Treatment Decisions Research Articles

The critical role of quality-of-life data in managing patients with central nervous system disorders

Quality of life (QoL) is an essential metric in evaluating the overall well-being of patients with central nervous system (CNS) disorders. Understanding QoL data is crucial for tailoring treatment approaches, enhancing patient outcomes, and assessing the effectiveness of therapeutic interventions. This paper discusses the importance of QoL assessments in CNS disorders, including the impact on treatment decisions, patient satisfaction, and long-term health outcomes. It also explores the challenges and methodologies for collecting and analyzing QoL data, emphasizing the need for integrating these metrics into clinical practice. Ultimately, enhancing QoL is paramount in the comprehensive management of CNS disorders.

Reporting outcomes of minimally invasive glaucoma surgery.

This review presents guidelines for designing studies and reporting efficacy and safety outcomes in minimally invasive glaucoma surgery (MIGS) research. Adherence to reporting guidelines in MIGS studies is crucial for providers and patients to appraise surgical options. Recent guidelines have outlined appropriate methodology, efficacy outcomes, and safety reporting, so that study results are presented in an interpretable and uniform manner. MIGS are changing the glaucoma treatment paradigm by offering safer, less invasive alternatives to traditional filtering surgery. However, inconsistent reporting of outcomes in MIGS trials hampers comparison and clinical decision-making. Recent guidelines have aimed to highlight appropriate methodology and encourage standardization in reporting outcomes to improve the quality of MIGS literature. Key considerations include defining baseline intraocular pressure, reporting standardized demographic data, using consistent endpoints, presenting standardized figures, evaluating medication use, and documenting adverse events. By adhering to these guidelines, MIGS trials can offer clearer insights into surgical outcomes, aiding both surgeons and patients in treatment decisions.

Optimizing the Prediction of Depression Remission: A Longitudinal Machine Learning Approach.

Decisions about when to change antidepressant treatment are complex and benefit from accurate prediction of treatment outcome. Prognostic accuracy can be enhanced by incorporating repeated assessments of symptom severity collected during treatment. Participants (n = 714) from the Genome-Based Therapeutic Drugs for Depression study received escitalopram or nortriptyline over 12 weeks. Remission was defined as scoring ≤ 7 on the Hamilton Rating Scale. Predictors included demographic, clinical, and genetic variables (at 0 weeks) and measures of symptom severity (at 0, 2, 4, and 6 weeks). Longitudinal descriptors extracted with growth curves and topological data analysis were used to inform prediction of remission. Repeated assessments produced gradual and drug-specific improvements in predictive performance. By Week 4, models' discrimination in all samples reached levels that might usefully inform treatment decisions (area under the receiver operating curve (AUC) = 0.777 for nortriptyline; AUC = 0.807 for escitalopram; AUC = 0.794 for combined sample). Decisions around switching or modifying treatments for depression can be informed by repeated symptom assessments collected during treatment, but not until 4 weeks after the start of treatment.

Intra-articular knee injections in patients with primary osteoarthritis in a tertiary clinical setting: a best practice implementation project.

This project aimed to improve physicians' adherence to evidence-based practices regarding the selection and administration of intra-articular knee injections for patients with osteoarthritis. The project also aimed to empower patients by increasing their awareness of these evidence-based practices. In the management of knee osteoarthritis, intra-articular injections are commonly used when initial treatments prove inadequate. However, issues such as patients' demand for rapid relief and variability in physicians' familiarity with optimal practices often lead to suboptimal treatment decisions and potential adverse outcomes. This project followed the JBI Evidence Implementation Framework, which is grounded in an audit, feedback, and re-audit process. Initially, physicians were surveyed on the topic under consideration, and hospital records were reviewed. Subsequently, targeted interventions were implemented, including briefings and the distribution of informative flyers. The baseline audit indicated low adherence with all audit criteria. Various parameters, such as adherence to best clinical practices, informed decision-making by patients, and the recommendation of alternative treatment modalities, were significantly lacking. Following the interventions, substantial improvements were observed, including higher rates of adherence to best clinical practices by physicians for multiple criteria, such as stepwise referral to conservative therapy options and the content of intra-articular injections. Adherence to best clinical practices can be improved through educational briefings for physicians on the most current evidence-based treatment practices for injectable substances in knee osteoarthritis. The active engagement of patients, facilitated by informative flyers and physician assistance, contributed to better involvement in their treatment choices. However, the participation of health care institutions and providers as well as lifelong education practices may be necessary for more comprehensive and sustainable changes. http://links.lww.com/IJEBH/A277.

