Large Study Research Articles

Assessment of immunosuppression induction with basiliximab compared to antithymocyte-globulin in adult heart transplant patients.

Patients undergoing heart transplants are at risk of rejection which can have significant morbidity and mortality. Induction immunosuppression at the time of transplant reduces the early risk and has additional benefits. The induction agent of choice within our program was changed from rabbit antithymocyte-globulin (rATG) to basiliximab, so it was necessary to evaluate whether this had any impact on patient outcomes. Our primary objective was to describe rejection, infection, and other outcomes in adult heart transplant patients at the University of Alberta Hospital in Edmonton, Canada. This study was a nonrandomized, retrospective cohort study. Sixty-three patients were included with median ages 50 years versus 54 years. More female patients received rATG (20%vs. 42.4%). The most common indication for transplant in both cohorts was ICM (63.3%vs. 57.6%). Patients who received rATG had significantly higher PRA (0%vs. 43%, p<.001). Acute rejection episodes were similar between basiliximab and rATG at 3 months (16.7%vs. 15.1%; p=1.0) and 6-months (30.0%vs. 18.1%; p=.376). Infections were not statistically different with basiliximab compared to rATG at 3-months, 43.3%vs. 63.6% and at 6-months 60.0%vs. 66.7%). There were no fatalities in either group. Our study did not demonstrate differences in rejection with basiliximab compared to rATG. Mortality did not differ, but basiliximab-treated patients had fewer infections and infection-related hospitalizations than those treated with rATG. Larger studies with longer durations are needed to more completely describe the differences in rejection and infectious outcomes.

Robotic-assisted treatment of paraesophageal hernias in the emergency setting: a retrospective study.

Emergency treatment of paraesophageal hernias can be carried out through laparotomy or minimally invasive approaches, however, evidence in this regard is weak. The aim of our study was to assess safety and feasibility of the robotic-assisted treatment of paraesophageal hernias in the emergency setting. At the Bellinzona e Valli Regional Hospital, Switzerland, we conducted a retrospective analysis of patients operated on from January 2020 to January 2024 with robotic surgery for emergency presentation of paraesophageal hernias. Demographic and clinical details, operative techniques, and postoperative outcomes were collected and analyzed. Out of 82 patients who underwent robotic-assisted paraesophageal hernia repair, 17 were treated in the emergency setting. Median age was 79years (IQR 77-85), 3 (17.6%) patients were male, and median BMI was 23.9kg/m2 (IQR 21.0-26.0). Most frequent presentation symptoms were pain (100%), regurgitation (88.2%), and dyspnea (17.6%). No intraoperative complication, conversion to open surgery or stomach resections were recorded. Two complications of grade 3 according to the Clavien-Dindo classification and one of grade 2 occurred; all were successfully treated until resolution. The median length of hospital stay was 8days (IQR 5-16). After a mean follow-up of 15.9months (IQR 6.5-25.6) only two small axial asymptomatic recurrences that required no treatment. Despite limitations, our study demonstrated a very low rate of intra- and postoperative complications, likely supporting the safety and feasibility of robotic-assisted treatment for paraesophageal hernias in emergency settings. Larger studies with a control arm are needed to validate our initial findings.

Decoding the Prevalent High-Risk Breast Cancers: Demographics, Pathological, Imaging Insights, and Long-Term Outcome.

Objective: To investigate the features and outcomes of breast cancer in high-risk subgroups. Materials and Methods: REB approved an observational study of women diagnosed with breast cancer from 2010 to 2019. Three radiologists, using the BI-RADS lexicon, blindly reviewed mammogram and MRI screenings without a washout period. Consensus was reached with 2 additional reviewers. Inter-rater agreement was measured by Fleiss Kappa. Statistical analysis included Mann-Whitney U, Chi-square tests for cohort analysis, and Kaplan-Meier for survival rates, with a Cox model for comparative analysis using gene mutation as a reference. Results: The study included 140 high-risk women, finding 155 malignant lesions. Significant age differences noted: chest radiation therapy (median age 44, IQR: 37.0-46.2), gene mutation (median age 49, IQR: 39.8-58.0), and familial risk (median age 51, IQR: 44.5-56.0) (P = .007). Gene mutation carriers had smaller (P = .01), higher-grade tumours (P = .002), and more triple-negative ER- (P = .02), PR- (P = .002), and HER2- (P = .02) cases. MRI outperformed mammography in all subgroups. Substantial to near-perfect inter-rater agreement observed. Over 10 years, no deaths occurred in chest radiation group, with no significant survival difference between gene mutation and familial risk groups, HR = 0.93 (95% CI: 0.27, 3.26), P = .92. Conclusion: The study highlights the importance of age and specific tumour characteristics in identifying high-risk breast cancer subgroups. MRI is confirmed as an effective screening tool. Despite the aggressive nature of cancers in gene mutation carriers, early detection is crucial for survival outcomes. These insights, while necessitating further validation with larger studies, advocate for a move toward personalized medical care, strengthening the existing healthcare guidelines.

