Numerous large randomized trials have shown a significant morbidity and mortality benefit with the transradial approach (TRA) over the transfemoral approach (TFA) for endovascular procedures. ...However, this technique is routinely avoided or aborted due to unfamiliarity with the technique and the associated anatomical difficulties that may be faced in this approach. The objective of this review is to identify both the common and uncommon challenges that may be encountered during a transradial approach for cerebrovascular catheterization and to provide tips and tricks to overcome the transradial learning curve.
A careful review of the literature and of all our transradial cases was carried out to identify the common challenges and complications that are encountered when using TRA for diagnostic cerebral angiography and neurointerventions.
A stepwise approach is provided to prevent and manage common challenges including radial artery access failure, radial artery spasm, radial artery anomalies and tortuosity, radial artery occlusion, radial artery perforation and hematoma, subclavian tortuosity and anomalies, and catheter knots and kinks.
The ability to recognize and navigate anatomical variations and complications unique to TRA will accelerate learning, decrease unnecessary morbidity and mortality, and further advance the neurovascular field.
Capsular polysaccharides (CPSs) play multiple roles in protecting bacteria from host and environmental factors, and many commensal bacteria can produce multiple capsule types. To better understand ...the roles of different CPSs in competitive intestinal colonization, we individually expressed the eight different capsules of the human gut symbiont Bacteroides thetaiotaomicron. Certain CPSs were most advantageous in vivo, and increased anti-CPS immunoglobulin A correlated with increased fitness of a strain expressing one particular capsule, CPS5, suggesting that it promotes avoidance of adaptive immunity. A strain with the ability to switch between multiple capsules was more competitive than those expressing any single capsule except CPS5. After antibiotic perturbation, only the wild-type, capsule-switching strain remained in the gut, shifting to prominent expression of CPS5 only in mice with intact adaptive immunity. These data suggest that different capsules equip mutualistic gut bacteria with the ability to thrive in various niches, including those influenced by immune responses and antibiotic perturbations.
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•B. thetaiotaomicron dynamically changes its capsular polysaccharides (CPSs) in vivo•One capsule, CPS5, provides the most advantage in the presence of adaptive immunity•The ability to express multiple CPS types promotes survival during antibiotic stress•CPS5 is one of the most prevalent B. thetaiotaomicron CPS in human samples
Symbiotic Bacteroides species encode for multiple capsular polysaccharides, the roles of which have remained poorly defined. Porter et al. identify one capsule involved in competitive colonization of the mouse gut that assists in evading adaptive immune responses. The genes for synthesizing this capsule are frequently identified in human gut samples.
Despite several retrospective studies analyzing the safety and efficacy of transradial access (TRA) versus transfemoral access (TFA) for cerebral angiography, this transition for neurointerventional ...procedures has been gradual. Nonetheless, based on our positive initial institutional experience with TRA for mechanical thrombectomy in acute ischemic stroke patients, we have started transitioning more of our cerebral angiography cases to TRA. Here we present our single institution experience.
We performed a retrospective review of patients receiving TRA cerebral angiography at our institution between January 2016 and February 2017. We present our experience transitioning from TFA to TRA, including our criteria for patient selection, technical nuances, patient experience, complications, and operator learning curve.
We included 148 angiograms performed in 141 people by one of four operators. No major complications were observed, and the technical success of the procedures was consistent with those of TFA. Marked improvement in operator efficiency was achieved in a short number of cases during this transition when looking at operator proficiency as a function of angiograms performed and days of exposure to TRA (4.3 vs 3.6 min/vessel, P<0.05).
Safety and efficiency can be preserved while transitioning to TRA. While further investigation is necessary to support transition to TRA, these findings should call for a re-evaluation of the role of TRA in catheter cerebral angiography.
Cerebral aneurysms (CAs) are characterized by a pathological wall structure with internal elastic lamina and media disruption, which leads to focal weakened pouches of the arterial wall. The ...prevalence of unruptured CAs has been estimated to be 2%-5% in the general population. During the past few decades, the pathophysiological mechanisms behind the formation, growth, and rupture of CAs have been the focus of numerous research studies. In the present review, we have summarized the inflammatory pathways, genetics, and risk factors for the formation, growth, and rupture of CAs. In addition, we have discussed the concepts of geometric indexes, flow patterns, and fluid dynamics that govern CA development.
The newly emerging Middle East Respiratory Syndrome coronavirus (MERS-CoV) causes a Severe Acute Respiratory Syndrome-like disease with ∼43% mortality. Given the recent detection of virus in ...dromedary camels, zoonotic transfer of MERS-CoV to humans is suspected. In addition, little is known about the role of human neutralizing Ab (nAb) pressure as a driving force in MERS-CoV adaptive evolution. Here, we used a well-characterized nonimmune human Ab-phage library and a panning strategy with proteoliposomes and cells to identify seven human nAbs against the receptor-binding domain (RBD) of the MERS-CoV Spike protein. These nAbs bind to three different epitopes in the RBD and human dipeptidyl peptidase 4 (hDPP4) interface with subnanomolar/nanomolar binding affinities and block the binding of MERS-CoV Spike protein with its hDPP4 receptor. Escape mutant assays identified five amino acid residues that are critical for neutralization escape. Despite the close proximity of the three epitopes on the RBD interface, escape from one epitope did not have a major impact on neutralization with Abs directed to a different epitope. Importantly, the majority of escape mutations had negative impacts on hDPP4 receptor binding and viral fitness. To our knowledge, these results provide the first report on human nAbs against MERS-CoV that may contribute to MERS-CoV clearance and evolution. Moreover, in the absence of a licensed vaccine or antiviral for MERS, this panel of nAbs offers the possibility of developing human mAb-based immunotherapy, especially for health-care workers.
