Anatomic Obstruction Research Articles

0427 Airway Pressures Define Collapsibility of Specific Pharyngeal Sites of Obstruction during Drug-induced Sleep Endoscopy

Abstract Introduction Obstructive sleep apnea (OSA) is characterized by repetitive episodes of pharyngeal obstruction at one or more collapse sites. Multilevel collapse is a negative predictive factor for PAP-alternative surgical treatments. Pharyngeal manometry during drug-induced sleep endoscopy (DISE) permits an objective evaluation of anatomical obstruction sites and mechanisms, and may play a role in patient selection for PAP alternative therapies. We hypothesized that patients with multilevel collapse would have primary velopharyngeal collapse and secondary, downstream sites. Methods This prospective cohort of twenty consecutive patients with diagnosed OSA underwent DISE with nasal airflow monitoring and pharyngeal manometry. Two pressure catheters were placed at the (1) distal margin of the soft palate (Pus) and (2) retroepiglottic space (Pds). We sought to delineate site(s) of collapse by evaluating dissociations in airflow and air pressure during inspiratory flow limitation and/or complete obstruction. The primary site of collapse was defined by the initial segment at which inspiratory airflow and pressure dissociated (the critical pressure, Pcrit). Secondary site(s) were defined as the pressure at which the Pus and/or Pds signals subsequently dissociated (beyond the initial point of maximal flow). Results Twenty-one patients were evaluated of which signal quality and catheter placement in twenty were sufficient for analysis. Participants were elderly (58.3±14.3yrs, mean±SD), overweight (BMI 28.7±2. kg/m2), and had moderate-severe OSA (AHI 28.2±14.2 events/hour). Six patients had a single site of collapse, of which one was naso-palatal (Pcrit -2.6cmH2O) and five were infra-palatal (mean Pcrit -1.3cmH2O). In the patients with multilevel collapse (N=14), all had primary naso-palatal collapse (mean Pcrit 0.17±2.0cmH2O) and secondary infra-palatal sites of collapse (mean Pcrit -11.7±5.8cmH2O). Pcrit differed between the primary and secondary site by 11.9±6.5cmH2O (p< 0.01). Conclusion These findings suggest that single-site pharyngeal collapse is usually infra-palatal. In contrast, multilevel collapse is primarily due to velopharyngeal collapse with varying degrees of instability in downstream pharyngeal segments. When secondary infra-palatal sites readily collapse with minimal additional respiratory effort, laxity of the tongue and/or lateral walls may be strongly implicated in the pathogenesis of pharyngeal obstruction. Future studies can utilize pharyngomanometry to further target specific pharyngeal structures for OSA therapy. Support (if any) National Institutes of Health 1R01HL144859 (PIs: Schwartz, Dedhia)

Nasal Airflow Dynamics Before and After Septorhinoplasty for Correction of Cleft Lip Nasal Deformity: A Single Patient Case Report

Background: Unilateral cleft lip nasal deformity (uCLND) creates multiple sites of nasal airway obstruction, impacting patients’ quality of life. Surgical restoration of function remains technically challenging and complex. Objectives: This is a single patient case report to determine consistency of patient’s subjective perception of nasal outcomes after septorhinoplasty with objective assessments, and effectiveness of standard surgical techniques in targeting sites of greatest nasal anatomical obstruction. Method: Patient-reported quality of life (QOL) measures were collected. Pre- and post-surgery radiographic images of a patient with uCLND were obtained for computational fluid dynamics (CFD) modeling of patient-specific nasal function. Objective assessments were obtained using rhinomanometry and CFD. CFD-derived localized resistance at multiple cross-sectional segments were determined and used to identify greatest nasal obstructive sites. Results: Patient-reported QOL scores improved by 20 to 73 points. CFD-calculated bilateral resistance decreased from 0.155 to 0.061 Pa.s/ml, cleft-side resistance from 0.407 to 0.091 Pa.s/ml, and non-cleft-side from 0.228 to 0.120 Pa.s/ml. Rhinomanometry showed similar decreases in resistance. On the cleft side, 25 identified sites of greatest obstruction decreased to 15 sites post-surgery; on the non-cleft side, 23 sites of greatest obstruction decreased to 16 sites post-surgery. Conclusion: Results suggest improvement in nasal patency after septorhinoplasty. Additional greatest obstructive sites in the post-surgical airway were mostly around the superior airway.

