Anatomical Score Research Articles

Preserving Essential Skills: The Future of Vaginal Hysterectomy Training in Urogynaecology.

This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications. A cross-sectional survey. An electronic questionnaire. European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members. A total of 33 questions evaluating surgeon preference regarding vaginal surgeries. Demographics, surgical selection, proficiency and technique, and training methods. There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency. Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques.

Surgical treatment of AO/OTA 41B3 and 41C tibial plateau fractures with a temporary bi-frame fixator combined with the MIPPO technique

BackgroundThis study evaluated the clinical effects of the use of a temporary bi-frame fixator in conjunction with minimally invasive percutaneous plate osteosynthesis (MIPPO) for treating AO/OTA 41B3 and 41C tibial plateau fractures (TPFs).MethodsThis was a retrospective analysis of 30 patients with TPFs affected by vertical compression seen from October 2019 to October 2020. All patients were treated with a bi-frame fixator to correct the vertical shortening deformity, with the MIPPO technique used after reduction. All patients underwent routine examinations at 1, 3, 6, 12 and 24months postoperatively and then annually. Clinical parameters assessed included the Hospital for Special Surgery score (HSS), number of assistants, intraoperative hemorrhage, intraoperative fluoroscopy frequency, length of hospital stay, and time to fracture healing. Radiographic findings were assessed using Rasmussen scores.ResultsAll patients had satisfactory fracture reduction on postoperative imaging. The average operating time was 112.03 ± 20.9 min, with 15.79 ± 3.45 fluoroscopic exposures; the average blood loss was 66.63 ± 10.88 mL, the average length of hospital stay was 12.86 ± 5.11 days, and the average fracture healing time was 10.33 ± 1.48 weeks. The mean follow-up time was 23.18 ± 2.59 months. At the last follow-up, the Rasmussen anatomical score was excellent in 22 (75.3%) patients, good in 5 (16.7%), and fair in 3 (10%). The average HSS was 65.7 ± 3.26, 82.26 ± 2.28, and 87.66 ± 2.4 after 1, 6, and 12 months, respectively, and it was 92.56 ± 2.96 at the last follow-up (F = 1073.073, P < 0.001). No complications occurred in any patient during follow-up.ConclusionFor AO/OTA 41B3 and 41C fractures of the tibial plateau, the use of a temporary bi-frame fixator combined with the MIPPO technique can correct the compressed displacement, reduce soft tissue damage, and facilitate surgical reduction, which aid the recovery of joint function.

A novel preoperative evaluation technique for partial nephrectomy: three-dimensional extended renal tumor plane.

To develop a three-dimensional (3D) image based extended tumor plane technique for robotic-assisted partial nephrectomy (RAPN). We prospectively enrolled patients with a local renal tumor for RAPN between March 2019 and Mar 2022. 3D virtual model was reconstructed based on the computed tomography urography. The tumor plane was extended equidistantly (10mm) to form a virtual plane. According to the relationship between the extended plane and the collection system, patients are divided into those with no collecting system involvement, renal medulla involvement, and renal calyx involvement. The primary endpoint was trifecta achievement, which was defined as warm ischemic time ≤ 25min, negative surgical margins, and no major perioperative complications. This study enrolled a total of 215 patients. The median preoperative aspects and dimensions used for an anatomical (PADUA) score was 9 (6-15). The average warm ischemic time was 21.64 ± 9.35min. Postoperative complications occurred in 26 (12.1%) patients, of whom 14 (6.5%) classified as major complication. The number of cases with trifecta failure was 1 (5.3%) in the no involvement group, 28 (20.6%) in the renal medullary involvement group, and 24 (40.0%) in the renal calyx involvement group (p < 0.001). Logistic regression indicated that renal calyx involvement was a risk factor for trifecta failure (OR = 2.639, 95% confidence interval [1.268-5.492], p = 0.009). The extended tumor plane based on three-dimensional images can is useful for the evaluation of RAPN. Determining whether the extended plane involves the collecting system, particularly the renal calyx, may impact the achievement of trifecta.

Prognostic Role of Neutrophil Percentage-to-Albumin Ratio in Patients with Non-ST-Elevation Myocardial Infarction.

