Initial Evaluation Research Articles

This community service activity aims to enhance students’ literacy skills through the implementation of the Reading Aloud method for elementary school pupils at SDN Kapasari I, conducted by lecturers and students of Universitas Dr. Soetomo. The program was designed to foster students’ reading interest and fluency in English by engaging them in expressive reading activities. The implementation consisted of three stages: initial assessment, service delivery, and evaluation. Documentation techniques were used to collect data throughout the process. Approximately fifty students participated actively in the program. They were encouraged to read selected fables both aloud and silently, record their performances, and present them before their peers. The results showed that the Reading Aloud activity effectively increased students’ motivation, confidence, and fluency in reading English texts. In conclusion, this community service project successfully contributed to improving elementary students’ literacy competence and confidence in public reading performance.

Major depressive disorder is a mood disorder with significant psychological and physical symptoms that can lead to disability and other severe consequences. This disorder is influenced by both genetic and environmental factors, causing neurotransmitter imbalances and inflammation. Given mayor depressive disorder's high prevalence and impact, it is crucial to implement a health promotion and intervention program aimed at this disorder. Investigating the feasibility of physical therapy, including therapeutic exercise and health education, compared to psychiatric and psychological approaches is an essential component of this program and of improving the quality of life for patients affected by mayor depressive disorder. A concurrent nested mixed-methods study with quantitative dominance will be conducted. The quantitative study will be a quasi-experimental pilot study with a pre-post design. This study will additionally include a qualitative narrative design. Initial and post-intervention evaluations will include sociodemographic and clinical data. Quantitative data will be collected using the EQ-5D-3L, MADRS, NRS, GSE, and GCPC-UN-ESU questionnaires. These tools assess health status, depression severity, pain intensity, self-efficacy, and satisfaction levels. Qualitative data will be collected from focus groups with 6-8 participants. The question guide for patients will cover their experiences with their illness and intervention, while the guide for professionals will cover their perceptions of patient management and observed barriers and facilitators. All participants will receive the same evidence-based intervention over 3-6 weeks, with 2 weekly sessions of approximately 45 minutes each. Each session will consist of therapeutic exercise and health education to improve patients' physical condition and self-management skills. This study aims to evaluate the feasibility and acceptability of a physiotherapy intervention program for MDD patients. It will also provide preliminary insights into the effects on quality of life, pain, and self-efficacy, which will inform the design of a future definitive trial. The findings from this research will provide valuable scientific insights and a basis for guiding health-care policymakers on the potential inclusion of physical therapy in clinical practice guidelines and standard hospital treatments for major depressive disorders. NCT06983405.

Introduction A significant amount of effort and attention has been provided to China’s Belt and Road Initiative (BRI) strategy. Frequently, the existing analyses focus on the political or economic implications of China’s engagement with its BRI partners. Only recently have these state-centric analyses broadened their focus to include the roles played by subnational actors. However, even though the analytical focus of research works on China’s BRI strategy has expanded, the thematic foci on political/economic relations remains dominant. This study attempts to fill a gap in the literature by exploring social perceptions of Chinese subnational relations. Methods Combining interviews and an original survey, this study represents an initial foray into understanding Chinese perceptions of subnational relations with countries on and off the BRI. Results The findings suggest that there is a difference between how such relations are perceived, depending on the normative alignment provided by the BRI. They also indicate that shared economic interests were the most important aspect in creating a subnational partnership. Discussion By discussing the findings in the context of China’s strategy toward its Asian neighbors, this study strives to offer an initial evaluation of the impact of the BRI on China’s subnational relations with the neighboring countries.