Metabolic bariatric surgery and combined multilevel surgery as a treatment for obstructive sleep apnea patient with obesity


 
 
 Body mass index (BMI) and the degree of obstructive sleep apnea (OSA) are strongly correlated. Managing obesity is an important strategy for preventing and treating OSA. Bariatric surgery can lead to significant weight loss and improvements in metabolic function, which can have beneficial effects on OSA symptoms within obese population. There is a relative lack of data directly comparing the different types of bariatric surgery and multilevel upper airway surgery for the treatment of obstructive sleep apnea (OSA). While there is some evidence to suggest that bariatric surgery can improve OSA symptoms in obese individuals, and multilevel upper airway surgery can improve OSA symptoms in some cases of anatomical obstruction, there is limited research directly comparing these treatment options. Therefore, this review provides an update on the relationship between OSA, MBS and MLS for demonstrating the significance of multidisciplinary surgery approach for obese patients with OSA.
 
 

Obstructive Sleep Apnea and Its Management: A Narrative Review.

Obstructive sleep apnea (OSA) is a disorder in which there is repeated collapse of the upper airway when the person is in sleep, which causes oxygen desaturation and interrupted sleep. While asleep, airway blockages and collapse are accompanied by awakenings with or without oxygen desaturation. OSA is a prevalent disorder, especially in people with known risk factors and other illnesses. Pathogenesis is variable, and the risk factors include low chest volume, erratic respiratory regulation, and muscular dysfunction in the upper airway dilators. The high-risk factors include overweight, male sex, aging, adenotonsillar hypertrophy, interruption of the menstrual cycle, preservation of liquids, and smoking. The signs are snoring, drowsiness, and apneas. A sleep history, assessment of symptoms, and physical examination are all part of the screening process for OSA, and the data can help determine which people need to be tested for the condition. The results of the polysomnogram or at-home sleep apnea test assist in determining the presence and severity of OSA. Still, it is seen many times that the accuracy of home sleep apnea tests is significantly less, so one should take an expert opinion for the same. OSA results in systemic hypertension, drowsiness, and driving accidents. It is additionally related to diabetes mellitus, congestive heart failure (CHF), cerebral infarction, and myocardial infarction, but the exact mechanism is not known. The preferred treatment is continuous positive airway pressure with 60-70% adherence. Other management options include reducing weight, therapy of oral appliances, and correcting any anatomical obstruction (narrow pharyngeal airway, adenoid hypertrophy, and mass in the pharynx). OSA indirectly causes headaches just after awakening and daytime sleepiness. However, there are no age boundaries in OSA as it can occur in any age group. Still, more prevalence is seen in individuals of more than 60 years of age.

Comparative study between three-snip punctoplasty with and without mitomycin C in the management of punctal stenosis or occlusion

Background Punctal stenosis is a progressive constriction of the puncta with resultant epiphora. One of the most effective treatment options is one- to four-snip punctoplasty with or without mitomycin C (MMC). Aim The aim of this study was to assess the effectiveness of intraoperative MMC in increasing the success rate of three-snip punctoplasty in cases of punctal stenosis. Patients and methods This is a nonrandomized interventional prospective comparative study that was conducted at the Department of Ophthalmology, Al-Hussein and Bab El Sheria Al-Azhar University Hospitals, Cairo, Egypt. It included 31 eyes of 18 patients who underwent three-snip punctoplasty. The patients were divided into two groups: group 1 (15 eyes), in which MMC was not used during surgery, and group 2 (16 eyes), in which MMC was used intraoperatively for 2 min. Complete ocular examinations were performed in all patients using the slit lamp. Punctal stenosis grading was done as follows: grade 0 (absent punctum), grade 1 (a membrane covering the papilla), grade 2 (less than average size, however, can be recognized), grade 3 (normal), grade 4 (small slit <2 mm), and grade 5 (large slit ≥2 mm). Follow-up was conducted at 1 week, 1 month, and at 3 months postoperatively. Results In group 1, five (33.3%) eyes had a total postoperative recurrent anatomical obstruction and scarring of their puncta, compared with one (6.2%) case in group 2, with a statistically significant difference (P=0.000). Conclusion MMC demonstrated a favorable, secure, and efficient adjunct treatment for punctal stenosis in the punctoplasty procedure.