Evolving Patient-Centred Therapies for Metastatic NSCLC

The metastatic non-small cell lung cancer (mNSCLC) treatment landscape has vastly expanded over the past two decades as a result of advancements in biomarker testing. However, unmet needs remain both in terms of treatment options for some patient groups, and patient support throughout the treatment journey. In this symposium, Jarushka Naidoo, Consultant Medical Oncologist, Beaumont RCSI Cancer Centre, Dublin, Ireland; Terri Conneran, KRAS Kickers, Charlotte, North Carolina, USA; Luis Paz-Ares, Chair of the Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain; and Alexander Drilon, Chief of Early Drug Development and Thoracic Oncology, Memorial Sloan Kettering Cancer Center, New York, USA, focused on patient-centric approaches to mNSCLC treatment, starting with a patient and patient advocacy group perspective on what patients want from their care team during their treatment journey. The panel also discussed both immuno-oncology (I-O) monotherapy and combination therapy, including dual I-O therapies for patients with programmed death-ligand 1 (PD-L1) tumour expression <1%, as well as the treatment landscape for KRASG12C-mutated mNSCLC, and ongoing trials of KRAS-targeted agents. In addition, the latest data on tyrosine kinase inhibitors (TKI) for patients with alterations in ROS1 and NTRK genes were discussed, focusing on next-generation TKIs. Finally, the panel discussed patient cases, taking into account specific considerations and how to best approach treatment decisions.

What matters most to healthy older adults in treatment decision making: a discrete choice experiment

Abstract Introduction Shifting to a patient centered approach is crucial for a sustainable healthcare system. Understanding individuals’ priorities is essential for personalized care, especially in critical illness. Treatment decisions are often aimed at disease-specific outcomes such as life extension or survival, while patient-specific outcomes like maintaining independence may be equally vital. How healthy older adults prioritize treatment outcomes in case of a critical illness is currently unknown. Enhanced insight into their priorities can refine healthcare policy, for more personalized care. This study investigated outcomes (attributes) prioritized in hypothetical decision-making by healthy adults over 50 yr. Methods We conducted a Discrete Choice Experiment with individuals aged ≥50, comparing six pairs of hypothetical treatments with five attributes: life expectancy, independence, pain, memory complaints and societal costs. Attribute utility was analyzed using a conditional logit model, and latent class analyses were employed to explore preferences in groups. Results In 333 participants (mean age 70 +/- 7.7) all attributes emerged as impactful with independence being strongest (p < 0.05). Increased life expectancy had positive utility, but only for a two-year increase. Negative utility was found for all other attributes except mild pain and memory complaints. Latent class analyses identified two groups (22.4% and 77.6%). Group one valued life expectancy more (p .019 vs .940), whereas the second group valued independence (p .058 vs.<.001 and societal costs (p.053 vs. <.001) more. Conclusions In a hypothetical case of life-threatening disease, for people aged ≥ 50 life expectancy was not the sole relevant outcome for treatment decisions; pain, independence and societal costs are important and should be discussed in clinical decision making or healthcare policy. Key messages • Older adults find patient-specific outcomes relevant for decision making. • Societal costs are found relevant for decision making for treatment by older adults.

A Multicenter Physician Survey Evaluating the Use of Ki-67 in Breast Cancer Management in Canada

Background: Ki-67’s response to pre-operative endocrine therapy (ET) in early breast cancer is an evidence-based tool to guide adjuvant treatment decisions. Physicians across Canada were surveyed to explore current practice patterns and perceived barriers to the use of Ki-67 in practice. Methods: Physicians were invited to participate in an anonymous survey and were eligible if they prescribed systemic therapy for breast cancer in Canada. Respondents were asked to describe their usage of Ki-67, perceptions of the evidence surrounding Ki-67 ET response, and interest in future trials using this approach. Results: The survey received 48/163 responses (29.4%). The majority of respondents (97.6%) reported access to Ki-67 testing upon request. Treatment decisions for adjuvant Abemaciclib was the most common reason (97.6%), followed by adjuvant chemotherapy decisions (16.7%). Only 19.0% had used Ki-67’s response to pre-operative ET in practice. Common barriers to this approach that were identified included a lack of awareness from other providers (54.8%), an increased resource requirement (54.8%), and a lack of timely medical oncology consultation (52.4%). The majority of physicians (85.3%) reported that they would participate in future trials using the Ki-67 endocrine response, and that rate of treatment decision change (95.2%) and cost analysis (42.3%) were important endpoints. Conclusions: Despite the widespread availability of Ki-67 testing, few physicians in Canada currently use it to assess endocrine response, predominantly due to logistical and resource constraints. There is a high level of interest in participating in future trials using this strategy, which should focus on disease related outcomes, feasibility, and the financial impact on the public healthcare system.

