Distal Research Articles

Accuracy of Point‐Of‐Care Cardiac Ultrasound Performed on Patients Admitted to a Pediatric Intensive Care Unit in Shock

ABSTRACTPurposeTo assess agreement between a novice pediatric critical care fellow's interpretation of left and right ventricular (LV, RV) function using point‐of‐care ultrasound (POCUS) compared with assessments by pediatric cardiologists and echocardiography.MethodsEchocardiographic clips (parasternal long axis, parasternal short axis, and apical four‐chamber) and measurements for LV and RV functions (E‐point septal separation, ejection fraction, and tricuspid annular plane systolic excursion) were obtained by PICU fellow in patients 0–18 years old with shock. A pediatric cardiologist reviewed the POCUS images. Agreement between the interpretations by the intensivist, cardiologist, and comprehensive echocardiograms were analyzed using Cohen's kappa.ResultsThirty‐one patients were included: 22 had comprehensive echocardiograms. The PICU fellow detected LV dysfunction with 100% sensitivity and > 85% specificity compared with the cardiologist's interpretation and formal echocardiography. Substantial agreement (κ = 0.62) was noted between the intensivist and cardiologist for interpretation of LV function and RV size and pressure (κ = 0.72). The intensivist's assessments showed perfect agreement (κ = 1.0) with echocardiography for LV and RV function. POCUS images ranged from 100% adequate in the parasternal long axis, 90% in the parasternal short axis, and 43% in apical four‐chambered views.ConclusionsA novice PICU fellow could reliably use POCUS to assess the cardiac function in pediatric patients with shock.

Surgical Innovation in Serial Reconstruction of Micrognathia Using Free Fibular Flap: Insights From a Study and Literature Review.

Free fibular flap (FFF) is the main modality in the reconstruction of maxillofacial defects. Micrognathia is a condition where the mandible is smaller than it should be. Micrognathia is typically treated with mandibular distraction osteogenesis, bilateral sagittal split osteotomy, and conventional costochondral graft. In cases in which these procedures cannot be performed, FFF becomes a suitable alternative. Publications regarding the use of FFF in cases of micrognathia are currently still limited. In this case, we present the use of FFF in the reconstruction of a severely micrognathic mandible in an adult patient. A 28-year-old woman with micrognathia was referred to Dr. Ciptomangunkusumo Hospital for reconstruction. The patient had previously undergone temporomandibular joint (TMJ) reconstruction surgery with interpositional TMJ arthroplasty 10 years prior due to an ankylosing TMJ that prevented the opening of the jaw. The treatment for ankylosing TMJ was necessitated due to the patient's inability to open their mouth, resulting in significant challenges with alimentation, speech, and facial morphology. Here the authors reported mandibular lengthening reconstruction in the anteroposterior axis with FFF. A surgical osteotomy was performed on the posterior segment of the bilateral mandibular ramus, then the segmented fibula was inserted into the resulting defect. Flap refinement was also performed following FFF. Postsurgical evaluation revealed notable enhancements in the patient's esthetic appearance, occlusal function, and amelioration of obstructive sleep apnea symptoms. FFF for mandibular reconstruction is feasible and effective in improving esthetic and functional outcomes in patients with micrognathia.

The Conversion of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty with Non-CT-Based Robotic Assistance: A Novel Surgical Technique and Case Series.

Robotic-assisted devices help provide precise component positioning in conversion of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). A few studies offer surgical techniques for computed tomography (CT) based robotic-assisted conversion of UKA to TKA; however, no studies to date detail this procedure utilizing a non-CT-based robotic-assisted device. This article introduces a novel technique employing a non-CT-based robotic-assisted device (ROSA Knee System, Zimmer Biomet, Warsaw, IN) for converting UKA to TKA with a focus on its efficacy in gap balancing. We present three patients (ages 46-66 years) who were evaluated for conversion of UKA to TKA for aseptic loosening, stress fracture, and progressive osteoarthritis. Each patient underwent robotic-assisted conversion to TKA. Postoperative assessments at 6 months revealed improved pain, function, and radiographic stability. Preoperative planning included biplanar long leg radiographs to determine the anatomic and mechanical axis of the leg. After arthrotomy with a standard medial parapatellar approach, infrared reflectors were pinned into the femur and tibia, followed by topographical mapping of the knee with the UKA in situ. The intraoperative software was utilized to evaluate flexion and extension balancing and plan bony resections. Then, the robotic arm guided placement of the femoral and tibial guide pins and the UKA components were removed. After bony resection of the distal femur and proximal tibia, the intraoperative software was used to reassess the extension gap, and plan posterior condylar resection to have the flexion gap match the extension gap. The use of a non-CT-based robotic-assisted device in conversion of UKA to TKA is a novel technique and a good option for surgeons familiar with robotic-assisted arthroplasty, resulting in excellent outcomes at 6 months.