Functional epiphora: an under-reported entity

PurposeTo determine the etiology of epiphora in a tertiary Australian lacrimal clinic and highlight the high proportion of ‘functional’ cases.MethodsSingle-center retrospective review: Records of adult patients presenting to a tertiary lacrimal clinic from January 2011 to February 2021 with epiphora were reviewed. Patients underwent testing with syringing/probing and lacrimal imaging to reach a diagnosis of functional epiphora. Functional epiphora was diagnosed based on the exclusion of alternate causes of epiphora on clinical examination, patent lacrimal syringing, normal dacryocystography, and delay on dacryoscintigraphy.ResultsFive hundred and seventy-six symptomatic eyes of 372 adult patients (mean 66.2 ± 15.5 years, 63.4% females) with epiphora were evaluated for causes. Post-sac obstruction (stenosis/complete obstruction) and functional epiphora (non-anatomical delay) were the most common causes of presentations to the lacrimal clinic (26% each). Functional epiphora with post-sac delay was substantially more common than functional epiphora with pre-sac delay (89% vs. 11% of functional epiphora cases). In 16% of the cases, no cause for the epiphora was found while more than one cause (multifactorial) was present 11% of the time.ConclusionFunctional epiphora was found to be as common as a nasolacrimal anatomical obstruction when lacrimal imaging is utilized.

The Effects of Nasal Surgery on Pulmonary Function: A Systematic Review and Meta-Analysis.

A deviated nasal septum (DNS) can result in an anatomical obstruction and impact lung function through prolonged suboptimal inspiration. Given the improvements in respiration reported by patients following septoplasty or septorhinoplasty (with or without inferior turbinate reduction), our study investigated the effect of these procedures on pulmonary function through a systematic review and meta-analysis. Medline, Embase, Cochrane Databases, Web of Science, and Google Scholar. The review was registered with PROSPERO [CRD42022316309]. The study population was composed of adult patients (18-65) who were symptomatic with confirmed DNS. Extracted outcomes (pre-operative versus postoperative) included the six-minute walk test (6MWT) and pulmonary function tests (FEV1, FVC, FEV1/FVC, FEF25-75, PEF). Meta-analyses were performed using a random-effects model. Three studies included measures of the 6MWT in meters and all three found a statistically significant increase in the distance walked after surgery with a mean difference of 62.40 m (95% CI 24.79-100.00). Statistically significant improvements in PFT outcomes were observed with a standard mean difference of 0.72 for FEV1 (95% CI 0.31-1.13), 0.63 for FVC (95% CI 0.26-1.00), and 0.64 for PEF (95% CI 0.47-0.82). Of the twelve studies which measured PFT outcomes, six showed statistically significant improvements, three studies showed mixed results, and three studies found no difference in PFT outcomes between pre-and post-surgery testing. The present study suggests that pulmonary function does improve after nasal surgery for DNS, but the high heterogeneity observed in the meta-analyses indicates that the evidence supporting this conclusion is low. Laryngoscope, 133:2837-2845, 2023.

Urethral Sphincter Botulinum Toxin A Injection for Non-Spinal Cord Injured Patients with Voiding Dysfunction without Anatomical Obstructions: Which Patients Benefit Most?

Treating voiding dysfunction without anatomical obstructions is challenging. Urethral onabotulinum toxin A (BoNT-A) is used in treating voiding dysfunction; however, the success rate varies widely, and patients may not be satisfied with the treatment outcome. This study compared the efficacy of the urethral BoNT-A injection between patients with different non-spinal cord injury (SCI) voiding dysfunctions. This study retrospectively analyzed patients with refractory voiding dysfunction, including detrusor underactivity (DU), dysfunctional voiding (DV), and poor relaxation of the external sphincter (PRES) who received the urethral sphincter 100 U BoNT-A injection. The treatment outcomes were assessed via a global response assessment (GRA) one month after treatment. Baseline and follow-up videourodynamic study (VUDS) parameters were also compared. Totally, 161 patients (60 with DU, 77 with DV, and 24 with PRES) with a mean age of 58.8 ± 20.2 were enrolled, of which 62.1% had a good response (GRA ≥ 2) after urethral BoNT-A injection. DV patients had a higher success rate (76.6%) than DU (50%) and PRES (45.8%) patients (p = 0.002). A diagnosis of DV, higher voided volume and recurrent urinary tract infection were predictors of a good treatment response, while the cervical cancer status post-radical surgery predicted a poor response. Receiver operating characteristic (ROC) curve analyses identified PVR > 250 mL as a negative predictor (p = 0.008) in DU patients. The urethral BoNT-A injection provides a satisfactory success rate for non-SCI voiding dysfunction. Patients with DV benefit most from both subjective and objective parameters. Approximately 50% of patients with DU and PRES also had a fair response. PVR > 250 mL was a negative predictor in DU patients.

