International Study Research Articles

The Impact of IoT on Smart City Infrastructure in India

Today, we live in a society where digital communication systems are so advanced that by the mid 2050’s the world will be completely filled by smart buildings on the internet highway like those portrayed in science fiction movies. This is possible because of tech savvy tiny sensors or Internet of Things (IoT) devices embedded in the smart network in order to collect meaningful information about the citizens and their interaction with the ubiquitous environment. Smart sustainable cities are modelled on the Internet of Things blending ICT for better standard of living and citizen services. IoT will modify indoor temperatures and switch off unnecessary lights in homes, detect snags in equipment and fix machines remotely, and provide commuters with information on traffic jams on the go. IoT in smart cities can be implemented by the development authorities but the stake holders of this task are citizens, the municipal government and private organizations engaged in this partnership. Using sophisticated ICT systems makes the city smarter and improves community building and connectivity by interweaving all the components of a city. Privacy and security are the two watch words when it comes to capturing citizens’ data. This data needs to be anonymised before it reaches the civic authorities. This study evaluates the advantages and disadvantages of using IoT in Indian smart cities after discussing an international case study of a smart sustainable city.

PATIENT FACTORS ASSOCIATED WITH NOVEL EAR-Q APPEARANCE, PSYCHOSOCIAL AND SOCIAL SCALES: A CROSS-SECTIONAL STUDY AND REGRESSION ANALYSIS

IntroductionThe EAR-Q is a rigorously validated patient-reported outcome measure which evaluates ear appearance and health-related quality of life (HRQL) in patients with congenital or acquired ear conditions. The aim of this study was to conduct an exploratory analysis to examine factors associated with EAR-Q appearance and HRQL scale scores. Methods862 participants, aged 8-29 years, with a congenital or acquired ear condition, completed the EAR-Q as part of an international field-test study. Patients responded to demographic and clinical questions as well as the EAR-Q. Univariable and multivariable linear regression analyses were used to determine which factors were significant predictors for scores on the EAR-Q Appearance, Psychological, and Social scales. ResultsMost participants were male (57.4%), awaiting treatment (55.0%), and had a microtia diagnosis (70.4%), with a mean age of 13 (±4) years. Worse ear appearance scores were associated (p<0.02) with male gender, microtia, no history of treatment, ear surgery within 6 months, unilateral involvement, and greater self-reported ear asymmetry. Decreased psychological scores were associated (p<0.01) with increasing participant age, no treatment history, recent ear surgery and dissatisfaction with ears matching/overall. Lower social scores were associated (p≤0.04) with no treatment history, those awaiting surgery, ear surgery within the last 6 months, bilateral involvement, and self-reported ears matching/appearance overall. ConclusionThis analysis identifies patient factors that may influence ear appearance and HRQL scale scores. The findings provide evidence of patient factors that should be adjusted for when undertaking future observational research designs using the EAR-Q in this patient population.

Development of ecotourism in the Volga region: Case studies and strategies

Purpose: This study investigates the advancement of ecotourism in the Volga Region, drawing insights from international and Russian case studies. The aim is to identify key factors contributing to successful ecotourism development and to provide recommendations for enhancing sustainability in the region's tourism sector. Research Methodology: Employing qualitative and comparative methodologies, the study utilized interviews, surveys, and document analysis for data collection. Additionally, site visits and observations were conducted to gain firsthand insights into ecotourism practices. Results: The Volga Region demonstrates substantial potential for ecotourism development, leveraging its rich natural resources, cultural heritage, and a burgeoning interest in sustainable tourism practices. However, challenges such as infrastructure limitations and inadequate marketing strategies need to be addressed to fully capitalize on this potential. Limitations: The study is constrained by data availability, time limitations, and the scope of the case studies examined. Additionally, the subjective nature of qualitative research methods may introduce bias into the findings. Contribution: This research enhances our comprehension of ecotourism development strategies, particularly within the Volga Region context. It offers valuable insights for policymakers, researchers, and industry practitioners aiming to foster sustainable tourism practices and economic growth in the region.

An international phantom study of inter-site variability in Technetium-99m image quantification: analyses from the TARGET radioembolization study.