Background and Objectives: This study aimed to investigate whether neutrophil percentage-to-albumin ratio (NPAR) levels on admission have prognostic significance regarding one-year major adverse cardiovascular and cerebrovascular events (MACCEs) in non-ST-elevation myocardial infarction (NSTEMI) patients. Materials and Methods: A total of 464 patients aged 59.2 ± 11.6 years constituted the cohort of this retrospectively designed study. Considering a 1-year follow-up period, the patients were divided into two groups: those with MACCEs and those without. The complete blood count, serum C-reactive protein and serum albumin levels were measured at admission. The NPAR, C-reactive protein/albumin ratio (CAR) and systemic immune-inflammation (SII) index were calculated for all patients, and the associations of these inflammatory-based biomarkers with 1-year MACCEs were evaluated. Results: During the 12-month follow-up period, MACCEs were observed in 75 (16.2%) patients, of which 35 (7.5%) patients died. The patients with MACCEs had higher CRP (p < 0.001), a higher percentage of neutrophils (p < 0.001), lower albumin levels (p < 0.001), a higher CAR (p < 0.001), a higher SII index (p = 0.008) and a higher NPAR (p < 0.001). A high anatomical SxSI score, a high low-density lipoprotein cholesterol level, hypoalbuminemia, high neutrophil counts, a high NPAR level and a high CAR level were independent predictors for one-year MACCEs (all p < 0.05). The NPAR (area under the curve [AUC] = 0.775, p < 0.001) and albumin level (AUC = 0.708, p < 0.001) had better and sufficient discriminatory power and predictive accuracy in determining one-year MACCEs, when compared to the neutrophil (AUC = 0.693, p < 0.001), CAR (AUC = 0.639, p < 0.001) and SII index (AUC = 0.660, p < 0.001), in terms of the receiver operating characteristic curve. The DeLong test revealed that the predictive performance of the NPAR was superior to that of the other inflammatory parameters. In particular, individuals with an NPAR value greater than 17.6 were at greater risk of developing MACCEs (p < 0.001). Conclusions: The NPAR can be used as a newly identified promising inflammatory biomarker to predict one-year MACCEs in NSTEMI patients undergoing revascularization therapy.

Robot-assisted partial nephrectomy in complex renal tumors using the Versius platform: An initial but promising experience

ABSTRACT Background and objectives The widespread utilization of robotic surgeries in urology encouraged several teams to explore the option of performing robot-assisted partial nephrectomy (RAPN), taking advantage of its magnified stereoscopic vision and the articulating instruments that facilitate tumor resection and the reconstructive steps of hemostasis and renorrhaphy. The implementation of the CMR Versius system in RAPN, especially in complex masses, has not been explored yet. Herein, we present our initial experience in performing RAPN in complex renal masses using this novel platform. Methods Between July 2022 and November 2023, thirty patients who had complex renal masses and were candidates for RAPN were enrolled in this study. Tumor complexity was assessed using the preoperative aspects of the dimension used for anatomic (PADUA) nephrometry scores. Perioperative data were prospectively collected and analyzed. ‘TRIFECTA’ was defined as free surgical margins, warm ischemia time (WIT)< 30 minutes, and no major complications (>Clavien-Dindo II). Results All cases were successfully completed with no conversion to radical, open, or laparoscopic surgery. The median PADUA score was 9.5 (8–11). The mean docking time, console time, and total operative time were 9.17 ± 0.91, 149 ± 14.27, and 177.17 ± 29.53 minutes, respectively. The mean WIT was 26.67 ± 3.66 minutes. Surgical margins were free in all cases. TRIFECTA was fulfilled in 25/30 patients (83.33%). Five patients (16.66%) did not fulfill TRIFECTA; two patients had prolonged WIT > 30 minutes, two had prolonged WIT with prolonged urine leakage necessitating DJ stent insertion, and the fifth patient had only prolonged urine leakage and DJ insertion. None of the patients developed tumor recurrence or acute kidney injury during follow-up. Conclusion Performing RAPN with the CMR Versius platform is a feasible option in complex renal masses with slightly increased but accepted WIT and total operative time. It should be wisely restricted to well-experienced teams.

Protocol for the MERINO study: A randomized placebo-controlled trial assessing the efficacy, safety, and cost-effectiveness of methotrexate in people with erosive hand osteoarthritis.

Previous studies on the efficacy of methotrexate in people with hand osteoarthritis (OA) have shown conflicting results. The MERINO trial aims to investigate the efficacy and safety of methotrexate in people with painful inflammatory erosive hand OA. In total 163 participants with erosive hand OA, synovitis by ultrasound, and finger joint pain of 40-80​mm on a visual analogue scale (VAS) will be recruited from a rheumatology outpatient clinic. Participants are randomized 1:1 to receive either encapsulated oral methotrexate 20​mg/week or placebo for 12 months in a double-blind manner. The primary endpoint is VAS finger joint pain at 6 months. Key secondary outcomes are hand function by the Australian/Canadian hand index (AUSCAN) at 6 months and radiographic progression by the Verbruggen-Veys anatomical phase scoring system at 12 months. Other secondary endpoints include hand stiffness, disease activity, health-related quality of life, grip strength, clinical joint counts, synovitis by ultrasound and MRI, bone marrow lesions by MRI, cost-effectiveness, and symptoms in knees and hips. Adverse events will be recorded. The primary analysis will be performed on full analysis set. The findings of this trial will be clinically relevant for patients with erosive hand OA and may influence future treatment recommendations. EU CT number: 2023-510523-30-00, NCT04579848.

