Individual Cases Research Articles

Time to childbirth and assisted reproductive treatment in women with congenital heart disease

ObjectiveTo investigate the time to first childbirth and to compare the prevalence of assisted reproductive treatment (ART) in women with congenital heart disease (CHD) compared with women without CHD.MethodsAll women...

Classifying electrocardiograph waveforms using trained deep learning neural network based on wavelet representation

<span lang="EN-US">Due to the rise in cardiac patients, an automated system that can identify different heart disorders has been created to lighten and distribute the duty of physicians. This research uses three different electrocardiograph (ECG) signals as indicators of a person's cardiac problems: Normal sinus rhythm (NSR), arrhythmia (ARR), and congestive heart failure (CHF). The continuous wavelet transform (CWT) provides the mechanism for classifying the 190 individual cases of ECG data into a 2-dimensional time-frequency representation. In this paper, the modified GoogLeNet is used for ECG data classification. Using a transfer learning approach and adjustments to parts of the output layers, ECG classification was conducted and the effectiveness of convolutional neural network (CNN) designs was tested. By comparing the results that the optimized neural network and GoogLeNet both had classification accuracy about of 80% and 100%, respectively. The GoogLeNet provide the best result in term of accuracy and training time.</span>

Artificial intelligence at sentencing: when do algorithms perform well enough to replace humans?

AbstractArtificial intelligence is currently supplanting the work of humans in many societal contexts. The purpose of this article is to consider the question of when algorithmic tools should be regarded as performing sufficiently well to replace human judgements and decision-making at sentencing. More precisely, the question as to which are the ethically plausible criteria for the comparative performance assessments of algorithms and humans is considered with regard to both risk assessment algorithms that are designed to provide predictions of recidivism and sentencing algorithms designed to determine sentences in individual criminal cases. It is argued, first, that the prima facie most obvious assessment criteria do not stand up to ethical scrutiny. Second, that ethically plausible criteria presuppose ethical theory on penal distribution which currently has not been sufficiently developed. And third, that the current lack of assessment criteria has comprehensive implications regarding when algorithmic tools should be implemented in criminal justice practice.

Prediction of Tropical Cyclogenesis Based on Machine Learning Methods and Its SHAP Interpretation

AbstractThis study trains three machine learning models with varying complexity—Random Forest, Support Vector Machine, and Neural Network—to predict cyclogenesis at a forecast lead time of 24 hr for given tropical disturbances identified by an optimized Kalman Filter algorithm. The overall performance is competent in terms of f1‐scores (∼0.8) compared to previous research of the same kind. An assessment by SHapley Additive exPlanations (SHAP) values reveals that mid‐level (500 hPa) vorticity is the most influential factor in deciding if a tropical disturbance is developing or non‐developing for all three models. Wind shear and tilting are found to hold a certain level of importance as well. These results encourage further experiments that use physical models to explore the dynamical, mid‐level pathway to tropical cyclogenesis. Another usage of SHAP values in this work is to explain how a machine learning model decides if an individual tropical disturbance case will develop, by listing the contribution of each feature to the output genesis probability, illustrated by a case study of Typhoon Halong. This increases the reliability of the machine learning models, and forecasters can take advantage of such information to issue tropical cyclone formation warnings more accurately. Several caveats of the current machine learning application in the studies of tropical cyclogenesis are discussed and can be considered for future research. These can benefit the interpretation and emphasis of certain output fields in the operational dynamical prediction system, which can contribute to more timely cyclogenesis forecasts.

Governing schools in times of pandemic: A set‐theoretical analysis of the role of policy capacities in school closure

AbstractPolicy capacity plays a pivotal role in shaping the extent of global governmental responses to the COVID‐19 pandemic. While scholars have primarily examined this phenomenon through individual case studies, focusing on demographic variables that influence governments' COVID‐19 responses, little understanding exists regarding how existing policy capacities (systemic, organizational, and individual) have either constrained or empowered governments to navigate the pandemic diversely. To address this gap, our study focuses on the worldwide patterns of school closures and re‐openings during COVID‐19. Utilizing configurational analysis on data from 110 countries, we reveal that factors such as less professional organizational capacities, flawed individual leadership capacities, and contextual factors such as heightened political polarization serve as quasi‐sufficient conditions for longer school closures, while their significant presence leads to extended periods of schools remaining open. The research is supported by detailed case studies of the US, Colombia, Israel, and South Korea, elucidating diverse policy trajectories and combinations influencing prolonged closures or swift re‐openings.