Personalised multi-compartment dosimetry based on [99mTc]Tc-MAA is a valuable tool for planning 90Y radioembolization treatments. The establishment and effective application of dose-effect relationships in yttrium-90 (90Y) radioembolization requires [99mTc]Tc-MAA SPECT quantification ideally independent of clinical site. The purpose of this multi-centre phantom study was to evaluate inter-site variability of [99mTc]Tc-MAA imaging and evaluate a standardised imaging protocol. Data was obtained from the TARGET study, an international, retrospective multi-centre study including 14 sites across 8 countries. The impact of imaging related factors was estimated using a NEMA IQ phantom (representing the liver), and a uniformly filled cylindrical phantom (representing the lungs). Imaging was performed using site-specific protocols and a standardized protocol. In addition, the impact of implementing key image corrections (scatter and attenuation correction) in the site-specific protocols was investigated. Inter-site dosimetry accuracy was evaluated by comparing computed Lung Shunt Fraction (LSF) measured using planar imaging of the cylindrical and NEMA phantom, and contrast recovery coefficient (CRC) measured using SPECT imaging of the NEMA IQ phantom. Regarding the LSF, inter-site variation with planar site-specific protocols was minimal, as determined by comparing computed LSF between sites (interquartile range 9.6-10.1%). A standardised protocol did not improve variation (interquartile range 8.4-9.0%) but did improve mean accuracy compared to the site-specific protocols (5.0%error for standardised protocol vs 8.8% error for site-specific protocols). Regarding the CRC, inter-system variation was notable for site-specific SPECT protocols and could not be improved by the standardised protocol (CRC interquartile range for 37mm sphere 0.5-0.7 and 0.6-0.8 respectively), however the standardised protocol did improve accuracy of sphere:background determination. Implementation of key image corrections did improve inter-site variation (CRC interquartile range for 37mm sphere 0.6-0.7). Eliminating sources of variability in image corrections between imaging protocols reduces inter-site variation in quantification. A standardised protocol was not able to improve consistency of LSF or CRC but was able to improve accuracy.

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis.

Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden. A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income. Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

Effects of social distancing during COVID-19 on informal learning behaviours and work performance: the role of organisational remote working cultures

ABSTRACT We explored the impact of social distancing and the subsequent shift to remote work during the COVID-19 pandemic on informal learning behaviours and work performance. To accomplish this, we conducted a large-scale international study at the peak of the pandemic in 2021, utilising self-report questionnaires distributed via online social business networks, with a total of N = 1,236 participants. In our study, we developed a research model wherein social distancing served as the independent variable and remote working cultures as the moderating variable. This model was validated using confirmatory factor analysis and regression analysis techniques. Our investigation affirms that social distancing had adverse effects on informal learning within organisations. Additionally, it suggests that social distancing alone does not necessarily cultivate a remote working culture. However, our study reveals that a remote working culture can mitigate the repercussions of social distancing. Consequently, we observed positive effects on work performance through informal learning, even amidst the pandemic. A key outcome is that business leaders should promote a remote work culture and, based on this framework, establish hybrid work arrangements that effectively combine in-person and remote work.

Improved procedural workflow for catheter ablation of paroxysmal AF with high density mapping system and advanced technology: insights from a multicenter, international study

Abstract Background A high incidence of pulmonary vein (PV) reconnection has been reported in patients with clinical recurrences of AF. Low-voltage activity beyond PVs (e.g. antral activity potentials, RAP) likely represent vulnerabilities in antral lesion sets and they may contribute to ablation failures. Purpose The aim of this study is to validate a structured application of an approach that includes the complete abolition of any antral potential achieving electrical quiescence in antral regions. Methods DELETE AF is a prospective, single-arm, international post-market cohort study. Consecutive patients from 10 centers who were undergoing radiofrequency ablation of paroxysmal AF were included. The Lumipoint map-analysis tool was used sequentially on each PV component. Post-ablation, all patients were monitored with ambulatory event monitoring, starting within 30 days post-ablation to proactively detect and manage any recurrences within the 90-day blanking period, as well as Holter monitoring at 3, 6, 9, and 12 months post-ablation. Additional ECG monitoring were performed as indicated by patient symptoms. The ablation endpoint was PV isolation (PVI). Long-term outcome was the recurrence of AF over follow-up. Data are reported as median [IQ range]. Results One-hundred ten cases of AF ablation were analyzed: 28 (25.5%) females, age=63[56-69] years, 24 (21.8%) patients with a history of AT/AFL. The procedure duration was 58[24-76] min (RF delivery time=18[12-28] min, number of ablation spots=77[44-101]) and the fluoroscopy time was 13[9-19] min. Thirty-eight (34.5%) were repeat ablation: in these patients after initial mapping a total of 114 PV gaps (PVGs) in 29 (76.3%) patients and 69 RAPs in 15 patients (39.5%) were found. After ablation, a total of 5 early PVGs in 2 (1.8%) patients (all in de novo procedures) and a total of 10 RAPs in 7 (6.3%) patients (3 out 38 -7.9%- of repeat ablations vs 4 out 72 -5.6%- of de novo cases, p=0.690) were detected after first remapping. Each residual PVG was first targeted and additional focal ablations were performed at any low-voltage propagation suspected within the region of previous antral ablation. Acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study patients except for one that still exhibited a residual low-voltage antral signal after adenosine infusion with no PV conduction. Eighty-six (78.2%) patients had complete follow-up information. During the 90-day blanking period, 8 (9.2%) patients experienced an early recurrence. After the blanking period, over a follow-up of 357[190-380] days, 13 patients (15.1%) suffered an AF recurrence (time to recurrence: 207[144-300] days). No major complications or adverse events occurred. Conclusion A structured ablation workflow for catheter ablation, with consistent high-density mapping and improved diagnostic tools to guide the ablation, proved to be safe and effective in paroxysmal AF.

