Long-term Management Research Articles

Unusual “Mini-Rugby Ball” Pattern Solitary Lung Metastasis in Relapsed Ewing's Sarcoma

AbstractEwing's sarcoma (ES) is a mesenchymal origin malignant neoplasm that affects children and adolescents. It is the second most common type of bone sarcoma and accounts for approximately 1.5% of all childhood cancers with an annual incidence of 1 to 3 cases per million children under 16 years of age. In this article, we present the case of a 16-year-old adolescent girl. Lung metastasis at the initial diagnosis of ES is relatively uncommon but carries significant prognostic implications. Lung metastases in ES can vary significantly in size, ranging from small nodules (just a few millimeters in size) to the largest reported case being 15 cm. The size of the metastases impacts the choice of therapeutic strategies and the prognosis. Approximately 30% of patients with ES experience a relapse, with the lungs being a common site for metastatic disease. Relapsed lung metastasis on follow-up is a critical concern in the long-term management of ES. We describe a relapsed case of ES in a 16-year-old adolescent girl who presented with a solitary large metastatic right lung mass, with the longest dimension of 16 cm on craniocaudal measurement. The primary site of the tumor was the left distal femur, for which the patient received six cycles of neoadjuvant chemotherapy, followed by en bloc tumor excision and rotationplasty of the left distal femur, after which the patient received seven cycles of adjuvant chemotherapy. Subsequent 5 years of regular follow-up was asymptomatic. Later, the patient presented with back pain and cough, and was diagnosed with a solitary large right lung mass. Computed tomography (CT) guided biopsy of the right lung mass revealed a metastatic ES, for which she underwent chemoradiotherapy. This case highlights the large size of solitary lung metastases in relapsed ES.

Resistance to protoporphyrinogen oxidase inhibitors in giant ragweed (Ambrosia trifida).

Giant ragweed (Ambrosia trifida L.) is one of the most troublesome weed species in corn (Zea mays L.) and soybean [Glycine max (L.) Merr.] cropping systems. Following numerous reports in 2018 of suspected herbicide resistance in several Ambrosia trifida populations from Wisconsin, our objective was to characterize the response of these accessions to acetolactate synthase (ALS), enolpyruvyl shikimate phosphate synthase (EPSPS), and protoporphyrinogen oxidase (PPO) inhibitors applied POST. Four accessions (AT1, AT4, AT6, and AT10) exhibited ≥ 50% plant survival after exposure to the cloransulam 3× rate. Two accessions (AT8 and AT10) and one accession (AT2) exhibited ≥ 50% plant survival after exposure to glyphosate and fomesafen 1× rates, respectively. The AT10 accession exhibited multiple resistance to cloransulam and glyphosate. The AT12 accession was 28.8-fold resistant to fomesafen and 3.7-fold resistant to lactofen. A codon change in PPX2 conferring a R98L substitution was identified as the most likely mechanism conferring PPO-inhibitor resistance. To our knowledge, this is the first confirmed case of PPO-inhibitor resistance in Ambrosia trifida globally and we identified the genetic mutation likely conferring resistance. Proactive and diversified integrated weed management strategies are of paramount importance for sustainable long-term Ambrosia trifida management. © 2024 The Author(s). Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Adaptive interventions for advancing in situ wildlife disease management.

There is a critical need for advancements in disease management strategies for wildlife, but free-living animals pose numerous challenges that can hinder progress. Most disease management attempts involve fixed interventions accompanied by post hoc outcome assessments focused on success or failure. Though these approaches have led to valuable management advances, there are limitations to both the rate of advancement and amount of information that can be gained. As such, strategies that support more rapid progress are required. Sarcoptic mange, caused by epidermal infection with Sarcoptes scabiei mites, is a globally emerging and re-emerging panzootic that exemplifies this problem. The bare-nosed wombat (Vombatus ursinus), a marsupial endemic to southeastern Australia, is impacted by sarcoptic mange throughout its geographic range and enhanced disease management capabilities are needed to improve upon existing in situ methods. We sought to advance in situ wildlife disease management for sarcoptic mange in free-living bare-nosed wombats, implementing an adaptive approach using fluralaner (Bravecto, MSD Animal Health) and a structured process of learning and method-optimisation. By using surveillance of treated wombats to inform real-time management changes, we have demonstrated the efficacy of topically administered fluralaner at 45 and 85 mg/kg against sarcoptic mange. Importantly, we observed variation in the effects of 45 mg/kg doses, but through our adaptive approach found that 85 mg/kg doses consistently reduced mange severity. Through modifying our surveillance program, we also identified individual-level variation in wombat observability and used this to quantify the level of surveillance needed to assess long-term management success. Our adaptive intervention represents the first report of sarcoptic mange management with fluralaner in free-living wildlife and evaluation of its efficacy in situ. This study illustrates how adapting interventions in real time can advance wildlife disease management and may be applicable to accelerating in situ improvements for other host-pathogen systems.