Extremely rare coronary anomaly as cause of palpitations. A case report of single right coronary artery - multimodality imaging and its impact on treatment decisions

Abstract Background We report the case of a white caucasian 63-year-old patient admitted to the clinic because of atypical angina and palpitations. Other comorbidities included hypertension, hyperuricemia and hypercholesterolaemia. He was admitted to a tertiary cardiac centre for deepened diagnostics of his complaints. Case summary Echocardiography revealed no pathology, but due to high Calcium Score (Agatston > 400 units), signs of arrhythmia during exercise and atypical angina complaints further investigations were performed. Invasive coronary angiography revealed stenosis up to 53% in the middle part of the right coronary artery and computed tomography angiography showed no left coronary artery, only malignant-coursed vessel, running from the proximal part of the right coronary artery. Single photon emission tomography findings allowed to come to a decision to not perform invasive treatment (coronary artery bypass grafting), due to acceptable perfusion and viability of the heart muscle. Discussion Single coronary artery is an extremely rare anomaly. This requires highly individualised diagnostic approaches, which include multiple imaging modalities, as each adds different information. While the only coronary vessel was narrowed in 53%, no significant ischemia was detected. Left ventricular function remained preserved.

Machine learning methods for diagnostic disease prediction and treatment decisions in parvovirus B19 positive viral cardiomyopathy

Abstract Background Parvovirus B19 (B19V) is the most common type of virus found in endomyocardial biopsies (EMB) from patients with inflammatory heart disease. However, the detection of genomic B19V-DNA appears to have little clinical significance and is often considered an incidental finding. Recent analyses of a large cohort of B19V-positive patients revealed that the detection of RNA transcripts rather than DNA is of clinical importance, as B19V-RNA-positive patients have a significantly worse cardiovascular outcome. Here, we applied machine learning (ML) methods to assess the impact of B19V transcriptional activity on cardiac inflammation and patient clinical outcome. Methods and results A total of 305 patients with a known clinical course and a positive endomyocardial B19V-DNA test were included in this study. Follow-up measurements of the B19V-specific transcripts VP1/2 and NS1 revealed significantly worse clinical courses than in patients without B19V-RNA detection (P=0.019, hazard ratio (95% CI)=1.62 (1.10-2.57)). LVEF at follow-up was significantly lower in patients with detected B19V-RNA (P=0.007), and adverse events such as worsening LV function (P=0.003) or stable systolic dysfunction (P=0.013) were more frequent in this group. Importantly, analysis of inflammatory markers in EMB showed no difference in patients with and without RNA detection (P=0.432), suggesting that the deterioration in clinical outcome was related to B19V transcriptional activity rather than an increase in inflammation. The analysis of area under the receiver operating characteristic curve (AUROC) of B19V-RNA-negative patients revealed that the macrophage marker MAC-1 (AUROC=0.66, P=0.002) was the single most prognostically relevant parameter, while the T cell marker CD3 (AUROC=0.73, P<0.001) was identified as the most prognostically relevant marker in B19V-RNA-positive patients. The linear combination of several inflammatory markers increased the AUROC value to 0.67 in B19V-RNA-negative patients and to 0.74 in B19V-RNA-positive patients. To further increase prognostic accuracy, we trained ML models on features derived from EMB inflammatory markers. For the prediction of major adverse cardiac events within 60 months, the best ML-models achieved an AUROC of 0.87 in B19V-RNA-positive and of 0.86 in B19V-RNA-negative patients, while models that neglect the differentiation of patients with regard to the presence of B19V RNA transcripts only achieved an AUROC of up to 0.76. Conclusions These results show that B19V transcriptional activity is an independent risk marker for adverse cardiac events in patients with viral cardiomyopathy and thus confirm the clinical-therapeutic importance of myocardial biopsy. Furthermore, we present an ML-based algorithm that accurately indicates disease progression in B19V-positive cardiomyopathy patients and is thus helpful for appropriate therapy recommendation.

