Anatomic Severity Research Articles

Is there a gender difference in the effects of cardiovascular risk factors on the anatomical localization and severity of obstruction on coronary arteries?

Abstract Background Whether there is a gender difference in the effects of traditional cardiovascular risk factors(CVRF) on the anatomical localization(AL) and severity(AS) of obstruction on coronary arteries(CA) remains unclear. Purpose In our study, we investigated whether there is a gender difference in the relationship between CVRF and obstruction on CA . Methods We included 978 patients(49.9% women, mean age: 61+10.3) with stable chest pain undergoing invasive coronary angiography between 2019-2021 who were recruited from the database of our clinic. We examined the gender difference in hypertension(HT), diabetes mellitus(DM), smoking, hyperlipidemia, previous history of CAD(H.CAD) and family history of premature CAD(F.CAD) and their correlation with the AL and AS of obstruction on CA in both gender. Results Women were older(p<0.001) with higher rates of HT (p=0.001) and DM(p=0.026) and higher TC, LDLC and HDLC levels respectively (rs) as (p=0.001, p=0.001, p=0.001). Whereas H.CAD and smoking rates were higher in men rs as (p=0.001, p=0.009). The incidence of critical stenosis (≥70 obstruction) & intermediate lesions (50-69%) on all CA and Syntax scores were higher in men(p<0,01). In patients with HT, severe CAD was more prominent on circumflex (Cx)(p=0.029) and right coronary artery(RCA)(p=0.002) in women and on the proximal ( p=0.024) and mid portion of left anterior descending artery(LAD) (p=0.045) in men. In patients with DM a statistically significant(ss) correlation was found between the presence of DM and AS in all vessels except for left main coronary artery (LMCA) in women (LAD prox:p=0.001; LAD mid:p=0.001; diagonal artery(Dg):p=0.003; Cx:p=0.001; RCA:p=0.001 ;LMCA:p>0.05). However no such correlation was observed in men(p>0.05). In patients with H.CAD moderate/severe lesions were more common on proximal(p=0.013) and mid portions of LAD(p=0.021), on CX( p=0.006) and on RCA(p=0.016) in men and more common on the proximal portion of LAD(p=0.047), CX(p=0.014) and RCA(p=0.009) in women. For either smoking and F.CAD there was no such correlation in either gender (p>0,05). As for blood lipid levels no correlation was observed between LDLC, HDLC and triglyceride levels and AL&AS in men(p>0,05). However there was a negative, weak correlation between the HDLC levels and obstruction on LAD mid portion(r=-0.140; p=0.003); on Dg(r=-0.100; p=0.034) on CX (r=-0.154; p=0.001) and on RCA (r=-0.151; p=0.001) in women. Conclusion Major traditional CVRFs have a sex specific impact on AL and AS of obstruction on CA. In the era of precisıon medicine we need gender specific risk scoring systems taking these gender differences into account.

Prognostic value of quantitative anatomical and functional measures of coronary artery disease in diabetic and non-diabetic patients

