Anatomical Score Research Articles

Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN).

Simple SummaryGestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment.Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.

Global Limb Anatomic Staging System Score correlates with the clinical outcomes in chronic limb threatening ischemia patients.

Chronic limb-threatening ischemia (CLTI) affects millions of people and causes health care burden around the globe. Global Limb Anatomic Staging System (GLASS) was proposed as a new anatomic system for integrating the complexity of threatened limb. We retrospectively classified computed tomography angiography images of threatened limbs into GLASS stages between January 2018 and April 2020. Comorbidities, limb treatments, and outcomes including amputation-free survival (AFS), reintervention and mortality were compared and the likelihood of benefit from revascularization was estimated according to GLASS. Kaplan-Meier estimate was used to determine the rates of endpoint events at 1 year. Multivariate analysis was performed to identify predictors of those outcomes. In our study, 285 threatened limbs in 263 patients were stratified including GLASS stage I disease (N.=53, 19%), stage II (N.=129; 45%) and stage III (N.=103; 36%) disease. The percentage of limbs undergoing endovascular revascularization and minor amputation increased significantly with increasing GLASS stage. On Kaplan-Meier analysis, increasing GLASS stage was associated with 1-year reduced AFS (stage I: 96.1%, stage II: 94.1%, stage III: 83.9%; log rank P=0.016). The percentage of 1-year reintervention rate in infrapopliteal GLASS grade 3-4 (15%) was significantly higher than the percentage of reintervention in infrapopliteal GLASS grade 0-2 (5%) (Log rank P=0.002). Infrapopliteal GLASS grade 3 and 4 was the independent predictor of reduced AFS. GLASS stage correlated with intensity of limb treatment and with clinical outcomes at 1 year. Infrapopliteal GLASS grade 3 and 4 independently predicted the reduced amputation-free survival.

Impact of coronary anatomy and residual syntax score on arrhythmic events in patients with ischemic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background ICD implantation is a cornerstone for primary prevention in patients with ischemic cardiomyopathy and impaired left ventricular function; reduced ejection fraction alone, however, doesn’t seem enough to discriminate which patients will really experience arrhythmic events in the follow up. Purpose We hypothesized that coronary anatomy and the extent of residual coronary lesions, measured with syntax score, could be a better predictor of the outcome in this setting. Materials and method Data of all patients implanted with single or dual chamber ICD in primary prevention for ischemic cardiomyopathy from 2011 to 2020 were retrospectively collected, together with follow up data obtained from clinical visits and ICD remote monitoring. Residual syntax score (RSS) was calculated for each patient, taking into consideration the last coronary angiography performed before ICD implantation. Results 110 patients were included in our registry. 90.1% were male, mean age was 66±7 years. 23.6% ICD were dual chamber devices. 96 (87.2%), 8 (7.3%) and 6 (5.5%) patients presented respectively with low (0-22), intermediate (23-32) or high (≥33) RSS. After a mean follow up of 4.4±2.9 years, 31 patients (28.2%) died; 20 patients (18.2%) and 27 patients (24.5%) received any appropriate ICD therapy, either shock or ATP. 12 patients (10.9%) experienced inappropriate shock. The composite outcome of death or any appropriate therapy (MACE) was observed in 47 patients (42.7%); left main or left descending artery stenosis were predictors of MACE (p = 0.026 and p = 0.040, respectively). Intermediate or high RSS was the only predictor of appropriate shock (p = 0.046). Conclusions Coronary anatomy and residual coronary stenosis quantified with syntax score are promising predictors of arrhytmic events during the follow up in patients with ischaemic cardiomyopathy and ICD implanted in primary prevention.

State-of-the-art development of anatomical and clinical-anatomical scores for choosing a myocardial revascularization strategy based on the SYNTAX study

Treatment of patients with multivessel coronary artery disease is percutaneous coronary intervention or coronary artery bypass grafting according to current European and American guidelines. Depending on the anatomical complexity of the coronary artery lesion, one of the methods is chosen, with usage of a risk scale based on the SYNTAX study. However, Syntax score is actively discussed as not an optimal risk scale, because of unmatched with modern clinical possibilities This article presents current, different opinions on anatomical and clino-anatomical risk scores, which allows to choose the optimal method of revascularization for patients with three-vessel disease and/or left main coronary artery lesions.