Bipolar catheter ablation of left ventricular summit PVC

Abstract Background Premature ventricular contractions (PVC) arising from the left ventricular summit are a challenging arrhythmia to manage, often refractory to conventional radiofrequency ablation. This study aimed to investigate the effectiveness of bipolar ablation as a therapeutic option for PVCs originating from this anatomically complex region. Methods We conducted a retrospective analysis of a prospective ablation registry to identify patients with recurrent, symptomatic PVCs originating from the left ventricular (LV) summit who underwent bipolar ablation. Bipolar ablation involved the use of two ablation catheters, delivering radiofrequency energy from opposite sides of the summit. The catheters were connected by a dedicated adapter, allowing to connect one ablation catheter in position of a return electrode. Procedural success was defined as the elimination of PVCs during the procedure and freedom from PVCs on follow-up monitoring. Results were compared to a similar patient group who had received unipolar ablation of summit-PVCs. Results A total of 12 pts received bipolar ablation between July 2022 and October 2023. Three pts underwent ablation for VT and were excluded. A total of 9 pts (mean age 57±18 years, n=7 [78%] male, BMI 28±5kg/m2) were included in the analysis. All but one had a history of a previous unsuccessful ablation attempt (median 1 [1-2]). In a group of 33 patients undergoing unipolar ablation 8 (32%) had received ≥ 1 previous ablation and were included in the analysis. Baseline parameters did not differ between groups. The acute procedural success rate for bipolar ablation was 89% in bipolar pts and 75% in unipolar pts, with a mean procedural time of 173±33 min, a mean fluoroscopy time of 14±9 min (158±55 min [p=0.478] and 14±12 min [p=0.995] for unipolar pts). Bipolar ablation was performed between the LVOT and RVOT in 6, and between LVOT and the distal CS in 6 pts with 25-35 W. No major complications were detected in bipolar pts while one non-fatal tamponade occurred in the unipolar pts group. Follow-up data at 97 [93-269] days revealed a sustained reduction in PVC burden in bipolar pts (from 18±13% to 7±9%; p=0.026) while unipolar ablation did not show a significant burden reduction (15±6% to 11±10%; p=0.382). The success rate of a relative burden reduction &amp;gt;50% did not differ significantly between the groups (bipolar: 6 pts [67%] 3 pts [38%]; p=0.347). Conclusion Bipolar ablation offers an effective and safe therapeutic approach for PVCs originating from the LV summit. It significantly reduced PVC burden in this analysis. The data suggest that a repeat procedure after a failed summit PVC ablation should only be performed if bipolar ablation is available during the second procedure. Larger studies are warranted to confirm efficacy and safety of this ablation method.

Significance of Coherent Mapping in unveiling slow conduction zones of ventricular tachycardia substrate in ischemic cardiomyopathy

Abstract Introduction Ventricular tachycardia (VT) presents a formidable challenge, particularly in cases with extensive myocardial scar tissue, complicating critical ablation site identification. Prolonged interventions not only extend procedural durations but also heighten the risk of complications. This study aimed to assess the efficacy of coherent mapping techniques in precisely locating regions of slow conduction within scar tissue and explored potential correlations with electrophysiological markers in scar-related VT. Methods Seventeen patients (mean age: 61.6 ± 9.2 years, mean EF: 28 ± 9%) with ischemic cardiomyopathy (ICM) and frequent implantable cardioverter-defibrillator (ICD) shocks underwent high-density (&amp;gt;2000 points) left ventricular (LV) substrate mapping (15 endo, 2 epicardial) during sinus or right ventricular (RV) pacing and ablation. Coherent mapping tool was utilized for the identification of slow conduction, demonstrated by vector thickening. Bipolar low voltage areas (LVAs) below 0.5 mV were defined as dense scar, and bipolar voltage between 0.5 and 1.5 mV was defined as the border zone (Figure, panel A). Late potentials (LPs) and local abnormal ventricular activities (LAVA) were manually identified and tagged. Isochronal late activation mapping (ILAM) was also performed to elucidate the functional properties of the substrate (Figure, Panel B). Results LPs and LAVA were identified in all cases, with a mean number of LPs being 10.0 ± 7.1. Of these, 14/17 cases had LPs located in dense scar, while 4/17 cases had LPs in the border zone. The mean area of LAVA was 9.9 ± 7.7 mm², located in dense scar in 6/17 cases and in the border zone in 15/17 cases. Average deceleration zones (DZ, &amp;gt;3 isochrones in 1 cm radius) identified by ILAM was 2 ± 1. Coherent mapping consistently identified slow conduction zones adjacent to LVA in all cases, with these coherent map-based slow conduction zones (CM-SCZ) located in dense scar in 3/17 cases and in the border zone in 14/17 cases. The distance of CM-SCZ to LPs was 12.6 ± 13.9 mm (in 4 cases, LPs were recorded on the spot), and the distance to LAVAs was 18.8 ± 13.7 mm (in 2 cases, LAVAs were recorded on the spot). CM-SCZ was colocalized with DZ in 14/17 of the patients. Ablation lesions covered CM-SCZ in 10/17 cases. Over a mean follow-up duration of 11 ± 6.5 months, 4 patients experienced VT recurrence, with 3 having no ablation lesions covering CM-SCZ, and 2 patients died due to pump failure. Conclusion This study underscores the significance of coherent mapping in refining the understanding of VT substrate in ICM. Identifying and ablating CM-SCZ during substrate-based mapping may provide a potential additional benefit for VT ablation. Nevertheless, larger studies are needed to clarify the prognostic significance and validate the clinical benefits of this approach.Figure 1