Mesoscopic axially swept oblique plane microscope for the imaging of freely moving organisms with near-isotropic resolution

Rapid three-dimensional imaging over extended fields of view (FOVs) is crucial to the study of organism-wide systems and biological processes in vivo. Selective-plane illumination microscopy (SPIM) is a powerful method for high spatio-temporal resolution in toto imaging of such biological specimens. However, typical SPIM implementations preclude conventional sample mounting and have anisotropic imaging performance, in particular when designed for large FOVs over 1 mm diameter. Here, we introduce axial sweeping of the illumination into a non-orthogonal dual-objective oblique plane microscope (OPM) design, thereby enabling the observation of freely moving animals over millimeter-sized FOVs, at close to isotropic, sub-cellular resolution. We apply our mesoscopic axially swept OPM (MASOPM) to image the behavioral dynamics of the sea anemone Nematostella vectensis over 1 × 0.7 × 0.4 mm at 1.7 × 2.6 × 3.7 µm resolution and 0.5 Hz volume rate.

Homozygosity for a hypomorphic mutation in frizzled class receptor 5 causes syndromic ocular coloboma with microcornea in humans.

Ocular coloboma (OC) is a congenital disorder caused by the incomplete closure of the embryonic ocular fissure. OC can present as a simple anomaly or, in more complex forms, be associated with additional ocular abnormalities. It can occur in isolation or as part of a broader syndrome, exhibiting considerable genetic heterogeneity. Diagnostic yield for OC remains below 30%, indicating the need for further genetic exploration. Mutations in the Wnt receptor FZD5, which is expressed throughout eye development, have been linked to both isolated and complex forms of coloboma. These mutations often result in a dominant-negative effect, where the mutated FZD5 protein disrupts WNT signaling by sequestering WNT ligands. Here, we describe a case of syndromic bilateral OC with additional features such as microcornea, bone developmental anomalies, and mild intellectual disability. Whole exome sequencing revealed a homozygous rare missense variant in FZD5. Consistent with a loss-of-function effect, overexpressing of fzd5 mRNA harboring the missense variant in zebrafish embryos does not influence embryonic development, whereas overexpression of wild-type fzd5 mRNA results in body axis duplications. However, in vitro TOPFlash assays revealed that the missense variant only caused partial loss-of-function, behaving as a hypomorphic mutation. We further showed that the mutant protein still localized to the cell membrane and maintained proper conformation when modeled in silico, suggesting that the impairment lies in signal transduction. This hypothesis is further supported by the fact that the variant affects a highly conserved amino acid known to be crucial for protein-protein interactions.

Effects of visual disruption on static and dynamic postural control in people with and without chronic ankle instability