Multiparametric Measurements of the Eustachian tube and Peritubal Region Using Computed Tomography as a Preoperative Workup for Tuboplasty.

Eustachian tube dysfunction (ETD) is considered a causative factor for middle ear disease as well as treatment failure. The pathogenesis may be a result of chronic infection, allergy, laryngopharyngeal reflux, primary mucosal disease, dysfunction of the dilation mechanism and anatomical obstruction. Hence, it becomes essential to know the structure and anatomical variations of the Eustachian tube(ET), particularly with the advent of novel therapeutic options such as tuboplasty to ensure optimal therapeutic outcome. This cross-sectional study is done to perform multiparametric measurements of the ET and peritubal region using computed tomography and develop a structured protocol for pre-tuboplasty workup. This study was done for a period of 20 months, in 100 normal subjects aged between 18 and 60 years, who underwent computed tomography (CT) study of the head and face region, for indications other than nasal/ pharyngeal and sinus disease. The mean bony, cartilaginous and overall ET lengths were higher in males. In females, the mean ET angles with Reid's plane were higher. Higher mean craniocaudal diameters of the ET lumen were observed in males. Carotid canal dehiscence was seen in equal prevalence on both sides (5%), with no significant gender differences. Therapeutic interventions such as eustachian tuboplasty will benefit from preoperative imaging based planning. This structured protocol provides standardization of pre-operative workup for tuboplasty.

Sinonasal Complications Following the Sinus Lift Procedure.

Background: Although the incidence of postoperative acute and chronic rhinosinusitis in patients undergoing a sinus lift procedure is relatively high, a paucity of rhinology literature examines the management of and outcomes for this patient population. The objective of this study was to review the management and postoperative care of sinonasal complications and identify possible risk factors that should be considered prior to and following sinus augmentation. Methods: We identified sequential patients who had undergone a sinus lift procedure and were referred to the senior author (AK) at a tertiary rhinology practice for intractable sinonasal complications and reviewed their charts for demographic data, history of illness including prereferral treatment, examination findings, imaging results, treatment modalities, and culture results. Results: Nine patients were initially treated medically without improvement and subsequently underwent endoscopic sinus surgery. The sinus lift graft material remained intact in 7 patients. Two patients had extrusion of the graft material into the facial soft tissues, resulting in facial cellulitis requiring graft removal and debridement. Seven of the 9 patients had predisposing factors that could have prompted referral to an otolaryngologist for optimization prior to sinus lifting. The mean follow-up was 10 months, and all patients had full resolution of symptoms. Conclusion: Acute and chronic rhinosinusitis is a complication of the sinus lift procedure and is more commonly seen in patients with preexisting sinus disease, anatomic sinonasal obstruction, and Schneiderian membrane perforation. Preoperative evaluation by an otolaryngologist may improve outcomes in patients at risk of sinonasal complications from sinus lift surgery.

Maksiller Büyüme Yönü ile Sinonazal Bölgenin Anatomik Varyasyonları Arasındaki İlişkinin İncelenmesi Vaka-Kontrol Araştırması Maksiller Büyüme Yönü ve Sinonazal Varyasyonlar