Cardiovascular Adverse Drug Reactions of Anti-Calcitonin Gene-Related Peptide Monoclonal Antibodies for Migraine Prevention: An Analysis from the European Spontaneous Adverse Event Reporting System.

Anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP-mAbs) have recently been approved for the prevention of migraine, and their safety profile is not fully characterized. The aim of this study was to evaluate the adverse drug reactions (ADRs) of anti-CGRP-mAbs through the analysis of individual case safety reports (ICSRs) collected in the EudraVigilance (EV) database, with a specific focus on cardiovascular (CV) ADRs. Data on ICSRs recorded between July 2018 and December 2022 in the EV database, involving one of the anti-CGRP-mAbs for migraine prevention-erenumab (ERE), galcanezumab (GMB), fremanezumab (FMB), and eptinezumab (EPT)-were included in the analysis. All ICSRs reporting at least one CV ADR, as identified within the MedDRA® System Organ Classes (SOCs) "cardiac disorders" or "vascular disorders," were selected for the analysis. The frequency of disproportionate reporting was expressed as the reporting odds ratio (ROR) with its 95% confidence interval (CI), to evaluate the frequency of reporting of CV ADRs for each anti-CGRP-mAb compared with all other monoclonal antibodies (mAbs). A case-by-case analysis was conducted paying particular attention to serious CV ADR reports, focusing on the type of seriousness, age group, sex, and concomitant drugs. A total of 9441 ICSRs were recorded in the EV database from 2018 to 2022, of which more than half were related to ERE (58.9%), followed by GMB (21.4%), FMB (19.0%), and EPT (0.7%). CV ICSRs accounted for 1205 cases (12.8%), with a total of 1599 CV ADRs. The CV ICSRs were mainly related to female patients (82.6%) aged 18-64 years (73.4%). Of the reported CV ADRs, 67.5% were considered serious. Among the total number of ICSRs related to each anti-CGRP-mAb, those associated with FMB had a higher percentage of CV ADRs (n = 253; 14.1%), followed by ERE (n = 707; 12.7%), EPT (n = 8; 12.7%), and GMB (n = 237; 11.7%). A higher frequency of reporting hypertension was shown for ERE (ROR = 1.45; 95% CI = 1.14-1.85). Pallor was mainly observed with FMB (5.00; 1.68-14.89), as well as deep vein thrombosis (3.86; 1.57-9.51), hot flush (2.16; 1.43-3.25), and palpitations (1.48; 1.05-2.08). Atrial fibrillation (2.36; 1.02-5.46) and myocardial infarction (2.21; 1.37-3.58) were mostly reported for GMB. The analysis of anti-CGRP-related CV ADRs was consistent with the information reported in the literature. However, hypertension with ERE, atrial fibrillation and myocardial infarction with GMB, as well as pallor, deep vein thrombosis, hot flush, and palpitations with FMB were not reported in the Summary of Product Characteristics (SmPCs). Considering this, more post-marketing analyses are needed to improve knowledge on the CV safety profiles of anti-CGRP-mAbs, especially for the last approved medication, EPT.