IntroductionChronic Ankle Instability (CAI) is a chronic syndrome resulting from repeated ankle sprains that lead to persistent dysfunction.the purpose of this study is to determine whether visual disruption could influence static and dynamic postural control in people with and without chronic ankle instability (CAI), with the objective of gaining a comprehensive understanding of the interactions between visual inputs and postural control.MethodsThirty people with CAI (21 males and 9 females, age = 22.0 ± 1.8 years, height = 174.4 ± 10.2 cm, body mass = 72.5 ± 15.4 kg; Cumberland Ankle Instability Tool (CAIT) score = 19.7 ± 1.8) and twenty-nine without CAI (24 males and 5 females, age = 22.9 ± 1.6 years, height = 172.8 ± 8.0 cm, body mass = 69.0 ± 11.3 kg; CAIT score = 29.0 ± 0.7) were recruited. Their static and dynamic postural control was measured in two conditions with or without visual disruption, simulated using stroboscopic glasses. Static postural control was measured during single-limb standing and represented by root mean square (RMS) of the plantar center of pressure (CoP), dynamic postural control was measured during a Y-balance test and represented by the relative reach distance. Two-way mixed ANOVA (between group: CAI vs non-CAI, within group: normal vision vs visual disruption) was used to analyze data.Results and discussionSignificant interactions were detected in the CoP-RMS in the anteroposterior (AP) (p = 0.021, η2p = 0.090) and mediolateral (ML) (p < 0.001, η2p = 0.208) directions, and the relative reach distances in the posteromedial (PM) p = 0.023, η2p = 0.088) and posterolateral (PL) (p = 0.009, η2p = 0.113) directions, from normal vision to visual disruption. The CoP-RMS in the AP and ML directions significantly increased and the relative reach distances in the PM and PL directions significantly decreased in people with CAI while remaining unchanged in those without CAI. People with CAI are susceptible to visual disruption on postural control, highlighting the importance of visual input in maintaining stable posture in this population.

Run-and-tumble motion of ellipsoidal microswimmers

A hallmark of bacteria is their so-called “run-and-tumble” motion and its variants, consisting of a sequence of linear directed “runs” and distinct rotation events that constantly alternate due to biochemical feedback. It plays a crucial role in the ability of bacteria to move through chemical gradients and has inspired a fundamental active particle model. Nevertheless, synthetic active particles generally do not exhibit run-and-tumble motion but rather active Brownian motion. We show in experiments that ellipsoidal thermophoretic Janus particles, propelling along their short axis, can yield run-and-reverse motion, i.e., where rotation events flip the direction of motion, even without feedback. Their hydrodynamic wall interactions under strong confinement give rise to an effective double-well potential for the declination of the short axis. The geometry-induced timescale separation of the in-plane rotational dynamics and noise-induced transitions in the potential then yield run-and-reverse motion. Published by the American Physical Society 2024

An Integrated Multimodal-Based CAD System for Breast Cancer Diagnosis

Breast cancer has been one of the main causes of death among women recently, and it has been the focus of attention of many specialists and researchers in the health field. Because of its seriousness and spread speed, breast cancer-resisting methods, early diagnosis, diagnosis, and treatment have been the points of research discussion. Many computers-aided diagnosis (CAD) systems have been proposed to reduce the load on physicians and increase the accuracy of breast tumor diagnosis. To the best of our knowledge, combining patient information, including medical history, breast density, age, and other factors, with mammogram features from both breasts in craniocaudal (CC) and mediolateral oblique (MLO) views has not been previously investigated for breast tumor classification. In this paper, we investigated the effectiveness of using those inputs by comparing two combination approaches. The soft voting approach, produced from statistical information-based models (decision tree, random forest, K-nearest neighbor, Gaussian naive Bayes, gradient boosting, and MLP) and an image-based model (CNN), achieved 90% accuracy. Additionally, concatenating statistical and image-based features in a deep learning model achieved 93% accuracy. We found that it produced promising results that would enhance the CAD systems. As a result, this study finds that using both sides of mammograms outperformed the result of using only the infected side. In addition, integrating the mammogram features with statistical information enhanced the accuracy of the tumor classification. Our findings, based on a novel dataset, incorporate both patient information and four-view mammogram images, covering multiple classes: normal, benign, and malignant.