Abstract Background Diabetes is associated with increased risk of coronary artery disease (CAD). However, the relative prognostic importance of anatomical and functional findings of CAD in the presence vs. absence of diabetes is incompletely understood. Technological advances have made quantitative analysis of coronary artery plaques and stenosis feasible by coronary computed tomography angiography (CTA). In turn, positron emission tomography (PET) enables absolute quantification of myocardial blood flow (MBF). Purpose To study long-term prognostic value of quantified severity of coronary atherosclerosis and myocardial perfusion in non-diabetic vs. diabetic patients with suspected CAD. Methods From two academic medical centres, we identified symptomatic patients with suspected CAD who had undergone coronary CTA and [15O]H2O PET myocardial perfusion imaging during adenosine stress. Based on artificial intelligence -guided quantitative analysis of coronary CTA scans, the anatomical severity of CAD was measured as the presence of obstructive CAD (≥50% diameter stenosis) and percent atheroma volume (PAV; higher vs. lower than median). The functional severity of CAD was measured as the presence of regional myocardial ischemia (≥2 adjacent segments with stress MBF <2.3 ml/g/min) and global stress MBF (<2.2 ml/g/min vs. ≥ 2.2 ml/g/min) by PET. Annual rates of adverse events (AER) including all-cause mortality, myocardial infarction (MI), and unstable angina pectoris (UAP) were evaluated. Results Among 1311 patients, 251 (19%) had diabetes. Patients with diabetes had more frequently obstructive CAD (55% vs. 43%, p<0.001) and regional myocardial ischemia (51% vs. 43%, p=0.015), higher plaque burden by PAV (12% vs. 7%, p<0.001), and lower global stress MBF (2.78 ml/g/min vs. 3.05 ml/g/min, p<0.001). During median follow-up of 7.1 years, 171 (13.0%) patients experienced AE (85 deaths, 56 MIs, and 30 UAPs). Patients with diabetes had higher AER than non-diabetic patients (3.1% vs. 1.6%, p<0.001). The presence of obstructive stenosis was associated with increased AER in non-diabetic (2.6% vs. 1.0%, p<0.001) and diabetic patients (4.2% vs. 1.9%, p<0.001). High plaque burden by PAV was associated with increased AER in non-diabetic (2.8% vs. 0.7%, p<0.001) and diabetic patients (3.9% vs. 1.7%, p<0.001). The presence of regional myocardial ischemia was associated with increased AER in non-diabetic (2.5% vs. 1.1%, p<0.001), but not in diabetic patients (3.4% vs. 2.7%, p=0.238). Low global stress MBF was associated with increased AER in non-diabetic (2.9% vs. 1.3%, p<0.001), but not among diabetic patients (3.2% vs. 3.0%, p=0.286). Conclusions Diabetes was associated with more advanced CAD. Quantified severity of anatomical findings predicted long-term adverse outcome in non-diabetic and diabetic patients. In contrast, functional imaging risk stratified non-diabetic patients, whereas diabetic patients had impaired long-term outcome irrespective of perfusion findings.

Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis

Abstract Objectives To perform a systematic review and meta-analysis on diagnostic accuracy and other outcomes of coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (CT-FFR) in candidates for trans-catheter aortic valve implantation (TAVI). Background Screening for obstructive coronary artery disease (CAD) with CCTA during TAVI work-up could prevent unnecessary invasive coronary angiography (ICA). This becomes increasingly relevant as the TAVI-population grows. CT-FFR improves CCTA accuracy in chest pain patients, but its reliability is unknown in the TAVI-population. Methods Pubmed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI-candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis. Results Twenty-four of the 29 included articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 3.494 and 797 patients respectively. Reference standard was anatomical severity of CAD in most studies. At patient-level, pooled CCTA sensitivity was 94.3% and specificity 74.8%. CT-FFR sensitivity was 91.5% and specificity 60.3% with strong variation between studies. CCTA correctly ruled out CAD in 52% of all patients, but 42% of positive CCTAs were false positives. CT-FFR correctly ruled out CAD in 47% of all patients included in this meta-analysis, but showed better accuracy than CCTA in studies that compared both. In these studies, sensitivity of CCTA versus CT-FFR was 70.7% versus 79.0% and specificity was 64.4% versus 92.9%. Conclusions Negative CCTA effectively rules-out CAD in the TAVI-population. Adding CCTA to TAVI work-up could lead to significant reduction in pre-TAVI ICA procedures, but the proportion of false-positives remains high. In studies performing a direct comparison, CT-FFR performed better than CCTA. This is not reflected in the CT-FFR meta-analysis. Therefore, diagnostic accuracy of CT-FFR and added value over CCTA in the TAVI-population remains unclear. Further research regarding validation and reliability is warranted.Meta-analysis of CCTA and CT-FFR

Association of non-invasive assessed anatomical features with functional testing in coronary artery anomalies - NARCO trial