In this study, the failure mechanisms of fluoroether rubber (FM) and hydrogenated nitrile butadiene rubber (HNBR) seal rings employed in two feedstock gas coalescers operating within an ultra-high H2S gas field were investigated. Both seal rings experienced breakage and failure after 30days of operation. To analyze the failure mechanisms under ultra-high H2S conditions, a high-temperature and high-pressure (HTHP) dynamic autoclave, along with an O-ring sealing fixture, was employed to replicate on-site conditions. Corrosion experiments were conducted on FM and HNBR under simulated conditions for 7days. The progression of performance and failure behavior was assessed through comparative analyses of mechanical performance, fracture morphology, Fourier transform infrared spectroscopy (FTIR), and thermogravimetric (TG) results. These analyses were carried out on samples in their initial state, after 7days under simulated conditions, and following 30 days of field operation. Initial evaluations revealed ductile fracture characteristics for both FM and HNBR. After 7 days of simulated testing, no breakage was observed, and the thermal stability and mechanical properties of both materials remained largely unchanged. The tensile fractures maintained their ductile nature, although resistance to compression set declined, and porous defects were detected. Additionally, HNBR exhibited a slight increase in tensile strength. After 30 days of service, both FM and HNBR demonstrated brittle fracture failure accompanied by significant reductions in mechanical properties and thermal stability. The tensile strength decreased to 1.96 MPa for FM and 4.09 MPa for HNBR, while elongation at break declined to 46.2% and 59.9%, respectively. FTIR analysis indicated that the molecular chains of FM experienced breakdown and degradation, while those of HNBR underwent additional crosslinking. The deterioration in mechanical properties is primarily attributed to molecular chain degradation, crosslinking, and breakage, highlighting the impact of ultra-high H2S exposure on these materials.

Abstract The present study introduces a method for recovering rare earth elements (REEs) by producing a master slag derived from apatite concentrate. The process begins with dephosphorization, which effectively removes over 90% of phosphorus at approximately 2000 ℃ with a holding time of 1 h, thereby significantly increasing the REE concentration within the concentrate. The resulting dephosphorized apatite is subsequently doped with neodymium oxide (Nd 2 O 3 ) and additional compounds, following the CaO–SiO 2 –Nd 2 O 3 phase diagram to target an optimal crystal phase composition. Initial evaluations using synthetic slag helped refine process parameters, including the multistage melting and crushing necessary to retrieve homogeneity. The master slag formation and crystal growth experiments were conducted at 1500–1600 ℃ with holding times ranging from 0 to 60 min, allowing assessment of REE incorporation and crystal growth behavior. Advanced characterization techniques were used to assess slag properties and crystal structure evolution, including DTA–TGA for thermal analysis, ICP-MS for chemical composition, and XRD and SEM–EDS for phase identification. The results confirm the formation of the desired (Ca, Nd) 2 SiO 4 phase within the slag, indicating that the process stabilizes REEs and enhances their concentration in a recoverable phase. This pyrometallurgical route also avoids the production of hazardous liquid waste and enables the simultaneous removal of phosphorus as a gaseous byproduct, offering additional value in sustainable processing. This approach demonstrates a viable pathway for efficient REE extraction from apatite concentrate and shows strong potential for industrial-scale applications in REE recovery and sustainability efforts within the REE supply chain. Graphical Abstract

BACKGROUND: Clinical phenotyping in osteoarthritis has the potential to improve the personalization of care for this heterogenous condition. To date, research studies have identified numerous clinical phenotypes, but with very limited guidance on how to integrate phenotyping into physical therapy clinical practice. Phenotyping focused on distinct clinical profiles of psychological distress in patients with osteoarthritis offers a timely and relevant example of how to integrate this innovative approach into care. CLINICAL QUESTIONS: How can psychological phenotyping be incorporated into clinical practice at initial evaluation to inform decision-making in the management of osteoarthritis? What are common challenges that must be overcome to successfully deliver this approach to care? How can our experiences with psychological phenotyping inform different applications of clinical phenotyping in physical therapy? KEY RESULTS: We implemented psychological phenotyping within a physical therapist-led whole person care model of osteoarthritis management. In this model, clinicians assign psychological phenotypes using a standardized assessment and algorithm and are offered care pathway recommendations that address phenotype-specific psychological traits. Implementation challenges included phenotype assignment uncertainty, collection of valid and complete assessment data, avoiding stigma associated with classifying patients, and changing clinician behavior. CLINICAL APPLICATION: Phenotyping has the potential to improve the consistency and scalability of tailored care for musculoskeletal conditions, in this case related to management of psychological distress among patients with osteoarthritis. Lessons from this example can aid in implementation of phenotyping programs that consider additional biopsychosocial domains and inform translation of this framework to other musculoskeletal conditions.