CTCF-dependent insulation of Hoxb13 and the heterochronic control of tail length

Mammalian tail length is controlled by several genetic determinants, among which are Hox13 genes, whose function is to terminate the body axis. Accordingly, the precise timing in the transcriptional activation of these genes may impact upon body length. Unlike other Hox clusters, HoxB lacks posterior genes between Hoxb9 and Hoxb13, two genes separated by a ca. 70 kb large DNA segment containing a high number of CTCF sites, potentially isolating Hoxb13 from the rest of the cluster and thereby delaying its negative impact on trunk extension. We deleted the spacer DNA to induce a potential heterochronic gain of function of Hoxb13 at physiological concentration and observed a shortening of the tail as well as other abnormal phenotypes. These defects were all rescued by inactivating Hoxb13 in-cis with the deletion. A comparable gain of function was observed in mutant Embryonic Stem (ES) cells grown as pseudoembryos in vitro, which allowed us to examine in detail the importance of both the number and the orientation of CTCF sites in the insulating activity of the DNA spacer. A short cassette containing all the CTCF sites was sufficient to insulate Hoxb13 from the rest of HoxB, and additional modifications of this CTCF cassette showed that two CTCF sites in convergent orientations were already capable of importantly delaying Hoxb13 activation in these conditions. We discuss the relative importance of genomic distance versus number and orientation of CTCF sites in preventing Hoxb13 to be activated too early during trunk extension and hence to modulate tail length.

The Tibial Tunnel Size Relative to the Proximal Tibia Affects the Tibial Tunnel Widening in Anatomical Anterior Cruciate Ligament Reconstruction.

The impact of the bone tunnel size relative to body size on clinical results in anterior cruciate ligament (ACL) reconstruction remains unclear. This study aimed to assess the morphological alteration of the tibial tunnel aperture and relationship between the tibial tunnel size relative to the proximal tibia among the tibial tunnel widening (TW) and clinical results following ACL reconstruction. This study comprised 131 patients who had undergone anatomical ACL reconstruction utilizing bone-patellar tendon-bone autografts. The morphology and enlargement of the tibial tunnel were examined via three-dimensional computed tomography 1 week and 1 year postoperatively. The anteroposterior (AP) and mediolateral (ML) positions were determined as a percentage relative to the proximal AP and ML tibial dimensions, respectively. Clinical assessment was conducted 2 years postoperatively. The association between the primary tibial tunnel size among TW and clinical outcomes was examined. The tibial tunnel significantly migrated posterolaterally. The ML diameter significantly widened; however, the AP diameter did not exhibit widening. AP widening was associated with the AP diameter of the primary tibial tunnel (r = -0.482, p < 0.01), and ML widening correlated with the ML diameter of that tunnel (r = -0.478, p < 0.01). However, there was no significant correlation observed between the primary tibial tunnel size and clinical outcomes. The tibial tunnel migrated and enlarged laterally in the ML plane, but did not enlarge in the AP plane. The primary tibial tunnel diameter relative to the proximal tibia negatively correlated with the tibial TW in the AP and ML planes. Level of evidence: level IV.

First Specimens of the Cornutan Stylophora Phyllocystis (Echinodermata) in the Ordovician (Volkhov Regional Stage, Dapingian and Darrivilian) of Baltica and Special Aspects of Stylophora Axial Symmetry

Described two new species of cornutan stylophora of the genus Phyllocystis from the Volkhov Regional Stage (Middle Ordovician, Dapingian) of Baltica. This points to the biogeographic connection between Afro-European part of Gondwana and Baltica since the very beginning of the Middle Ordovician. Both species were confined to cold-water, shallow conditions with low water mobility. Analysis of the axial symmetry of the stylophora and the location of the hydropore indicates the absence of torsion in their ontogeny and the location of the ambulacral system to the right of their anteroposterior axis. To explain this structure, two alternative hypotheses have been proposed: 1) inversion inversion in the development of right and left coelomes; 2) inverted state of stylophora compared to other invertebrates, what makes them similar to the chordates in terms of the position of the dorsal and ventral sides.

Dual-Fluoroscopy vs. Single-Fluoroscopy in Balloon Kyphoplasty: A Study of Efficiency and Safety