State-of-the-art development of anatomical and clinical-anatomical scores for choosing a myocardial revascularization strategy based on the SYNTAX study

Treatment of patients with multivessel coronary artery disease is percutaneous coronary intervention or coronary artery bypass grafting according to current European and American guidelines. Depending on the anatomical complexity of the coronary artery lesion, one of the methods is chosen, with usage of a risk scale based on the SYNTAX study. However, Syntax score is actively discussed as not an optimal risk scale, because of unmatched with modern clinical possibilities This article presents current, different opinions on anatomical and clino-anatomical risk scores, which allows to choose the optimal method of revascularization for patients with three-vessel disease and/or left main coronary artery lesions.

D-30 | Association of Residual Coronary Artery Disease with Clinical Outcomes After Percutaneous Coronary Intervention in the Veterans Affairs Clinical Assessment Reporting and Tracking Program

Anatomic scoring systems have been used to assess completeness of revascularization. However, the prevalence of complete revascularization and its association with longitudinal clinical outcomes has not been ascertained in real-world populations due to the limitations of applying these scoring systems to large datasets.

Outcomes of Endurant II Stent Graft According to Anatomic Severity Grade Score

Objectives: This study’s objective was to evaluate Endurant II (Medtronic Inc, Minneapolis, Minnesota) stent graft’s early and midterm outcomes and compare the results according to the anatomic severity grade (ASG) scores. Methods: This was a retrospective study of patients treated with the Endurant II stent graft between January 2013 and May 2021. The patients were divided into 2 independent groups, including those with a low ASG score (score <14) and a high ASG score (score >14). Results: A total of 165 consecutive patients (89% males, age 74±8 years) were included. There were 110 (67%) patients in the low-score group and 55 (33%) patients in the high-score group. Technical success was achieved in all cases. Primary clinical success at 30 days was 100% and at 1 year was 96%. Median operative time was longer in the high-score group with no statistical significance (133 vs 120 minutes, p=0.116). The median dose area product of low-score patients (50.9 Gy·cm2; IQR 22.4–75.5 Gy·cm2) was significantly lower than high-score patients (85.0 Gy·cm2; IQR 46.5–127.9 Gy·cm2) with p=0.025. Median fluoroscopic time was lower in low-score patients (17 minutes; IQR 13–24 minutes) compared with high-score patients (19 minutes; IQR 16–23 minutes) without a significant difference at p=0.148. At a midterm follow-up of 32 months (range 2–63 months), combined complications (29% vs 8%, p<0.001) and implant-related complications (13% vs 4%, p=0.043) were higher in the high-score group. Systemic complications at 30 days were higher in the high-score group without a statistically significant difference (15% vs 11%, p=0.500). The Kaplan-Meier estimate of freedom from reintervention was significantly higher in the low-risk group at 1 (97% vs 90%), 2 (96% vs 88%), and 3 years (96% vs 85%) with (p=0.035). The cumulative survival rate was significantly higher in the low-score group than high-score group (p=0.001) at 1 (99% vs 87%), 2 (98% vs 85%), and 3 years (96% vs 82%). Conclusions: Endurant II endovascular aneurysm repair seems to be safe in both low-score and high-score patients. However, patients in the high-score group showed more implant-related complications and midterm mortalities than those in the low-score group.

Utilisation of anatomic grading of nerve-spare during robot-assisted radical prostatectomy to prognosticate erectile function recovery