Introduction: Constrictive pericarditis (CP) is a rare but reversible cause of diastolic heart failure caused by chronic pericardial inflammation, fibrosis, and calcification that impairs ventricular filling. Often misdiagnosed as HFpEF (heart failure with preserved ejection fraction), CP has an estimated U.S. prevalence of 9–10 cases per million. Early recognition is crucial, as surgical pericardiectomy can be curative. Case Presentation: A 60-year-old male with hypertension, type 2 diabetes, and obstructive sleep apnea presented with progressive exertional dyspnea, fatigue, bilateral lower extremity edema, intermittent exertional chest pain, orthostatic dizziness, and palpitations. Initial evaluation in 2022 showed preserved left ventricular ejection fraction and no pericardial abnormalities on transthoracic echocardiogram. Myocardial perfusion SPECT revealed a mild right coronary artery perfusion defect. EKG showed right bundle branch block with nonspecific ST-T changes. In February 2024, left heart catheterization revealed mild coronary artery disease and incidental pericardial calcifications. By June 2024, CT angiography confirmed diffuse pericardial thickening and dense calcifications around the left ventricular apex, consistent with prior pericarditis. Right heart catheterization in July 2024 demonstrated equalization of diastolic pressures (Right Atrium: 25 mmHg, Right Ventricular End Diastolic Pressure: 24 mmHg, Pulmonary Capillary Wedge Pressure: 24 mmHg, Left Ventricular End Diastolic Pressure: 24–25 mmHg), reduced cardiac output (1.6 L/min), low cardiac index (1.7 L/min/m 2 ), and mildly elevated Pulmonary Vascular Resistance (3.2 Wood units), confirming CP. The patient underwent pericardiectomy without cardiopulmonary bypass in August 2024. Pathology showed pericardial calcifications and chronic inflammation. Postoperatively, the patient reported improved exercise tolerance and resolution of symptoms. Discussion: This case highlights the diagnostic challenge of CP, especially in patients without classic risk factors such as prior surgery, radiation, or tuberculosis. The clinical picture mimicked HFpEF, but subtle clues—pericardial calcification and invasive hemodynamic findings—were critical for diagnosis. Timely pericardiectomy led to significant clinical improvement, emphasizing the importance of early recognition and intervention in CP.

Background: The clinical presentation of patients with acute pulmonary embolism (PE) greatly varies and can range from incidental imaging findings in asymptomatic patients to sudden cardiac death. The management depends upon patient risk and hemodynamic profiles, which is further complicated in patients with a clot in transit (CIT) due to the risk of clinical deterioration and an increased mortality (~25-40 %). Here we present a case of an intermediate high-risk PE with a CIT and a patent foramen ovale with extension of clot from the right to left atrium. Case Description: A 69-year old nursing home resident, bedbound from a previous motor vehicle accident and multiple lumbar fusions presents with sudden onset shortness of breath. On initial evaluation, the patient was hypoxic requiring high flow nasal cannula and point of care ultrasound echocardiography showed a CIT ( Figure 1 ). CT PE showed extensive bilateral PE’s with a CIT in the RA ( Figure 2 ). PERT decision was made to take the patient for urgent thrombectomy with ECMO backup. Peri-procedure TTE guidance was utilized to assist with retrieval of the CIT, and a sizable thrombus straddling a patent foramen ovale going from the right to left atrium was noted. Given the patient’s prohibitive surgical risk as determined by CTS, the decision was made to proceed with thrombectomy and percutaneous removal of the CIT with 3D echocardiographic guidance ( Figure 3 ). At the conclusion of the case, all thrombus was successfully removed with the INARI FlowTriever 24 Fr catheter from bilateral pulmonary arteries in addition to the CIT extending from the right to left atrium that was retrieved utilizing the INARI FlowTriever 20 Fr Curved catheter ( Figure 2 ). The patient was monitored in the CCU and then discharged several days later to a skilled nursing facility in stable condition. Discussion: Decisions regarding the management of patients with pulmonary embolism and CIT is complex. This is especially true for this case where there was extension of clot from the right to left atrium increasing the risk of stroke. Here we report the case of a patient who presented with symptomatic intermediate high-risk PE and a CIT with a patent foramen ovale, where a successful thrombectomy was performed. In this high-risk case, mechanical thrombectomy served as a lifesaving management strategy that likely prevented clinical decompensation in this patient.