Anatomical variations and their impact on chronic rhinosinusitis: a retrospective analysis from an Indonesian tertiary hospital

BackgroundChronic rhinosinusitis (CRS) is an inflammation of the paranasal sinus mucosa lasting over 12 weeks. Its etiology includes infections, allergies, immune system failures, anatomical abnormalities, and mucociliary transport disorders. The complex anatomy of the sinonasal region can hinder mucociliary drainage; necessitating CT scans to evaluate predisposing factors and minimize surgical risks. This study aimed to understand the anatomical variations in the paranasal sinuses and their correlation with CRS.ResultsThe study included 128 CRS patients aged 20 to 75, averaging 36.2 years. The most common symptoms were nasal congestion (98%), runny nose (85%), facial pressure (57%), reduced sense of smell (53%), and posterior nasal discharge (43%). Maxillary rhinosinusitis was the most prevalent (88%), followed by ethmoid (84%), frontal (58%), and sphenoid (48%) rhinosinusitis. Anatomical variations were present in 96% of patients, with deviated nasal septum (81.3%), agger nasi pneumatization (73.4%), and frontoethmoidal cells (60.2%) being the most common. Logistic regression indicated a significant association between concha bullosa and maxillary rhinosinusitis (p < 0.05). No significant correlation was found between anatomical variations number and SNOT-22 scores (r = − 0.177, p > 0.05).ConclusionThis study found a high prevalence of anatomical variations in CRS patients, with deviated nasal septum, agger nasi pneumatization, and frontoethmoidal cells being the most common. A significant association was identified between concha bullosa and maxillary rhinosinusitis.

Abstract 4134796: Safety of over 1000 consecutive, selected low risk patients with accelerated discharge from a chest pain unit with early generation cardiac troponin use, no cardiac functional or anatomic testing and no clinical risk scores

Introduction: Over 6 million patients (pts) present to US emergency departments annually with chest pain (CP), of which the majority are found to have no serious disease. Evaluation of these pts results in substantial costs for unnecessary hospitalization and extensive testing. We evaluated the utility of early discharge of selected low-risk (LR) CP pts from a chest pain unit (CPU) in which no predischarge testing or risk scores were used. Methods: This retrospective study analyzed 1,037 consecutive LR CP pts from a prospectively recorded database. LR was based on normal examination, stable hemodynamics, normal electrocardiograms (ECG), and negative cardiac troponin I, without pre-discharge functional or anatomic cardiac testing or risk scores. We assessed demographics, comorbidities, medications, and major cardiac events at 30 d and 6 mos post-discharge. Results: The study group of 1037 pts comprised 26% of the 4010 pts admitted to the CPU during the study interval from May 2005 to March 2015. Mean patient age was 55 yrs, 56% (n=575) were women, and comorbid conditions were frequent: hypertension (64.1%), dyslipidemia (46.1%), diabetes (25.7%), documented coronary artery disease (19.3%), previous revascularization (20.6%), previous myocardial infarction (10.1%). Length of stay (LOS) in the CPU to discharge was 10.4 hrs. Women received more discharge cardiac medications than men: antiplatelet agents, statins, beta blockers, ACE inhibitors, angiotensin II blockers, calcium channel blockers, and nitrates (p=0.0002 - 0.04). Follow-up (F/U) at 30 d was 91% (n=948) complete and revealed 0.3% (n=3) cardiac deaths, 0.6% (n=6) acute coronary syndromes (ACS), and 6.2% (n= 64) receiving revascularization. F/U at 6 mos was 90% (n=936) complete and total cumulative cardiac deaths were 0.9% (n=9), 0.7% (n=7) ACS and 6.3% (n=65) revascularization. Discussion: Cardiac events at both 30 d and 6 mos were very low and did not differ in men and women (P=0.8). LOS in CPU was minimized and patient safety was maintained. These selected LR pts remained at reduced risk for cardiac events despite a high rate of comorbidities. Early discharge of selected LR CP pts based on history, examination, ECG, and biomarker evaluation was safe and effective. Conclusion: This approach in selected LR pts has the potential to reduce unnecessary diagnostic testing and CPU LOS. This strategy could lead to substantial savings in healthcare costs without compromising patient safety.

Quantitative myocardial blood flow distribution derived from CCTA and determination of myocardium at risk in the FAST TRACK CABG trial

Abstract Background In the anatomic SYNTAX score derived from invasive coronary angiography, the ischemic impact of each stenotic coronary segment is weighed with a fixed score based on the severity of luminal diameter narrowing and the theoretical amount of blood flow supplied to the myocardium(1). This method neither accounts for individual variation nor reflects the true extent of myocardium ischemia. Purpose We aim to provide a quantitative CT SYNTAX score derived from coronary computed tomography angiography (CCTA) with customized percent blood flow distribution to the myocardium supplied by each stenotic coronary segment to determine the myocardium at risk of ischemia. Methods Patients with 3VD and/or left main coronary artery disease (CAD) were included in the first-in-human FAST TRACK CABG trial and received surgical revascularization guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT). The recently reported anatomic CT-SYNTAX score was calculated for all cases. The FFRCT value and percent myocardial blood flow distribution(%MBF) were computed for all 16 SYNTAX score segments using the validated method of Keulards et al(2). On the pre-CABG CCTA, the segments located distal to the site where the FFRCT value dropped below 0.80 were considered at risk of ischemia, and the individual weight point per segment was calculated as 6×%MBF for each segment. The SYNTAX score derived from %MBF is compared to the anatomic and functional CT-SYNTAX score. Results Out of 114 patients enrolled, FFRCT and %MBF were analyzable in 106 patients. After excluding vessels with total occlusion, the coronary flow distribution between the right and left coronary systems was 20.5% vs 79.5%, respectively, similar to the 1:5 ratio in the anatomic SYNTAX score. The anatomic and functional CT-SYNTAX scores were 43.6 and 41.1, respectively. The average total %MBF per patient was 72.0(19.1)%, and the average SYNTAX score derived from %MBF was 38.0. There is a strong correlation between functional SYNTAX score and SYNTAX score derived from %MBF (Peason’s R=0.93). Passing-Bablock regression trends showed that the functional SYNTAX score slightly overestimated the SYNTAX score derived from %MBF (Figure 1). The coronary segment weight varied significantly per individual, especially in the presence of total occlusion. Overall, the fixed weight of the anatomic SYNTAX score is a good surrogate for the individualized weighing based on %MBF (Figure 2). Conclusion CCTA-derived %MBF enabled clinicians to quantify the individualized myocardium at risk of ischemia or injury in patients with severe CAD. Retrospectively, the fixed weight score used in the anatomical SYNTAX score appeared to be a robust surrogate for myocardial blood flow distribution.Figure 1Figure 2