Associations of smoking status with long-term cardiovascular events in different arterial territories: the EPIC Norfolk prospective population cohort

Abstract Background Smoking cessation is associated with a reduced risk of cardiovascular disease (CVD) events, mainly in ischemic heart disease (IHD) and stroke. However, the impact of smoking status (never, former or current smoking) on long-term CVD events across different arterial territories remains understudied. Knowledge of such associations is important, as it may assist in risk communication and smoking cessation motivation. We therefore investigated associations between smoking status and territory-specific CVD events in a large cohort with ≥20 years follow-up. Methods We included participants without baseline CVD from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population cohort. The strengths of associations between smoking, former smoking and never smoking with the first occurrence of a CVD event were evaluated using a competing risk-adjusted regression model. CVD events were defined as hospitalisation or death due to IHD, ischemic stroke, haemorrhagic stroke, peripheral arterial disease (PAD) or aortic aneurysm (AA). Patients were followed-up until the first event, non-CVD death (competing risk) or end of study (15-03-2018). The model was adjusted for sex, age, systolic blood pressure, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), diabetes, renal function and body mass index. We compared former and current smoking (at baseline) with never smoking. Results We included 23,581 participants (56% women) with a median baseline age of 58 years [interquartile range (IQR) 51-66]. During median follow up of 21.3 years (IQR 19.0-22.8), 26.4% experienced ≥1 CVD event. The first event of occurrence was IHD in 17.3%, ischemic stroke in 3.6%, haemorrhagic stroke in 1.4%, PAD in 3.1% and AA in 1.4%. Current (vs. never) smoking was associated with IHD [adjusted hazard rate (aHR) 1.53, 95% confidence interval (CI) 1.36-1.72], PAD (aHR 1.29, 95%CI 1.07-1.56) and AA (aHR 4.81, 95%CI 3.54-6.54). Current smoking was not significantly associated with ischemic stroke (aHR 1.20, 95% CI 0.95-1.52) and haemorrhagic stroke (aHR 1.18, 95% CI 0.81-1.70). In former (vs. never) smoking individuals, the association with AA remained statistically significant but less pronounced [aHR 1.69, 95%CI 1.29-2.23]. Conversely, former smoking was not associated with IHD (aHR 1.07, 95%CI 0.99-1.16) or PAD (aHR 1.09, 95%CI 0.95-1.26) (Figure 1). Conclusion After 20-years of follow-up, former smokers, compared to never-smokers, remain at considerably higher risk for CVD events, particularly for aortic aneurysm. This knowledge may assist in treatment decisions and risk communication.

Meta-Heart Team: enhancing multidisciplinary heart teams through virtual reality in the metaverse

Abstract Introduction Cardiovascular Multidisciplinary Heart Teams (MDHTs) are integral for patient management, but persistent challenges, including limited subspecialty expertise and time constraints, necessitate innovative approaches. This study explores the viability of conducting international Meta-Heart Team sessions utilizing virtual reality (VR) within the metaverse, aiming to address these challenges. Methods The Meta-Heart Team, comprising participants from diverse medical specialties and countries, engaged in VR sessions facilitated by VR headsets and web browsers. The immersive Aimedis metaverse platform recreated a three-dimensional hospital setting, complete with a dedicated Meta-Heart Team room featuring large screens displaying patient data such as coronary angiograms and echocardiograms. A 0-10 scale questionnaire evaluated participant experiences, covering technical quality, immersion, willingness to participate again, and overall satisfaction. Results The virtual environment effectively facilitated discussions on valvular heart disease cases among 10 participants, dedicating 15 minutes to each case. Technical stability was robust (90%), with only one participant experiencing internet disconnection. Positive participant feedback highlighted high ratings for technical quality (8.0±1.8) and engagement, a good immersive experience (8.0±1.3), willingness to participate again (9.2±0.8), and confidence in treatment decisions (80%). Despite a sense of digital fatigue reported by a few participants, the majority expressed that the VR session saved time compared to traditional meetings. Privacy concerns were acknowledged by 80% of participants. Discussion The virtual environment demonstrated potential in augmenting MDHT collaboration, providing advantages in global accessibility, multidimensional analysis, and adaptability. Participants recognized limitations in non-verbal communication and interpersonal connections but underscored the adaptability and effectiveness of the virtual setting. Technical challenges, including a single internet disconnection, emphasized the importance of a robust technical infrastructure. Privacy issues, digital fatigue, and potential exclusions were highlighted, prompting consideration of ethical guidelines and ongoing technological advancements. Conclusion Leveraging VR in the metaverse for MDHT sessions is feasible and offers substantial benefits. Despite challenges such as technical issues and privacy concerns, the Meta-Heart Team complements traditional interactions, ushering in a new era in collaborative decision-making while demanding ongoing attention to technological and ethical considerations.Two presenters explaining the processThe Metaverse-based Heart Team room