Objective: To determine if a precise 5-point nerve-spare (NS) scoring system at the time of robot-assisted radical prostatectomy (RARP) correlates with post-operative erectile function recovery (EFR). Patients and methods: From 2014 to 2018, 277 patients underwent RARP by a single surgeon. NS quality was recorded as: grade 1, non-NS; grade 2, &lt;50%; grade 3, 50%; grade 4, 75%; grade 5, ⩾95%. EFR rates were compared using Fisher’s exact test or Pearson’s chi-square test at 3–24 months, grouped based on the degree of NS: 1 = bilateral full NS (grade 5); 2 = bilateral NS with one good NS (⩾grade 4); 3 = unilateral good NS; 4 = incremental NS (grade 3); 5 = partial neurovascular bundle (NVB) resection (grade 2); 6 = complete NVB resection (grade 1). Results: At 24 months, EFR defined as Sexual Health Inventory for Men (SHIM) score ⩾17 was 75%, 55%, 41%, 23%, 12% and 0% for groups 1–6, respectively ( p = 0.001). EFR defined as spontaneous erection sufficient for intercourse with or without PDE5i was 60%, 58%, 40%, 33%, 0% and 11% for groups 1–6, respectively ( p &lt; 0.001). Conclusion: A precise anatomic NS scoring system at RARP allows good prognostication of EFR, which may inform patient counselling and erectile dysfunction management. Level of evidence: 4

Prevalence of Erectile Dysfunction in Patients With Abdominal Aortic Aneurysm: An Exploratory Study.

IntroductionErectile dysfunction (ED) is defined as the recurrent inability to achieve and maintain a satisfactory erection for sexual intercourse. Many studies have highlighted that ED shares common cardiovascular risk factors with cardiovascular disease. No data are reported about the prevalence of ED in patients with the abdominal aortic aneurysm (AAA). The aim of our study was to investigate the preoperative information given about sexual functions of patients undergoing endovascular aneurysm repair (EVAR) and to compare it with the presence and severity of steno-occlusive atherosclerotic lesions of the pelvic arterial tree at pre-operative Computed Tomography Angiography (CTA).MethodsWe prospectively enrolled all men patients who underwent elective EVAR from September to November 2021. Preoperative ED was evaluated using the International Index of Erectile Function (IIEF-5) questionnaire. Preoperative imaging was routinely performed with CTA scan of the abdominal aorta and iliac-pelvic district. An innovative score of pelvic arterial disease associated to AAA was defined, dividing the iliac district in 4 zones attributing a grading of severity for each zone bilaterally (score ranges 0–24). Linear regression analysis was used to correlate IIEF-5 score to anatomical score of pelvic arterial steno-occlusive disease.ResultsA total of 25 patients were enrolled. Median age was 74 ± 5.3 years. IIEF-5 average score was 14.8 ± 7.1. Eight cases (32%) had severe ED; one case (4%) had moderate, five patients (20%) had mild to moderate ED; five patients (20%) had mild ED, and 6 (24%) patients had no ED. CTA evaluation revealed an average anatomical score of 7.9 ± 4.5. Pelvic disease was considered moderate-severe in 20 cases (80%) and not significant in 20% (five cases). Linear regression analysis confirmed the hypothesis that a more diseased pelvic arterial tree was correlated to a more severe ED (Y = −1.531* × + 26.35 [slope CI: −1.946 to −1.117, p < 0.0001]).ConclusionAlthough typically unreported, the prevalence of ED associated to AAA was found to be high. A vasculogenic origin of ED in patients with AAA is plausible and may be easily confirmed by the evaluation of pelvic arterial distribution at angio-CT performed for EVAR planning. Our proposed “MAPPING AND SCORING SHEET” may help to identify the vasculogenic origin of ED in AAA patients.

Surgery and Adjuvant Therapy Improve Derkay Scores in Adult and Pediatric Respiratory Papillomatosis.

Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory papillomatosis (RRP). Restrospective study. Retrospective review of juvenile-onset (JO) and adult-onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12-month follow-up. One hundred and twelve patients met inclusion criteria (68 JO-RRP and 44 AO-RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n=42), CO2 (n=21), or microdebrider (n=49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO2 group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P=.73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P=.01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO-RRP population had more patients with dysplasia (50%) compared to JO-RRP population (10%) (P < .001). Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO-RRP patients have more concomitant dysplasia. 3 Laryngoscope, 132:2420-2426, 2022.