Abstract Introduction Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital condition believed to carry an increased risk for myocardial ischemia. However, correlation between anatomical characteristics and ischemia remains unclear. Therefore, this study aimed to assess: 1. The difference of invasive fractional flow reserve (FFR) and intravascular ultrasound (IVUS)-based minimal lumen area (MLA) between baseline and stress. 2. The association of coronary computed tomography angiography (CCTA)-based anatomical characteristics to invasively measured hemodynamics and IVUS in AAOCA. Methods Consecutive patients with AAOCA and presence of ≥1 anatomical high-risk features (i.e. intramural course (IM), slit-like ostium, acute take-off angle or proximal narrowing), were systematically evaluated as part of the NARCO trial using CCTA, FFR using adenosine (140 µg/kg/min), dobutamine-volume stress (20-40mcg/kg/min, 0.5-1mg atropine and 3L of saline solution) and IVUS- MLA of IM. Anatomic high-risk features were quantified by CCTA including ostial lumen area and IM-MLA, IM-width, IM-height, IM-elliptic ratio, take-off angle, proximal narrowing and IM length of the anomalous coronary segment. Results A total of 94 patients with AAOCA were screened, whereas 48 showed high-risk anatomic features and underwent the complete stress protocol. Mean age was 54±12 years and 36 (75%) were male and 39 (81%) presented with symptoms. FFRstress was significantly lower than FFRadenosine (0.88 [0.81-0.91] vs. 0.91 [0.87-0.94], p<0.001) (Figure 1). FFRadenosine was ≤0.8 in 5 patients (10%), and FFRdobutamine was ≤0.8 in 12 patients (25%), resulting in 7 (15%) with FFRadenosine >0.8 while FFRdobutamine was ≤0.8. IVUS-MLA was decreased from 6.3 (5.4-8.2) mm2 to 5.4 (4.2-7.1) mm2 during stress (p<0.001) (Figure 2), while elliptic ratio increased from 2.6 (2.1-3.4) to 3.3 (2.5-4.4) (p<0.001). Logistic regression analysis for body surface area adjusted CCTA derived high-risk features showed, that only ostial lumen area, IM-MLA, -elliptic ratio and -width could predict FFRstress ≤0.8. Receiver operating curve analysis showed that ostial width had the greatest AUC with 0.86 (accuracy 83%, sensitivity 83%, and specificity 83%). Eight out of 12 (67%) patients with hemodynamic relevance underwent surgery, 2 (17%) underwent stenting and 2 (17%) were treated with medication. Conclusion In patients with AAOCA and anatomic high-risk features, only one quarter are hemodynamic relevant. FFR during dobutamine-volume stress showed to be the more sensitive stress modality as compared to FFRadenosine. CCTA derived ostial and IM anatomical severity is associated with ischemia under stress. Comprehensive functional and anatomical assessment of AAOCA helps to optimize patient management and avoid unnecessary revascularization.Figure 1:FFRadenosine vs FFRstressFigure 2:IVUS-MLArest vs IVUS-MLAstress

TCT-510 The Association Between Anatomical and Ischemic Severity of Coronary Artery Disease With Experimentally Verified Angina

TCT-510 The Association Between Anatomical and Ischemic Severity of Coronary Artery Disease With Experimentally Verified Angina

Value of Ischemia and Coronary Anatomy in Prognosis and Guiding Revascularization Among Patients With Stable Ischemic Heart Disease.

The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated. A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index. The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21). Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).

Relationship between Earlobe Crease and Anatomical Severity of Coronary Artery Disease in ST-segment Elevation Myocardial Infarction.

Objective Earlobe crease (ELC) is an easily detectable physical sign of cardiovascular risk and coronary artery disease (CAD). However, the relationship between ELC and CAD severity in patients with ST-segment elevation myocardial infarction (STEMI) requiring urgent clinical judgment is unknown. Using the residual synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score, we investigated the relationship between ELC and anatomical severity of CAD. Methods We studied 219 consecutive patients with STEMI (median age, 71 years old) and divided them into 2 groups according to the presence of ELC (ELC group, n=161; non-ELC group, n=58). Results The ELC group had a significantly higher number of diseased vessels than the non-ELC group (≥2 diseased vessels, 79% vs. 46%; ≥3 diseased vessels, 35% vs. 12%; p<0.001). In addition, a higher median residual SYNTAX score was observed after primary percutaneous coronary intervention than the non-ELC group [8 (4-12) vs. 3 (0-8), p<0.001]. Furthermore, a multivariable regression analysis showed that ELC was an independent predictor of the residual SYNTAX score (β=3.620, p<0.001). Conclusions The presence of ELC was significantly associated with the anatomical severity of diseased coronary vessels in patients with STEMI who required emergency clinical judgment and treatment.

Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis.

Thresholds of aortic valve calcification (AVC) to define hemodynamically moderate aortic stenosis (AS) from mild are lacking. We aimed to establish a novel grading classification of AVC as quantified by computed tomography and determine its prognostic value. This study included 915 patients with at least mild AS (mean age 70±12 years, 30% women) from a multicenter prospective registry. All patients underwent Doppler-echocardiography and noncontrast computed tomography within 3 months. Primary end point was the occurrence of all-cause death. Receiver operating characteristic curves analyses were used to determine the sensitivity and specificity of sex-specific thresholds of AVC to identify hemodynamically moderate AS. Optimal thresholds (ie, with best sensitivity/specificity) of AVC to distinguish moderate (aortic valve area 1.0-1.5 cm2 and mean gradient 20-39 mm Hg) from mild AS (aortic valve area >1.5 cm2 and mean gradient <20 mm Hg) were AVC ≥360 arbitrary units in women and ≥1037 arbitrary units in men. Based on the guidelines' thresholds for severe AS and the new thresholds in our study for moderate AS, 312 (34%) patients had mild, 253 (28%) moderate, and 350 (38%) severe AVC. During a mean follow-up of 5.6±3.9 years, 183 (27%) deaths occurred. In Cox multivariable models, AVC remained associated with an increased risk of death (adjusted hazard ratio per grade increase, 1.94 [95% CI, 1.53-2.56]; P<0.001). A novel grading classification of anatomic AS severity based on sex-specific thresholds of AVC provides significant prognostic value for predicting mortality. These findings support the complementarity of computed tomography-calcium scoring to Doppler-echocardiography to corroborate AS severity and enhance risk stratification in patients with AS.

Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients.

Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.

Intra-abdominal infection and sepsis in immunocompromised intensive care unit patients: Disease expression, microbial aetiology, and clinical outcomes

We compared epidemiology of intra-abdominal infection (IAI) between immunocompromised and non-immunocompromised ICU patients and identified risk factors for mortality.We performed a secondary analysis on the “AbSeS” database, a prospective, observational study with IAI patients from 309 ICUs in 42 countries. Immunocompromised status was defined as either neutropenia or prolonged corticosteroids use, chemotherapy or radiotherapy in the past year, bone marrow or solid organ transplantation, congenital immunodeficiency, or immunosuppressive drugs use. Mortality was defined as ICU mortality at any time or 28-day mortality for those discharged earlier. Associations with mortality were assessed by logistic regression.The cohort included 2589 patients of which 239 immunocompromised (9.2 %), most with secondary peritonitis. Among immunocompromised patients, biliary tract infections were less frequent, typhlitis more frequent, and IAIs were more frequently healthcare-associated or early-onset hospital-acquired compared with immunocompetent patients. No difference existed in grade of anatomical disruption, disease severity, organ failure, pathogens, and resistance patterns. Septic shock was significantly more frequent in the immunocompromised population. Mortality was similar in both groups (31.1% vs. 28.9 %; p = 0.468). Immunocompromise was not a risk factor for mortality (OR 0.98, 95 % CI 0.66–1.43). Independent risk factors for mortality among immunocompromised patients included septic shock at presentation (OR 6.64, 95 % CI 1.27–55.72), and unsuccessful source control with persistent inflammation (OR 5.48, 95 % CI 2.29–12.57). In immunocompromised ICU patients with IAI, short-term mortality was similar to immunocompetent patients, despite the former presented more frequently with septic shock, and septic shock and persistent inflammation after source control were independent risk factors for death.

Racial and Ethnic Disparities in Health Care Usage and Death by Neighborhood Poverty Among Individuals With Congenital Heart Defects, 4 US Surveillance Sites, 2011 to 2013.