Cluster-specific risk factors for suboptimal thromboprophylaxis in contemporary European cohort of patients with atrial fibrillation: the EHRA-PATHS Project

Abstract Background Oral anticoagulation (OAC) is essential to optimal thromboprophylaxis in patients with atrial fibrillation (AF). Owing to bleeding risk concerns, OAC use may be challenging in clinically complex high-risk AF patients. Comorbidities might lead to suboptimal OAC use. We assessed cluster-specific risk factors for non-prescribing OAC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was constructed using data from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific risk factors for non-prescribing OAC were identified using univariate and multivariate logistic regression analyses. Results Of 18.799 patients, 2086 (11.1%) were not prescribed with OAC. Among the three clusters (see Table), OAC non-prescribing was significantly more prevalent in Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) or Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), both P<0.001, with no significant difference between Clusters 2 and 3 (P=0.161). Cluster-specific multivariable risk factors for non-prescribing OAC are shown in Table. In all three clusters AF clinical type was significantly associated with OAC non-use. In Cluster 1, OAC non-use was less likely in the presence of CHA2DS2-VASc stroke risk factors, while bleeding risk factors were predominant multivariable predictors of OAC non-use among elderly (Clusters 2 and 3). Conclusion Our findings in a large contemporary European cohort suggest that different considerations prevail in treatment decision on OAC use in AF patients in clinical practice, depending on patient’s age and AF clinical type, as well as the presence and type of underlying comorbidities. Our findings could help in formulating targeted interventions to optimize stroke prevention in different subgroups of AF patients.

6.A. Round table: Building a Public Health Innovation Ecosystem in the WHO European Region