Evaluation of Post-Vaccination Immunity in Children and Adolescents after Viral Hepatitis B Vaccine

Vaccination against viral hepatitis B is an effective method of protection against this infection. There is multiple decrease in the hepatitis B incidence. However, there was increase in chronic hepatitis B by 42.5%, 15 cases of acute viral hepatitis B in children and 2 deaths from this infection were registered according to the state report “On the sanitary and epidemiological wellbeing of the population of the Russian Federation for 2022”. The criteria for evaluating protection against viral hepatitis B are the anti-HBs level and the duration of post-vaccination immunity.Objective. The aim of the study is to evaluate the duration of postvaccination immunity in temporal aspect in children and adolescents vaccinated against viral hepatitis B.Methods. Prospective open-label study was conducted to assess post-vaccination immunity against viral hepatitis B in 143 children and adolescents. The study of anti-HBs was implemented via the immunoenzyme test system “Vectohep B-HBs-antigen”. Microsoft Office Excel 2010 package and the Prism9 program (GraphPad, USA) were used for statistical analysis.Results. It has been shown that hepatitis B vaccine provides 100% seroconversion. However, decrease in anti-HBs levels was revealed already 6 months after vaccination in 15.07% of cases of seronegative individuals, after 1 year their number has increased up to 28.77% of cases. On average, every fourth person had low protective level of anti-HBs. Almost two-thirds of adolescents became seronegative by the age of 14.Conclusion. Vaccination against viral hepatitis B ensures the maximum production of anti-HBs 1 month after the completed vaccination in 100% of cases. Antibody level begins to decrease 6 months after the third completed vaccination against hepatitis B, and in 14 years, 72.74% of those immunized become seronegative. All of these dictates the need to consider a booster dose in adolescents at the age of 14 years.

Pathomorphological characteristics of cardiac hemangiosarcoma in a dog (a clinical case)

Hemangiosarcoma is a prevalent and lethal type of cancer in dogs. The tumour grows and spreads rapidly, often giving no warning signs to the owner until the sudden death of the dog. Hemangiosarcoma typically affects older dogs. A confirmed case study of an animal’s death shows that angiosarcoma mainly develops in dogs of a specific age and breed. The dog examined in this study was seven years old. Detecting cardiac hemangiosarcoma can be challenging, as X-ray exams may produce false-negative results, as seen in the current study. Pathological mitotic divisions are often the most recognizable sign of a heart tumour, which can be identified through an incisional biopsy. However, in our case, this was not feasible due to the patient’s rapid decline. The patient’s enlarged heart was visible on a chest X-ray, while an ultrasound revealed a pericardial effusion. Pericardiocentesis was performed, and 80 ml of hemorrhagic pericardial fluid was drained. Unfortunately, the results of the cytological examination of the fluid were negative, as confirmed by this study. Classic clinical signs of hemangiosarcoma are not present, except for abrupt and severe internal bleeding. The animal’s owner reported periodic lethargy or fatigue and shortness of breath as clinical signs. During our examination, we noted tachycardia and muted heart sounds as additional clinical indications. During the pathological examination, the changes found in the body are not specific and may differ in individual cases of death. An autopsy established the absence of visual metastatic foci and in other organs: blood filling of the spleen; blood filling and liver enlargement; speckled haemorrhages on the lung pleura, mucous membrane of the stomach and small intestine; the mucous membrane of the large intestine is covered with a large amount of mucus and multiple haemorrhages. Histopathological studies have established a cavernous hemangioma, a large cavity of various shapes, filled with blood and lined with endothelium, separated by thin connective tissue partitions. In places, the blood in the cavities coagulates, and the formed thrombotic masses yield to their organizing.

A Rare Case of Recurrent Vulvovaginal Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP)

Smooth muscle tumours are the most common mesenchymal tumors of the vulva and vagina, yet their infrequency is demonstrated by the prevalence of published reports as individual cases or small case series. This article reports a case of a 42-year-old woman who presented with apparently recurrent vulvovaginal leiomyoma and a past history of surgical excisions. Histopathology revealed Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP).