Surgical Management of Synchronous, Bilateral Renal Masses: A 1-decade Referral Center Experience

BackgroundManagement and decision-making in patients with bilateral renal masses are controversial. ObjectiveTo report our experience of surgical management in patients with bilateral renal masses undergoing surgery at a high-volume center. Design, setting, and participantsWe retrospectively collected data from patients treated with partial nephrectomy (PN) or radical nephrectomy for bilateral renal masses at a single referral institution between June 2008 and June 2019. Patient- and tumor-related features, timing (one vs two stage), and surgical approach (open vs robotic) were analyzed. Surgical procedureA one- versus two-stage strategy was adopted according to the opportunity to perform at least one PN using a clampless or selective-clamping approach, in order to avoid acute kidney injury. MeasurementsOperative time, warm ischemia time, and intra- and postoperative complications were recorded. Histopathological results and tumor histology were assessed. Results and limitationsOverall, 41 patients were included. The median age was 67 yr and the median preoperative estimated glomerular filtration rate (eGFR) was 84 ml/min/1.73 m2. The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (interquartile range [IQR] 7–8) for both sides. In 17 (42%) patients, a simultaneous approach was chosen, with a pure robotic approach in 11/17 cases, while among the 24 (58.6%) patients treated with a two-stage strategy, 15 (62.5%) were treated with a robotic approach on both sides. Intraoperative complications and postoperative major (CDC ≥3) complications were recorded in 7.3% and 4.9% of cases, respectively. The overall positive surgical margins rate was 2.4%. At a median follow-up of 42 (IQR 18–59) mo, the median eGFR was 73 (IQR 64–80) ml/min/1.73 m2, while disease-free survival and cancer-specific mortality were 90.2% and 7.3%, respectively. ConclusionsOur experience underlines that both simultaneous and staged surgical treatment of patients with bilateral renal masses are feasible and safe if grounded on proper patient selection. Patient summaryManagement of patients with bilateral renal masses is challenging, given the heterogeneity of clinical scenarios and the need to optimize the timing of treatment to achieve maximal functional preservation while ensuring oncological efficacy.

Simplified PADUA renal (SPARE) nephrometry score validation and long-term outcomes after robot-assisted partial nephrectomy.

International guidelines suggest the use of anatomic scores to predict surgical outcomes after partial nephrectomy (PN). We aimed at validating the use of Simplified PADUA Renal (SPARE) nephrometry score in robot-assisted PN (RAPN). Three hundred and sixty-eight consecutive RAPN patients were included. Primary endpoints were overall complications, postoperative acute kidney injury (AKI) and TRIFECTA achievement. Secondary endpoint was estimated glomerular filtration rate (eGFR) decrease at last follow-up. Multivariable logistic and linear regression models were used. Of 368 patients, 229 (62%) vs. 116 (31%) vs. 23 (6.2%) harboured low- vs. intermediate- vs. high-risk renal mass, according to SPARE classification. SPARE score predicted higher risk of overall complications (Odds ratio [OR]: 1.23, 95%CI 1.09-1.39; P < 0.001), and postoperative AKI (OR: 1.20, 95%CI 1.08-1.35; P < 0.01). Moreover, SPARE score was associated with lower TRIFECTA achievement (OR: 0.89, 95%CI 0.81-0.98; P = 0.02). Predicted accuracy was 0.643, 0.614 and 0.613, respectively. After a median follow-up of 40 (IQR: 21-66) months, eGFR decrease ranged from -7% in low-risk to -17% in high-risk SPARE. SPARE scoring system predicts surgical success in RAPN patients. Moreover, SPARE score is associated with eGFR decrease at long-term follow-up. Thus, the adoption of SPARE score to objectively assess tumor complexity prior to RAPN may be preferable.

10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization inPatientsWithHeavyCalcification.

The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization. This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG). The 532 patients with≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P< 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95%CI: 1.09-1.69; P=0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (Pinteraction=0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95%CI: 0.97-1.41; P=0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95%CI: 0.64-1.13; P=0.264). At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Pedal arterial calcification score is associated with the risk of major amputation in chronic limb-threatening ischemia.