Substrate characterization and outcomes of ventricular tachycardia ablation in amyloid cardiomyopathy: a worldwide study

Abstract Background the electrophysiological substrate underpinning ventricular tachycardia (VT) in cardiac amyloidosis (CA) remains elusive, and outcomes of catheter ablation in this peculiar population are currently unknown. Purpose we sought to describe the electrophysiological substrate and clinical outcomes of VT ablation in a cohort of patients with CA. Methods we included 19 consecutive patients (mean age, 69±10 years; male sex, 89%) with CA (ATTR, n=13; AL, n=6) undergoing catheter ablation for VT/ventricular fibrillation (VF) between 2013 and 2023 in a retrospective, observational, international study, involving 7 referral European and North American electrophysiology units. The primary efficacy outcome was recurrent VT/VF during follow-up, while the primary safety outcome included major procedure-related adverse events. Results the indication for ablation was drug-refractory VT in 16 patients (84%), and PVC-initiated polymorphic VT/VF in 3 (16%). Catheter ablation was performed using endocardial (n=14, 74%) or endo-epicardial approaches (n=5, 26%). Complete endocardial electroanatomical voltage maps of the left and right ventricles were obtained in 14 (74%) and 6 (32%) patients, respectively. Each patient had evidence of low-voltage areas, most commonly involving the interventricular septum (n=12); late potentials were recorded in 13 patients (68%). A median of 1 (1-2) VTs were inducible per patient; in 10 subjects (43% of mappable VTs), activation mapping was consistent with septal VT origin. Complete procedural success was obtained in 13 patients (68%), at the expense of 4 (21%) major procedure-related adverse events. After a median follow-up of 36 (18-54) months, sustained VT/VF recurrence was observed in 9 patients (47%); survival free from VT/VF recurrence was 74% (95%CI, 56-96%) at 12 months, and 53% (95%CI, 34-94%) at 36-month follow-up; the majority of patients remained on antiarrhythmic drugs (Figure). Low-voltage QRS (HR,21.96; p=0.022) and complete procedural success (HR,0.08; p=0.029) were associated with recurrent VT/VF at multivariable analysis (Figure). Conclusions catheter ablation of VT/VF is associated with favorable acute and mid-term arrhythmia control, yet with substantial risk of procedure-related complications and long-term recurrences. Septal substrate and frailty challenge successful management of patients with CA and VT/VF.Multimodality evaluation of LV substrateMain Study Outcomes

Long-term outcomes of catheter ablation for atrial fibrillation in octogenarians

Abstract Background Catheter ablation is superior to standard medical therapy in controlling atrial fibrillation (AF). There is limited data on the long-term outcomes of AF ablation in octogenarians. Purpose This study aims to rigorously evaluate the efficacy and safety of AF catheter ablation in octogenarians, compared to non-octogenarians. Methods In this retrospective, multicentre, international study in 13 centres in the United Kingdom, France, and Switzerland, the long-term outcomes of 473 consecutive octogenarian patients undergoing catheter ablation for AF were compared to 473 propensity-matched non-octogenarian controls (median age 81.3 [80.0, 83.0] vs 64.4 [56.5, 70.7] years, 54.3% vs 35.1% females; p-value for both &amp;lt;0.001). The primary endpoint was the recurrence of atrial arrhythmia during 365 days' follow-up after an initial blanking period of 90 days (median follow-up time 322 [153, 365] days. Results Acute success of the ablation was achieved in 97% of octogenarians. When comparing non-octogenarians vs octogenarians, there were more complications in the octogenarians group (11.4% vs 7.0%, p=0.018), with the most common adverse events being vascular complications (3.8% vs 2.7%). The median follow-up time was 322 [153, 365] days. Through day 365, 131 (27.7%) octogenarians had a recurrence of atrial arrhythmia as compared to 111 (23.5%) non-octogenarians (odds ratio 1.49; 95% confidence interval 1.16-1.92; p=0.002). In a multivariable regression model including gender, previous AF ablation, vascular disease, chronic kidney disease, CHA2DS2-VASc score, left atrial dilatation, and indwelling cardiac implantable electronic device, age above 80 remained an independent predictor of recurrence of atrial arrhythmias throughout 365 days' follow-up. Conclusion Age over 80 is associated with higher rates of recurrence of atrial arrhythmia on 365 days' follow-up post-catheter ablation for atrial fibrillation. Arrhythmia recurrence on follow-up