Analysis of postoperative weight loss associated with prognosis after sublobar resections for lung cancer.

Sublobar resections for lung cancer are increasing worldwide. However, the prognostic significance of weight loss after sublobar resection remains unclear. We aimed to investigate the prognostic significance of weight loss after sublobar resection for lung cancer. Patients who underwent sublobar resection for non-small cell lung cancer between January 2016 and June 2021 were analysed. The percentage weight change at 3, 6, and 12months postoperatively was determined based on the preoperative weight. Patients were divided into two groups: those with or without weight loss ≥ 5%, referring to the diagnostic criteria for frailty, to assess prognosis. Subsequently, the prognosis-related timing of weight loss ≥ 5% and its risk factors were analyzed. We reviewed 147 patients; 39 (26.5%) showed weight loss ≥ 5% within 1-year post-surgery. A total of 32 patients (21.8%) died, 13 from primary lung cancer and 19 from non-lung cancer causes. Cancer recurrence occurred in 22 patients (15.0%). Weight loss ≥ 5% within 1-year post-surgery was a poor prognostic factor for overall and recurrence-free survival (log-rank; p = 0.014 and 0.018, respectively). Additionally, weight loss ≥ 5% at 6-12months postoperatively was associated with poor overall and recurrence-free survival (p < 0.05, both). In the multivariable analysis, an age-adjusted Charlson comorbidity index ≥ 4 was a predictive factor for weight loss ≥ 5% at 6-12months postoperatively (odds ratio, 3.920; p = 0.023). Weight loss ≥ 5% at 6-12months postoperatively was associated with poor prognosis. Long-term nutritional management is important in the treatment plan of sublobar resection in high-risk patients.

Comparing the effectiveness and cost-effectiveness of alternative Type 2 Diabetes monitoring intervals in resource limited settings.

Type 2 Diabetes (T2D) represents a growing disease burden in South Africa. While glycated haemoglobin (HbA1c) testing is the gold standard for long-term blood glucose management, recommendations for HbA1c monitoring frequency are based on expert opinion. This study investigates the effectiveness and cost effectiveness of alternative HbA1c monitoring intervals in the management of T2D. A Markov model with three health states (HbA1c <7%, HbA1c ≥ 7%, Dead) was used to estimate lifetime costs and quality-adjusted-life-years (QALYs) of alternative HbA1c monitoring intervals among patients with T2D, using a provider's perspective and a 3% discount rate. HbA1c monitoring strategies (three-monthly, four-monthly, six-monthly, and annual tests) were evaluated with respect to the incremental cost-effectiveness ratio (ICER) assessing each comparator against a less costly, undominated alternative. The scope of costs included the direct medical costs of managing diabetes. Transition probabilities were obtained from routinely collected public sector HbA1c data, while health service utilization and health-related-quality-of-life (HRQoL) data were obtained from a local cluster randomized controlled trial. Other parameters were obtained from published studies. Robustness of findings was evaluated using one-way and probabilistic sensitivity analyses. A South African indicative cost-effectiveness threshold of USD2,665 was adopted. Annual and lifetime costs of managing diabetes increased with HbA1c monitoring, while increased monitoring provides higher QALYs and Life Years. For the overall cohort, the ICER for six-monthly vs annual monitoring was cost-effective (USD 2,322.37 per QALY gained), whereas the ICER of moving from six-monthly to three-monthly monitoring was not cost-effective(USD 6,437.79 per QALY gained). The ICER for four-monthly vs six-monthly monitoring was extended dominated. The sensitivity analysis showed that the ICERs were most sensitive to health service utilization rates. While the factors influencing glycaemic control are multifactorial, six-monthly monitoring is potentially cost-effective while more frequent monitoring could further improve patient HrQoL.