The medial arterial calcification (MAC) score is a simple metric that describes the burden of inframalleolar calcification using a plain foot radiograph. We hypothesized that a higher MAC score would be independently associated with the risk of major amputation in patients with chronic limb-threatening ischemia (CLTI). We performed a single-institution, retrospective study of 250 patients who had undergone infrainguinal revascularization for CLTI from January 2011 to July 2019 and had foot radiographs available for MAC score calculation. A single blinded reviewer assigned MAC scores of 0 to 5 using two-view minimum plain foot radiographs, with 1 point each for calcification of>2cm in the dorsalis pedis, plantar, and metatarsal arteries and >1cm in the hallux and non-hallux digital arteries. The MAC score was 0 in 36%, 1 in 5.2%, 2 in 8.4%, 3 in 14%, 4 in 14%, and 5 in 21%. The MAC score was trichotomized to facilitate analysis and clinical utility (mild, MAC score 0-1; moderate, MAC score 2-4; and severe, MAC score 5). The variables independently associated with a higher MAC score were male sex, diabetes, end-stage renal disease, and the global limb anatomic staging system pedal score. The MAC score was not associated with the Society for Vascular Surgery WIfI (wound, ischemia, foot infection) grade or overall WIfI stage (P= .58). The median follow-up was 759days (interquartile range, 264-1541days). A higher MAC score was significantly associated with the risk of major amputation (P< .0001). In a Cox proportional hazards multiple regression model for major amputation that included the trichotomized MAC score, diabetes, end-stage renal disease, and WIfI stage (1-3 vs 4). The MAC score (MAC score 5: hazard ratio [HR], 4.9; 95% confidence interval [CI], 1.9-13.1; P= .001; MAC score 2-4: HR, 3.4; 95% CI, 1.3-8.8; P= .01) and WIfI stage (WIfI stage 4: HR, 2.1; 95% CI, 1.1-3.9; P= .03) were significantly associated with the risk of major amputation. In the subsets of patients with the most advanced WIfI stage of 3 to 4 (191 of 250; 76%) and patients with diabetes (185 of 250; 74%), the MAC score further stratified the risk of major amputation on univariate and multivariate analyses. The MAC score is a simple, practical tool and a strong independent predictor of major amputation in patients with CLTI. It provides novel clinical data that are currently unmeasured using any validated CLTI staging system. The MAC score is a promising standardized measure of inframalleolar disease burden that can be used in conjunction with the WIfI staging system to help improve outcomes stratification and determine the optimal treatment strategies for patients with CLTI.

Evaluation of injury severity scores of patients with sternal fracture after blunt thoracic trauma

Traumatic sternal fractures are rare injuries. The most common etiologic cause is a blunt injury to the anterior chest wall. When an individual is exposed to serious trauma, the first goal of treatment is to preserve the patient’s life and avoid multiple organ failures and other complications through rapid and effective intervention. The aim of this study was to statistically analyze the trauma scores and sternal fracture localizations that were calculated following the analysis of the data of the patients who were admitted to the emergency department after blunting thoracic trauma. It is planned to compare the obtained data with the literature. The trauma scores of the patients were determined through the implementation of the anatomical scoring systems, the Abbreviated Injury Scale (AIS), and the Injury Severity Score (ISS), which are calculated by squaring the AIS scores of the three most severely injured body systems. Out of our 96 patients, 65 were male and 31 were female. In the statistical analysis performed between the sternal fracture localization that occurred after trauma and the ISS, the highest scores were found in mixed type fractures, with a mean value of 36.77±9.62 (p=0.001). Statistical analyses of the relationship between ISS interval values, sternal fracture localization and the number of rib fractures accompanying the sternal fracture were found to be significant (p=0.035, p&lt;0.001). It is thought that determining the probability of mortality by calculating the trauma score (especially ISS) in patients with sternal fractures as a result of high-energy traumas will contribute significantly to the literature.

Baseline Myocardial Work on Echocardiography Reflects the Severity of Coronary Disease in Patients Presenting with Acute Coronary Syndrome