#50 The relationship between pre-dialysis plasma endothelin-1 and the intradialytic decline in blood pressure

Abstract Background and Aims Endothelin-1 (ET-1), a potent vasoconstrictor, may play an important role in the blood pressure (BP) response to hemodialysis (HD). Patients receiving maintenance HD have higher concentrations of plasma endothelin-1 than non-HD patients with advanced chronic kidney disease or patients receiving peritoneal dialysis. We wished to examine the association between the pre-HD level of ET-1 and the magnitude of intradialytic systolic BP decline. Methods Data was collected in a prospective study of 50 patients receiving maintenance HD admitted to Brigham and Women's Hospital in Boston, MA, USA. BP was measured before and every 15 min during a single HD session using an automated BP cuff. The systolic BP decline was calculated as the pre-HD minus the lowest intradialytic systolic BP. Blood samples were collected pre-HD. Patients with missing data, HD &amp;lt;3 h, or pre-dialysis BP &amp;lt;85/55 mmHg were excluded from the analysis (n = 8). Spearman's rho (ρ) was used to assess the correlation between pre-HD ET-1 and intradialytic systolic BP decline. Results Of the 42 included patients, 17 were females, median age 62 [25th, 75th percentile: 50, 70] years. The median HD duration was 232 [210, 242] min and median ultrafiltration was 2.1 [2, 3] L. Before HD, the median ET-1 was 2.4 [1.9, 3.0] pg/mL, the median systolic BP was 141 [119, 167] mmHg, and the median diastolic BP was 68 [63, 84] mmHg. A moderate negative correlation was observed between the baseline ET-1 and the intradialytic decline in systolic BP (ρ = –0.34, P = 0.03). This correlation was stronger in patients with baseline systolic BP &amp;gt;120 mmHg (ρ = –0.51, P = 0.004, n = 30) and much stronger in patients with baseline systolic BP &amp;gt;140 mmHg (ρ = –0.66, P = 0.001, n = 21). Almost all cases (8 out of 9) with an intradialytic decline in systolic BP of &amp;gt;50 mmHg occurred in patients with baseline ET-1 below the pre-HD median level. Conclusions Our results suggest that hospitalized patients with pre-HD systolic BP &amp;gt;140 mmHg and lower baseline ET-1 may be more likely to experience larger intradialytic declines in systolic BP. Whether measurement of pre-HD ET-1 could help identify hypotensive-prone patients requires further investigation in larger studies.

Diagnostic Accuracy of DNA-Methylation in Detection of Cervical Dysplasia: Findings from a Population-Based Screening Program

Background: Epigenetic biomarkers in cancer have emerged as promising tools for early detection, prognosis, and treatment response prediction. In cervical cells, hypermethylation of the host and viral HPV-genome increases with the severity of lesions, providing a useful biomarker in the triage of hr-HPV-positive women and during treatment. The present study focuses on evaluating the clinical performance of the FAM19A4/miR124-2 methylation test in a population-based cervical screening program. Methods: Previously collected cervical samples, after bisulfite-converted DNA, were analyzed by PreCursor-M+ kit (distributed by Fujirebio Europe), for DNA methylation. The sensitivity, specificity, and negative/positive predictive values of DNA methylation were compared to histology, colposcopy, the HPV-DNA test, and cytology results. Results: Among the 61-sample set, the specificity of methylation vs. positive histology (≥CIN2) and colposcopy (≥G2) were 87% and 90%, whereas the sensitivity was 50% and 33.3%, respectively. The combination of methylation analysis with standard methods increases diagnostic accuracy. Conclusions: Overall, we found a good specificity of DNA methylation in comparison to currently used techniques. Further larger studies could support the use of FAM19A4/miR124-2 as reliable biomarkers in the prevention of cervical cancer as triage in the screening protocol.