Segmental post-PCI physiological gradients using ultrasonic or optical flow ratio

Abstract Background Segmental pressure gradients post percutaneous coronary intervention (PCI) may detect residual disease and potential targets for optimization. Ultrasonic flow ratio (UFR) or optical flow ratio (OFR) provide simultaneous physiological and morphological data using a single imaging catheter. Notably, both have been validated against wire based FFR Objectives To evaluate the utility of UFR and OFR to identify residual disease post-PCI. Methods The present study is a sub analysis of the ASET (Acetyl Salicylic Elimination Trial) JAPAN pilot study Phase I which showed the feasibility and safety of low dose prasugrel monotherapy following PCI in Japanese patients presenting with chronic coronary syndrome and an anatomical SYNTAX score &amp;lt;23. Patients with complete intra-vascular imaging pullback data were included with UFR/OFR acquired in all patients post-PCI. Quantitative and qualitative assessment of IVUS or OCT pullbacks was performed by automatically delineating vessel, lumen, and stent contours every 0.5 mm using QCU-CMS (version 4.69, Division of Image Processing, Leiden University Medical Centre). UFR or OFR was calculated using the respective IvusPlus or OctPlus software, Pulse Medical, Shanghai, China.(13)(15) All UFR and OFR tracings, and IVUS and OCT pullbacks were analyzed at the CORRIB Core lab, Galway, Ireland by two analysts blinded to clinical and procedural data. Anatomically focal lesions distal and proximal to the stent were evaluated in segments ≥5mm long. UFR/OFR virtual pullback curves were used to calculate intra-stent pressure gradients and physiologically define lesions as focal or diffuse by segmental pressure drops ≥0.05 over lengths &amp;lt;10mm or ≥10mm, respectively. Results The median post-PCI UFR/OFR was 0.93 (0.88-0.96) with 69/195 vessels (35.4%) having a UFR/OFR≤0.90. There were significantly more focal anatomical and physiological lesions proximal and distal to the stent in vessels with a UFR/OFR≤0.90 versus &amp;gt;0.90. In vessels with a UFR/OFR≤0.90 there was moderate agreement (weighted kappa=0.553, p&amp;lt;0.001) between anatomical and physiological focal lesions proximal to the stent, whilst it was fair (weighted kappa=0.219, p=0.002) distally. In-stent gradient had poor discriminative ability to detect significant stent under-expansion. The performance of a proximal or distal virtual FFR gradient to detect proximal or distal anatomically focal disease was good (AUC–0.835 and 0.877, respectively) Conclusions UFR/OFR enables suboptimal vessel physiology post-PCI to be detected and helps identify the precise anatomical location with corroboration from intra-vascular imaging. Adequately powered physiology optimization trials using UFR/OFR will determine the role of combined morphology and physiological evaluation post PCI in improving clinical outcomes.

One-year clinical outcome of aspirin-free prasugrel monotherapy following stent implantation in patients with chronic coronary syndrome: insight from ASET-JAPAN study