Objective: This study investigated the frequency of anatomic variations in the sinonasal region with septal deviation and the relationship of these anatomic variations with the developmental direction of the maxilla in cone-beam computed tomography images. Material and Methods: Forty-eight patients who underwent orthognathic surgery were included in this study. These patients were divided into 3 groups: normal maxilla (n=16), prognathic maxilla (n=16), and retrognathic maxilla (n=16) by determining the position of the maxillae in relation to the skull base on lateral cephalometric radiographs. The anatomic variations of the sinonasal region and the presence of maxillary sinus ostium (MSO) obstruction were studied in all groups. The relationship between the anatomical variations and the different developmental aspects of the maxilla was analyzed. Results: The most common anatomical changes in all patients were: hypertrophy of the inferior turbinate (68.8%), deviation of the nasal septum (66.7%), and concha bullosa (62.5%). No statistically significant difference was found between the groups with different skeletal deformities based on the position of the maxilla in relation to the skull base (p>0.05). While there was a statistically significant difference between gender distribution and hypertrophy of the middle concha (p=0.016), no statistically significant difference was found between other anatomical variations and gender distribution (p>0.05). Conclusion: In conclusion, in this study, we investigated the relationship between the anatomical variations of the sinonasal region and the direction of maxillary growth. There was no significant relationship between the above anatomical variations and MSO obstruction between the groups.

Management of hypertrophic rhinitis by application of Kadali kshara

Nasal obstruction is a predominant symptom in hypertrophied inferior turbinate. It can be understood as Nasanaha (~nasal obstruction) in Ayurveda. Even though there are many conditions of the nose causing nasal blockage; inferior turbinate hypertrophy which is a cardinal feature in hypertrophic rhinitis is one of the most common causes of anatomical nasal obstruction, the others being internal nasal valve stenosis and septal deviation. The turbinate hypertrophy in this condition can be managed medically using nasal decongestants and corticosteroids and it can be also managed surgically. Continuous use of nasal decongestants can cause rebound congestion. Surgical management also has limitations such as synechiae formation and postoperative bleeding. Kshara pratisarana (~external application of alkali), which is one among the types of parasurgical procedures explained in Ayurveda, can be used effectively in this condition. Moreover, nasal obstruction is one of the most common symptoms presented to an otorhinolaryngologist and it badly affects the quality of life of the patient. The present case report is a case of a 24-year-old female who was unable to sleep properly due to severe nasal obstruction and chronic rhinitis along with hypertrophy of both inferior turbinates. This also affected her studies badly. She also complains of thick nasal discharge along with obstruction. The patient had the complaints for two years but the symptoms became more severe during the past six months. On anterior rhinoscopic examination using Thudicum's nasal speculum, the presence of bilateral inferior turbinate hypertrophy was observed. The patient was treated with Pratisarana of Kadali kshara (~alkali of Musa paradisiaca Linn.) along with Sigrusimhyadi taila nasya. The treatment was effective in the present case with no recurrence during a follow-up period of 30 days. This case report revealed that nasal obstruction, which is a common problem seen nowadays can be managed effectively using Ayurvedic intervention.

Compromised Cranio-Spinal Suspension in Chiari Malformation Type 1: A Potential Role as Secondary Pathophysiology.

In Chiari Malformation Type I (CM1), low-lying tonsils obstruct the cisterna magna at the foramen magnum, thereby compromising the essential juncture between the cranial and spinal compartments. The anatomical obstruction of the cisterna magna inhibits bi-directional CSF flow as well as CSF pulse pressure equilibration between the intracranial compartment and the intraspinal compartment in response to instances of increased intracranial pressure. Less understood, however, are the roles of the spinal cord suspension structures at the craniocervical junction which lend viscoelastic support to the spinal cord and tonsils, as well as maintain the anatomical integrity of the cisterna magna and the dura. These include extradural ligaments including the myodural bridges (MDBs), as well as intradural dentate ligaments and the arachnoid framework. We propose that when these elements are disrupted by the cisterna magna obstruction, tonsillar pathology, and altered CSF dynamics, there may arise a secondary pathophysiology of compromised and dysfunctional cranio-spinal suspension in CM1. We present intraoperative images and videos captured during surgical exposure of the craniocervical junction in CM1 to illustrate this proposal.