Abstract Background In the WHO European region, challenges persist in bridging the gap between innovative health solutions and their widespread implementation at a population scale. Despite advancements in AI, digital systems, precision medicine, genomics, and social innovations, these potential solutions often go underutilized. Immediate action is necessary to address the multifaceted issues faced by health systems, such as aging populations, noncommunicable diseases, antimicrobial resistance, and climate change impacts on health. To effectively tackle these challenges, it is essential to develop and implement innovations that respond to critical health issues in a contextual manner. Establishing an innovation ecosystem that fosters collaboration, strategic partnerships, and effective scaling of innovative solutions is crucial. Robust policy frameworks and governance mechanisms are needed to engage with the private sector and other nontraditional public health partners to drive equitable and value-driven innovations in public health. Rationale The workshop at the 17th European Public Health Conference 2024 aims to explore the role of public-private collaborations in driving innovative solutions for public health. By examining synergies between sectors, the workshop seeks to accelerate innovation, improve preventive services, and enhance health delivery to address pressing public health challenges. Leveraging the private sector’s expertise and resources is crucial in addressing complex health issues and improving public health outcomes. The workshop will provide a platform to strategize on utilizing these collaborations for sustainable innovation in public health. Overall Objective Foster a deeper understanding of the benefits and challenges of public-private collaborations in advancing public health innovation. Specific Objectives - Facilitate knowledge exchange on successful collaboration models between the private sector and public health entities. - Identify key strategies to utilize private sector resources for innovative public health solutions. Outcomes: - Inspire the formation of new partnerships to drive innovation in public health. - Develop actionable insights to enhance collaboration between the private sector and public health stakeholders for sustainable innovation. Workshop Structure: The workshop will begin with a Scene-setting presentation of Dr Gauden Galea, Strategic Advisor to the Regional Director, WHO Europe, on WHO Europe’s approach to leveraging innovation for public health outcomes (10 mins). Panelists will then discuss concrete examples of public-private collaboration leading to improvements in public health outcomes (40 mins). Key success factors for meaningful partnerships with the private sector will be explored, emphasizing policy considerations and the importance of behavioral and cultural insights in innovation. Interactive Q&A session with audience will close the meeting (10 mins). Key messages • Establishing an innovation ecosystem fosters partnerships that drive equitable and sustainable solutions in public health. • Public-private collaborations accelerate innovation for public health, vital for addressing complex challenges effectively. Speakers/Panelists Götz Gottschalk, YouTube, Berlin, Germany Götz Gottschalk (Head of Health, YouTube Germany) will discuss the role of technology, particularly YouTube, in disseminating accurate health information to the public. He will also share insights on how digital platforms can be utilized to promote public health initiatives, address misinformation, and engage with diverse audiences effectively. His talk will also focus on the importance of collaboration between the public and private sectors in leveraging technology for public health outcomes, emphasizing the need for responsible and accurate health communication in the digital age. Phillippe Menu SOPHiA Genetics, Rolle, Switzerland Phillippe Menu (Chief Medical Officer and Chief Product Officer, SOPHiA Genetics, Switzerland) will discuss how data-driven approaches, artificial intelligence, and genomic insights can revolutionize diagnostics, treatment decisions, and personalized medicine. His talk will highlight the potential of integrating advanced technologies into public health to improve patient outcomes, enhance clinical decision-making, and drive innovation in the field of precision medicine. Els Torreele Institute for Innovation and Public Purpose, University College London, London, UK Els Torreele (Policy Associate, UCL Institute for Innovation and Public Purpose) will discuss policy frameworks, governance structures, and strategies to promote equitable access to public health innovations, particularly in low- and middle-income countries. Her talk will shed light on the intersection of innovation, public policy, and global health, emphasizing the importance of addressing systemic barriers to ensure that innovative healthcare solutions reach those who need them the most. Andrew Nerlinger Global Security Fund, Geneva, Switzerland Andrew Nerlinger (Executive Director, Global Security Fund) will discuss pandemic preparedness, biosecurity measures, and the role of non-profit organizations in addressing global health threats. His talk will explore how innovative approaches, partnerships, and funding mechanisms can strengthen global health security, mitigate risks, and build resilience in the face of emerging health crises. Susan Michie Centre for Behaviour Change, University College London, London, UK Susan Michie (Professor of Health Psychology and Director of the UCL Centre for Behaviour Change) will discuss evidence-based strategies for promoting behavior change, improving health outcomes, and addressing public health challenges through behavioural and cultural insights. Her talk is expected to highlight the importance of understanding human behavior, motivations, and decision-making processes in designing effective health interventions and shaping public health policies.

Prediction of microvascular invasion in hepatocellular carcinoma with conventional ultrasound, Sonazoid-enhanced ultrasound, and biochemical indicator: a multicenter study

PurposeTo develop and validate a preoperative prediction model based on multimodal ultrasound and biochemical indicator for identifying microvascular invasion (MVI) in patients with a single hepatocellular carcinoma (HCC) ≤ 5 cm.MethodsFrom May 2022 to November 2023, a total of 318 patients with pathologically confirmed single HCC ≤ 5 cm from three institutions were enrolled. All of them underwent preoperative biochemical, conventional ultrasound (US), and contrast-enhanced ultrasound (CEUS) (Sonazoid, 0.6 mL, bolus injection) examinations. Univariate and multivariate logistic regression analyses on clinical information, biochemical indicator, and US imaging features were performed in the training set to seek independent predictors for MVI-positive. The models were constructed and evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis in both validation and test sets. Subgroup analyses in patients with different liver background and tumor sizes were conducted to further investigate the model’s performance.ResultsLogistic regression analyses showed that obscure tumor boundary in B-mode US, intra-tumoral artery in pulsed-wave Doppler US, complete Kupffer-phase agent clearance in Sonazoid-CEUS, and biomedical indicator PIVKA-II were independently correlated with MVI-positive. The combined model comprising all predictors showed the highest AUC, which were 0.937 and 0.893 in the validation and test sets. Good calibration and prominent net benefit were achieved in both sets. No significant difference was found in subgroup analyses.ConclusionsThe combination of biochemical indicator, conventional US, and Sonazoid-CEUS features could help preoperative MVI prediction in patients with a single HCC ≤ 5 cm.Critical relevance statementInvestigation of imaging features in conventional US, Sonazoid-CEUS, and biochemical indicators showed a significant relation with MVI-positivity in patients with a single HCC ≤ 5 cm, allowing the construction of a model for preoperative prediction of MVI status to help treatment decision making.Key PointsMVI status is important for patients with a single HCC ≤ 5 cm.The model based on conventional US, Sonazoid-CEUS and PIVKA-II performs best for MVI prediction.The combined model has potential for preoperative prediction of MVI status.Graphical

Posterior Fossa Arachnoid cysts (PFACs) in pediatric patients: a single-center retrospective study and proposal of a treatment flow-chart.