Socioeconomic factors may lead to a disproportionate impact on health care usage and death among individuals with congenital heart defects (CHD) by race, ethnicity, and socioeconomic factors. How neighborhood poverty affects racial and ethnic disparities in health care usage and death among individuals with CHD across the life span is not well described. Individuals aged 1 to 64 years, with at least 1 CHD-related International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code were identified from health care encounters between January 1, 2011, and December 31, 2013, from 4 US sites. Residence was classified into lower- or higher-poverty neighborhoods on the basis of zip code tabulation area from the 2014 American Community Survey 5-year estimates. Multivariable logistic regression models, adjusting for site, sex, CHD anatomic severity, and insurance-evaluated associations between race and ethnicity, and health care usage and death, stratified by neighborhood poverty. Of 31 542 individuals, 22.2% were non-Hispanic Black and 17.0% Hispanic. In high-poverty neighborhoods, non-Hispanic Black (44.4%) and Hispanic (47.7%) individuals, respectively, were more likely to be hospitalized (adjusted odds ratio [aOR], 1.2 [95% CI, 1.1-1.3]; and aOR, 1.3 [95% CI, 1.2-1.5]) and have emergency department visits (aOR, 1.3 [95% CI, 1.2-1.5] and aOR, 1.8 [95% CI, 1.5-2.0]) compared with non-Hispanic White individuals. In high poverty neighborhoods, non-Hispanic Black individuals with CHD had 1.7 times the odds of death compared with non-Hispanic White individuals in high-poverty neighborhoods (95% CI, 1.1-2.7). Racial and ethnic disparities in health care usage were similar in low-poverty neighborhoods, but disparities in death were attenuated (aOR for non-Hispanic Black, 1.2 [95% CI=0.9-1.7]). Racial and ethnic disparities in health care usage were found among individuals with CHD in low- and high-poverty neighborhoods, but mortality disparities were larger in high-poverty neighborhoods. Understanding individual- and community-level social determinants of health, including access to health care, may help address racial and ethnic inequities in health care usage and death among individuals with CHD.

Measuring Pelvic Organ Prolapse: An Evolution.

Advances in our understanding of pelvic organ prolapse (POP) have been made with the introduction of valid, reliable measures of anatomy and patient-reported outcome measures. This review provides an overview of the evolution of POP measurement and its implications for clinical practice and research. Since the introduction of the Pelvic Organ Prolapse Quantification (POPQ), studies have demonstrated that some degree of loss of anatomic support is normal, with as many as 40% of normal women having stage 2 prolapse. Vaginal support is dynamic and can wax and wane but is largely stable over time. Vaginal bulge symptoms are the most reliable and specific symptom for POP and the hymen is an important threshold for symptom development. Most pelvic floor symptoms have only weak to moderate correlation with the anatomic severity of POP. Treatment success rates are highly variable depending upon criteria used and definitions of anatomic success commonly used are too strict and often not clinically relevant. There is substantial discordance between subjective and anatomic measures of success, and both are dynamic, fluctuating between success and failure for many patients without intervening treatment. Pelvic organ prolapse is multidimensional, dynamic, and has a complex impact on patients. Patients' symptoms are more clinically relevant than anatomic support. Symptomatic cure, particularly the absence of vaginal bulge symptoms, is more clinically relevant than anatomic cure and composite outcomes can be misleading and overestimate failure rates. Future studies should compare treatments using continuous variables along multiple dimensions rather than using composite outcomes or dichotomizing patients into success or failure.

Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm.

Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.

Study on anatomical variations of nose and paranasal sinuses in patients with sinonasal polyposis