Abstract Background Single antiplatelet therapy with a potent P2Y12 inhibitor without aspirin after coronary stent implantation may provide an adequate balance between ischemic and bleeding risks in selected patients. The 3-month follow-up of the Acetyl-Salicylic Elimination Trial (ASET)-Japan pilot study demonstrated the feasibility and safety of Prasugrel monotherapy without aspirin after successful percutaneous coronary intervention (PCI) in selected patients with chronic coronary syndrome (CCS). Purpose The current study aimed to evaluate the 1-year clinical outcome in the ASET-Japan. Methods The ASET-Japan pilot study was designed to demonstrate the feasibility and safety of the approved dose of prasugrel monotherapy in Japan without aspirin after optimal PCI with a platinum-chromium everolimus-eluting stent in CCS population. After successful procedure, all patients were treated with a locally approved maintenance dose of 3.75 mg/day of Prasugrel monotherapy up to 3-month. After 3-month, the choice of antiplatelet therapy was left to the discretion of the investigators. Patients were followed up to 1 year. The target lesion-related endpoint was a composite of cardiac death, spontaneous target-vessel myocardial infarction (MI) &amp;gt;48 h after the index PCI or clinical-driven target lesion revascularisation. Patient-Oriented Composite Endpoint (POCE) was defined as a composite of all cause mortality, any stroke, any MI and any revascularisation. Spontaneous MI was defined according to Forth universal definition. The event rate was estimated by the Kaplan-Meier method. The event was adjudicated by an independent clinical event committee. Results A total of 208 patients were enrolled in the study. The average anatomical SYNTAX score was 7.96 (±4.6). After procedure, prasugrel monotherapy was immediately initiated. After 3-month, Prasugrel monotherapy was continued in 88.6% up to 1-year. Aspirin monotherapy was prescribed to 10 patients (5.0%), while 6 patients (3.0%) were on DAPT at 1-year. All-cause mortality rate was 1.49%, with no occurrence of cardiovascular death. Revascularisation occurred in 4.0% (n=8) with no occurrence of TLR, while one patient (0.5%) underwent a clinical driven target vessel revascularisation. In summary, 7 out of 8 revascularisations were non-target vessel revascularisation (6 clinically-driven non-TVR). Spontaneous non TV-MI occured in 0.5% (n=1) of patients. There was no definite/probable stent thrombosis up to 1 year. The target lesion related endpoint rate at 1-year was 0%, whereas 1-year POCE rate was 7.0% (n=14). Conclusion Discontinuation of Aspirin and Prasugrel monotherapy at a low maintenance dose of 3.75 mg/day following an angiographically successful stent deployment was feasible and safe in selected patients with CCS and low SYNTAX score. This safety profile is confirmed at 1 year while the investigators, in their large majority and at their own discretion, had maintained the prasugrel treatment.

Clinical outcome based on functional complete revascularization in patients with three-vessel coronary artery disease: The FAME 3 Trial

Abstract Background Anatomic complete revascularization after angiography-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. The impact of functional complete revascularization (PCI of all fractional flow reserve (FFR) positive lesions) in patients with 3-vessel coronary artery disease (3VD) amenable to PCI or coronary artery bypass grafting (CABG) is unknown. Purpose To investigate the clinical impact of functional complete revascularization after FFR-guided PCI in the FAME 3 trial Methods The FAME 3 trial is a multicenter, international, randomized study comparing FFR-guided PCI with CABG in patients with angiographic 3VD. This pre-specified sub-study evaluated the impact of functional complete revascularization after PCI on the primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. The degree of functional complete revascularization was quantified by calculating the residual functional SYNTAX score (rFSS), defined as the residual anatomic SYNTAX score based on post-PCI angiography minus any FFR-negative deferred lesions. Results Of the 757 patients treated with FFR-guided PCI, the rFSS could be calculated by the core laboratory in 81% (n=601). Among the angiographically significant lesions, PCI was deferred based on FFR in 17% (51 % of patients had deferral of at least one lesion). The patients were divided into two groups according to acceptable functional complete revascularization: rFSS 0-8 (63%) and functional incomplete revascularization: rFSS&amp;gt;8 (37%). The cumulative incidence of death, MI, or stroke at 3 years was significantly lower in patients with rFSS 0-8 (9% vs. 17%, Hazard ratio[HR]:0.5, 95% confidence interval[CI]:0.3-0.8, p=0.006) compared with rFSS&amp;gt;8. In comparison with the CABG arm, the patients with rFSS 0-8 had similar outcome (HR:0.97, 95%CI:0.6-1.5, p=0.87), while in those with rFSS &amp;gt;8 outcome was worse (HR:1.9, 95%CI: 1.3-2.8, p=0.002) (Figure). There was no difference in death, MI or stroke in CABG patients with or without anatomic complete revascularization. In a multivariate-adjusted model, rFSS&amp;gt;8 showed a significant association with death, MI or stroke at three years (adjusted HR: 1.83, 95% CI: 1.09-3.09, p=0.02). Conclusions Acceptable functional complete revascularization with FFR-guided PCI in patients with 3VD is an independent predictor of death, MI or stroke at three years and can be achieved in 63% of patients resulting in similar outcomes compared with CABG.

Thirty days clinical outcomes following stent implantation with aspirin-free prasugrel monotherapy in non-ST segment elevation myocardial infarction. Interim report from ASET-Japan pilot study