Nontraditional yeasts prevalent in tropical agricultural fermentations such as coffee and cocoa are known to contribute to aroma profiles, yet the functional roles and interactions between the ...associated microbial consortia in a farm fermentation are unclear. Here, boiled green bean extract (GBE) from green coffee beans was developed as a rich screening medium to deconstruct the microbial consortia and their interactions during the fermentation of dried green coffee beans. When cultivated in coculture with S. cerevisiae on GBE, strain-specific groupings with distinct volatile organic profiles were observed for nontraditional yeasts (e.g., Hanseniaspora spp., Pichia kudriavzevii). Further changes are evident when constructed consortia composed of nontraditional yeast, S. cerevisiae, and Lactococcus lactis var. cremoris were cultured in GBE, and a comparison with abiotically acidified GBE suggests that pH plays a major role in the influence of lactic acid bacteria (LAB) on fermentation aromas. This approach represents a tool for the development of starter culture formulations to create different flavor profiles in coffee fermentation.
Dural arteriovenous fistulas (DAVFs) are complex lesions consisting of abnormal connections between meningeal arteries and dural venous sinuses and/or cerebral veins. The goal of treatment is ...surgical or endovascular occlusion of the fistula or fistulous nidus or at least the disconnection of the feeding vessels and the draining veins. Delayed angiographic data on previously embolized dural fistulas is lacking. The authors report their experience and the long-term angiographic results with embolization of intracranial DAVF using Onyx.
All cases of DAVF treated primarily with Onyx at the authors' institution from 2006 to 2013 were retrospectively reviewed. Patient demographics, fistula characteristics, embolization details, and angiographic follow-up were analyzed.
Fifty-eight patients with DAVFs were treated during the study period. Twenty-two patients were treated with open surgery with or without prior embolization. Thirty-six patients were treated with embolization alone, of whom 26 underwent an attempt at curative embolization and are the subject of this review. All but 2 of these patients were treated in a single session. Angiographic "cure" was achieved in all cases following treatment. Follow-up angiography was performed in 21 patients at a mean of 14 months after treatment (range 2-39 months). Asymptomatic angiographic recurrence of the fistula was evident in 3 of the 21 patients (14.3%). On reviewing the procedural angiograms of the cases in which the DAVFs recurred, it was observed that the Onyx cast did not reach the venous portion in 1 case, whereas it did reach the vein in the other 2 cases.
Recurrence following initial angiographic cure of DAVF is not uncommon. Incomplete penetration of the embolic material into the proximal portion of the venous outlet may lead to delayed recurrence. Long-term angiographic follow-up is highly recommended.
The authors conducted a 15-week randomized controlled trial of the alpha-1 adrenoreceptor antagonist prazosin for combat trauma nightmares, sleep quality, global function, and overall symptoms in ...active-duty soldiers with posttraumatic stress disorder (PTSD) returned from combat deployments to Iraq and Afghanistan.
Sixty-seven soldiers were randomly assigned to treatment with prazosin or placebo for 15 weeks. Drug was titrated based on nightmare response over 6 weeks to a possible maximum dose of 5 mg midmorning and 20 mg at bedtime for men and 2 mg midmorning and 10 mg at bedtime for women. Mean achieved bedtime doses were 15.6 mg of prazosin (SD=6.0) and 18.8 mg of placebo (SD=3.3) for men and 7.0 mg of prazosin (SD=3.5) and 10.0 mg of placebo (SD=0.0) for women. Mean achieved midmorning doses were 4.0 mg of prazosin (SD=1.4) and 4.8 mg of placebo (SD=0.8) for men and 1.7 mg of prazosin (SD=0.5) and 2.0 mg of placebo (SD=0.0) mg for women. Primary outcome measures were the nightmare item of the Clinician-Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the change item of the Clinical Global Impressions Scale anchored to functioning. Secondary outcome measures were the 17-item CAPS, the Hamilton Depression Rating Scale, the Patient Health Questionnaire-9, and the Quality of Life Index. Maintenance psychotropic medications and supportive psychotherapy were held constant.
Prazosin was effective for trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster. Prazosin was well tolerated, and blood pressure changes did not differ between groups.
Prazosin is effective for combat-related PTSD with trauma nightmares in active-duty soldiers, and benefits are clinically meaningful. Substantial residual symptoms suggest that studies combining prazosin with effective psychotherapies might demonstrate further benefit.
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