To investigate how different presentations of posterior fossa arachnoid cysts (PFACs) influence surgical indication and strategies and their impact on clinical and radiological outcome in children, proposing a treatment flow-chart. In this retrospective study, children < 14 years old with PFAC diagnosed at IRCCS Giannina Gaslini Hospital from 2008 to 2023 were identified Patients showing a mega cisterna magna (MCM), Dandy-Walker syndrome (DWS), Blake's pouch cyst (BPC), neuroenteric cysts or multiple cysts were excluded. Data regarding type of treatment, age at surgery, surgical complications were collected and analyzed. Clinical and radiological outcomes were considered at 1-, 3- and 5-years follow-up. A "wait and see" strategy in asymptomatic showed better clinical outcomes at 1-year follow-up (p = 0.047). No significant difference in clinical outcome or risk of re-surgery were observed between microsurgical fenestration, endoscopical fenestration or shunting were reported, while location of the cyst influenced surgical strategy (p = 0.015). Age < 12 months at surgery (p = 0.008), hydrocephalus (p = 0.001), especially when associated with macrocephaly (p = 0.004), and the placement of a shunt (p = 0.006) resulted as risk factors of re-surgery. An association between radiological and clinical outcomes was observed at 1-year follow-up. Treatment decision should be based on clinical presentation rather than radiological presentation. While a "wait and see" strategy is suggested in asymptomatic patients, when surgery is indicated, several factors should be considered, such as presence of hydrocephalus, location of the cyst and age of the patient, to improve clinical outcomes, reducing complications.

Arterial hypertension in the era of obesity bias: the impact of obesity status on pharmacological treatment intensification in patients with diabetes

Abstract Background Obesity is recognized as a significant risk factor for several chronic conditions, such as diabetes and hypertension. Despite the growing healthcare needs of individuals with obesity, they often encounter obesity bias, potentially impacting the quality of medical care they receive. Purpose The aim of this study was to explore the impact of obesity on the appropriateness of antihypertensive treatment decisions in individuals with concurrent diabetes and hypertension. Methods In this multicenter cross-sectional study, patients with type 2 diabetes and arterial hypertension who were receiving outpatient care across four centers in Southern Brazil were enrolled. Participants were categorized into two groups based on their Body Mass Index (BMI): eutrophic (BMI &amp;lt;25.0 kg/m²) and patients with obesity (BMI ≥30.0 kg/m²). The primary outcome evaluated was the difference in pharmacological treatment decisions for hypertension between groups, considering individualized hypertension targets from American Diabetes Association (ADA), European Society of Hypertension (ESH), and European Society of Cardiology (ESC). Analysis was conducted on whether patients failed to receive necessary treatment intensification, comparing groups through multivariable logistic regression. Results The study comprised 204 individuals with type 2 diabetes and arterial hypertension, including 53 eutrophic and 151 patients with obesity. It was observed that patients with obesity more frequently fail to receive appropriate treatment intensification when compared to eutrophic individuals. This finding was statistically significant across the hypertension targets set by the ESH (adjusted Odds Ratio [OR] 2.03 [95% Confidence Interval [CI] 1.08-3.83], p = 0.022), ESC (adjusted OR 1.94 [95% CI 1.03-3.65], p = 0.035), and ADA (adjusted OR 2.01 [95% CI 1.07-3.79], p = 0.021). Conclusion The study indicates that obesity may contribute to disparities in the management of hypertension, suggesting a link between obesity status and therapeutic inertia in treating arterial hypertension among these patients.