#1800 Cascade filtration in severe pulmonary-kidney syndrome: an one-center experience

Abstract Background and Aims In some forms of rapidly progressive glomerulonephritis (RPGN), the effect of plasma exchange (PE) is not well understood. Cascade filtration (CF) differs from standard PE in that it uses a double filter system, where the first filter is used to separate plasma from whole blood and the second filter is used to filter high-molecular weight substances. In this study, we investigated the efficacy and safety of CF in patients with ANCA-associated vasculitis (AAV) and Goodpasture's syndrome (GPS). Method During one year we included 18 patients with RPGN whose received CF in the study. The eligibility criteria was eGFR ≤15 ml/min/1.73 m2 and/or diffuse alveolar hemorrhage (DAH), presence of antineutrophilic antibodies or anti-GBM-antibodies. CF was performed on a Plasauto Sigma using a Plasmaflo OP-05W plasma separator and a Cascadeflo EC-30W separator with a fresh frozen plasma or 25% albumin solution. All patients received immunosuppressive therapy with steroids and cyclophosphamide, one patient with AAV received rituximab due to anemia and thromobocytopenia. All data were obtained from one hospitalization with the median of 43 days. Results Eight patients with AAV and three patients with GPS met the eligibility criteria. The median age of the patients in the AAV group was 59.8 (48; 66) years, with a female to male ratio of 1:1. All patients had evidence of systemic disease: seven patients had lung damage, including DAH, two patients had arthralgia, one had purpura and one had severe sinonasal involvement. The median creatinine level was 588 µmol/l (382; 1352), dialysis was initiated in 6 patients, and the median Birmingham Vasculitis Activity Score (BVAS) was 17 (15; 20). After three procedures of CF, all patients showed positive changes on CT scan, and dialysis was stopped in three patients. The immunological response to CF was observed quite rapidly in seven patients, with decreasing ANCA titer after three exchanges and decreasing antibody levels after six exchanges in one patient. There was a significant decrease in inflammatory markers, median C-reactive protein at baseline 179 (147; 226) decreased to 23 (2.8; 30.9) mg/l (p = 0.041). The CF was well tolerated with no significant adverse events. One patient receiving rituximab died after 4 months due to a severe COVID 19 infection. Three patients with GPS, one male 23 years old and two females 56 and 60 years old, also received CF. Creatinine concentrations at baseline were 1285, 1299 and 661 µmol/l, BVAS scores were 18, 20 and 15, respectively. After three procedures of CF, there was an immunological response: decrease in antibody levels from 121 U/ml to 15 U/ml, from 88.2 to 18.4 U/ml, from &amp;gt; 200.0 to 85.4 U/ml, CRP from 252 to 0.7 mg/l, from 120 to 5 mg/l, from 81.9 to 12.58 mg/l. There were no deaths and all three patients remained on dialysis. Conclusion CF was an effective and well tolerated method of treating severe AAV and GPS in addition to immunosuppressive treatment. Possibly due to the different filtration principle and the absence of donor plasma, we did not observe any infection-related adverse events and a lower number of procedures of CF was required compared to standard plasma exchanges. Further larger studies are needed to evaluate the benefits and safety of CF in combination with immunosuppressive treatment in RPGN patients.

#2955 Incidental findings in a renal magnetic resonance imaging study for evaluation of chronic kidney disease in type 2 diabetes population

Abstract Background and Aims Novel Magnetic Resonance Imaging (MRI) techniques are potential methods to non-invasively assess and quantify functional, structural and pathophysiological changes in chronic kidney disease (CKD) that may improve diagnosis, prognosis and treatment of these patients. Advances in imaging techniques are also likely to result in the detection of unexpected and asymptomatic incidental findings. We retrospectively analyzed the overall prevalence of incidental findings in the participants of our previously reported study utilizing a non-contrast multiparametric MRI protocol in patients with type 2 DM (T2DM) as compared to healthy controls. Method The subjects of this sub-study were participants of our original prospective, single-center, observational study, in which several MRI biomarkers were evaluated to differentiate diabetic versus healthy kidneys, and various stages of CKD. A complete medical history and physical examination were performed. The inclusion criteria for the T2DM cohort were: Age 18-70 years, type II DM with CKD staged 3-4 (estimated glomerular filtration rate [eGFR] 15-60 ml/min/1.73 m2, body mass index (BMI) 18-35 and provision of written informed consent. The control group comprised of healthy volunteers who were age- and sex-matched and had the following inclusion criteria: Age 18-70 years, eGFR &amp;gt;80 ml/min/1.73 m2, UACR &amp;lt;30 mmol/g, BMI 18-35 and provision of written informed consent. Exclusion criteria for the diabetic group were any apparent cause/s of CKD other than diabetes, previous kidney transplantation, pregnancy, contraindication for MRI examination, heart failure (NYHA class III or IV), allergies to iodine-based contrast agents. Factors that excluded healthy participants were pregnancy, contraindication for MRI examination, allergy to iodine-based contrast agents and any active or chronic disease/diagnosis. Measured GFR (mGFR) was assessed in all participants using iohexol clearance. An MRI scan using a wide range of non-contrast techniques was performed at baseline. Total scan time for patients did not exceed 45 min per session and no gadolinium-based contrast agents were used in any of the MRI examinations. All patients with incidental findings on MRI were further evaluated and referred to appropriate specialists for management. Results A total of 38 T2DM patients with CKD and 20 age- and gender-matched healthy volunteers who completed the study were included in the analysis. Of the T2DM patients, 2 were found to have CKD stage 2 by mGFR and 36 CKD stages 3–4. Clinically significant incidental findings (excluding 4 cases of renal cysts requiring only follow-up without further intervention) were found in 13 of the 38 (34%) T2DM patients. The most frequent findings were intraductal papillary mucinous neoplasm (IPMN) in 7 patients, followed by 3 cancers (1 case of kidney cancer, 1 bladder cancer and 1 lymphoma) and 3 cases of adrenal gland mass later diagnosed to be benign adenoma on further investigation. In contrast, of the 20 healthy volunteers, 2 (10%) were found to have significant incidental findings, which were IPMN in both. The follow-up duration varied between 2-6 years. The patient with bladder cancer had metastatic disease and died shortly after the diagnosis, the one with kidney cancer is under observation and the one with lymphoma underwent adequate treatment and is under remission. The cases of IPMN are being followed up regularly at our surgical department. Conclusion Clinically important incidental findings on renal MRI appear to be more common in T2DM patients than in healthy volunteers, which would have been missed without MRI examination. Mechanisms for reporting and strategies for dealing with incidental findings need to be taken into account in such investigational imaging studies. The detection of incidental findings also poses various practical and ethical issues. Further larger studies with long-term follow-up are needed to delineate the clinical relevance, natural course and management of such incidental findings.