Abstract Background Dual antiplatelet therapy with a P2Y12 inhibitor, in addition to aspirin, is the standard therapy after percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) to prevent ischemic cardiovascular events. The Acetyl-Salicylic Elimination Trial (ASET) pilot studies conducted in Japan in patients with NSTE-ACS investigated the safety and feasibility of a low-dose prasugrel monotherapy after PCI. Purpose To ensure the safety of the patients, enrolment in the study was implemented only after confirmation of a successful procedure. The abstract reports our interim analysis, aimed at evaluating preliminary safety and feasibility. Methods The ASET-Japan pilot study was designed to explore the feasibility and safety of a low dose of prasugrel monotherapy (3.75mg/day), without adjunctive aspirin, after optimal PCI using Everolimus eluting stent (EES) in Japanese patients with non-ST-segment elevation acute coronary syndromes. The primary endpoint in the ASET-Japan NSTE-ACS (Phase 2) is a 12-month clinical outcome. The study is currently in the follow-up phase. All the target lesions were treated with a platinum-chromium everolimus-eluting stent. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis, and the primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding up to 12-month. If more than 3 events occurred, trial enrollment would have to be terminated by the data and safety monitoring board. Results One hundred one patients were enrolled after successful index PCI and completed a 30 days follow-up. The mean age was 69.1±12.3 years and 75.2% was male. The mean anatomical SYNTAX score was 7.9±4.7. Unstable angina (UAP) and NSTEMI were seen in 24.8% (25/101) and 75.2% (75/101) patients, respectively. According to the Braunwald classification, 8 percent of the patients were categorised as Class IA UAP, 48% as Class IB, 20% as Class IIB, 4% as Class IIIA and 20% as Class IIIB. In NSTEMI patients, the median (IQR) pre-procedural troponin value (cardiac Troponin T or I) was 2.79 (1.12 – 22.27) times the Upper Limit of Normal. According to the PRECISE DAPT score, 36.6% of patients were categorised as High Bleeding Risk (HBR) with scores above 25. At one month, the primary ischemic endpoints of cardiac death, target-vessel spontaneous MI or definite Stent thrombosis did not occur. Two patients (2.0%) had BARC type 3a bleeding. Conclusion Prasugrel monotherapy in the first 30 days following platinum-chromium everolimus-eluting stent deployment is a feasible and safe strategy in NSTE-ACS patients with simple anatomy and successful PCI.

Coronary bypass surgery guided by multislice computed tomography angiography in a low surgical risk population

Abstract Background In patients with three-vessel disease and/or left main disease, selecting revascularization strategies based on coronary computed tomography angiography (CCTA) has a high level of virtual agreement with treatment decisions based on invasive coronary angiography(ICA).(1) Purpose The FASTTRACK CABG trial aims to assess the feasibility and safety of using CCTA and FFRCT as guidance for planning and performing CABG in patients with 3VD and/or LMCAD. Methods In this multicentre study, coronary artery bypass grafts (CABG) were planned and performed based on CCTA without knowledge of ICA. CABG strategy was recommended by a central Core laboratory assessing the anatomy and functionality of the coronary circulation. The primary feasibility endpoint was the percentage of operations performed without access to the ICA. The primary safety endpoint was graft patency on 30-day follow-up CCTA. Secondary endpoints included topographical adequacy of grafting, major adverse cardiac and cerebrovascular events (MACCE), and major bleeding events at 30 days. The study was considered positive if the lower boundary of confidence intervals(CI) for feasibility ≥75%.(2) Results The study enrolled 114 patients with a mean (standard deviation) anatomical SYNTAX Score and Society of Thoracic Surgery score of 43.6 (15.3) and 0.81 (0.63), respectively. Three patients did not undergo CABG due to the patient’s preference for percutaneous treatment (n=1) or lack of graft material. Unblinding ICA was required in one case, yielding a feasibility of 99.1% (95%CI: 95.2%-100%). The concordance and agreement in revascularization planning between the ICA- and CCTA-Heart Team was 82.9% with a moderate kappa of 0.58 (95%CI:0.50-0.66). The concordance and agreement in revascularization planning between the CCTA-Heart Team and actual treatment was 83.7% with a substantial kappa of 0.61 (95%CI:0.53-0.68). The 30-day follow-up CCTA was performed in 102 (91.9%) of the 111 operated patients, which showed an anastomosis patency rate of 92.6%. At 30 days, the incidence of MACCE was 7.2% whereas major bleeding was 2.7%. Conclusions CABG guided by CCTA is feasible and has an acceptable safety profile in a selected population of complex coronary artery disease.

Streamlining management in thoracic trauma: radiomics- and AI-based assessment of patient risks.

In blunt chest trauma, patient management is challenging because clinical guidelines miss tools for risk assessment. No clinical scale reliably measures the severity of cases and the chance of complications. The objective of the study was to optimize the management of patients with blunt chest trauma by creating models prognosticating the transfer to the intensive care unit and in-hospital length of stay (LOS). The study cohort consisted of 212 cases. We retrieved information on the cases from the hospital's trauma registry. After segmenting the lungs with Lung CT Analyzer, we performed volumetric feature extraction with data-characterization algorithms in PyRadiomics. To predict whether the patient will require intensive care, we used the three groups of findings: ambulance, admission, and radiomics data. When trained on the ambulance data, the models exhibited a borderline performance. The metrics improved after we retrained the models on a combination of ambulance, laboratory, radiologic, and physical examination data (81.5% vs. 94.4% Sn). Radiomics data were the top-accurate predictors (96.3% Sn). Age, vital signs, anthropometrics, and first aid time were the best-performing features collected by the ambulance service. Laboratory findings, AIS scores for the lower extremity, abdomen, head, and thorax constituted the top-rank predictors received on admission to the hospital. The original first-order kurtosis had the highest predictive value among radiomics data. Top-informative radiomics features were derived from the right hemithorax because the right lung is larger. We constructed regression models that can adequately reflect the in-hospital LOS. When trained on different groups of data, the machine-learning regression models showed similar performance (MAE/ROV 8%). Anatomic scores for the body parts other than thorax and laboratory markers of hemorrhage had the highest predictive value. Hence, the number of injured body parts correlated with the case severity. The study findings can be used to optimize the management of patients with a chest blunt injury as a specific case of monotrauma. The models we built may help physicians to stratify patients by risk of worsening and overcome the limitations of existing tools for risk assessment. High-quality AI models trained on radiomics data demonstrate superior performance.