Understanding and addressing the risk of disguised compliance in CVE programming

ABSTRACT Disguised compliance refers to individuals participating in programmes to counter violent extremism (CVE), deceiving, and manipulating intervention staff about the degree to which they are deradicalised and disengaged. It is a particular challenge that confronts CVE case managed programmes. Recent cases of individuals committing terrorist acts who have participated in CVE interventions have demonstrated the risks that disguised compliance presents. However disguised compliance is a common challenge confronting behavioural change programmes. This paper reports results from interviews with practitioners directly involved in the delivery of CVE interventions about their understandings of disguised compliance, its occurrence, identification, and management. The results indicate that the occurrence of disguised compliance is highly contextual and shaped by individual motivations and capacities, with it comprising a spectrum of behaviours. Interviewees emphasised that the detection of disguised compliance requires a mix of strategies and approaches, and that these should not undermine rapport and trust building with a client. The implications of the results for policy and practice are considered including the type of indicators that constitute authentic indicators of behavioural and cognitive change.

Adverse events following immunization reported with COVID-19 vaccines in Burkina Faso: Analysis of spontaneous reports

The rapid deployment of COVID-19 vaccines to a large proportion of the population requires a focus on safety. However, few studies have assessed the safety of COVID-19 vaccines in Africa. In Burkina Faso, this issue has not yet been addressed. The objective of this study was to contribute to the description of the characteristics of adverse events following immunization (AEFIs) related to COVID-19 vaccines in Burkina Faso. This was a cross-sectional descriptive retrospective study of spontaneous reports of COVID-19 vaccine-related AEFIs recorded in VigiBase® between June 2021 and November 2022 in Burkina Faso. Individual case safety reports (ICSRs) were extracted from VigiBase® using the Anatomical Therapeutic Chemical level 2 (ATC2) code. The proportion of ICSRs according to the reporter’s qualification, the reporting rate, the time taken to submit and record ICSRs, and the completeness score were calculated. A total of 973 ICSRs concerned COVID-19 vaccines and represented 32.6% of all 2,988 reports in VigiBase®. Overall, 82.0% of the reporters were nurses/midwives, 7.8% were physicians, 6.7% were pharmacists, and 3.4% were patients. The median time between the onset of AEFIs and the submission of the report to the Pharmacovigilance Center was 180 days (IQR: 136; 281). The median registration time was 188 days (IQR: 149; 286). The mean ICSR completeness score was 0.8 (standard deviation = 0.1). The overall AEFI reporting rate was 27.8 per 100,000 vaccine doses. The AEFI reporting rates for the ChAdOx1-nCoV-19, JNJ 78436735, Elasomeran, Tozinameran, and HB02 vaccines were 454.2, 17.4, 11.0, 10.2, and 0.4 per 100,000 vaccine doses, respectively. The majority of AEFIs were systemic in nature (90.1%). Headache (21.2%), fever (19.4%), and myalgia (11.0%) were the most frequently reported AEFIs. Eighteen cases (1.8%) of serious AEFIs (9 hospitalizations, 4 life threatening, 3 temporary disabilities, and 2 others unspecified) were reported. The majority of AEFIs reported were systemic in nature and mild. However, there have been reports of serious AEFIs. The overall AEFI reporting rate was low. There is a need to strengthen the monitoring of these vaccines to better organize strategies to optimize the adherence of the population of Burkina Faso.

How should respiratory depression and loss of airway patency be handled during initiation of palliative sedation?

Loss of airway patency has been reported during initiation of palliative sedation. In present guidelines the loss of airway patency during initiation of palliative sedation is not addressed. Airway patency can be restored by jaw thrust/chin lift or placing the patient in the recovery position. A structured ethical analysis of how respiratory depression and loss of airway patency during initiation of palliative sedation should be handled. The essence of the dilemma is whether it is appropriate to apply simple non-invasive methods to restore airway patency in order to avoid the patient's immediate death. A structured analysis based on the four principles of healthcare ethics and stakeholders' interests. Beneficence and autonomy support a decision not to regain airway patency whereas non-maleficence lends weight to a decision to restore airway patency. Whether the proportionality criterion of the principle of double effect is met depends on the features of the individual case. The ethical problem appears to be a genuine dilemma where important values and arguments point to different conclusions. Whether to restore airway patency when the airway is obstructed during initiation of palliative sedation will ultimately be based on clinical judgment taking into account both any known patient preferences and relevant clinical information. There are strong arguments favoring both options in this clinical and ethical dilemma. The fact that a clear and universal recommendation cannot be made does not imply indifference regarding what is the clinically and ethically best option for each individual patient.