Long-term successfull management of recurrent episodes of nontuberculous mycobacterial infection in an apparently healthy Chinese woman

BackgroundDisseminated non-tuberculous mycobacteria (dNTM) infections are mostly reported among individuals with an underlying congenital or acquired immunodeficiency or receiving immunosuppressive treatment, but are rarely documented in otherwise healthy subjects.Case presentationWe describe a case of recurrent disseminated mycobacterial infection in an apparently immunocompetent Chinese woman. Mycobacterium szulgai and Mycobacterium avium-complex were identified in distinct episodes. Long-term antimycobacterial therapy was administered given the occurrence of recurrent events when off-treatment. Successful management over more than 10 years and immunologic data are reported.ConclusionsThis case-report highlights that dNTM should be suspected also among apparently immunocompetent hosts and that thorough assessment of underling immune-impairments is helpful to define patients’ management. Long-term antimycobacterial therapy and close monitoring is required to grant successful outcomes in case of recurrent dNTM infections.

Review of the Longitudinal Management of Autoimmune Encephalitis, Potential Biomarkers, and Novel Therapeutics.

Increasing awareness and earlier diagnosis of autoimmune encephalitis (AE) have led to a greater number of patients being cared for longitudinally by neurologists. Although many neurologists are now familiar with the general approach to diagnosis and acute immunosuppression, this review aims to provide neurologists with guidance related to management beyond the acute phase of disease, including long-term immunosuppression, monitoring, potential biomarkers of disease activity, outcome measures, and symptom management. Observational studies in AE have demonstrated that early diagnosis and treatment is associated with improved neurologic outcomes, particularly in AE with antibodies targeting neuronal cell surface/synaptic proteins. The literature regarding long-term management is evolving. In addition to traditional immunosuppressive approaches, there is emerging use of novel immunosuppressive therapies (ISTs) in case series, and several randomized controlled trials are planned. Novel biomarkers of disease activity and methods to measure outcomes and response to treatment are being explored. Furthermore, it is increasingly recognized that many individuals have chronic symptoms affecting quality of life including seizures, cognitive impairment, fatigue, sleep disorders, and mood disorders, and there are emerging data supporting the use of patient centered outcome measures and multidisciplinary symptom-based care. This review aims to summarize recent literature and offer a practical approach to long-term management of adult patients with AE through a multidisciplinary approach. We summarize current knowledge on ISTs, potential biomarkers of disease activity, outcome measures, and long-term sequelae. Further research is needed to answer questions regarding optimal IST, biomarker validity, and sequelae of disease.

Multiphysics framework for cost-effective, long-term monitoring of carbon storage in a carbonate reservoir

We evaluate an effective and cost-efficient multiphysics approach for long-term monitoring of carbon storage in carbonate reservoirs. A key focus of our study is to advocate for a cost-effective, long-term monitoring strategy for carbon storage projects through the integration of surface and borehole multiphysics measurements. By leveraging technologies related to electromagnetic (EM) and gravity methods, we present a framework that addresses the monitoring of the dynamic behavior of injected CO2 over an extended period. The modeling setup integrates realistic static reservoir models with simulated dynamic saturation models to provide results as close as possible to real experimental conditions. Results demonstrate the high sensitivity of EM fields to changes in reservoir CO2 saturation, especially when surface-to-reservoir acquisition configurations are adopted. Additionally, gravity simulations, employing three-axis vector surface gravity measurements and borehole vector gravity, effectively capture density variations over time. Our proposed framework highlights the sequential use of seismic imaging for preinjection site characterization and the transition to EM and gravity surveys for continuous monitoring during and after the injection phases. The multiphysics simulation results performed on realistic carbon storage conditions contribute to the evolving landscape of effective geophysical CO2 monitoring technology for reliable long-term reservoir management.

Opportunities for optimizing fungal biological control agents for long-term and effective management of insect pests of orchards and vineyards: a review

Opportunities for optimizing fungal biological control agents for long-term and effective management of insect pests of orchards and vineyards: a review

Prolactinoma: Navigating the Dual Challenge of Side Effects and Treatment Strategies - A Comprehensive Review

This narrative review provides a succinct exploration of prolactinoma, the most common pituitary adenoma, focusing on its epidemiology, clinical manifestations, and therapeutic interventions. Beginning with an overview of its prevalence and aetiology, the review delves into the gender distribution and familial associations of prolactinoma. Clinical presentations, including endocrine disruptions, reproductive health issues, and metabolic disturbances, are examined, emphasizing their impact on hormonal regulation and cardiovascular health. The narrative then navigates through pharmacological treatments, surgical interventions, and radiation therapy, highlighting their efficacy, side effects, and long-term management challenges. Strategies to mitigate side effects and optimize treatment outcomes are discussed, emphasizing the importance of multidisciplinary collaboration in prolactinoma management. This review is a concise yet comprehensive resource for healthcare professionals and researchers, providing insights into prolactinoma’s clinical complexities and therapeutic nuances to guide optimal patient care strategies.