Background: Nearly four centuries after Lazare Rivière’s first description of infective endocarditis—and over two centuries since septic embolization was recognized—a new epidemic has emerged: infective endocarditis in the era of drug use disorder. Case report: A 36-year-old woman, with drug use disorder was found unconscious with fentanyl and needles nearby. On initial evaluation, she met criteria for systemic inflammatory response syndrome: fever (T 101°F), tachycardia (HR 142 bpm), and hypotension (BP 70/43 mmHg). She was unresponsive to noxious stimuli and had a 15 cm chronic soft tissue ulcer on her right leg. Immediate management was started including endotracheal intubation, mechanical ventilation, followed by intravenous fluid resuscitation, vasopressors, and empiric Meropenem due to documented beta-lactam anaphylaxis. Laboratory studies were remarkable for elevated white blood cell count (36,700/μL), procalcitonin (17 ng/mL), CRP (13 mg/dL), ESR (110 mm/h), and lactate (7 mmol/L). Acute ischemic infarcts in bilateral frontoparietal regions and a punctate infarct in the right cerebellum were demonstrated on computerized tomography. Transthoracic and transesophageal echocardiography identified a 23 mm mobile vegetation on the aortic valve with severe regurgitation. Serratia marcescens, a gram negative fermenter bacilli susceptible to Meropenem, grew on blood and wound cultures. On hospital day 3, severe neurological deficit was observed due to hemorrhagic transformación of the left middle cerebral artery territory infarct. Discussion: This case underscores the complexity of infective endocarditis in the context of drug use disorders. In this case, a chronic wound represented an unconventional but lethal portal for gram-negative seeding of the aortic valve. Infective endocarditis goes beyond infection and requires a multidisciplinary approach with shared decision making. Though the presence of a large, mobile vegetation, severe valve dysfunction, and systemic embolization were indicative of urgent valve replacement; the hemorrhagic transformation of the MCA territory infarct precluded safe anticoagulation delaying aortic valve replacement. In addition, persistent severe neurological deficit required long-term supportive care such as tracheostomy and percutaneous endoscopic gastrostomy. Early recognition of drug use disorders, multidisciplinary collaboration, and integration of resources are essential to improving outcomes in this high-risk population.

Introduction/Background: Sinus of Valsalva aneurysms are very rare congenital heart disease. Most cases of ruptured sinus of Valsalva aneurysms (RSVA) are associated with other congenital defects. We present a case of Sinus of valsalva aneurysm (SoVA) rupture with underlying supracristal VSD (sVSD). Case Presentation: A 27-year-old male with a past medical history significant for a VSD (diagnosed at childhood but lost to follow up at 18 years of age) who was admitted to the intensive care unit for management of undifferentiated shock, acute renal failure and acute liver failure. Upon initial evaluation, vital signs showed blood pressure of 130/34 mmHg, heart rate 118 bpm, SpO2 100% on 3L NC. An emergent transthoracic echocardiogram with color doppler showed unrestricted left to right flow from the RSoV to RVOT in systole and diastole with concern for ruptured SoV aneurysm. A non-contrast CT scan of the chest also showed a dilated pulmonary trunk with a connection between the SoV and RVOT. Patient underwent primary closure of the VSD, as well as a patch repair of a large fistula between R sinus of Valsalva and RVOT. Patient steadily improved with normalization of renal function and hepatic function. Discussion: Aneurysm of the sinus of Valsalva (SoV) is a rare acquired or congenital anomaly predominantly affecting the right and the noncoronary sinuses, with an estimated prevalence of 0.09% of the population. Most sinus of Valsalva aneurysms arise from the right or the noncoronary sinuses. The most common site of rupture of SOV aneurysm is into the right ventricle followed by right atrium, left ventricle, and the left atrium. Hemodynamically, the flow through VSD produces Venturi effect “windsock effect. This left to right shunt caused by the supracristal VSD weakens the elastic lamina of the aortic sinus creating the SOV aneurysm. Overtime due to continuous negative pressure a SOVA develops on the right aortic root, which can rupture into the right ventricular outflow tract as seen in our case. Conclusion: Sinus of Valsalva aneurysm rupture is a rare but potentially fatal complication and should be considered on the differential in a young individual with underlying sVSD presenting with hemodynamic collapse.