Background: Vertebral compression fractures (VCFs) are the most prevalent type of osteoporotic fractures, often causing significant pain, morbidity, and mortality. Vertebral augmentation procedures like balloon kyphoplasty (BK) are effective in treating VCFs. These procedures are typically performed using a single fluoroscopy machine (SF) for anteroposterior (AP) and lateral views. We have implemented a dual-fluoroscopy (DF) technique to reduce procedure time and radiation exposure. The goal of this study was to determine whether dual-fluoroscopy could optimize surgical efficiency without compromising safety, offering a more effective alternative to traditional single-fluoroscopy methods. Methods: This retrospective study included 126 patients who underwent BK with either SF (n = 74, 58.7%) or DF (n = 52, 41.3%) between 2020 and 2024. We collected data on procedure duration per pedicle (PDPP), radiation exposure (reference air kerma and dose-area product [DAP]), and radiation duration. A sub-analysis of post-learning phase cases was performed. Results: A learning curve was identified for the first 24 cases and 15 cases using the SF technique and DF technique, respectively, which was followed by a stabilization in procedure duration per pedicle (Levene’s statistic = 10.623, p = 0.002 for SD difference, p &lt; 0.001 for mean PDPP difference). After the completion of the learning phase for both techniques, the DF group demonstrated a significantly shorter PDPP (11.83 ± 4.3 vs. 14.03 ± 5.57 min, p = 0.049). No significant differences were found in radiation exposure, including radiation duration (p = 0.577), reference air kerma, or DAP. Conclusions: Dual-fluoroscopy significantly reduces procedure time after the learning curve is overcome, improving efficiency without increasing radiation exposure. This technique holds promise for optimizing kyphoplasty workflow and safety, supporting broader clinical adoption.

Defining multilevel developmental cervical spinal stenosis using MRI.

Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM. This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery. A total of 2,114 individuals aged 64.6 years (SD 11.9) who underwent surgery from March 2009 to December 2016 were studied. The most optimal cut-off canal diameters for DcSS are: C3 < 12.9 mm, C4 < 11.8 mm, C5 < 11.9 mm, C6 < 12.3 mm, and C7 < 13.3 mm. Overall, 13.0% (262 of 2,019) of the population-based cohort had multilevel DcSS. Multilevel DcSS (odds ratio (OR) 6.12 (95% CI 3.97 to 9.42); p < 0.001) and male sex (OR 4.06 (95% CI 2.55 to 6.45); p < 0.001) were predictors of developing DCM. This is the first MRI-based study for defining DcSS with multilevel canal narrowing. Level-specific cut-off canal diameters for DcSS can be used for early identification of individuals at risk of developing DCM. Individuals with DcSS at ≥ three levels and male sex are recommended for close monitoring or early intervention to avoid traumatic spinal cord injuries from stenosis.

The eyestalk photophore of Northern krill Meganyctiphanes norvegica (M. Sars) (Euphausiacea) re-investigated: Innervation by specialized ommatidia of the compound eye

Members of the Euphausiacea (“krill”) generate bioluminescence using light organs, the so-called photophores, including one pair associated with the eyestalks, two pairs on the thoracic segments, and four unpaired photophores on the pleon. The photophores generate light via a luciferin–luciferase type of biochemical reaction in light-emitting cells comprised in a photophore compartment called “lantern”. The behavioral significance of bioluminescence in krill is discussed controversially, and possible functions include a defensive function, camouflage by counter-shading, and intra-specific communication. Light production of all krill photophores is controlled by hormonal and neuronal pathways but our knowledge about the nature of these pathways is still rudimentary. Here, we provide a detailed description of the eyestalk photophore's histology in Northern krill Meganyctiphanes norvegica, and used immunohistochemistry combined with confocal laser-scan microscopy to explore this organ's serotonergic innervation. Furthermore, we provide evidence that the photophore is innervated by a distinct photophore nerve that originates from a specialized cluster of ca. 30 highly modified ommatidia at the dorsal rim of the compound eye that are optically isolated from the other ommatidia. Our findings suggest the compound eye – photophore link as a major anatomical axis to adjust the photophore activity.