Impact of functional gene groups on outcomes after ablation of ventricular tachycardia in patients with inherited left ventricular cardiomyopathy: an international multicentre study

Abstract Background Advances in genetic testing has enabled identification of pathogenic variants of different functional gene groups associated with non-dilated left ventricular cardiomyopathy (NDLCM)/dilated cardiomyopathy (DCM) and ventricular tachycardia (VT). However, there is limited data on the impact of functional groups on VT ablation outcome. Aim We aimed to assess the impact of likely pathogenic/pathogenic variants (LP/Pv) of different functional gene groups on heart failure (HF) outcomes and VT recurrence in patients with NDLCM/DCM after VT ablation. Methods Patients with NDLCM/DCM who underwent genetic testing (next-generation sequencing) and were referred for VT ablation were enrolled at 6 participating centers. Patients were followed for VT recurrence, HF-related adverse outcomes (death, left ventricular assist device [LVAD], or heart transplantation due to HF), and all-cause mortality. Results A total of 239 patients (age 55±14yrs; male n=193; LVEF 40±12%; amiodarone at admission n=103; ICD n=180) were included. LP/Pv were identified in 128 patients (54%), predominantly found in genes encoding sarcomeric (n=36/128, [28%]; titin n=20, myosin binding protein C n=12), followed by nuclear membrane (n=27/128, [22%]; lamin A/C; n=26), desmosomal (n=23/128, [18%]; desmoplakin n=11, plakophilin n=9), cytoskeleton (n=12/128, [9%]; filamin C n=8), and sarcoplasmic reticulum proteins (n=12/128, [9%]; phospholamban n=10). Variants of unknown significance (n=32) were grouped with patients who tested negative. Acute complete ablation success, defined as non-VT inducibility of any sustained monomorphic VT, was achieved in 113 patients (47%), 63 (56%) with LP/Pv. During a median follow-up of 32 months, 108 patients (45%) had VT recurrence, 41 (17%) had HF-related adverse outcomes (death with/without LVAD in 34, LVAD in 2, heart transplantation in 5) and 47 (20%) died. Patients with LP/Pv were more likely to have VT recurrence, HF-related adverse outcomes and had a higher mortality compared to those without (VT, 68 [53%] vs. 40 [36%]; HF-related adverse outcomes, 30 [23%] vs. 11 [10%]; mortality, 30 [23%] vs. 17 [15%]; log-rank, P&amp;lt;0.01 for all). As compared to patients without LP/Pv, those with LP/Pv in genes encoding nuclear membrane or sarcomeric proteins had significantly worse (P&amp;lt;0.01 for both) and those with LP/Pv in genes encoding desmosomal proteins had similar HF and VT recurrence outcomes (Figure). Of interest, patients with LP/Pv in genes encoding cytoskeleton proteins had favorable HF-related adverse outcomes, but worse VT recurrence (P=0.02) compared to those without LP/Pv (Figure). Conclusion In patients with NDLCM/DCM and VT, the impact of LP/Pv on HF and VT-recurrence outcomes after ablation differs across functional groups. Integrating genetic testing in the comprehensive evaluation of patients with NDLCM/DCM undergoing VT ablation may facilitate personalized ablation strategies and early consideration of alternative HF treatments.