A Case of End-stage Post-Covid-19 Pulmonary Fibrosis in a Kenyan Hospital

Post-COVID-19 pulmonary fibrosis (PC19-PF) is one of the severe manifestations of the “long COVID syndrome,” with a prevalence of about 7%, and is characterized by the presence of persistent fibrotic lung changes (on a CT scan of the lungs) associated with impairment of pulmonary function. Some of the risk factors for PC19-PF include advanced age, the occurrence of acute respiratory distress syndrome (ARDS), the need for supplemental oxygen, mechanical ventilation, smoking, etc. Antifibrotic agents, e.g., pirfenidone and nintedanib, are increasingly being used in the management of PC19-PF with good outcomes, but larger studies on efficacy and benefit are needed. In this study, we present the case of a young woman in a rural Kenyan hospital found to have end-stage PC19-PF needing long-term oxygen therapy to highlight the reality of PC19-PF in the post-COVID-19 clinical era.

#495 Effect of Vit D supplementation on bone mineral density in haemodialysis patients. A comparative study

Abstract Background and Aims Low serum 25(OH) vit D levels are usually observed in haemodialysis patients. In this population, vit D deficiency is associated with secondary hyperparathyroidism (SHPT) and low bone mineral density (BMD). Although, vit D supplements are routinely prescribed in haemodialysis patients, their exact role in preventing bone loss hasn't been studied thoroughly. The primary aim of this study was to estimate the effect of cholecalciferol (vit D3) use on BMD changes of haemodialysis patients. Secondary aim was to evaluate how parathyroid hormone (PTH), phosphorus and calcium levels are affected by vit D3 supplementation. Method Twelve (12) haemodialysis patients with low levels of serum vit D were included. All of them had their bone density measured with Dual - Energy X-Ray Absorptionmetry (DXA). The study population was then divided in two groups. Half of them (6 patients) received oral cholecarciferol (study group) and the rest continued with their standard treatment (control group). Initial dose of cholecalciferol was 25000 iu weekly and titrated upwards until 25 (OH) vit D levels were reaching 20 ng/ml. Then, cholecarciferol was continued in maintenance dose to keep vit D levels between 20 and 40 ng/ml. Thirty (30) months later, DXA was repeated in all patients. BMD in total hip region was evaluated. During the study period, phosphorus, calcium and PTH levels were measured monthly while 25 (OH) vit D levels were measured every three months. Results Patients’ mean age was 61.9 (±8.8) years. There were no differences in age, initial BMD, PTH or vit D levels between the two groups. Overall, initial mean vit D value was 8.5 ng/ml. At the end of the study, vit D levels had increased to 23.6 ng/ml in the study group while remaining unchanged in the control group. At the beginning of the study, mean BMD in the whole population was 0.742 gr/cm3 and it decreased by 0.042 gr/cm3 after 30 months. No differences in BMD change were observed between the two groups (ΔBMD was −0.057 versus -0.029 gr/cm3 in the study and control group respectively, p = 0.12). PTH levels were reduced in the study group and increased in the control group but the observed difference was not significant (p = 0.11). Phosphorus and calcium levels were not affected by vit D supplementation. Of note, three fractures were observed in the study group and one in the control group during the study period. Conclusion Vit D3 supplementation didn't seem to affect the rate of bone loss in haemodialysis patients, at least in the doses received and levels of 25 (OH) achieved above. Its exact effect in PTH levels as well as in the rate of bone fractures needs to be verified by larger studies.