Background: Knowledge regarding the sinonasal variations plays an important role in the management of sinonasal diseases. Despite being postulated as one of the risk factors for sinonasal diseases, its role in the pathogenesis of nasal polyp is still unclear. This study was done to determine the prevalence of sinonasal anatomical variations by CT imaging and examine its association with sinonasal polyposis (SNP). Method: A descriptive cross-sectional study was conducted from January, 2019 to January, 2020 at a tertiary care center after receiving ethical approval from the institutional review committee of the hospital. Patients above 17 years of age having sinonasal polyp and not responding to 3-4 weeks of medical treatment were included in the study. Convenience sampling was done. Data were collected and entered in Microsoft excel and analyzed using statistical package for the social sciences version 24.0. Results: Among 72 patients, 86.11% of the patients were found to have anatomical variations of nose and paranasal sinuses with Agger nasi (79.09%) and deviated nasal septum (DNS) (72.5%) being the most common variations noted, 29% of patients were found to have a single variation while multiple variations were seen 70.9% of patients. Conclusions: Our study showed that patients with sinonasal polyps have a higher prevalence of sinonasal anatomical variations and severity of polyp increased with the presence of more than one variation in a patient.

Applicability of the Anatomic Severity Grading Score in Endovascular Abdominal Aortic Aneurysm Repair

Applicability of the Anatomic Severity Grading Score in Endovascular Abdominal Aortic Aneurysm Repair

Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures.

The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures. A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms. The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries. Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.

Navigating the spectrum of double-outlet right ventricle presentations: Outcomes from a contemporary cohort based on subtypes.

Our aim in this study was to investigate the prenatal and postnatal prognosis of double outlet right ventricle (DORV) cases diagnosed prenatally by analyzing the outcomes based on the subtype. This study is a retrospective chart review. Cases diagnosed with fetal DORV by prenatal ultrasound in the maternal-fetal medicine department of our hospital between 2014 and 2022 were included. Data on maternal characteristics, fetal echocardiographic features (type of DORV), pregnancy and neonatal outcomes (termination of pregnancy [TOP], intrauterine fetal death [IUD], neonatal death [NND], death in infancy (IND), survival) were collected and analyzed. Ninety-nine cases of prenatally diagnosed cases of DORV were included. The prenatal diagnosis was right in 97% of the liveborn fetuses. The cases were classified into subtypes, including transposition of great arteries (TGA), Fallot, ventricular septal defect (VSD), remote, and heterotaxy types. The cohort consisted of 32.3% TGA type, 19.1% fallot type, 11.1% VSD type, 2% remotetype, and 35.3% heterotaxy type of DORV. An additional cardiac anomaly was observed in 87% and an extra-cardiac anomaly was observed in 54% of the cases. When we excluded the cases with heterotaxy type but without any chromosomal abnormality, additional genetic abnormalities were detected in 42% of the remaining cases. Outcome of pregnancy was livebirth in 68/99 (68.7%), IUFD in 5/99 (5.1%), and TOP in 26/99 (26.3%). Postnatal cardiac surgical repair was performed in 48 cases. Survival among livebirths was 39/68 (57.3%). Twenty-nine neonates or infants who had additional cardiac anomalies and/or genetic abnormalities died before any surgical intervention. The postoperative survival rate was 39/48 (81.2%). The prognosis in DORV depends on the anatomical subtype, the presence, and severity of associated anomalies. Survival increases in isolated cases without any additional structural or genetic anomalies.

Spina Bifida Prevention: A Narrative Review of Folic Acid Supplements for Childbearing Age Women.

Neural tube defects (NTDs) are malformations that occur during embryonic development, and they account for most central nervous system birth anomalies. Genetic and environmental factors have been shown to play a role in the etiology of NTDs. The different types of NTDs are classified according to anatomic location and severity of the defect, with most of the neural axis anomalies occurring in the caudal spinal or cranial areas. Spina bifida is a type of NTD that is characterized by an opening in the vertebral arch, and the level of severity is determined by the extent to which the neural tissue protrudes through the opened arch(es). Prevention of NTDs by administration of folic acid has been studied and described in the literature, yet there are approximately 300,000 cases of NTDs that occur annually, with 88,000 deaths occurring per year worldwide. A daily intake of at least 400 μg of folic acid is recommended especially for women of childbearing age. To provide the benefits of folic acid, prenatal vitamins are recommended in pregnancy, and many countries have been fortifying foods such as cereal grain products with folic acid; however, not all countries have instituted folic acid fortification programs. The present investigation includes a description of the pharmacology of folic acid, neural tube formation, defects such as spina bifida, and the relevance of folic acid to developing spina bifida. Women's knowledge and awareness of folic acid regarding its importance in the prevention of spina bifida is a major factor in reducing incidence worldwide.