The multicenter ablate-by-LAW study: personalized paroxysmal atrial fibrillation ablation according to the local left atrial wall thickness

Abstract Background Personalized radiofrequency (RF) catheter ablation for paroxysmal atrial fibrillation (PAF), tailoring the ablation index (AI) to the local left atrial wall thickness (LAWT), has proven to be an efficient procedure with high arrhythmia-free survival rates. However, to date, only monocentric experiences have been reported in the literature. Purpose The present study sought to report a multicenter experience in order to assess the safety, efficacy, and efficiency, of a LAWT-guided personalized pulmonary vein isolation (PVI) approach for PAF ablation (ClinicalTrials.gov, NCT04218604). Methods We conducted an international multicenter prospective study at five tertiary hospitals (two in Spain, one in Italy, one in Germany, and one in the United States). Consecutive patients referred for first-time RF catheter ablation of PAF were prospectively enrolled from November 2020 to September 2022. In all patients a three-dimensional map of LAWT were obtained from preprocedural multidetector computed tomography (MDCT)-derived data postprocessing. LAWT was categorized into 1 mm layers and AI was titrated according to the LAWT. All procedures were performed under general anesthesia, utilizing high-rate low-tidal volume (HR-LTV) ventilation (Figure 1). All antiarrhythmic drugs were discontinued following the 3-month blanking period. The primary endpoint was freedom from any documented sustained atrial arrhythmia at 12-month follow-up, regardless of symptoms. Results One hundred and nine patients (60.1±9.4 years, 64.2% male) were prospectively enrolled. The mean LA diameter was 38.7±5.8 mm and the mean left ventricular ejection fraction was 60.7±4.7%. The median procedure time was 61.7 minutes (IQR 48.4–83.8), and the median RF application time was 13.9 minutes (IQR 12.3–16.8). The mean number of VisiTags was 63.2 ± 18. First-pass PVI was achieved in the 83.5% of patients. The median fluoroscopy time was 61.5 seconds (IQR 22.5–197.5). In 94 (86.2%) patients, ablation was performed with a single femoral venous puncture. At 12-month follow-up, the rate of freedom from any documented atrial arrhythmia was 93.4% (Figure 1). Two (1.8%) patients died during follow-up, one from unknown cause three months after the procedure, and another from complications following multiple trauma after falling from a ladder. One patient (0.9%) developed femoral artery pseudoaneurysm, with no other serious procedure-related complications. Conclusion The Ablate-by-LAW multicenter study proved that a personalized PAF ablation protocol, tailoring the AI to the local LAWT is highly efficient and achieved a high acute first-pass PVI rates. The study reported a high 12-month survival-free from any documented sustained atrial arrhythmias, exceeding 90%, and an exceptionally low incidence of serious procedure-related complications.

B.1 CT Or MRI protocol for acute stroke reperfusion with EVT (COMPARE): an international retrospective cohort study

Background: Patients with an acute ischemic stroke (AIS) are selected to receive reperfusion therapy using either computed tomography (CT-CTA) or magnetic brain imaging (MRI). The aim of this study was to compare CT and MRI as the primary imaging modality for AIS patients undergoing EVT. Methods: Data for AIS patients between January 2018 and January 2021 were extracted from two prospective multicenter EVT cohorts: the ETIS registry in France (MRI) and the OPTIMISE registry in Canada (CT). Demographics, procedural data and outcomes were collected. We assessed the association of qualifying imaging (CT vs. MRI) with time metrics and functional outcome. Results: From January 2018 to January 2021, 4059 patients selected by MRI and 1324 patients selected by CT were included in the study. Demographics were similar between the two groups. The median imaging-to-arterial puncture time was 37 minutes longer in the MRI group. Patients selected by CT had more favorable 90-day functional outcomes (mRS 0-2) as compared to patients selected by MRI (48.5% vs 44.4%; adjusted OR (aOR), 1.54, 95%CI 1.31 to 1.80, p&lt;0.001). Conclusions: Patients with AIS undergoing EVT who were selected with MRI as opposed to CT had longer imaging-to-arterial-puncture delays and worse functional outcomes at 90 days.

Ventricular arrhythmias associated with electrical cardioversion for atrial fibrillation, a multicenter study