Prognostic evaluation of the Ki-67 labeling system in histological grading of non-small round cell sarcoma: a supplementary analysis of a randomized controlled trial, JCOG1306.

Soft tissue sarcoma (STS) has various histological types and is rare, making it difficult to evaluate the malignancy of each histological type. Thus, comprehensive histological grading is most important in the pathological examination of STS. The Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grading system is most commonly used in daily pathological analysis of STS. Among the FNCLCC grading system parameters, mitotic count is a key morphological parameter reflecting the proliferative activity of tumor cells, although its reproducibility may be lacking. Here, we compared the prognostic utility of the conventional and modified FNCLCC grading systems in JCOG1306. We analyzed 140 patients with non-small round cell sarcoma. We performed Ki-67 immunostaining using open biopsy specimens before preoperative chemotherapy in all patients. We assessed histological grade in individual cases by conventional FNCLCC grading (tumor differentiation, mitotic count, and necrosis) and modified FNCLCC grading using the Ki-67 labeling index instead of mitotic count. We conducted univariable and multivariable Cox regression analyses to investigate the influence of grade on overall survival. In univariable analysis, prognosis was worse for patients with conventional FNCLCC Grade 3 tumors compared with Grade 1 or 2 tumors (hazard ratio [HR] 4.21, 95% confidence interval [CI] 1.47-12.05, P=0.008). Moreover, prognosis was worse in patients with modified FNCLCC Grade 3 tumors compared with Grade 1 or 2 tumors (HR 4.90, 95% CI 1.64-14.65, P=0.004). In multivariable analysis including both conventional and modified FNCLCC grading, the modified grading more strongly affected overall survival (HR 6.70, 95% CI 1.58-28.40, P=0.010). The modified FNCLCC grading system was superior to the conventional system in predicting the prognosis of patients with non-small round cell sarcoma according to this supplementary analysis of data from the randomized controlled trial JCOG1306.

Ex Vivo Fluorescence Confocal Microscopy of MRI-Guided Targeted Prostate Biopsies for Rapid Detection of Clinically Significant Carcinomas-A Feasibility Study.

MRI-guided prostate biopsies from visible tumor-specific lesions (TBx) can be used to diagnose clinically significant carcinomas (csPCa) requiring treatment more selectively than conventional systematic biopsies (SBx). Ex vivo fluorescence confocal microscopy (FCM) is a novel technique that can be used to examine TBx prior to conventional histologic workup. TBx from 150 patients were examined with FCM on the day of collection. Preliminary findings were reported within 2 h of collection. The results were statistically compared with the final histology. 27/40 (68%) of the csPCa were already recognized in the intraday FCM in accordance with the results of conventional histology. Even non-significant carcinomas (cisPCa) of the intermediate and high-risk groups (serum prostate-specific antigen (PSA) > 10 or 20 ng/mL) according to conventional risk stratifications were reliably detectable. In contrast, small foci of cisPCa were often not detected or were difficult to distinguish from reactive changes. The rapid reporting of preliminary FCM findings helps to reduce the psychological stress on patients, and can improve the clinical management of csPCa. Additional SBx can be avoided in individual cases, leading to lower rates of complications and scarring in the future surgical area. Additional staging examinations can be arranged without losing time. FCM represents a promising basis for future AI-based diagnostic algorithms.

Traumatic atlantoaxial rotatory fixation in adults: a systematic review of published cases.