Background: Bicuspid aortic valve (BAV) is the most common congenital defect affecting 1-2% of general population. It often presents with progressive AV stenosis/regurgitation and ascending aortopathy (AA) which often require surgical intervention. Objective: We sought to report characteristics and long-term outcomes of a contemporary cohort of patients with BAV and concomitant AA. Methods: We included 3782 patients with a documented BAV and an unrepaired AA (≥4 cm) who underwent a clinical evaluation between 1/2010 and 12/2023 at our large tertiary referral center. Patients presenting with acute aortic dissection/rupture as an initial presentation were excluded. Clinical (including aortic surgery/dissection/rupture during follow-up) and imaging data were collected. Primary outcome was all-cause mortality. Results: Characteristics of the patients are shown in Figure 1. At 1±2.2 years from initial evaluation, 2363 (62%) patients underwent surgery (AV repair/replacement [882 {37%}], isolated ascending aortic replacement [402 {17%}] and combined AV+ascending aortic surgery [1079 {46%}]), with 6 (0.25%) in-hospital deaths. Of 2096 AV surgeries, there were 241 (12%) mechanical prostheses, 1326 (63%) bioprosthesis, 16 (1%) homografts, 44 (2%) autografts and 473 (23%) AV repairs. During a mean follow-up of 3.9±3.9 years (range 0-15 years), there were 171 deaths (4.5%), 65 (1.7%) aortic dissections and 4 (0.1%) aortic ruptures. At 1571±1405 days following an evaluation, aortic dissection/rupture occurred in 25/1419 (1.8%) unoperated and 44/2363 (1.9%) operated patients (p=ns). Of these 44 operated patients with dissection, 28 occurred in the distal aorta in those with AA replacement. On survival analysis, longer-term deaths were higher in the unoperated vs. operated patients (71/1419 [5.0%) vs. 100/2363 (4.2%), p-value 0.03, Figure 2). Longer-term deaths were similar in patients undergoing AV repair/replacement (39/843 [4.6%]) vs. isolated AA replacement (20/402 [5.0%]) vs. combined AV+AA surgery (41/1079 [3.8%]), p-value 0.69, Figure 3). Conclusions: In a large contemporary cohort of patients with BAV and AA managed at a high-volume tertiary care center, majority eventually undergo surgery, with a very high longer-term survival and freedom from aortic dissection/rupture. There were no differences in the longer-term survival of patients getting isolated AV or aortic surgery vs. combination AV/aortic surgery.

Acrodermatitis continua of Hallopeau (ACH) is a sterile pustular psoriasis variant that is refractory to conventional therapies. The eruption typically develops following local trauma or infection, with other potential etiological factors including neural, inflammatory, and genetic origins. Notably, ACH is exceptionally rare in pediatric populations and presents significant therapeutic challenges owing to the safety limitations of conventional systemic therapies. A 7-year-old male patient with no personal or family history of psoriasis presented with recurrent episodes of erythema, edema, and pustule formation localized to the nail beds of 3 digits. Repeated microbiological analyses of pustular secretions, including mycological examinations, bacterial and/or atypical mycobacterial cultures, and viral tests, yielded negative results. Histopathology revealed parakeratosis, epidermal neutrophilic infiltrates, and ectatic dermal papillary vessels. Consequently, a diagnosis of ACH was established. After initial laboratory evaluations revealed no significant abnormalities, the patient received spesolimab at a dose of 450mg (15mg/kg) intravenously at weeks 0 and 1, with informed consent from the patient and his parents. Periungual inflammation resolved completely by week 8, accompanied by initiation of fingernail regrowth. No treatment-related adverse events occurred during therapy or follow-up. Our case report presents the successful application of spesolimab in a 7-year-old child with ACH, thus further supporting the potential of this targeted biologic agent in pediatric ACH treatment.

Artificial intelligence (AI) is increasingly embedded in oncology. While initial technical evaluations emphasize diagnostic accuracy and efficiency, the impact on patient–physician interaction (PPI)—the foundation of trust, communication, comprehension, and shared decision-making—remains underexplored. In this review, we studied the current development of AI technology facing both physicians and patients with a focus in cancer care. Among different AI technologies, chatbots, large language model agents, and extended reality applications have shown the promise to date. Survey data suggest oncologists recognize AI's potential to augment efficiency but remain cautious about liability and the erosion of relational care. Key to future AI success in improving cancer care critically depends on design, validation, governance, and human guidance and gatekeeping in care delivery.

Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe hypersensitivity reaction characterized by rash, fevers, eosinophilia and multi-organ involvement. Cardiac involvement in the form of eosinophilic myocarditis is particularly rare, with a mortality rate of 52% within 72 hours of admission. Case Presentation: A 34-year-old woman presented epigastric pain and rash following 10-day course of trimethoprim-sulfamethoxazole, metronidazole, and fluconazole for a vaginal infection. Initial evaluation revealed fever of 102°F, eosinophilia (0.7 × 10 9 /L), and elevated liver enzymes (AST 234 U/L, ALT 396 U/L, ALP 365 U/L). Skin biopsy was consistent with a drug-induced hypersensitivity reaction, and despite treatment with 1 mg/kg of prednisone, she developed chest pain, dyspnea, hypotension and elevated troponins (>5000 ng/L). Electrocardiogram revealed diffuse ST-segment elevations, and echocardiograms demonstrated a significant reduction in left ventricular ejection fraction (55% to 25%) with global hypokinesis. Cardiac MRI (Image A/B) confirmed severe myocarditis with endomyocardial biopsy (Image C) revealing eosinophilic infiltration consistent with eosinophilic myocarditis. The patient progressed to cardiogenic shock requiring VA ECMO. Given the lack of improvement with medical management the decision was made to proceed with an orthotopic heart transplant. Post-transplant, she was managed with a regimen of immunosuppressants, and recovery was closely monitored with serial cardiac biopsies and imaging studies. Discussion: Cardiac involvement in DRESS syndrome is exceptionally rare but carries a high mortality rate when complicated by myocarditis. Early recognition and prompt management are crucial for improving outcomes. While systemic corticosteroids are the mainstay of treatment for DRESS, their efficacy in preventing myocarditis may be limited. Other immunomodulating therapies have been attempted with variable success. Our patient’s case highlights the limitations of current therapeutic options for severe DRESS-associated myocarditis. Despite aggressive medical management, progression to cardiogenic shock necessitated mechanical circulatory support and ultimately heart transplantation. Clinicians should maintain a high index of suspicion for cardiac involvement in patients with DRESS who present with hemodynamic instability or elevated cardiac biomarkers, even in the absence of classic cardiac symptoms.

Description of Case: A 76-year-old female with a past medical history including HTN, DM, HLD, bilateral breast cancer (status post bilateral mastectomy and radiation), and prior thymoma presented with acute-onset dyspnea and chest pain. Initial evaluation revealed elevated troponin levels up to 9 ng/mL and sinus tachycardia with RBBB on ECG. CT chest demonstrated a large left anterior mediastinal mass infiltrating the pericardium, with suspected invasion into the left inferior pulmonary vein.Transthoracic echocardiography revealed a heterogeneous mediastinal mass invading the aortic root, causing extrinsic compression of the left main coronary artery, as well as involvement of the left superior pulmonary vein, left atrial lateral wall, and basal lateral left ventricular wall. A 2.1 x 2.1 cm echogenic mass was noted in the left atrial cavity. Initial coronary angiography revealed 75% narrowing of the left main coronary artery, but no intervention was performed. Surgical consultation with both cardiothoracic and thoracic surgery deemed the patient not a suitable candidate for resection or bypass due to extensive local invasion and overall frailty. A repeat angiogram one week later revealed progression to 90% left main stenosis, prompting an urgent high-risk PCI with successful stent placement. Discussion: Given rapid progression of left main coronary stenosis secondary to extrinsic tumor compression, and the patient’s inoperable status, a heart team approach led to the decision for high-risk PCI. The procedure was performed successfully, restoring perfusion and relieving symptoms.This case is an example of uncommon etiology of left main coronary artery compression from an invasive mediastinal tumor. When surgery was not feasible, PCI offered a successful alternative and served as a palliative measure when other options were not viable.