Abstract Background Cases of ventricular arrhythmias (VAs) associated with QT prolongation after electrical cardioversion (ECV) for atrial fibrillation have been reported. Purpose To assess the incidence, timing and clinical characteristics of patients with VAs post-ECV for AF. Methods This is a multicenter international study. Seventy-seven centers were approached. Data was received from 13 worldwide centers. VAs included were torsades de pointes (TdP), NSPVT&amp;gt;3 beats or SCD within 7 days of ECV. The total number of ECVs performed at each center during the time period for which data was sent was provided. Results VAs occurred after ECV at an estimated incidence of 0.16%, range 0- 1.3% at different centers. Twenty-three patients with VAs were identified from 8 European centers, from 2008-2023, of whom 18 (78%) were from 2019-2023. There were 13 (56.5%) females, aged 71+11 years, mean LVEF=45+9%. AF duration prior to ECV was 72+65 days. Antiarrhythmic drugs (AADs) used prior to ECV were amiodarone in 9 (39%), sotalol in 4 (17%), class Ic in 3 (13%), beta blockers in 19 (83%), CCB in 1(4%) and digoxin in 4 (17%) patients. Five (22%) patients received QT prolonging drugs other then AADs. Baseline hypokalemia &amp;lt;3.5mmol/L was seen in 3(13%) patients (range 2.9-3.4mmol/L). ECV was elective, urgent and emergent in 10 (43%), 12 (52%) and 1(4%) patient, respectively. The arrhythmias documented were TdP in 17(74%), NSPVT &amp;gt;3 beats in 5(22%) and 1(4%) SCD. Arrhythmia documentation was available in 19 (83%) patients. Baseline mean HR pre-ECV was 115+30bpm and QT 388+61ms, both significantly differed from post-ECV mean HR which was 58+11bpm and QT 469+63ms, P&amp;lt;0.0001. Arrhythmia occurred 45+54 hours post-ECV, median 28.5 hours, range 5 minutes- 10 days. Figure 1 demonstrates an example of serial ECG changes from baseline to TdP occurrence. An arrhythmic storm occurred in 11 (48%) patients. Arrhythmia reoccurred in 9 (39%) patients, mean 13.25 + 15 (range 0.5-48) hours after the index event. The arrhythmias which reoccurred were TdP in 5 (22%), VF in 2 (9%), NSPVT in 1 (4%) and monomorphic VT in 1 (4%) patient. Acute therapy with DCCV was needed in 10 (43%) patients. AADs were discontinued in 16 patients. IV electrolytes were helpful in arrhythmia control in 16 (89%) of 18 patients, IV isoproterenol was helpful in 1 (25%) of 4 patients, temporary pacing with arrhythmia control in 2(40%) of 5 patients in whom it was used. ICD was implanted in 7 patients and a pacemaker in 4 others. Two (8.7%) patients expired, 1 died suddenly at home 12 hours after ECV and 1 suffered from acute heart failure and fatal TdP 72 hours after ECV while hospitalized. Conclusion VAs associated with QT prolongation after ECV for AF occur mainly 24-48 hours after ECV and may reoccur. Prolonged monitoring prior to discharge should be considered for prevention of fatal outcomes in patients with any evidence of QT prolongation following ECV.Figure 1

Technical details of robotic pancreatojejunostomy using a modified Blumgart anastomosis: Thread manipulation using gauze and an assisted port.

Pancreatojejunostomy is a technically demanding procedure during robotic pancreaticoduodenectomy (RPD). Modified Blumgart anastomosis (mBA) is a common method for the pancreatojejunostomy; however, the technical details for roboticmBA are not well established. During RPD, we performed a mBA for the pancreatojejunostomy using thread manipulation with gauze and an additional assist port. Patients who underwent robotic pancreatoduodenectomy at Fujita Health University from November 2009 to May 2023 were retrospectively investigated, and technical details for the robotic-modified Blumgart anastomosis were demonstrated. Among 78 patients who underwent RPD during the study period, 33 underwent robotic mBA. Postoperative pancreatic fistula (POPF) occurred in six patients (18%). None of the patients suffered POPF Grade C according to the international study group of pancreatic surgery definition. The anastomotic time for mBA was 80min (54-125min). Robotic mBA resulted in reasonable outcomes. We propose that mBA could be used as one of the standard methods for robotic pancreatojejunosotomy.

Associations between Stigma, Depression, and Adherence to Antiretroviral Therapy in Brazilian Men Who Have Sex with Men Living with HIV

Adherence to antiretroviral therapy (ART) is a complex and multi-determined process that is influenced by psychosocial variables. Although international studies have pointed to the adverse impact of HIV stigma, sexual stigma, and depression on ART adherence among men who have sex with men (MSM) with HIV, less is known about this association among Brazilians. We aimed to (a) evaluate indicators of depression, stigma related to HIV and homosexuality, and adherence to ART in a sample of Brazilian MSM living with HIV; (b) assess possible correlations between the variables analyzed, and (c) assess the impact of HIV and sexual stigma and depression on ART adherence. This cross-sectional study comprised 138 Brazilian MSM living with HIV as participants. Scales used included: a sociodemographic/clinical questionnaire, the questionnaire for assessment of adherence to antiretroviral therapy (CEAT-HIV), the Beck depression inventory (BDI-II), the internalized homophobia scale, and the HIV stigmatization scale. The mean adherence score was relatively high (78.83, within a range of 17–89 points). However, we observed inadequate ART adherence (CEAT-HIV &lt; 75) in 28 (20.2%) respondents. Participants reported high scores for internalized sexual stigma, perceived sexual stigma in the community, and HIV stigma. Symptoms of depression were identified in 48.47% of participants. We found negative correlations between depression, HIV stigma, and treatment adherence, but not between sexual stigma and ART adherence. HIV-related stigma and sexual stigma were positively correlated with depression. Our regression analysis indicated that each year of age at diagnosis of HIV increased adherence by 0.22 points, on average. Each additional BDI-II score reduced adherence to ART by 0.20 points. The high prevalence of depression, HIV stigma, and sexual stigma, and their adverse effects on ART adherence and mental health, point to the need to implement evidence-based interventions to reduce sexual and serological stigma in the general population, as well as to mitigate the negative impacts of stigma on MSM living in HIV in Brazil. They also highlight the importance of periodically screening for these variables among MSM treated in Brazilian public health services, especially among those with inadequate adherence to ART.