Shared Care for Patients with a Left Ventricular Assist Device: A Scoping Review.

Left ventricular assist devices (LVADs) are increasingly implanted in patients with advanced heart failure. Currently, LVAD care is predominantly concentrated at specialized tertiary care hospitals. The increasing workload and logistical burden for implanting centers poses significant challenges to access to care for individual patients in remote areas. An emerging approach to LVAD patient management is the use of a shared care model (SCM), which allows implanting centers to collaborate with local non-implanting hospitals. This scoping review explores and synthesizes the current scientific evidence on the use of an SCM in LVAD care management. Eligible studies were identified in EMBASE, Pubmed MEDLINE, Web of Science, Cochrane, and Google Scholar. The PRISMA-ScR method was used to systematically synthesize findings. Of the 950 records screened, five articles met the inclusion criteria. Four review articles focused on the proposed benefits and challenges of using an SCM. Main benefits included improved patient satisfaction and continuity of care. Important challenges were initial education of non-implanting center staff and maintaining competency. One prospective study showed that absence of LVAD-specific care was associated with impaired survival and higher rates of pump thrombosis and LVAD-related infections. The use of an SCM is a promising approach in the long-term management of LVAD patients. However, sufficient evidence about the impact of an SCM on patients and the healthcare system is currently lacking. Standardized protocols based on prospective studies are needed to develop safe and effective shared care for LVAD patients.

OPTIMIZATION OF WASTE MANAGEMENT IN SUMBAWA DISTRICT USING A DYNAMIC SYSTEM MODEL

The main problem that occurs in society today apart from basic needs is the problem of waste. This waste problem certainly needs a solution in good, effective, sustainable and long-term management. The waste issue not only occur in big cities but also in developing areas. Sumbawa Regency as one of the regions that continues to develop and grow requires optimum and long-term planning of solid waste management and systems. In 2021, the waste handled in Sumbawa Regency will only be around 17.5% of the total waste. This shows that the waste management system in Sumbawa Regency is not optimal. Optimal waste management can be achieved by taking an academic approach through model development. One such model is the dynamic system model. This can describe the causal relationship between variables that affect solid waste problems and to provide an overview of the waste management system through simulations based on the factors that influence the processing model. Therefore, it is necessary to develop an optimization model for waste management specifically in Sumbawa Regency using a dynamic systems approach. The purpose of this study is to describe waste management in the form of an optimization model for waste management in Sumbawa Regency with a dynamic system. Optimization results show that the optimistic model yields a total of 127.01 tons/day, the moderate model yields a total of 98.23 tons/day and the pessimistic model produces 62.5 tons/day

Impact of radiotherapy on second primary lung cancer incidence and survival in esophageal cancer survivors

Esophageal cancer, ranked as the seventh most common cancer globally, encompasses squamous cell carcinoma and adenocarcinoma. Despite advancements in treatment modalities like surgery, chemotherapy, radiotherapy, and immunotherapy, radiotherapy, while crucial for enhancing local control and survival, poses risks for long-term side effects and the development of second primary malignancies (SPM), notably Second primary lung cancer (SPLC). This study aims to analyze the incidence of second primary lung cancer (SPLC) among esophageal cancer survivors, with a focus on the influence of radiotherapy, analyze variations across different demographic and clinical subgroups, and assess patient survival outcomes. Using data from the Surveillance, epidemiology, and end results (SEER) program on 56,493 esophageal cancer patients (2000–2020), we compared SPLC incidence in those with and without prior radiotherapy. We applied a competing risks framework, propensity score matching (PSM), and survival analyses to assess SPLC risk and radiotherapy’s impact. The study showed that patients treated with radiotherapy have a significantly higher long-term risk of SPLC compared to those without it. Radiotherapy significantly raised SPLC risk (HR 1.41, 95% CI 1.06–1.88), with higher SIRs particularly in younger patients and females. Post-PSM, there were significant differences in cancer-specific survival between esophageal cancer survivors with post-radiotherapy SPLC and those with only primary lung cancer. This cohort study shows that radiotherapy in esophageal cancer survivors increases SPLC risk but does not worsen survival compared to those with OPLC, highlighting the need for long-term monitoring and management.