Effect of inflammation on association between cancer and coronary artery disease

BackgroundCancer and coronary artery disease (CAD) is reported to often co-exist in same individuals, however, whether cancer is directly associated with anatomical severity of CAD is rarely studied. The present study aimed to observe the relationship between newly diagnosed cancer and anatomical severity of CAD, moreover, to investigate effect of inflammation on the relationship of cancer with CAD.Methods374 patients with newly diagnosed cancer who underwent coronary angiography (CAG) were enrolled. Through 1:3 propensity score matching (PSM) to cancer patients based on the age and gender among 51,106 non-cancer patients who underwent CAG, 1122 non-cancer patients were selected as control patients. Anatomical severity of CAD was assessed using SYNTAX score (SXscore) based on coronary angiographic image. SXscore ≤ 22 (highest quartile) was defined as SX-low, and SXscore > 22 as SX-high. The ratio of neutrophil to lymphocyte count (NLR) was used to describe inflammation level. Association between cancer and the anatomical severity of CAD was investigated using logistic regression.ResultsUnivariate logistic regression analysis showed a correlation between cancer and anatomical severity of CAD (OR: 1.419, 95% CI: 1.083–1.859; P = 0.011). Cancer was associated with increased risk of SX-high after adjusted for common risk factors of CAD (OR: 1.598, 95% CI: 1.172–2.179, P = 0.003). Significant association between cancer and SX-high was revealed among patients with high inflammation (OR: 1.656, 95% CI: 1.099–2.497, P = 0.016), but not among patients with low inflammation (OR: 1.530, 95% CI: 0.973–2.498, P = 0.089).ConclusionsCancer was associated with severity of CAD, however, the association between the two diseases was significant among patients with high inflammation rather than among patients with low inflammation.

Infectious sacroiliitis: MRI- and CT-based assessment of disease extent, complications, and anatomic correlation.

To describe the frequency of MR and CT features of infectious sacroiliitis (ISI) and assess its extent and complications MATERIALS AND METHODS: This retrospective study included patients with ISI who were evaluated between 2008 and 2021 in a single center. Two radiologists reviewed MRI and CT images to determine the anatomical distribution (unilateral/bilateral, iliac/sacral bone, proximal/middle/distal), severity (bone marrow edema [BME]/periostitis/erosions), concurrent infection (vertebral/nonvertebral), and complications (abscess/probable adjacent osteomyelitis/cavitation/devitalized areas/sequestrum/pelvic venous thrombosis) of ISI. Interobserver reproducibility was assessed. Correlation analysis evaluated the effect of the causative microorganism on severity. Two human bodies were dissected to outline possible ways that ISI can spread. Forty patients with ISI (40 years ± 22; 26 women) were evaluated. Ten patients had bilateral ISI. Concurrent vertebral infection was associated in 15% of cases. Reproducibility of sacral BME, periostitis, and reactive locoregional abnormalities was perfect (κ = 1). Reproducibility was low for erosion count (κ = 0.52[0.52-0.82]) and periarticular osteopenia (κ = 0.50[0.18-0.82]). Inflammatory changes were BME (42/42 joints), muscle edema (38/42), and severe periostitis along the ilium (33/37). Destructive structural changes occurred with confluent erosions (iliac, 20/48; sacral, 13/48), sequestrum (20/48), and cavitation (12/48). Complications occurred in 75% of cases, including periarticular abscesses (n = 30/47), probable adjacent osteomyelitis (n = 16/37), and pelvic thrombophlebitis (n = 3). Tuberculous ISI (6/40) correlated with sclerosis (rs = 0.45[0.16; 0.67]; p < 10-2) and bone devitalization (rs = 0.38[0.16; 0.67]; p = .02). The anatomical study highlighted the shared venous vascularization of sacroiliac joints, pelvic organs, and mobile spine. Complications of ISI are frequent, including abscesses, adjacent osteomyelitis, and periostitis. ISI had bilateral involvement nonrarely and is commonly associated with another spinal infection.