Novel synthetic UV screen compounds inspired in mycosporine-like amino acids (MAAs): Antioxidant capacity, photoprotective properties and toxicity

The combination of environmental stress on the ozone layer, climate change and a greater sun exposure due to outdoor habits has led to an increase in skin cancer cases and other health issues related with UV radiation. Researchers are searching for new alternative UV filters that could protect our skin from the deleterious effects of UV radiation while also presenting low toxicity and biodegradable character (unlike the UV filters currently available in the market). In this work, two compounds inspired in the natural oxo-mycosporine-like amino acids (MAAs) have been synthesized and their antioxidant and photoprotective properties, as well as their in vitro and in vivo toxicity effects were evaluated. Both compounds featured a strong UV-B absorption together with a high antioxidant capacity, close to 50 μmol TE g−1 DW in the ABTS assay. Compound 1 presented an absorption peak at 285–300 nm, whereas compound 2 showed a wider band with a peak around 295–305 nm and two shoulders at 318 and 342 nm. The addition of 5 % of compound 2 to galenic formulas increased the photoprotection, reaching SPF values of 4. Both compounds were stable under UV radiation exposure. Regarding toxicity, the synthetic compounds did not show cytotoxic activity against healthy human cell lines or significant toxicity over zebrafish embryos. Compound 1 showed a complete lack of toxicity over zebrafish, although compound 2 showed slight, not-significant effects on viability, hatching, pericardial stability or body axis formation over 5 mg mL−1. Moreover, compound 1 presented relatively antitumoral activities against HCT-116 cells (selective index:1.49). The relevant antioxidant and photoprotective ability together with the great advantage provided by the reduced toxicity to health cells or zebrafish embryos, make these compounds promising candidates to be exploited as functional ingredients with specific applications in the biotechnological or pharma sector.

Does the FARNet neural network algorithm accurately identify Posteroanterior cephalometric landmarks?

BackgroundWe explored whether the feature aggregation and refinement network (FARNet) algorithm accurately identified posteroanterior (PA) cephalometric landmarks.MethodsWe identified 47 landmarks on 1,431 PA cephalograms of which 1,177 were used for training, 117 for validation, and 137 for testing. A FARNet-based artificial intelligence (AI) algorithm automatically detected the landmarks. Model effectiveness was calculated by deriving the mean radial error (MRE) and the successful detection rates (SDRs) within 2, 2.5, 3, and 4 mm. The Mann-Whitney U test was performed on the Euclidean differences between repeated manual identifications and AI trials. The direction in differences was analyzed, and whether differences moved in the same or opposite directions relative to ground truth on both the x and y-axis.ResultsThe AI system (web-based CranioCatch annotation software (Eskişehir, Turkey)) identified 47 anatomical landmarks in PA cephalograms. The right gonion SDRs were the highest, thus 96.4, 97.8, 100, and 100% within 2, 2.5, 3, and 4 mm, respectively. The right gonion MRE was 0.94 ± 0.53 mm. The right condylon SDRs were the lowest, thus 32.8, 45.3, 54.0, and 67.9% within the same thresholds. The right condylon MRE was 3.31 ± 2.25 mm. The AI model’s reliability and accuracy were similar to a human expert’s. AI was better at four skeleton points than the expert, whereas the expert was better at one skeletal and seven dental points (P < 0.05). Most of the points exhibited significant deviations along the y-axis. Compared to ground truth, most of the points in AI and the second trial showed opposite movement on the x-axis and the same on the y-axis.ConclusionsThe FARNet algorithm streamlined orthodontic diagnosis.

Differentiation and characterization of non-thymomatous ocular myasthenia gravis children with CT.

To compare thymic features using unenhanced computed tomography (CT) images between children with non-thymomatous ocular myasthenia gravis (OMG) and healthy children and determine the image feature cut-off values to allow differentiation of the two populations. We conducted a retrospective study involving 66 children who underwent chest CT, with 33 having non-thymomatous OMG and 33 healthy children without any abnormality. We recorded CT features of the thymus in each child, including the mean CT attenuation value, thymus area, area ratio, anteroposterior (AP) length, width (W), thickness (T), and transverse diameter (TD). These characteristics were analyzed to distinguish OMG from healthy controls. The receiver operating characteristic (ROC) analysis was used to clarify the best assessment, and the optimal cut-off values were determined. The mean CT attenuation value, the thymus area, area ratio, and TD were significantly different (P < 0.05) between the two groups. The mean CT attenuation value was the most significant characteristic in differentiating OMG and healthy controls (area under the curve [AUC] = 0.70). Using 50.41 as the cut-off value for mean CT attenuation, a specificity of 0.70 and sensitivity of 0.82 was observed for distinguishing the two groups (P = 0.003). Optimal differentiation was achieved by combining more than one characteristic including CT attenuation, thymus area, and TD with an optional area ratio (AUC = 0.72). Non-enhanced CT of the thymus complemented the clinical workup of children with non-thymomatous OMG. The cut-off values of the CT features may allow robust differentiation of OMG children.