Profound Pneumocephalus and Low-pressure Hydrocephalus Triggered by Ventriculoperitoneal Shunt Placement After Resection, Fat Graft Reconstruction, and Radiotherapy for a Malignant Skull Base Schwannoma

Background: Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement. Case History: A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal EVD was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined CSF leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial post-resection neurological baseline. Conclusion: Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.

Pediatric TAFRO syndrome: A multi-institution case series illustrating clinical challenges and excellent outcomes.

A rare lymphoproliferative disorder involving thrombocytopenia (T), anasarca (A), fever (F), reticulin fibrosis (R), renal dysfunction (R), and organomegaly (O), called TAFRO syndrome, was first reported in 2010. Considered a variant of idiopathic multicentric Castleman's disease, the recent discovery and rarity of this syndrome pose challenges to diagnosis and management. Herein, we review three pediatric cases, including an infant, that illustrate the heterogeneity of TAFRO syndrome. Despite differences in presentation and treatment responses, all patients experienced excellent outcomes. This multi-institutional case series highlights the need to work toward earlier diagnosis and improved long-term management recommendations for patients with TAFRO syndrome.

Effectiveness and Safety of Mycophenolate Mophetil in Myasthenia Gravis: A Real-Life Multicenter Experience

Background: Myasthenia gravis (MG) is an autoimmune disease characterized by fluctuating muscle weakness due to autoantibodies targeting neuromuscular junction proteins. Mycophenolate mofetil (MMF), an immunosuppressive therapy, has shown potential for managing MG with fewer side effects compared to other treatments. This study aims to evaluate the effectiveness and safety of MMF in MG patients in a real-life multicenter setting. Methods: A retrospective cohort study was conducted on generalized MG patients, refractory to azathioprine (AZA) and treated with MMF alone or with steroids, at three Italian centers from January 2011 to February 2024. Patients were assessed using the Myasthenia Gravis Foundation of America (MGFA) classification, MG composite score (MGCS), and MG activity of daily living (MGADL) scores at baseline, 6, 12, 18, and 24 months. Statistical analyses included the Spearman correlation, the Friedman test, and ANOVA. Results: Thirty-two patients were enrolled (13 males, mean age 66.5 ± 11.5 years). Significant improvements in MGADL and MGCS scores were observed at 6 and 12 months (p &lt; 0.001), with continued improvement over 24 months. Side effects were reported in 12% of patients. MMF showed a faster onset of symptom control compared to azathioprine, with a significant improvement noted within 6 months. Conclusions: A recent study found that MMF and AZA were equally effective in improving patients’ quality of life, but because AZA had more serious adverse events than MMF, lower doses of AZA were therefore recommended to reduce the adverse events while maintaining efficacy. Conversely, results showed that MMF is effective and well-tolerated in the long-term management of MG, providing faster symptom control and a favorable safety profile. Future prospective studies with larger cohorts are needed to confirm these findings and explore sex differences in response to MMF treatment.

Variations in plant–microbe–soil C:N:P stoichiometry along a 900-year age gradient in Torreya grandis ‘Merrillii’ plantations in Southeast China

Researches on the ecological stoichiometry of forest vegetation at different growth stages under long-term human management activities and its driving factors will help to clarify how the limited nutrient resources are allocated at different growth stages of forests, providing a basis and suggestions for scientific cultivation of artificial forests. In subtropical China, the C:N:P stoichiometry of an ancient Torreya grandis ‘Merrillii’ community was measured in leaves, twigs, roots, soils, and soil microbes with age gradients of 0–50, 50–100, 100–300, 300–500, and more than 500 years. The results showed that the nutrient use varied with tree ages. The N and P concentrations in the leaves, twigs, and roots of T. grandis had the similar increasing trends with the increasing tree age, and the N concentrations in leaves in 0-50-year-old forests were significantly lower than those forests of other ages. Particularly, the N:P ratio of different organs was always below 10, reflecting limited N supply of plants. The soil C content increased with the increasing T. grandis forest ages while the soil microbe C showed a fluctuated trend. There was a higher correlation among the C, N and P contents and their ratios in leaves, twigs and roots of 0-50-year-old forests than that in soil microbes, but inversely at more than 500-year-old forests. The homeostasis analysis results showed that the roots and soil microbes are more indicative of soil nutrient availability. The results of redundancy analysis showed that acid phosphatase activity had the highest impact on soil microbes in 0–10 and 10–20 cm soil layers, confirming that the decomposition and transformation of P in soils is very active. Moreover, soil enzyme activity mediates the influence of soil microbes on soil N and P limitation. In summary, tree age can effect the plant–microbe–soil C:N:P stoichiometry of T. grandis forests. The growth of T. grandis is mainly restricted by N, and reasonable application of N fertilizer is needed to promote its growth.

