deduce that it had a much thicker case. I can find no comparable statistics for USSR-produced systems.

Air-burst versus ground burst

Ever since the development of chemical bombs and artillery shells early in the 20th century, the general consensus among chemical weapons experts is that non-persistent agents are detonated at or near ground level, whereas persistent agents, whose primary purpose is contamination of terrain and equipment, are detonated as air bursts. Non-persistent agents are designed with production of casualties in mind and keeping the aerosol at or near ground level helps to maintain a higher concentration of the chemical agent than detonating in the air. The latter serves to dilute the concentration a little or a lot, depending on local conditions. With persistent agents, the idea is to have a wider radius of dispersal of droplets to cause contamination of terrain and equipment. The air-dropped bombs for delivering Sarin developed in the US in the Cold War were all impact fuzed for ground burst.

US MC-1 Sarin Bomb

What happens when the Sarin bomb is dropped

The following chain of events happens when a typical Sarin bomb is dropped in an air strike:

This chain of events causes dispersal The Sarin inside the bomb will end up dispersed in a number of ways simultaneously.

The distribution of the Sarin into these categories will vary heavily based on the design of the weapon and a little bit from local factors, such as weather conditions and the type of surface the bomb hits. For example a bomb dropped into a swamp will behave differently to one dropped onto dry land.

The eventual fate of these dispersed bits of Sarin will vary according to the categories above. Lets examine what happens to each category:

Part II Coming soon. How the Sarin bomb and its contents will interact with its victims. This will address the key issues of how Sarin enters the human body and how and why responders were seen handling victims with relatively little protective equipment.

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Anatomy of a Sarin Bomb Explosion (Part I) - bellingcat

Greys Anatomy Season 13, Episode 20 Spoilers: In the Air Tonight Features In-Flight Emergency; Meredith, Riggs Forced to Confront Feelings During Plane Ride?

Greys Anatomy season 13s episode 20, titled In the Air Tonight, will feature an in-flight emergency as Meredith and Riggs find themselves seated together during a plane ride. The two may be forced to confront their feelings towards one another.

The short synopsis for In the Air Tonight posted on TV Guide reads, Meredith (Ellen Pompeo) and Nathan (Martin Henderson) have to confront their feelings when they are stuck sitting next to each other on a plane.

The upcoming episode is set to be in an interesting one for Meredith and Nathan as they are finally forced to come clean about their feelings during a fateful plane ride. According to Cartermatt, episode 20 will be an emotional rollercoaster ride for the two.

The promo for episode 20 also hints at an in-flight emergency after the plane Meredith and Nathan are on experiences some turbulence causing passengers to panic. It begins with Meredith boarding the plane and finding Nathan on the seat next to hers. She then becomes clearly anxious.

In the next scene, Meredith is in the toilet when Nathan bursts through the door. The two then face each other in the cubicle.

Fans of the show have been waiting for some developments on Meredith and Nathans potential romance and it seems that the upcoming episode will finally push the two in the right direction. During a previous interview with Entertainment Weekly, Pompeo played down the idea of romance between her character and Hendersons. Pompeo said,Whether youre ready or not, you have to make the leap; I dont know if shes ready Dont get too excited.

Greys Anatomy season 13s episode 20, titled In the Air Tonight, is scheduled to air on ABC on April 13, 2017. It was directed by Chandra Wilson and written by Stacy McKee. It will be followed by episode 21, titled "Don't Stop Me Now," scheduled to be released on April27 and directed by Louis Venosta.

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Greys Anatomy Season 13 Episode 20 Spoilers In the Air Tonight Features In-Flight Emergency Meredith Riggs Forced ... - EconoTimes

Ruby was diagnosed with a rare, yet very destructive disease called Restrictive Cardiomyopathy, 19 months ago, and the doctor only gave her 24 months to live. Time is running out for her.

Most 15-year-old girls want fancy clothes, cute shoes and tickets to their favourite boy bands concert. But Ruby Ballack just wants to live to see her next birthday.

She was diagnosed with a rare, yet very destructive, disease called Restrictive Cardiomyopathy 19 months ago and at that time the doctor only gave her 24 months to live.

Time is running out for Ruby. She recently had a 3,2cm blood clot in her heart. Luckily it has dissolved. Due to poor blood flow in her heart chambers there is a major risk of blood clots forming again. And lets not even mention the three ICU admissions she had in December 2016 alone.

Also read:Hope towers over teens short life expectancy

During a recent visit to the hospital, Ruby was very ill and spent a few days in ICU. Photo: Submitted

Ruby also experiences tremendous pressure on her heart because of the accumulation of fluid in her hearts lining. She has had multiple pericardial taps to remove the fluid, but because it accumulates within weeks, the fluid causes ongoing incredible pressure, shortness of breath and pain.

Recently her chest pains have become severe, her fatigue is unbearable, and her health has deteriorated by the minute. But not all is lost for Ruby. She is still waiting for the life-altering phone call that could save her life.

Ruby is on the transplant list and is waiting for both a heart and lungs. In the past year there have been two possible referrals for matching donors, but due to medical reasons, they did not materialise.

Its exhausting to feel ill all the time, said Ruby. And when moms phone rings late at night, I always think it might be THE phone call that gives me a heart.

Despite everything, Ruby and her family remain positive and hopeful. Wanda, Rubys mom, said she also anticipates the call every day, but knows that someone has to die for her daughter to live. We have family and friends who have lost their precious children and donated their organs to save the lives of others, while experiencing the utmost grief, said Wanda.

Ruby underwent numerous blood tests during the past few weeks and will continue to have her blood drawn to make sure there are no complications. Photo: Submitted.

They are mourning their loss daily and their lives will never be the same again. We are not praying for a donor or for organs we are praying that when a family is approached whos loved one could be a match for Ruby, they will find it in their hearts to say Yes.

She also said that they arent the only family going through the tough trial of waiting for an organ.

More than 4 300 people are on the transplant list, and I know each and every one of them is going through the same hard time as we are. In a good year, only about 515 patients receive their second chance at life.

Rubys veins are even visible through her knuckles due to her illness.

This is why Wanda, like other mothers, is an organ donor. They know that something good can come from someone elses death. One persons organs can save seven lives.

Wanda also stresses that there are a lot of misconceptions when it comes to organ donation. Being an organ donor is completely free. You can be on the organ donor list without paying any monthly fees. Your family wouldnt have to pay for any medical costs if you donate your organs.

There are also other misconceptions when it comes to the process of donating organs when you die. When you are declared brain dead, the doctor will approach your family and inform them that you are an organ donor. They then ask your familys permission to harvest your organs. The ultimate decision stays with them.

Ruby was diagnosed with a rare, yet very destructive disease called Restrictive Cardiomyopathy, 19 months ago, and the doctor only gave her 24 months to live. Time is running out for her.

You can also choose which organs you want to donate and which you want to keep, and it takes only a few minutes to register as an organ donor.

If you are not a registered organ donor yet, please consider becoming one, as you can help save many people like Ruby. You have the power to change the statistics, said Wanda.

Visit http://www.odf.org.za for more details about organ donation.

Do you perhaps have more information pertaining to this story? Email us at krugersdorpnews@caxton.co.zaorphone us on 011 955 1130.

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Ruby's heart condition not an episode of Grey's Anatomy - Krugersdorp News