#1917 SGLT2-Inhibition in patients with Alport syndrome – an international, retrospective and in parts prospective observational large cohort study

Abstract Background and Aims Large-scale trials showed positive outcomes of SGLT2-inhibitors (SGLT2i) in elderly patients with CKD. Patients with Alport syndrome, a type IV collagen disease, develop CKD early in life. Whether the use of SGLT2i is safe and effective in patients with the type IV collagen disease Alport syndrome (and thus a different pathogenesis) has not yet been investigated specifically besides case reports. Method For the first time, this observational, multicenter, international study (NCT02378805) assessed 112 patients with AS from nine countries and 21 trial sites after start of SGLT2i at early stages of their chronic kidney disease (CKD). The study's primary endpoint was change of albuminuria in albumin/g creatinine after start of therapy with SGLT2i. Results Compared to the large randomized trials investigating the effect of SGLT2i in CKD, the adult patients in this trial were much younger (38 ± 14 years; n = 101), had a better eGFR (63 ± 35 ml/min/1.73m2; n = 98) and had a higher albuminuria (1699 ± 1472 mg/g creatinine; n = 51). At a mean time on SGLT2i-therapy of 6 ± 1 months, albuminuria decreased significantly (1727 ± 1564 vs. 1203 ± 1165 mg/g creatinine; n = 33; p = 0.01). Compared to baseline, at the first three follow-up visits after initiation of SGLT2i-therapy, a significant reduction of albuminuria &amp;gt;30% was observed. Mean loss of eGFR was 9 ± 12 ml/min/1.73 m² almost one year after initiation of SGLT2i-therapy (n = 35). At a mean follow up of 12 ± 2 month after initiation of SGLT2i-therapy, serum-albumin increased significantly from 3.7 ± 0.7 to 4.0 ± 0.4 g/dL (n = 18; p = 0.019). At a total of 68 patient-years at risk, adverse events occurred in 11/85 patients (13%). Two very serious adverse events (acute necrotizing pancreatitis and Fournier's gangrene) occurred. Conclusion This study demonstrated that SGLT2i, when added to RASi, have the potential to reduce the rate of albuminuria in adult patients with Alport Syndrome. The study will be continued to provide valuable data on the long-term course of CKD under SGLT2i-therapy in AS to investigate if the promising reduction of albuminuria results in a clinical relevant delay in renal failure. This observational study successfully formed the scientific basis for the current randomized controlled trial with SGLT2i in children and young adults with AS Double Protect Alport.

#955 Real-world validation of the mortality box score to predict death following kidney transplantation: an international study

Abstract Background and Aims The mortality box score (mBox) is a validated risk prediction score developed by the Paris Transplant Group (NCT03474003), aimed at predicting mortality after kidney transplantation (KT) using data available at the time of surgery. However, its applicability using data routinely collected in institutions' electronic health records (EHRs), enabling automatic computation, needs to be investigated. Method We assessed the mBox's prediction performance in two EHR-based multicenter cohorts of adult kidney transplant recipients (KTRs) transplanted between 2017 and 2021 from: 1) the Greater Paris University Hospitals (AP-HP); and 2) the University of California San Francisco's Hospitals (UCSF). These cohorts were built using solely structured data, routinely collected in the institutions' EHRs. The mBox's discriminative ability to predict death at 3 years following KT was assessed by computing the AUC. Adequation between predicted and observed risk of death was assessed with calibration. Results Out of 10 367, 191 and 5 885 623 patients, we identified 2 560 and 2 028 consecutive KTRs meeting the inclusion criteria in the AP-HP and UCSF cohorts, respectively. In the AP-HP cohort, 344 (13.4%) patients died, during a median follow-up of 3.1 years (interquartile range [IQR]: 1.8 to 4.1). In the UCSF cohort, 150 (7.4%) patients died, during a median follow-up of 2.7 years (IQR: 1.2 to 4.1). The mBox's AUC to predict death within 3 years following KT was 0.780 (95% confidence interval [CI]: 0.752 to 0.801) in the AP-HP cohort and 0.720 (95% CI: 0.672 to 0.768) in the UCSF cohort. Visual examination of the calibration curves showed that the mBox accurately estimated the actual risk of death in the UCSF cohort, and tended to underestimate the actual risk of death in the AP-HP cohort. Conclusion In this real-world international study, performed on 4 588 kidney transplant recipients, relying solely on data routinely collected in institutions' electronic health records, we demonstrate a fair accuracy of the mBox risk prediction score in predicting patient death following transplantation.