Treacher Collins syndrome: current and emerging treatment options

Treacher Collins syndrome is a rare congenital disorder characterized by bilateral craniofacial malformations, including mandibular and zygomatic hypoplasia, cleft palate, and eye anomalies, resulting in significant variability in symptom severity. The syndrome, with an incidence of approximately 1 in 50,000 births, is primarily caused by mutations in the TCOF1 gene and less frequently by mutations in POLR1C and POLR1D genes, disrupting ribosome biogenesis crucial for craniofacial development. Clinical manifestations encompass diverse craniofacial, auditory, and skeletal abnormalities, often leading to airway complications and hearing loss. Management involves a multidisciplinary approach, combining surgical interventions such as mandibular distraction osteogenesis and orthognathic surgeries with advanced imaging techniques for precise planning. Hearing loss is managed with bone conduction aids and cochlear implants, although outcomes may vary due to associated anomalies. Genetic testing aids in diagnosis and family planning decisions, while emerging therapies like genome editing and regenerative medicine show promise for future treatments. Despite challenges in long-term management and relapse rates in surgical corrections, ongoing research aims to enhance therapeutic efficacy and patient outcomes, emphasizing the need for tailored treatment strategies addressing both functional and aesthetic aspects.

Innovative approaches to atrial fibrillation prediction: Should polygenic scores and machine learning be implemented in clinical practice?

Atrial fibrillation (AF) prediction and screening are of important clinical interest because of the potential to prevent serious adverse events. Devices capable of detecting short episodes of arrhythmia are now widely available. Although it has recently been suggested that some high-risk patients with AF detected on implantable devices may benefit from anticoagulation, long-term management remains challenging in lower-risk patients and in those with AF detected on monitors or wearable devices as the development of clinically meaningful arrhythmia burden in this group remains unknown. Identification and prediction of clinically relevant AF is therefore of unprecedented importance to the cardiologic community. Family history and underlying genetic markers are important risk factors for AF. Recent studies suggest a good predictive ability of polygenic risk scores, with a possible additive value to clinical AF prediction scores. Artificial intelligence, enabled by the exponentially increasing computing power and digital datasets, has gained traction in the past decade and is of increasing interest in AF prediction using a single or multiple lead sinus rhythm ECG. Integrating these novel approaches could help predict AF substrate severity, thereby potentially improving the effectiveness of AF screening, and personalizing the management of patients presenting with conditions such as embolic stroke of undetermined source and subclinical AF. This review presents current evidence surrounding deep learning and polygenic risk scores in the prediction of incident AF and provides a futuristic outlook on possible ways of implementing these modalities into clinical practice, while considering current limitations and required areas of improvement.

Goal-Directed Osteoporosis Treatment: ASBMR/BHOF Task Force Position Statement 2024.

The overarching goal of osteoporosis management is to prevent fractures. A goal-directed approach to long-term management of fracture risk helps ensure that the most appropriate initial treatment and treatment sequence is selected for individual patients. Goal-directed treatment decisions require assessment of clinical fracture history, vertebral fracture identification (using vertebral imaging as appropriate), measurement of bone mineral density (BMD) and consideration of other major clinical risk factors. Treatment targets should be tailored to each patient's individual risk profile and based on the specific indication for beginning treatment, including recency, site, number and severity of prior fractures, and BMD levels at the total hip, femoral neck, and lumbar spine. Instead of first-line bisphosphonate treatment for all patients, selection of initial treatment should focus on reducing fracture risk rapidly for patients at very high and imminent risk, such as in those with recent fractures. Initial treatment selection should also consider the probability that a BMD treatment target can be attained within a reasonable period of time and the differential magnitude of fracture risk reduction and BMD impact with osteoanabolic versus antiresorptive therapy. This position statement of the ASBMR/BHOF Task Force on Goal-Directed Osteoporosis Treatment provides an overall summary of the major clinical recommendations about treatment targets and strategies to achieve those targets based on the best evidence available, derived primarily from studies in older postmenopausal women of European ancestry.