Development and initial evaluation of a digital service package for community-dwelling older females with pelvic floor dysfunction

Background: Infective endocarditis (IE) is a rare condition (15/100,000 in the US) with nonspecific symptoms, complicating diagnosis. Isolated pulmonary valve IE is exceptionally rare (1.5–2.5% of IE cases), typically linked to intravenous (IV) drug use or congenital heart disease. Enterococcus faecalis, a common IE pathogen, rarely causes isolated pulmonary valve IE. This abstract presents a rare case in a patient without typical risk factors, highlighting diagnostic and therapeutic challenges. Case Description: A 63-year-old male with diabetes, coronary artery disease, and recent ureteral stenting for nephrolithiasis (complicated by E. faecalis urinary tract infection) presented with malaise, chills, and polyuria. Initial evaluation revealed diabetic ketoacidosis, acute kidney injury, and E. faecalis bacteremia. Despite IV antibiotics, blood cultures remained positive for 10 days. Transesophageal echocardiogram (TEE) showed a pulmonary valve mass and moderate-to-severe regurgitation. Due to persistent infection, he underwent coronary artery bypass grafting and pulmonary valvectomy, revealing vegetations and a perforated cusp. Pathology confirmed E. faecalis endocarditis, ruling out tumors. Valve replacement was deferred due to recent bacteremia. Postoperatively, multifactorial shock required extracorporeal membrane oxygenation and mediastinal washouts for hemorrhage. Five days later, a 29-mm bioprosthetic pulmonary valve was implanted. The patient recovered and was discharged to rehabilitation. Discussion: This case highlights the challenge of diagnosing isolated pulmonary valve IE, especially with E. faecalis, given its rarity. The 2023 Modified Duke/ISCVID criteria, supported by TEE findings, confirmed IE. Persistent bacteremia necessitated surgery, consistent with complicated IE guidelines. The absence of risk factors and spheroid mass appearance initially suggested a tumor, but pathology clarified endocarditis. Right-sided IE is rare due to low pulmonary valve shear stress, making this case notable. Postoperative shock from blood loss and vasoplegia underscored the need for intensive management. Delayed valve replacement reduced reinfection risk, yielding a good outcome for this patient. Conclusion: Isolated pulmonary valve IE due to E. faecalis is rare and requires high degree of suspicion for diagnosis in persistent bacteremia. TEE, surgery, and delayed valve replacement were critical, demonstrating tailored management for favorable outcomes in complex IE.

Introduction: Transthoracic echocardiogram (TTE) is a critical diagnostic tool for detecting infective endocarditis (IE) in patients with bacteremia. Despite being a common sequela of disseminated infection and a source of morbidity and mortality, limited data exists on TTE yield by bacteriology. Research Question: This study compared the diagnostic yield of TTE in patients with atypical versus typical bacteremia. Typical organisms included Viridians group streptococci, Staphylococcus spp., and Enterococcus spp. Methods: A retrospective cohort analysis was conducted using the TriNetX database which included 143 healthcare organizations in the Global Health Collaborative Network. Two cohorts were analyzed: patients with atypical bacteremia ( n = 22,523) and patients with typical bacteremia ( n = 28,696). Inclusion criteria: patients ≥ 18 years with bacteremia diagnosed ≤ 1 month before TTE (index event). Propensity score matching adjusted for 35 potential confounders. The mean age was 64 years; the study population was approximately 53% male. Results/Data: The prevalence of endocarditis diagnosis was 5.54% in the typical bacteremia group and 2.19% in the atypical bacteremia group. This provided a number-needed-to-diagnose of 18 and 45 for typical and atypical bacteremia, respectively. The odds ratio (OR) for endocarditis diagnosis in atypical versus typical bacteremia was 0.382 (95% CI: 0.342 to 0.427, p<0.0001). The positive predictive value (PPV) of TTE was 37.9% for typical bacteremia and 19.4% for atypical bacteremia, while the negative predictive value (NPV) was 97.3% and 98.9%, respectively. TTE remains valuable for IE detection in bacteremia, but with 2.6 times greater diagnostic yield in typical bacteremia cases. Patients with atypical bacteremia were more likely to have TTE in the presence of rheumatic heart disease (13% vs 25%, p<0.0001). Conclusion(s): These findings highlight the role of the causative organism in bacteremia when interpreting TTE results. Although AHA/ACC guidelines recommend TTE for initial evaluation in patients with suspected IE, the lower odds ratio in atypical bacteremia supports a more selective approach to TTE use. Overall, this study establishes a need to develop or refine risk stratification tools to guide TTE utilization, optimizing resource allocation and improving diagnostic efficiency by reserving it for patients with additional risk factors or clinical signs suggestive of infective endocarditis.