Early serum biomarkers to characterise different phenotypes of primary graft dysfunction after lung transplantation: a systematic scoping review

BackgroundLung transplantation (LUTX) often is complicated by primary graft dysfunction (PGD). Plasma biomarkers hold potential for PGD phenotyping and targeted therapy. This scoping review aims to collect the available literature in search of serum biomarkers for PGD phenotyping.MethodsFollowing JBI and PRISMA guidelines, we conducted a systematic review searching MEDLINE, Web of Science, EMBASE, and The Cochrane Library for papers reporting the association between serum biomarkers measured within 72 h of reperfusion and PGD, following ISHLT guidelines. We extracted study details, patient demographics, PGD definition and timing, biomarker concentration, and their performance in identifying PGD cases.ResultsAmong the 1050 papers screened, 25 prospective observational studies were included, with only 9 conducted in the last decade. These papers included 1793 unique adult patients (1195 double LUTX, median study size 100 (IQR 44–119). Most (n=21) compared PGD grade 3 to less severe PGD, but only 4 adhered to 2016 PGD definitions. Enzyme-linked immunosorbent assays and the multiplex bead array technique were utilised in 23 and 2 papers, respectively. In total, 26 candidate biomarkers were identified, comprising 13 inflammatory, 3 endothelial activation, 3 epithelial injury, 3 cellular damage, 2 coagulation dysregulation markers. Only 5 biomarkers (sRAGE, ICAM-1, PAI-1, SP-D, FSTL-1) underwent AUROCC analysis, yielding a median value of 0.58 (0.51, 0.78) in 406 patients (276 double LUTX).ConclusionsSeveral biomarkers exhibit promise for future studies aimed at PGD phenotyping after LUTX. To uncover the significant existing knowledge gaps, further international prospective studies incorporating updated diagnostic criteria, modern platforms, and advanced statistical approaches are essential.

An international, multicenter, survey-based analysis of practice and management of acute liver failure.

Acute liver failure (ALF) is an acute liver dysfunction with coagulopathy and hepatic encephalopathy in a patient with no known liver disease. As ALF is rare and large clinical trials are lacking, the level of evidence regarding its management is low-moderate, favoring heterogeneous clinical practice. In this international multicenter survey study, we aimed to investigate the current practice and management of patients with ALF. An online survey targeting physicians who care for patients with ALF was developed by the International Liver Transplantation Society ALF Special-Interest Group. The survey focused on management and liver transplantation (LT) practices of ALF. Survey questions were summarized overall and by geographic region. A total of 267 physicians completed the survey with a survey response rate of 21.36%. Centers from all continents were represented. More than 90% of physicians were specialized in either transplant hepatology/surgery or anesthesiology/critical care. Two hundred and fifty-two (94.4%) respondents' institutions offered LT. A total of 76.8% of respondents' centers had a dedicated liver- or transplant- intensive care unit (p<0.001). Median time to LT was within 48 hours in 12.7% of respondents' centers, 72 hours in 35.6%, one week in 37.6%, and more than one week in 9.6% (p<0.001). Deceased-donor liver graft (49.6%) was the most common type of graft offered. For consideration of LT, 84.8% of physicians used King's College Criteria and 41.6% used Clichy Criteria. Significant differences were observed between Asia, Europe, and North America for offering LT, number of LTs performed, volume of ALF patients, admission to a dedicated intensive care unit, median time to LT, type of liver graft, monitoring hepatic encephalopathy and intracranial pressure, management of coagulopathy, and utilization of different criteria for LT. In our study, we observed significant geographic differences in the practice and management of ALF. As ALF is rare multicenter studies are valuable to identify global practice.

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Primary TKA with ALBC vs plain bone cement. The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.