Diagnostic accuracy of cell-free DNA in maternal blood in detecting chromosomal anomalies in twin pregnancies: systematic review and meta-analysis.

To report the diagnostic accuracy of cell-free DNA (cfDNA) in maternal blood in detecting chromosomal anomalies in twin pregnancies. Medline, Embase and Cochrane databases were searched. The inclusion criteria were twin pregnancies undergoing cfDNA screening for Trisomies 13, 18, 21, monosomy X0 and other sex chromosomal anomalies (SCA). The index test was represented by a positive results of cfDNA test. The reference standard was represented by the karyotype results (obtained either pre or postnatally) or, in case of negative cfDNA result, by a normal neonatal phenotype. The quality of the studies was assessed using the revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2). Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) and diagnostic odds ratio (DOR), with the corresponding 95% Confidence Intervals (95% CI), were computed using the bivariate random-effects model. Thirty-five studies were included. cfDNA had an overall high accuracy in detecting Trisomy 21 in twin pregnancies with a sensitivity of 98.8% (95% CI 96.5-100), a specificity of 100% (95% CI 99.9-100). Sensitivity and specificity were of 94.9% (95% CI 75.6-99.1) and 100 (95% CI 99.9-100) for Trisomy 18, and 84.6% (95% C% 54.6-98.1) and 100% (95% CI 99.9-100) for Trisomy 13 . We could not compute the diagnostic accuracy of cfDNA in detecting monosomy X0 in twins, while cfDNA had a sensitivity of 100% (95% CI 71.5-100) and a specificity of 99.8% (95% CI 99.7-99.9) in detecting other SCA (11 cases). The accuracy of cfDNA in detecting Trisomy 21, 18 and 13 was similar in dichorionic and monochorionic twin pregnancies. cfDNA has a high diagnostic accuracy in detecting Trisomy 18 and 21 in twin pregnancies, irrespective of chorionicity. Accuracy in the detection of Trisomy 13 and SCA was limited by the small number of affected cases and the difficulties in the confirmation of false negative cases in case of SCA and requires confirmation in larger studies. This article is protected by copyright. All rights reserved.

Transfemoral hepatic vein catheterization reduces procedure time in double vein embolization

BackgroundDouble vein embolization with simultaneous embolization of the portal and hepatic vein aims to grow the future liver remnant in preparation for major hepatectomy. Transvenous hepatic vein embolization is usually done via a transjugular access. The purpose of this study is to describe the transfemoral approach as an alternative option and to discuss potential advantages.ResultsTwenty-three patients undergoing hepatic vein embolization via a transjugular (n = 10) or transfemoral access (n = 13) were evaluated retrospectively. In all cases the portal vein embolization was done first. All procedures were technically successful. There were no peri-interventional complications. Only two patients were not able to proceed to surgery. Standardized future liver remnant hypertrophy was non-inferior with the transfemoral approach compared to the transjugular route. Procedure time was significantly shorter in the transfemoral access group (40 ± 13 min) compared to the transjugular group (67 ± 13 min, p < 0.001).ConclusionTransfemoral hepatic vein embolization is feasible, safe, and faster due to easier catheterization, improved stability, and simpler patient preparation. These findings will need to be validated in larger studies.

Role of CT in the Staging of Colorectal Tumors: A Preliminary Study on 10 Dogs

This study aimed to define the CT features of colorectal tumors in dogs and assess CT’s role in tumor staging. It was a retrospective, multicenter, descriptive study involving dogs with a cyto-histopathological diagnosis of colorectal tumors and high-quality pre- and post-contrast CT scans of the abdomen. CT successfully identified colorectal lesions in all cases, showing variations such as wall thickening, presence of masses, and luminal stenosis. It also detected lymph node involvement. Overall, this study helps us to understand the CT features of both epithelial and mesenchymal colorectal tumors, emphasizing CT’s importance in staging and surgical planning for affected dogs. Larger studies are needed to identify specific CT findings for different colorectal neoplasms.

Tissue expression of miR-449a as risk factor for occult neck metastasis in patients with cT3-T4 N0 laryngeal cancer. A pilot study.

To explore the potential role of miR-449a as biomarker for laryngeal squamous cell carcinoma (LSCC), especially in the decision strategy of neck dissection (ND). Each patient underwent total laryngectomy and bilateral ND (levels II-IV); during surgery, tissue samples of around 1 × 0.5cm were extracted from both healthy tissue adjacent to the tumor and the visibly affected tumor tissue. The extraction of total RNA, encompassing miRNA, was performed using a mirVana PARIS kit. To detect miR449a, cDNA was synthesized from 200ng of RNA using a TaqMan miRNA reverse transcription kit. The study group was formed of 66 patients (62 males, and 4 females) with LSCC, aged between 39 and 77years (mean 60 + 14.56yr). MiR-449a was up-regulated in twenty-eight tumors (42%), while it was down-regulated in 38 samples (58%). In the present study, there was a statistical relevance for miR-449a tissue expression for pN staging (p = 0.017), and PNI (p = 0.005). Eight tumors (12%) cN0 became pN + showing occult cervical lymph node metastases at the final histopathological examination, and all of these patients showed miR-449a downregulation. Super-selective ND (sparing the sub evels IIb and IV) might be the approach to cT3-T4 N0 LSCCs with upregulation of miR-449a; on the other hand, to ensure and effective control of occult neck metastases it would be appropriate to reserve elective ND (including sublevels IIb and IV) for cT3-T4 N0 LSCCs with miR-449a downregulation. Although promising, due to the small size of the cohort, the results of this work can be considered preliminary and need to be confirmed by prospective and larger studies.