Atlantoaxial rotatory fixation (AARF) in adults is a rare and clinically challenging condition characterized by a spectrum of etiological factors, predominantly attributed to traumatic and inflammatory pathologies within the craniovertebral region. Trauma is the most frequently identified cause within the adult population, with the first case report published in 1907. This study aims to conduct a systematic review that addresses the clinical presentations and management strategies relating to traumatic atlantoaxial rotatory fixation in adults. A comprehensive search of the PubMed database was executed, adhering to the PRISMA guidelines. The inclusion criteria encompassed case reports and series documenting AARF cases in individuals aged 18 and above, spanning database inception to July 2022. Studies not published in the English language were excluded. A total of 61 articles reporting cases of AARF in the adult population were included in the study. The mean age of affected individuals was 36.1years (± 15.6), with a distribution of 46% females and 54% males. Predominant mechanisms of injury included motor vehicle accidents and falls, constituting 38% and 22% of cases, respectively. Among the classification systems employed, Fielding and Hawkins type I accounted for the majority at 63%, followed by type II at 10%, and type III at 4%. Conservative management was used for treatment in 65% of acute (65%) cases and 29% of chronic cases. Traumatic AARF is a rare phenomenon in the adult population, is more common in younger adults, and does not often present with neurologic deficits. Patients diagnosed acutely are more likely to be successfully treated with conservative management, while patients diagnosed chronically are less likely to be reduced with conservatively and often require surgical treatment. Surgery should be considered for patients with irreducible dislocations, ligamentous injuries, unstable associated fractures, and persistent pain resistant to conservative management.

Key ingredients in regional climate modelling for improving the representation of typhoon tracks and intensities

Abstract. There is evidence of an increased frequency of rapid intensification events of tropical cyclones (TCs) in global offshore regions. This will not only result in increased peak wind speeds but may lead to more intense heavy precipitation events, leading to flooding in coastal regions. Therefore, high impacts are expected for urban agglomerations in coastal regions such as the densely populated Pearl River Delta (PRD) in China. Regional climate models (RCMs) such as the Weather Research and Forecasting (WRF) model are state-of-the-art tools commonly applied to predict TCs. However, typhoon simulations are connected with high uncertainties due to the high number of parameterization schemes of relevant physical processes (including possible interactions between the parameterization schemes) such as cumulus (CU) and microphysics (MP), as well as other crucial model settings such as domain setup, initial times, and spectral nudging. Since previous studies mostly focus on either individual typhoon cases or individual parameterization schemes, in this study a more comprehensive analysis is provided by considering four different typhoons of different intensity categories with landfall near the PRD, i.e. Typhoon Neoguri (2008), Typhoon Hagupit (2008), Typhoon Hato (2017), and Typhoon Usagi (2013), as well as two different schemes for CU and MP, respectively. Moreover, the impact of the model initialization and the driving data is studied by using three different initial times and two spectral nudging settings. Compared with the best-track reference data, the results show that the four typhoons show some consistency. For track bias, nudging only horizontal wind has a positive effect on reducing the track distance bias; for intensity, compared with a model explicitly resolving cumulus convection, i.e. without cumulus parameterization (CuOFF; nudging potential temperature and horizontal wind; late initial time), using the Kain–Fritsch scheme (KF; nudging only horizontal wind; early initial time) configuration shows relatively lower minimum sea level pressures and higher maximum wind speeds, which means stronger typhoon intensity. Intensity shows less sensitivity to two MP schemes compared with the CuOFF, nudging, and initial time settings. Furthermore, we found that compared with the CuOFF, using the KF scheme shows a relatively larger latent heat flux and higher equivalent potential temperature, providing more energy to typhoon development and inducing stronger TCs. This study could be used as a reference to configure WRF with the model's different combinations of schemes for historical and future TC simulations and also contributes to a better understanding of the performance of principal TC structures.