Background: Surgical myectomy (SM) is recommended to relieve left ventricular outflow tract obstruction (LVOTO) in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients who are intolerant to maximal background medical therapy. However, outcomes of such patients, if operated earlier at the onset of symptoms, remains uncertain. Objective: We sought to assess whether an earlier SM is associated with improved longer-term outcomes in oHCM. Methods: Between 1/2002 and 12/2018, out of 7954 HCM patients, 2904 with oHCM underwent SM following a thorough clinical evaluation at a large tertiary referral center. Clinical and imaging characteristics were recorded. Time to SM, cardiac transplantation, appropriate defibrillator discharge during follow-up were recorded. Primary outcome was a composite of mortality, appropriate internal cardioverter defibrillator (ICD) discharge or cardiac transplantation. Results: Baseline characteristics, divided based on New York Heart Association (NYHA) class I (n=328), II (n=1062) and III (n=1514) are shown in Figure 1. Patients undergoing SM after progressing to NYHA Class III/IV were older, more likely to be women, had significantly higher proportion of comorbidities and background HCM therapy, poorer functional capacity, along with a higher proportion of concomitant mitral regurgitation vs. those who were in NYHA Class I/II. Overall, in-hospital mortality was observed in 9 (0.3%) patients. At a mean follow-up of 12±5 years, there were 672 composite events (635 deaths, 9 cardiac transplants and 47 appropriate ICD discharges). Despite a much longer time from initial evaluation to SM, patients in NYHA Class III/IV at initial presentation had significantly higher proportion (similar to age-gender matched normal US population) of adjusted longer-term composite events vs. NYHA Class II and I, respectively (387 [26%] vs. 216 [20%] vs. 69 [21%], p<0.001, Figure 2). Conclusions: In a large sample of oHCM patients, evaluated at a high-volume tertiary care center, SM performed earlier closer to the time of symptom onset have significantly better long-term freedom from composite events vs. those who underwent SM after developing advanced symptoms. Better strategies for earlier symptom recognition, especially in women with oHCM, need to be developed. This would potentially enable early institution of appropriate therapies to relieve LVOTO.

Background: Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by elevated low density lipoprotein cholesterol (LDL-C) and increased lifetime risk of atherosclerotic cardiovascular disease (ASCVD). While clinical criteria have been established to diagnose FH, genetic testing is now widely available providing an additional avenue for diagnosis. We aimed to describe the yield of genetic testing for FH in children evaluated in a dedicated pediatric cardiology clinic. Methods: We conducted a retrospective cohort study based on the initial evaluation of children in a dyslipidemia clinic between 2017 and 2024. Genetic testing for FH was performed based on assessment of clinical criteria by the attending preventive cardiologist. The cohort was divided into three categories based on genetic testing: genotype positive, genotype negative and phenotype negative (genetic testing not ordered). Patient characteristics and lab parameters (fasting LDL-C and triglycerides, and lipoprotein(a) in mg/dL) were compared between the three groups using descriptive statistics, chi-squared, or Kruskal-Wallis tests. Results: Of 863 pediatric patients evaluated (47% female, mean age 12.6 ± 3.3 years) genetic testing was performed in 176 probands. A pathogenic or likely pathogenic variant was identified in 72 (41%) including 58 LDLR (81%), 12 APOB (17%), 2 PCSK9 (2%) variants. Data are summarized in Table 1. The genotype positive cohort had higher LDL-C compared to the phenotype negative and genotype negative cohorts. Genotype negative patients had higher lipoprotein (a). The phenotype negative group had higher triglyceride levels and BMI. An additional 304 patients (164 adult patients) underwent cascade family screening that yielded 169 patients (87 adult patients) with pathogenic or likely pathogenic variants (137 LDLR [81.5%], 31 APOB [18%], 1 PCSK9 [0.5%]). Conclusion: The diagnostic yield of genetic testing to confirm FH in clinically suspected pediatric patients is high and enables effective cascade screening. Lipoprotein (a) should be considered in all patients, especially those with negative FH genetic testing. Systematic implementation of pediatric lipid screening and targeted genetic testing may enhance early diagnosis of FH in children and family members, enabling timely interventions in this high-risk cohort.