Study on the efficacy of 3D printing technology combined with customized plates for the treatment of complex tibial plateau fractures

BackgroundAnatomical reduction and stable fixation of complex tibial plateau fractures remain challenging in clinical practice. This study examines the efficacy of using 3D printing technology combined with customized plates for treating these fractures.MethodsWe retrospectively analyzed 22 patients treated with 3D printing and customized plates at the Orthopedic Department of the Central Hospital affiliated with Shenyang Medical College from September 2020 to January 2023. These patients were matched with 22 patients treated with traditional plates with similar baseline characteristics. Patients were divided into an experimental group (3D-printed models and customized plates) and a control group (traditional plates). The control group underwent traditional surgical methods, while the experimental group had a preoperative 3D model and customized plates for surgical planning. We compared baseline characteristics and recorded various indicators, including preoperative preparation time, surgical time, intraoperative blood loss, number of intraoperative fluoroscopies, hospital stay duration, fracture healing time, complications, knee joint range of motion (ROM), Rasmussen anatomical and functional scores, and HSS scores.ResultsAll surgeries were successful with effective follow-up. The experimental group had shorter surgical time, less intraoperative blood loss, and fewer intraoperative fluoroscopies (P < 0.05). At 6 months and 1 year postoperatively, the experimental group had better knee joint HSS scores than the control group. Preoperative preparation time and total hospital stay were shorter in the control group (P < 0.05). There were no significant differences in fracture healing time and follow-up duration between groups. The experimental group showed better knee joint flexion angles (P < 0.05). Rasmussen scores showed no statistical difference between groups (P > 0.05). The incidence of complications was slightly lower in the experimental group but not significantly different.Conclusion3D printing technology combined with customized plates for complex tibial plateau fractures enables precise articular surface reduction, significantly shortens surgical time, and reduces intraoperative blood loss. This method improves knee joint function, offering a more effective treatment option.

The Revised Trauma Score: A Better Early Predictor for Survival of Head Trauma Patients than the Glasgow Coma Scale-Age-Pressure Score

Purpose: Trauma is a common cause of death worldwide and head injury is the most common form of trauma presented at the Emergency Department. Physiological scores are better for predicting outcome than anatomical scores. To reduce mortality rates, this study compared the capacity of the revised trauma scores (RTS) and the Glasgow coma scale- age- pressure (GAP) scores to predict the survival of patients and effectively channel resources.Methods: An observational study of head trauma patients aged 12 to 80 years was performed at a tertiary care center (N = 500). We noted demographic information, RTS and GAP trauma scores, and outcomes in terms of mortality or survival at 24 hours, 48 hours, and 7 days.Results: Of the 500 patients who were enrolled, 414 (82.8%) survived 24 hours, 373 (74.6%) survived 48 hours, and 265 (53%) survived after 7 days. Using the Receiver Operating Characteristic curve, the RTS score was a significantly better predictor of survival in patients with head trauma than the GAP score at 24 hours (p = 0.044) and 48 hours (p = 0.049) of admission. The results were not significantly different at 7 days (p = 0.240). Mortality or survival outcomes were not significantly different between the RTS and GAP scores (p = 0.373).Conclusion: RTS appears to be a better early predictor for mortality (within 48 hours of admission) than the GAP score. The RTS was more effective in directing the triage of patients which improved survival rates in head trauma patients.

Trifecta outcomes of robotic partial nephrectomy in obese patients: A comparison of body mass index

We analyzed robotic partial nephrectomy (RPN) outcomes in obese patients based on body mass index (BMI) and trifecta achievement. We retrospectively reviewed 296 patients who underwent RPN at Kansai Medical University Hospital between 2014 and 2022. The preoperative clinical data and perioperative outcomes were evaluated. Trifecta achievement (negative surgical margin, no major complications, and no acute kidney injury on postoperative day three) and its relationship to three BMI groups (<25, 25 to <30, and ≥30) were the primary outcome. The correlation between factors in achieving trifecta and BMI was evaluated. Univariate and multivariate analyses assessed variables for achieving the trifecta with logistic regression analysis. C-statistics quantitatively evaluated the prediction accuracy. Among 296 patients, 264 (89.2%) achieved trifecta (BMI categories were <25 [89.9%], 25 to <30 [89.4%], and ≥30 [82.6%]). There was no significant BMI-related difference (p = 0.566). Intraoperative blood loss increased with the BMI (p = 0.034). Multivariate analyses showed preoperative aspects and dimensions used for anatomic (PADUA) score independently predicted trifecta failure (odds ratio 1.71; 95% confidence interval 1.32-2.20; p < 0.001). The C-statistics of the PADUA score increased with increasing BMI. Higher BMI patients had more intraoperative blood loss during RPN. However, RPN remains safe and has acceptable quality and functional outcomes. Since patients with high PADUA scores combined with a high BMI may be at risk of trifecta failure, this should be explained before RPN.