The aim of the study is to establish a relationship between baseline myocardial work (MW) assessed by echocardiography and the extent of coronary artery disease (CAD) using SYNTAX score in patients presenting with acute coronary syndrome (ACS) who underwent coronary angiography (CA). SYNTAX score from CA has proven to be a clinically useful anatomical scoring system to assess the burden and complexity of coronary artery disease (CAD). MW is a novel non-invasive measure of cardiac function using echocardiography. Other parameters of cardiac function, such as left ventricular ejection fraction (LVEF) and wall motion score index (WMSI), were also assessed. In this retrospective study, consecutive patients with ACS underwent echocardiography at the presentation to a large, tertiary hospital emergency department from March 2019 to April 2020 were included and analysed. There were 94 patients recruited to the study; age ± 12 years, 62% male. Median Syntax score was 12 (IQR 7–19). All echocardiographic parameters correlated with SYNTAX score. While GLS and MW showed a strong relationship with SYNTAX score (GLS r=0.33, p<0.01; GWW r=0.29, p<0.01; GWE r=0.31, p<0.01), WMSI, a standard assessment in assessing the extent of coronary disease, was a less significant predictor for the complexity of CAD (r=0.22, p=0.03). Baseline assessment of myocardial work correlates better with the extent of coronary disease than standard measures. This assessment may have a role in assisting with the type and timing of coronary intervention in patients presenting with acute coronary syndrome.

Integration of Metabolomic and Clinical Data Improves the Prediction of Intensive Care Unit Length of Stay Following Major Traumatic Injury

Recent advances in emergency medicine and the co-ordinated delivery of trauma care mean more critically-injured patients now reach the hospital alive and survive life-saving operations. Indeed, between 2008 and 2017, the odds of surviving a major traumatic injury in the UK increased by nineteen percent. However, the improved survival rates of severely-injured patients have placed an increased burden on the healthcare system, with major trauma a common cause of intensive care unit (ICU) admissions that last ≥10 days. Improved understanding of the factors influencing patient outcomes is now urgently needed. We investigated the serum metabolomic profile of fifty-five major trauma patients across three post-injury phases: acute (days 0–4), intermediate (days 5–14) and late (days 15–112). Using ICU length of stay (LOS) as a clinical outcome, we aimed to determine whether the serum metabolome measured at days 0–4 post-injury for patients with an extended (≥10 days) ICU LOS differed from that of patients with a short (<10 days) ICU LOS. In addition, we investigated whether combining metabolomic profiles with clinical scoring systems would generate a variable that would identify patients with an extended ICU LOS with a greater degree of accuracy than models built on either variable alone. The number of metabolites unique to and shared across each time segment varied across acute, intermediate and late segments. A one-way ANOVA revealed the most variation in metabolite levels across the different time-points was for the metabolites lactate, glucose, anserine and 3-hydroxybutyrate. A total of eleven features were selected to differentiate between <10 days ICU LOS vs. >10 days ICU LOS. New Injury Severity Score (NISS), testosterone, and the metabolites cadaverine, urea, isoleucine, acetoacetate, dimethyl sulfone, syringate, creatinine, xylitol, and acetone form the integrated biomarker set. Using metabolic enrichment analysis, we found valine, leucine and isoleucine biosynthesis, glutathione metabolism, and glycine, serine and threonine metabolism were the top three pathways differentiating ICU LOS with a p < 0.05. A combined model of NISS and testosterone and all nine selected metabolites achieved an AUROC of 0.824. Differences exist in the serum metabolome of major trauma patients who subsequently experience a short or prolonged ICU LOS in the acute post-injury setting. Combining metabolomic data with anatomical scoring systems allowed us to discriminate between these two groups with a greater degree of accuracy than that of either variable alone.

Radiofrequency Ablation and Concomitant Sclerotherapy for the Treatment of Varicose Veins (VV): Perspectives from a Developing Country.

Objectives/Background: With decreased patient downtime and reduction in health expenditures, endovascular treatments have become popular for the treatment of venous insufficiency. In this study, we assessed the outcomes of using radiofrequency ablation (RFA) and sclerotherapy for refluxing veins and incompetent perforators in a developing country.Materials and Methods: Subjects were selected from an ongoing registry from October 15, 2015 to April 5, 2018. Patients were followed up until 6 months. Pre- and post-procedural Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) scores were compared, and complications were documented and treated accordingly.Results: In total, 102 limbs (n=97) with 76 great saphenous veins (GSVs) and 26 small saphenous veins (SSVs) underwent RFA, with 79% undergoing concomitant sclerotherapy. Mean follow-up time was 188 days (±33.16). Moreover, 59% were males and 41% females. At the end of follow-up, 99% of the legs had complete occlusion. Pre- and post-procedural CEAP scores were 4.21±1.5 and 3.36±1.7, respectively (p-value <0.001). Endovenous heat-induced thrombosis (EHIT) types 1, 2, 3, and 4 were found in 8.8%, 3.9%, 1.9%, and 0% of the legs, respectively. Most common complications were pain and tenderness (51%), bruising (18%), and paresthesia (7%).Conclusion: RFA and sclerotherapy have proved to be safe and efficacious. Computed tomography (CT) venous mapping aids in delineating complex venous anatomy and in ruling out deep vein thrombosis (DVT) in cases with discrepancy on Doppler ultrasound. Strict compliance of procedural and post-procedural protocol can assure promising results and futuristic value.