PSAT045 Spontaneous Adrenal Hemorrhage with Partial Adrenal Insufficiency in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome

Abstract Background Addison's disease secondary to adrenal hemorrhage is a rare complication of antiphospholipid syndrome (APLS). Anticoagulation with a direct oral anticoagulant (DOAC) might increase the risk of adrenal hemorrhage. We report a patient who developed bilateral adrenal hemorrhage after starting apixaban for deep venous thrombosis (DVT) and pulmonary embolism (PE) in the setting of latent APLS. Clinical Case A 45-year-old man without significant past medical history presented with a left lower extremity DVT and PE. He had no personal or family history of previous trauma, bleeding or clotting events. He was discharged on apixaban. Three days later he was readmitted with bilateral flank pain. Computerized tomography (CT) imaging showed bilateral adrenal gland edema. He was hemodynamically stable. Due to persistent right flank pain and concern for ileus, CT was repeated and revealed findings concerning for adrenal hemorrhage. He subsequently complained of asthenia. Further testing revealed a reduced morning cortisol of 1.4 ug/dL (reference: 6.0 - 18.4 ug/dL) and an elevated morning ACTH of 149 pg/mL (7.2-63.3 pg/mL). Plasma dehydroepiandrosterone sulphate (DHEA-S) was reduced at 39 mcg/dL (70 - 495 mcg/dL), and epinephrine and norepinephrine were undetectable. Morning plasma aldosterone was undetectable and renin activity was 0.76 ng/mL/h (0.25 - 5.82 ng/mL/h). He was started on stress dose steroids and discharged on maintenance hydrocortisone without reinitiating anticoagulation. Two weeks later, he re-presented with a right lower extremity DVT. An APLS panel revealed elevated anti-beta2 glycoprotein 1 IgG and anti-cardiolipin IgG. Laboratory work-up for other causes of thrombosis, including inherited and acquired thrombophilias, anatomical vascular obstruction, paroxysmal nocturnal hemoglobinuria (PNH), heparin-induced thrombocytopenia (HIT), and myeloproliferative neoplasms (MPN), was unrevealing. Warfarin was started with an international normalized ratio (INR) target range of 2-3. Hydrocortisone was continued at a total daily dose of 30mg. Since discharge, his morning cortisol levels have been low at 4.4-4.9 ug/dL and ACTH has remained high at 92-137 pg/mL, but aldosterone has been variable at <1 to 9 ng/dL, and renin has been normal at 0.35 ng/mL/h. This suggests what transpired had been microthrombi-associated intra-adrenal hemorrhage involving the zona fasciculata with sparing of the glomerulosa. Conclusion This case highlights DOAC-associated adrenal hemorrhage in a patient with underlying APLS, an under-appreciated complication. The extent to which the various layers of the adrenal gland are affected may vary. Since guidelines on the management of patients with partial adrenal insufficiency are lacking, further reporting is needed on long term outcomes and adrenal function of these patients. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Very early endoscopic DCR in acute suppurative dacryocystitis perspective

Acute dacryocystitis is not uncommon in oculofacial and general ophthalmology clinics admissions. It happens with sudden inflammation of lacrimal sac that frequently occurs in the setting of pre-existing nasolacrimal duct obstruction. Long standing tear flow stasis results in change of bacterial flora and bacterial over-growth in the lacrimal sac as a reservoir of stagnant tear., However, acute dacryocystitis can be associated with dacryoliths or indefinite pre-existing anatomic nasolacrimal duct obstruction.

Machine learning evaluation of LV outflow obstruction in hypertrophic cardiomyopathy using three-chamber cardiovascular magnetic resonance

Left ventricular outflow tract obstruction (LVOTO) is common in hypertrophic cardiomyopathy (HCM), but relationships between anatomical metrics and obstruction are poorly understood. We aimed to develop machine learning methods to evaluate LVOTO in HCM patients and quantify relationships between anatomical metrics and obstruction. This retrospective analysis of 1905 participants of the HCM Registry quantified 11 anatomical metrics derived from 14 landmarks automatically detected on the three-chamber long axis cine CMR images. Linear and logistic regression was used to quantify strengths of relationships with the presence of LVOTO (defined by resting Doppler pressure drop of > 30 mmHg), using the area under the receiver operating characteristic (AUC). Intraclass correlation coefficients between the network predictions and three independent observers showed similar agreement to that between observers. The distance from anterior mitral valve leaflet tip to basal septum (AML-BS) was most highly correlated with Doppler pressure drop (R2 = 0.19, p < 10–5). Multivariate stepwise regression found the best predictive model included AML-BS, AML length to aortic valve diameter ratio, AML length to LV width ratio, and midventricular septal thickness metrics (AUC 0.84). Excluding AML-BS, metrics grouped according to septal hypertrophy, LV geometry, and AML anatomy each had similar associations with LVOTO (AUC 0.71, 0.71, 0.68 respectively, p = ns), significantly less than their combination (AUC 0.77, p < 0.05 for each). Anatomical metrics derived from a standard three-chamber CMR cine acquisition can be used to highlight risk of LVOTO, and suggest further investigation if necessary. A combination of geometric factors is required to provide the best risk prediction.