Fumarate Hydratase-Deficient Renal Cell Carcinoma with Nucleolar Pattern of GATA3 Immunoexpression: Report of 2 Cases.

Fumarate hydratase-deficient renal cell carcinoma (FH-deficient RCC) is a rare aggressive type of renal cell carcinoma. The significant morphologic overlap with other types of renal neoplasia and the limited availability of FH and 2-succinylcholine immunostains for diagnostic use outside large referral centers have created numerous diagnostic pitfalls. As FH-deficient RCC can be associated with hereditary leiomyomatosis and renal cell cancer syndrome, the importance of an accurate diagnosis goes beyond the prognosis and treatment of an individual patient. We present 2 patients with FH-deficient RCC showing a peculiar pattern of GATA3 immunoexpression restricted to tumor nucleoli. If confirmed in further larger studies, this could provide an additional diagnostic clue for considering the FH-deficient RCC diagnosis, and given the frequent papillary morphology and possible hilar location can lead to the misdiagnosis as high-grade urothelial carcinoma, and is an important diagnostic pitfall to be aware of.

Short versus long duration of ceftaroline combination therapy and outcomes in persistent or high-grade MRSA bacteremia: A retrospective single-center study.

Methicillin-resistant Staphylococcus aureus (MRSA) is associated with high mortality rates. Despite antibiotic therapy, persistent bacteremia is challenging to treat. Combination therapy with ceftaroline has emerged as a potential treatment option; however, the optimal duration and clinical implications after bacteremia clearance are unknown. This retrospective cohort study examined patients with high-grade or persistent MRSA bacteremia who were treated with ceftaroline combination therapy at the University of New Mexico Hospital between January 2014 and June 2021. Patients were categorized into short- (<7 days) or long-duration (≥7 days) groups based on the duration of combination therapy after bacteremia clearance. Outcomes included 30-day all-cause mortality, bacteremia recurrence, post-bacteremia clearance length of stay, and adverse events. A total of 32 patients were included in this study. The most common sources of bacteremia were bone/joint and endovascular (28.1%, 9/32 each). The median duration of combination therapy after clearance was seven days (IQR 2.8, 11). Patients in the long-duration group had a lower Charlson comorbidity index (1.0 vs 5.5, p = 0.017) than those in the short-duration group. After adjusting for confounders, there was no significant difference in the 30-day all-cause mortality between the groups (AOR 0.17, 95% CI 0.007-1.85, p = 0.18). No association was found between combination therapy duration and recurrence (OR 2.53, 95% CI 0.19-inf, p = 0.24) or adverse drug events (OR 3.46, 95% CI 0.39-74.86, p = 0.31). After controlling for total hospital length of stay, there was no significant difference in the post-bacteremia clearance length of stay between the two groups (p = 0.37). Prolonging ceftaroline combination therapy after bacteremia clearance did not significantly improve outcomes in patients with persistent or high-grade MRSA bacteremia. The limitations of this study warrant cautious interpretation of its results. Larger studies are needed to determine the optimal duration and role of combination therapy for this difficult-to-treat infection.

The Role of Prognostic Scores in Assessing the Prognosis of Patients Admitted in the Cardiac Intensive Care Unit: Emphasis on Heart Failure Patients.

Background/Objectives: Patient care in Cardiac Intensive Care Units (CICU) has evolved but data on patient characteristics and outcomes are sparse. This retrospective observational study aimed to define clinical characteristics and risk factors of CICU patients, their in-hospital and 30-day mortality, and compare it with established risk scores. Methods: Consecutive patients (n = 294, mean age 70 years, 74% males) hospitalized within 15 months were studied; APACHE II, EHMRG, GWTG-HF, and GRACE II were calculated on admission. Results: Most patients were admitted for ACS (48.3%) and acute decompensated heart failure (ADHF) (31.3%). Median duration of hospitalization was 2 days (IQR = 1, 4). In-hospital infection occurred in 20%, 18% needed mechanical ventilation, 10% renal replacement therapy and 4% percutaneous ventricular assist devices (33%, 29%, 20% and 4%, respectively, for ADHF). In-hospital and 30-day mortality was 18% and 11% for all patients (29% and 23%, respectively, for ADHF). Established scores (especially APACHE II) had a good diagnostic accuracy (area under the curve-AUC). In univariate and multivariate analyses in-hospital intubation and infection, history of coronary artery disease, hypotension, uremia and hypoxemia on admission were the most important risk factors. Based on these, a proposed new score showed a diagnostic accuracy of 0.954 (AUC) for in-hospital mortality, outperforming previous scores. Conclusions: Patients are admitted mainly with ACS or ADHF, the latter with worse prognosis. Several patients need advanced support; intubation and infections adversely affect prognosis. Established scores predict mortality satisfactorily, but larger studies are needed to develop CICU-directed scores to identify risk factors, improve prediction, guide treatment and staff training.