Artificial intelligence to predict in-hospital mortality using novel anatomical injury score

The aim of the study is to develop artificial intelligence (AI) algorithm based on a deep learning model to predict mortality using abbreviate injury score (AIS). The performance of the conventional anatomic injury severity score (ISS) system in predicting in-hospital mortality is still limited. AIS data of 42,933 patients registered in the Korean trauma data bank from four Korean regional trauma centers were enrolled. After excluding patients who were younger than 19 years old and those who died within six hours from arrival, we included 37,762 patients, of which 36,493 (96.6%) survived and 1269 (3.4%) deceased. To enhance the AI model performance, we reduced the AIS codes to 46 input values by organizing them according to the organ location (Region-46). The total AIS and six categories of the anatomic region in the ISS system (Region-6) were used to compare the input features. The AI models were compared with the conventional ISS and new ISS (NISS) systems. We evaluated the performance pertaining to the 12 combinations of the features and models. The highest accuracy (85.05%) corresponded to Region-46 with DNN, followed by that of Region-6 with DNN (83.62%), AIS with DNN (81.27%), ISS-16 (80.50%), NISS-16 (79.18%), NISS-25 (77.09%), and ISS-25 (70.82%). The highest AUROC (0.9084) corresponded to Region-46 with DNN, followed by that of Region-6 with DNN (0.9013), AIS with DNN (0.8819), ISS (0.8709), and NISS (0.8681). The proposed deep learning scheme with feature combination exhibited high accuracy metrics such as the balanced accuracy and AUROC than the conventional ISS and NISS systems. We expect that our trial would be a cornerstone of more complex combination model.

Applicability of Anatomic and Physiologic Scoring Systems for the Prediction of Outcome in Polytraumatized Patients with Blunt Aortic Injuries.

Background: Most patients with blunt aortic injuries, who arrive alive in a clinic, suffer from traumatic pseudoaneurysms. Due to modern treatments, the perioperative mortality has significantly decreased. Therefore, it is unclear how exact the prediction of commonly used scoring systems of the outcome is. Methods: We analyzed data on 65 polytraumatized patients with blunt aortic injuries. The following scores were calculated: injury severity score (ISS), new injury severity score (NISS), trauma and injury severity score (TRISS), revised trauma score coded (RTSc) and acute physiology and chronic health evaluation II (APACHE II). Subsequently, their predictive value was evaluated using Spearman´s and Kendall´s correlation analysis, logistic regression and receiver operating characteristics (ROC) curves. Results: A proportion of 83% of the patients suffered from a thoracic aortic rupture or rupture with concomitant aortic wall dissection (54/65). The overall mortality was 24.6% (16/65). The sensitivity and specificity were calculated as the area under the receiver operating curves (AUC): NISS 0.812, ISS 0.791, APACHE II 0.884, RTSc 0.679 and TRISS 0.761. Logistic regression showed a slightly higher specificity to anatomical scoring systems (ISS 0.959, NISS 0.980, TRISS 0.957, APACHE II 0.938). The sensitivity was highest in the APACHE II with 0.545. Sensitivity and specificity for the RTSc were not significant. Conclusion: The predictive abilities of all scoring systems were very limited. All scoring systems, except the RTSc, had a high specificity but a low sensitivity. In our study population, the RTSc was not applicable. The APACHE II was the most sensitive score for mortality. Anatomical scoring systems showed a positive correlation with the amount of transfused blood products.