Ultra-high b-value DWI in rectal cancer: image quality assessment and regional lymph node prediction based on radiomics.

This study aims to evaluate image quality and regional lymph node metastasis (LNM) in patients with rectal cancer (RC) on multi-b-value diffusion-weighted imaging (DWI). This retrospective study included 199 patients with RC who had undergone multi-b-value DWI. Subjective (five-point Likert scale) and objective assessments of quality images were performed on DWIb1000, DWIb2000, and DWIb3000. Patients were randomly divided into a training (n = 140) or validation cohort (n = 59). Radiomics features were extracted within the whole volume tumor on ADC maps (b = 0, 1000 s/mm2), DWIb1000, DWIb2000, and DWIb3000, respectively. Five prediction models based on selected features were developed using logistic regression analysis. The performance of radiomics models was evaluated with a receiver operating characteristic curve, calibration, and decision curve analysis (DCA). The mean signal intensity of the tumor (SItumor), signal-to-noise ratio (SNR), and artifact and anatomic differentiability score gradually weredecreased as the b-value increased. However, the contrast-to-noise (CNR) on DWIb2000 was superior to those of DWIb1000 and DWIb3000 (4.58 ± 0.86, 3.82 ± 0.77, 4.18 ± 0.84, p < 0.001, respectively). The overall image quality score of DWIb2000 was higher than that of DWIb3000 (p < 0.001) and showed no significant difference between DWIb1000 and DWIb2000 (p = 0.059). The area under curve (AUC) value of the radiomics model based on DWIb2000 (0.728) was higher than conventional ADC maps (0.690), DWIb1000 (0.699), and DWIb3000 (0.707), but inferior to multi-b-value DWI (0.739) in predicting LNM. DWIb2000 provides better lesion conspicuity and LNM prediction than DWIb1000 and DWIb3000 in RC. DWIb2000 offers satisfactory visualization of lesions. Radiomics features based on DWIb2000 can be applied for preoperatively predicting regional lymph node metastasis in rectal cancer, thereby benefiting the stratified treatment strategy. Lymph node staging is required to determine the best treatment plan for rectal cancer. DWIb2000 provides superior contrast-to-noise ratio and lesion conspicuity and its derived radiomics best predict lymph node metastasis. DWIb2000 may be recommended as the optimal b-value in rectal MRI protocol.

The Role of Trending Shock Index Paediatric Adjusted (SIPA) in Paediatric Trauma as a Predictor of Morbidity and Mortality

Abstract Background and Purpose There are several injury scoring systems, anatomic, physiologic and combined scores, which have been used for prediction of patients' outcome such as mortality. Among physiologic scoring systems evolved shock index (heart rate divided by systolic blood pressure) which has been first described in 1967. In the world of paediatric and due to the physiological differences between different age groups, few adjustments have to be done considering these changes evolving shock index paediatric adjusted (SIPA). This study was conducted to evaluate SIPA as a quick feasible method for triaging and managing pediatric trauma and also to predict ICU admission and need for CT scan as a primary outcome and also secondary outcomes like length of hospital stay and (need for surgical intervention) and mortality rate. Study Design Prospective randomized controlled study. Setting The children’s accident and emergency department in Armed Forces Hospitals and Ain Shams University hospitals. Subjects We included 124 pediatric trauma children, and they were divided into 2 groups: Group A (62 children): assessed by SIPA in an incidence of trauma, and Group B (62 children): assessed by traditional vital signs (blood pressure, pulse and capillary refill). Methods All patients were subjected to full history taking, SIPA assessment on admission and its daily changes (baseline up to 48 hours). Assessment for need for ICU admission, ventilation, CT scan, surgical intervention, and Length of hospital stay, along with mortality rate recording. Results In the studied population, the mean age of all patients was (6.8 ± 3.2) years, with (65.3%) of patient males; and (34.7%) females. Regarding outcome data, comparative study between the 2 groups revealed; significant decrease in ICU admission, need for CT scan, LOS and mortality rate in Group A (SIPA) (p &amp;lt; 0.05). As regards SIPA trend, we found non-significant difference between mortality and no-mortality subgroups in SBP, heart rate, Capillary refill time and SIPA during the serial (baseline up to 48-h) measurements. Also, regarding ICU LOS, we found non-significant difference between mortality and no-mortality subgroups in SBP, heart rate, Capillary refill time and SIPA during the serial (baseline up to 48-h) measurements. Conclusion To conclude, SIPA score proven to be an accurate and specific predictor of morbidity, hospital stay and ICU admission, and mortality rate in pediatric trauma patients and is superior to capillary refill time, tachycardia or hypotension alone for predicting different outcomes.