Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with ...severe AS and normal left ventricular function remain debated.
The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm
with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.
Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 95% CI, 0.23-0.90;
=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome.
In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.
Internet of Things and Blockchain are considered two major technologies. Lower latency and a higher linked system number provide greater flexibility for remote execution of Internet of Things (IoT) ...applications. It is no secret that IoT devices often have insufficient computing capacity (both in terms of processing power and storage requirements) to support robust protection and encryption algorithms. The Internet of Things is facing many challenges such as poor interoperability, security vulnerabilities, privacy, and lack of industry standards. Cyber-attacks on IoT devices can have an impact on energy trading privacy and security. This paper suggests a method for introducing a basic interface to an IoT device’s security gateway architecture along with Blockchain to provide decentralization and authentication. It adds much-needed anonymity and versatility to IoT infrastructure, which is currently lacking. The solution enhances the reliability of data sent to remote services by applying compatible cryptographic algorithms to it before sending it. The solution’s benefits include compatibility with all IoT products and the ability to run any cryptographic algorithm on data that can be used for microgrid trading and can be initialized and securely transported over 5G or 6G network infrastructures. As a part of this work, a security procedure has been created that supports every cryptographic algorithm for all IoT devices in the network. In addition, the interface is guarded by the Blockchain technology which eliminates single control authority, records historical transactions performed by the IoT devices and provides a trust between devices.
Aristolochic acids (AAs) have been known as potent nephrotoxins since the use of AA-containing herbal medicines was linked with a series of sporadic renal fibrotic nephropathy cases, and yet an ...estimated 100 million people worldwide are still at risk today because of continued use of similar medicines. However, a similar nephropathic condition is endemic in the rural Balkan regions (e.g., Serbian farming villages) and AAs were again found to be the causative agents. In the case of this Balkan endemic nephropathy, AAs were found to have originated from a widespread local weed Aristolochia clematitis L. In this study, we tested the hypothesis that AAs released from decomposition of A. clematitis were also being leached into groundwater, thus polluting the drinking water of local residents. We initiated the study by developing a dispersive solid-phase extraction-based sample preparation method for water samples suspected of AA contamination. The validated method was then coupled with a liquid chromatography-tandem mass spectrometric method to measure AAs in groundwater samples collected from Serbia. Our study revealed for the first time that groundwater in Serbia is extensively contaminated with AA-I, at ng/L levels. Results also showed that AAs are long-lived water contaminants, with no observable concentration changes over a 2-month period of sample storage.
•Nephrotoxic aristolochic acids (AA) contaminated food and soil of Balkans.•Chronic exposure to AA via AA-tainted food resulted in renal fibrosis and cancer.•A new LC–MS/MS method was developed for ...analysis of AAs in food and soil samples.•Zn/H+ treatment dramatically increase analytical sensitivity of AA in LC–MS/MS.•The method detects for the first time AA in supermarket flour samples in Balkan area.
Prolonged dietary exposure to AA-contaminated food crops cultivated in contaminated farmland was shown to be one of the main culprits of Balkan endemic nephropathy. Ultra-sensitive methods for the detection of AA at trace levels are important for surveillance purposes. We report the development of a novel liquid chromatography-tandem mass spectrometry (LC–MS/MS) method for AA-detection. One striking feature of the method is that the Zn/H+-induced nitroreduction convert AA into their respective aristolactams, which dramatically enhances their analytical sensitivity. The method was applied to quantitate AA in food grains and soil samples collected from farming villages of Serbia, and flour samples purchased from supermarkets. To the best of our knowledge, this is the first report of detecting AA in food ingredients available in supermarkets, which is alarming because it reveals AA poses insidious threats not only to residents of rural farming villages, but also to people residing in urban areas.
It is not a secret that Internet of Things (IoT) devices often come with not so realistic processing power (i.e. processing power and storage requirements) that would provide a basis for strong ...security and encryption algorithms. This work proposes an approach to adding a simple interface as a security gateway architecture for IoT devices. The security interface provides mapping for the IoT device remote services as long as support for stronger cryptographic algorithms. The solution improves the security of the data that IoT devices send to remote services by performing compatible cryptographic algorithms on the data before it sends to remote services. The result of this work is the development of a security interface that provides support for any cryptographic algorithm, uses Internet Protocol (IP) mapping to prevent access to the devices behind the interface from non-authorized IP addresses. As such it provides robust protection against attacks and data manipulation. The work is tested for memory usage and the strength of the security it provides.
Coronavirus disease 2019 (COVID-19) pandemic has influenced health-care organization worldwide, including management of non-communicable diseases. The aim of this study was to determine the impact of ...COVID-19 pandemic on cardiac implantable electronic devices' (CIEDs) implantation rates in Croatia.
A retrospective, observational, national study was conducted. The data on CIEDs' implantation rates from 20 Croatian implantation centres, between January 2018 and June 2021, were extracted from the national Health Insurance Fund registry. Implantation rates before and after COVID-19 pandemic started, were compared.
The overall numbers of CIED implantations in Croatia during COVID-19 pandemic were not different in comparison to 2 years pre-COVID-19 time (2618 vs. 2807, p = .081). The pacemaker implantation rates decreased significantly (by 45%) during April (122 vs. 223, p < .001) and May 2020 (135 vs. 244, p = .001), as well as during November 2020 (177 vs. 264, p = .003), but significantly increased during summer months 2020 comparing to 2018 and 2019 (737 vs. 497, p<0.001). The ICD implantation rates decreased significantly by 59% in April 2020 (26 vs. 64, p = .048).
To the authors best knowledge this is a first study including complete national data on CIED implantation rates and COVID-19 pandemic impact. A significant reduction in number of both pacemaker and ICD implants during specific months of the COVID-19 pandemic was determined. However, afterwards compensation in implants resulted in similar total number when the complete year was evaluated.
We investigated the impact of multimorbidity and polypharmacy on the management of atrial fibrillation (AF) patients in clinical practice and assessed factors associated with polypharmacy and oral ...anticoagulation (OAC) use in AF patients with multimorbidity and polypharmacy.
A 14-week prospective study of consecutive non-valvular AF patients was performed in seven Balkan countries.
Of 2712 consecutive patients, 2263 patients (83.4%) had multimorbidity (AF + ≥2 concomitant diseases) and 1505 patients (55.5%) had polypharmacy. 1416 (52.2%) patients had both multimorbidity and polypharmacy. Overall, 1164 (82.2%) patients received OAC, 200 (14.1%) patients received antiplatelet drugs alone and 52 (3.7%) patients had no antithrombotic therapy (AT). Non-emergency centre and paroxysmal AF were significantly associated with OAC non-use in patients with multimorbidity, whilst age ≥80 years and non-emergency centre were identified to be independent predictors of OAC non-use in patients with polypharmacy.
Multimorbidity and polypharmacy were common among AF patients in our study. AT was suboptimal and approximately 18% of multimorbid patients with polypharmacy were not anticoagulated. Pattern of AF and non-emergency centre were associated with OAC non-use in AF patients with multimorbidity, whilst non-emergency centre and age ≥80 years were associated with OAC non-use in AF patients with polypharmacy.
Key Message
Multimorbidity and polypharmacy are common among patients with AF.
Antithrombotic therapy was suboptimal in AF patients with multimorbidity and polypharmacy.
Approximately, 18% of multimorbid patients with polypharmacy were not anticoagulated.
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