A population-based characterisation of the relationship between anatomical and electrical axes of the heart

Abstract Introduction Cardiac anatomy, including heart size, position and orientation within the torso, is known to impact ECG morphology. Understanding the relationship between cardiac anatomy and ECG morphology through their main axes has the potential to lead to more accurate and reliable ECG biomarkers. Nevertheless, there is no standardised method for the definition of the anatomical and electrical axes of the heart. Aims To evaluate definitions of anatomical and electrical axes of the heart based on a derived metric in an undiseased population in the UKBioBank. Methods The anatomical and electrical axes of 2189 healthy subjects were computed separately in five different ways (Figure 1). Cardiac bi-ventricular anatomy was automatically segmented from cardiac MRI. Anatomical axes were computed from different combinations of anatomical landmarks (valves and apex) and axis of inertia. ECGs were transformed into vectorcardiograms (VCGs) using the Kors transformation. A range of combinations of dipole magnitudes, weighted averages and loop shape were used to define the electrical axes of the QRS loop. The anatomical-electrical relationship was quantified with the cosine of the angle between each of the 25 pairs of anatomical and electrical axes definitions. Spatial consistency was assessed by the standard deviation of this cosine across the cohort, where a higher level of spatial consistency corresponds to a lower standard deviation. Results Spatial consistency between anatomical and electrical axes exhibited a large range of standard deviation values from 0.61 for the worst pair to 0.14 for the best pair of definitions. The pair with the highest spatial consistency was defined by the valvular plane centre and the apex (VPA) for the anatomical axis, and the direction of maximum QRS dipole magnitude (maxQRS) in the VCG for the electrical axis (Panel A and B in Figure 2). The anatomical-electrical relationship was not significantly correlated with BMI, age or gender despite the individual anatomical and electrical axes showing significant correlation (Frontal plane: anatomical axis was most impacted by BMI, R=0.53 &amp; p&amp;lt;0.0001, and electrical axis by gender R=0.37 &amp; p&amp;lt;0.0001). Conclusion In this healthy population, the most spatially consistent definition of anatomical and electrical axes is defined by VPA and maxQRS. This spatial consistency is not affected by BMI, age or gender, suggesting an intrinsic relationship between the pair of measures, and represents a potential strategy to permit correction for patient anatomic factors when interpreting ECGs.Figure 1.Axes Definition MethodsFigure 2.Results

The prognostic and incremental value of T1 mapping for predicting adverse events in hypertrophic cardiomyopathy