Vasculitic neuropathy: Therapeutic progress and prospects

AbstractVasculitic neuropathy has a broad range of etiologies, and roughly comprises nonsystemic vasculitic neuropathy and neuropathies accompanied by antineutrophil cytoplasmic antibody‐associated vasculitis (AAV). Recent morphological analyses of sural nerve specimens from patients with vasculitic neuropathy showed some distinct pathogeneses within vasculitic neuropathy. Several randomized, controlled studies and updated practice guidelines cover immunotherapies for AAV, whereas there is a paucity of evidence for vasculitic neuropathy, including neuropathies associated with AAV. Corticosteroids have been the mainstay of immunotherapy for vasculitic neuropathy, and cyclophosphamide is indispensable for refractory cases. Recent AAV guidelines are shifting their recommendations toward minimizing the harm caused by corticosteroids and cyclophosphamide with a reduced‐dose corticosteroid regimen and the recent advent of various optional drugs, especially molecular‐targeted agents. Clinicians expect the efficacy of reduced‐dose corticosteroid regimens and molecular‐targeted agents in treating vasculitic neuropathy to be verified, and clarification of the mechanism of vasculitic neuropathy might lead to the development of the best treatment based on the background pathogenesis of individual cases.

A Riordan group poset

In this paper, we look at Riordan arrays with nonnegative integer entries. In the set, if AT=B for a nonnegative integer matrix T, then we say A≤B. Our primary focus centers around six kinds of key arrays: Appell, Bell, two-Bell, Natural, Hankel, and Pseudo-involution. We examine relations among Hankel, Bell and two-Bell in general, while the other entries are treated case by case. We start by looking at individual cases related to the little and large Schröder numbers. Then we look at the families related to k-Catalan arrays, k-Schröder arrays, and k-Motzkin arrays. We often can give combinatorial interpretations. Along the way, several intriguing counterexamples occur.

Use of class IC antiarrhythmic drugs in patients with structural heart disease and implantable cardioverter defibrillator.

Due to suspected pro-arrhythmic effects and increased mortality associated with class-IC antiarrhythmic drugs (AADs) in previous trials, AAD therapy in structural heart disease (SHD) is mainly restricted to amiodarone. In the presence of diagnostic and therapeutic advancements in cardiovascular medicine, it remains unclear if previous studies adequately reflect contemporary patients. In clinical practice, class-IC-AADs are occasionally used in individual cases, particularly in patients with an implantable cardioverter defibrillator (ICD). This study retrospectively investigated outcome in ICD-carriers with SHD in whom class-IC-AADs were used as an individualized therapy due to failure, side effects, or unacceptable risk of alternative therapeutic options. Fifty patients from four tertiary centers were included (median age 48.5years; 52% female). The most common underlying SHD were dilated (42%) or ischemic cardiomyopathy (26%) (median LVEF = 45%). Indications for AAD were sustained ventricular arrhythmias (VA) (58%), symptomatic premature ventricular contractions (26%), or atrial arrhythmias (16%). Median follow-up was 27.8months. Freedom from sustained VA was 72%, and freedom from ICD therapy was 80%. In 19 patients (38%), AAD therapy was terminated. The most common reason was insufficient efficacy (n = 8). Pro-arrhythmia was suspected in three patients. Five patients died during follow-up (10.0%), two of cardiovascular cause (4.0%). In a multicenter cohort of ICD-carriers with SHD, class-IC-AADs were associated with a low rate of pro-arrhythmic effects or cardiovascular mortality. The majority of patients remained free from sustained VA during a follow-up of > 2years. Further efforts should be made to evaluate the safety of class-IC-AADs in SHD patients receiving contemporary cardiovascular therapy.

Endovascular tools for vascular access stenosis: Flow-chart proposal.

Stenosis represents the most relevant arteriovenous fistula (AVF) pathology and can affects the entire conduit forming the fistula, from afferent artery to central venous vessels. Correction of vascular access stenosis significantly affects the survival and quality of life for end stage renal disease patients (ESRD) dependent on hemodialysis. Guidelines consider the procedure of percutaneous transluminal angioplasty (PTA) relevant for the primary treatment of these lesions with excellent results in restoring AVF immediately at the end of the procedure. From first AVF angioplasty in 1981 to now, wide scientific innovation has led to development of new devices, composed by different materials and technologies, specific for the site and the type of stenosis to be treated, able to manage resistant stenotic lesion and to reduce stenosis recurrences. International guidelines do not clearly specify all treatment possibilities in the individual case. In this review the authors want to provide specific information on most used devices for stenosis treatment based on literature evidence, showing when and where to use the various tools available with flow-chart treatment proposal.