Genome-wide association study in patients with posterior urethral valves.

Congenital lower urinary tract obstructions (LUTO) are most often caused by posterior urethral valves (PUV), a male limited anatomical obstruction of the urethra affecting 1 in 4,000 male live births. Little is known about the genetic background of PUV. Here, we report the largest genome-wide association study (GWAS) for PUV in 4 cohorts of patients and controls. The final meta-analysis included 756 patients and 4,823 ethnicity matched controls and comprised 5,754,208 variants that were genotyped or imputed and passed quality control in all 4 cohorts. No genome-wide significant locus was identified, but 33 variants showed suggestive significance (P < 1 × 10−5). When considering only loci with multiple variants residing within < 10 kB of each other showing suggestive significance and with the same effect direction in all 4 cohorts, 3 loci comprising a total of 9 variants remained. These loci resided on chromosomes 13, 16, and 20. The present GWAS and meta-analysis is the largest genetic study on PUV performed to date. The fact that no genome-wide significant locus was identified, can be explained by lack of power or may indicate that common variants do not play a major role in the etiology of PUV. Nevertheless, future studies are warranted to replicate and validate the 3 loci that yielded suggestive associations.

Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research.

Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.

Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis.

A systematic review and meta-analysis to evaluate the diagnostic performance of lacrimal scintigraphy (LS) versus anatomical methods in the evaluation of the nasolacrimal duct obstruction (NLDO). A systematic search was performed using electronic bibliographic databases until the end of May 2021. Inclusion criteria: (a) used LS as a diagnostic method to evaluate NLDO; (b) used anatomical studies [including syringing, irrigation, probing, and dacryocystography (DCG)] as reference tests; and (c) provided adequate crude data. A hierarchical method was used to pool the sensitivity and specificity. The hierarchical summary receiver-operating characteristic model was performed. Additionally, the studies' heterogeneity and publication bias were analyzed. All analyses were conducted by the 'Midas' module of STATA 16. Twelve articles (with 14 separate populations) were considered eligible to enter the meta-analysis. They were divided into two groups based on the reference standard method, called irrigation and DCG groups. In the irrigation group, the pooled sensitivity and specificity were 89% [95% confidence interval (CI), 72-96%] and 25% (95% CI, 8-56%), respectively. In DCG group, the pooled sensitivity and specificity were 97% (95% CI, 85-100%) and 27% (95% CI, 0.12-0.49), in turn. LS is a sensitive modality to evaluate the anatomical obstruction of NLD. In contrast, it shows low pooled specificity compared with anatomical methods. Thus, LS can be used as the first noninvasive modality for the evaluation of epiphora. However, in case of any abnormality, confirmatory procedures are required.

Nasal nerve ablation, nasal swell body and inferior turbinate reduction for nasal obstruction and congestion relief.

Nasal obstruction and congestion can occur because of turbinate and septal variations with or without rhinitis. A combined treatment for nasal obstruction and congestion was examined retrospectively in cases where the nasal swell body was addressed with inferior turbinectomy, with or without posterior nasal nerve ablation. A 940 nm laser was utilised for contact (nasal swell body, septum and inferior turbinate) and non-contact (posterior nasal nerve) ablation. Total Nasal Symptoms Score, visual analogue scale pain score, complications and procedure location (office vs operating theatre) were recorded. All 242 patients underwent nasal swell body reduction with inferior turbinate reduction, and 150 had posterior nasal nerve ablation also. No laser complications were observed. An 80 per cent reduction in medication usage was noted. Total Nasal Symptoms Score decreased by 73 per cent; rhinorrhoea and congestion scores decreased by 54 per cent and 81 per cent respectively. Crusting, epistaxis and infections were minimal, and resolved within two weeks. Nasal swell body with inferior turbinate reduction, with or without posterior nasal nerve ablation, is a new method of treating nasal obstruction and congestion. Laser posterior nasal nerve ablation can be utilised as a complementary tool to deliver anatomical obstruction relief.