Abstract Background In patients with hypertrophic cardiomyopathy (HCM), the prognostic value of native T1 and extracellular volume fraction (ECV) for adverse cardiovascular events has not been well defined. Methods Consecutive 663 participants with HCM who underwent cardiovascular magnetic resonance (CMR) were recruited. The follow-up endpoints included heart failure (HF)-related death and sudden cardiac death (SCD) or aborted SCD. Results During the median follow-up time of 44 months (interquartile range [IQR]: 23 to 66.0 months), 56 (8.4%) participants reached composite endpoints including 38 (5.7%) with SCD or aborted SCD, 16 (2.4%) with HF-related death and 2 (0.3%) with heart transplantation. On multivariable Cox proportional hazards regression analyses, native T1 including late gadolinium enhancement (LGE) from three short axes were significantly associated with cardiac death (basal native T1: hazard ratio [HR], 1.06 per 10 ms increase; 95% confidence interval [CI], 1.02 to 1.09; middle native T1: HR, 1.05 per 10 ms increase; 95% CI, 1.01 to 1.09; apical native T1: HR, 1.04 per 10 ms increase; 95% CI, 1.02 to 1.07; all P &amp;lt; 0.05) after adjustment for non-sustained ventricular tachycardia, history of syncope, the extent of LGE, left atrial size, and NYHA class. Conversely, only basal ECV was associated with cardiac death (basal ECV including LGE area: HR, 1.08 per 1% increase, 95%CI, 1.03 to 1.13, P = 0.001; basal ECV excluding LGE: HR, 1.1 per 1% increase; 95%CI, 1.04 to 1.16; P &amp;lt; 0.001) In addition, participants with increased mean native T1 (≥1349.4 ms) or basal ECV(≥ 29.4%) were more likely to suffer from cardiac death in the entire study cohort or the subgroup with low LGE extent (&amp;lt;15%) or low ESC risk score (&amp;lt;6%) (all P &amp;lt; 0.05). Furthermore, the addition of mean LV native T1 (≥1349.4 ms) or basal ECV (≥ 29.4%) to current risk factors in the guidelines could further improve prediction for the composite endpoint (C-index increased to 0.719 from 0.521 for the AHA/ACC risk model, P &amp;lt; 0.001; C index increased to 0.709 from 0.514 for the ESC risk model; P &amp;lt; 0.001). Conclusions In this study of patients with HCM, mean native T1 of three short axes and basal ECV were independently associated with cardiac death and added incremental value to conventional clinical predictors for patients with HCM.Figure 1.Demonstrative images.Figure 2 Incremental Value of T1 mapping

Prediction of cancer therapy related cardiac dysfunction by using a machine learning approach with cardiac magnetic resonance images

Abstract Background There is inconsistent data on the value of baseline and early cardiac function assessment on identifying patients at risk of cancer therapy related cardiac dysfunction (CTRCD). Whether machine learning (ML) approaches applied to cardiac MRI (CMR) images may help risk stratify patients is unclear. Purpose In women with HER2+ breast cancer receiving sequential anthracyclines and trastuzumab we sought to (i) assess if a ML approach applied to pre-cancer therapy and early post anthracycline CMR short axis (SAX) cines can help identify patients at risk for future CTRCD and (ii) whether this approach is superior to using clinical and manual quantitative CMR data. Methods Women with HER2+ breast cancer from the EMBRACE-MRI study underwent 5 CMR studies (pre-cancer therapy, post anthracyclines, 3, 6 and 12 months during trastuzumab). CTRCD was defined using the CREC criteria by end of treatment. Three models were created: 1) clinical data (demographics, cardiovascular risk factors and medications); 2) clinical and manual quantitative CMR data (right and left ventricular volumes and LVEF); and 3) ML model based on SAX cine CMR images only. We focused on the pre-cancer therapy CMR and 1st visit post-anthracycline CMR. All images underwent standardised formatting. A 3D convolutional neural networks model architecture was used. The model consisted of multiple convolutional layers followed by max pooling and global average pooling layers. The output of the convolutional layers were then fed into a dense layer of 128 nodes incorporating an L2 activity regularizer and a subsequent dropout layer. To train and tune the model, the process was iterated 50 times. In each iteration, the patient participant dataset was shuffled, and a random 80% of patients were selected for training and tuning. The tuned model was then applied to the remaining 20% of patients in each iteration, and this entire cycle of shuffling, training, and testing was repeated 50 times with replacement. Area Under the Curve (AUC), accuracy, sensitivity, and specificity were calculated on the test set and averaged across folds to determine each model’s performance. Results 135 women were included (mean age 51.1±9.2 years) mean doxorubicin equivalent was dose 204.9±12.5mg/m2. Cardiovascular risk factors were prevalent: 33 (24%) had a smoking history; 21 (15%) had hypertension. 37 (27%) developed CTRCD. The ML model using baseline CMR cine data only had a higher AUC (0.84 95% CI [0.83-0.86]) for the detection of CTRCD compared to clinical data (0.62 95% CI [0.59-0.65]) and clinical and CMR data (0.62 95% CI [0.60-0.65]). This further improved with the addition of post-anthracycline CMR data (Table 1). Conclusion A ML model examining early cardiac MRI data with short axis cine CMR images performed better than those using clinical or manual quantitative CMR data for the prediction of CTRCD. Further studies including external validation are needed.Table 1 Mean and 95% CIs