Combinative approach of transzonular triamcinolone-moxifloxacin and perioperative drops to minimize postoperative complications of cataract surgery.

To investigate the effectiveness of combination therapy with transzonular triamcinolone-moxifloxacin and conventional perioperative drops in reducing postoperative complications of cataract surgery. Electronic medical records of cataract surgery patients (single surgeon) were reviewed from January 2018 to September 2021. The rate of postoperative complications including prolonged and/or recurrent postoperative inflammation, endophthalmitis, cystoid macular edema (CME), and intraocular pressure (IOP) was compared between the patients receiving combinative therapy and patients receiving drops only. Totally 596 patients and 1057 eyes (Combinative-Therapy group 493 and Drop-Only group 564) were included in this study. Using combination therapy reduced the relative risk of postoperative inflammation by 26.9% (16.6% Combinative-Therapy vs 22.7% Drop-Only, P=0.013). The incidence of endophthalmitis was 0 in Combinative-Therapy group vs 0.5% in Drop-Only group (relative risk reduction 100%), although not statistically significant (P=0.10). The incidence of severe IOP spikes was not significantly different between Combinative-Therapy (2.4%) and Drop-Only (1.6%) groups (P=0.33). The relative risk of postoperative CME was 51.4% less in three months follow up visit in Combinative-Therapy group, although not statistically significant (P=0.07). The visual outcome 1-month postop. (best corrected visual acuity) was significantly better in Combinative-Therapy (logMAR 0.10) compared to Drop-Only (logMAR 0.14) groups (P=0.02) while the baseline visual acuity was not significantly different. The combinative approach of transzonular triamcinolone-moxifloxacin plus perioperative eyedrops is an effective method to minimize postoperative inflammation, with better visual outcomes. It could potentially reduce the risk of postoperative endophthalmitis and CME (near-significant P-values; larger studies could analyze better considering low incidence).

Identification of patients' smoking status using an explainable AI approach: a Danish electronic health records case study.

Smoking is a critical risk factor responsible for over eight million annual deaths worldwide. It is essential to obtain information on smoking habits to advance research and implement preventive measures such as screening of high-risk individuals. In most countries, including Denmark, smoking habits are not systematically recorded and at best documented within unstructured free-text segments of electronic health records (EHRs). This would require researchers and clinicians to manually navigate through extensive amounts of unstructured data, which is one of the main reasons that smoking habits are rarely integrated into larger studies. Our aim is to develop machine learning models to classify patients' smoking status from their EHRs. This study proposes an efficient natural language processing (NLP) pipeline capable of classifying patients' smoking status and providing explanations for the decisions. The proposed NLP pipeline comprises four distinct components, which are; (1) considering preprocessing techniques to address abbreviations, punctuation, and other textual irregularities, (2) four cutting-edge feature extraction techniques, i.e. Embedding, BERT, Word2Vec, and Count Vectorizer, employed to extract the optimal features, (3) utilization of a Stacking-based Ensemble (SE) model and a Convolutional Long Short-Term Memory Neural Network (CNN-LSTM) for the identification of smoking status, and (4) application of a local interpretable model-agnostic explanation to explain the decisions rendered by the detection models. The EHRs of 23,132 patients with suspected lung cancer were collected from the Region of Southern Denmark during the period 1/1/2009-31/12/2018. A medical professional annotated the data into 'Smoker' and 'Non-Smoker' with further classifications as 'Active-Smoker', 'Former-Smoker', and 'Never-Smoker'. Subsequently, the annotated dataset was used for the development of binary and multiclass classification models. An extensive comparison was conducted of the detection performance across various model architectures. The results of experimental validation confirm the consistency among the models. However, for binary classification, BERT method with CNN-LSTM architecture outperformed other models by achieving precision, recall, and F1-scores between 97% and 99% for both Never-Smokers and Active-Smokers. In multiclass classification, the Embedding technique with CNN-LSTM architecture yielded the most favorable results in class-specific evaluations, with equal performance measures of 97% for Never-Smoker and measures in the range of 86 to 89% for Active-Smoker and 91-92% for Never-Smoker. Our proposed NLP pipeline achieved a high level of classification performance. In addition, we presented the explanation of the decision made by the best performing detection model. Future work will expand the model's capabilities to analyze longer notes and a broader range of categories to maximize its utility in further research and screening applications.