Diagnostic performance of coronary computed tomography angiography for coronary in-stent re-stenosis

Abstract Background Through the development of CT equipment and proper preparation before CT scanning, the accuracy of Coronary computed tomography angiography (CCTA) diagnosis of ischemic heart disease (IHD) is improving, and the role of CCTA in treatment decision is gradually expanding. The latest guidelines recommend CCTA as Class IIa to evaluate stent patency and native vessels in patients with chronic coronary disease. However, diagnostic performance of CCTA to evaluate stent patency in patients who underwent coronary stent was not clarified, respectively the role of CCTA in the evaluation of IHD in native coronary artery was established.. Purpose In the present study, we evaluate the agreement between CCTA and CAG in assessing stent patency in patients with de novo ischemic chest pain who underwent percutaneous coronary intervention (PCI) and evaluated which factors contribute to the differences. Methods From January 1, 2010 to December 31, 2020, we analyzed 845 patients who underwent new CCTA and CAG sequentially for the evaluation of chest pain previously underwent PCI. In CAG and CCTA, ISR is equally defined as a stenosis greater than 50% of the vessel diameter of within the stented segment or its edge (5-mm segments adjacent to the stent). The degree of In-stent restenosis was analyzed by an independently by quantitative coronary angiography (QCA). Results A total of 208 stents were analyzed, the pooled sensitivity and specificity for CCTA on the diagnosis of ISR were 0.78 (0.65-0.89) and 0.93 (0.88-0.96), respectively. LR+ and LR- were 11.19 (6.22-20.15) and 0.23 (0.14-0.39). As a result of analyzing the ISR diagnostic agreement of CCTA by dividing into ACS and CCD group, the agreement of CCTA for ISR diagnosis was relatively low in the ACS group (Sensitivity 0.69 (0.48-0.86) vs. 0.88 (0.69-0.97), specificity 0.92 (0.84-0.97) vs. 0.94 (0.86-0.98), LR+ 9 (4-20.24) vs. 13.9 (5.88-32.88), LR- 0.33 (0.19-0.6) vs. 0.13 (0.04-0.37)) (Table 1). As a result of analyzing related factors in cases of discrepancy in ISR diagnosis, the degree of stenosis in both ACS and CCD groups was mostly intermediate stenosis, which often required additional clinical evaluation (Figure 1). Conclusion When new ischemic chest pain occurred in a patient who previously underwent PCI, the diagnostic accuracy of ISR by CCTA differed depending on the patient’s IHD category. In the CCD group, the diagnostic usefulness of CCTA was comparable both native vessels and ISR, but not in the ACS group. As majority of ISR diagnostic discrepancies were in intermediate lesions, even in the ACS group, CCTA may be considered as a diagnostic tool.

Significant impact of a novel whole heart motion correction algorithm on cardiac computed tomography and aortic valve calcium scores

Abstract Introduction A new whole-heart motion-correction algorithm has been available in cardiac computed tomography (CT), and it has already revealed the higher diagnostic accuracy of significant coronary artery stenosis in cases with higher heart rate at the CT scan. Recently, aortic valve calcium scores (AVCS) are often measured for the decision-making of surgical treatment of aortic valve stenosis. However, the measurement of AVCS of the aortic valve has potential risks of motion artifact of the aortic valve. Therefore, we would like to know the clinical impact of a new whole-heart motion correction algorithm for accurately measuring aortic valve AVCS without motion artifacts. Purpose The purpose of this study is to evaluate the impact of a new whole-heart motion-correction algorithm on non-contrast cardiac CT images and the AVCS in trans-catheter aortic valve regurgitation (TAVR) candidates with severe aortic valve stenosis. Materials and methods Forty-two consecutive TAVR candidates (83 ± 7 years old, 21 males) who underwent ECG-gated CT using 256-row detector CT from November 2023 to February 2024 at our hospital were analyzed. The best phase non-contrast cardiac images were automatically selected, and they were reconstructed with both the standard (STD) algorithm and the new whole-heart motion-correction algorithm. AVCS was calculated using semi-automatic commercially available software. The aortic valve's image noise was also measured. Results Non-contrast best cardiac phase images were successfully reconstructed using the new motion correction algorithm in 36 patients (86%). The best cardiac phase was mainly the diastolic phase in 29 patients (81%). The overall Agatston score and calcified volume of the aortic valve in SSF2 were 1779 ± 896, and 1403 ± 689, respectively, and they were lower than 2195 ± 1132 and 1656 ± 851 of STD (all P &amp;lt; 0.01). Conclusion The new whole-heart motion-correction algorithm worked in almost all TAVR candidates, and revealed lower AVCS and shows a potential for increasing AVCS accuracy.

External validation of the HFA-ICOS risk stratification tool for prediction of cardiovascular complications after cancer treatment

Abstract Background The 2022 ESC Guidelines on Cardio-oncology recommends using the HFA-ICOS (Heart Failure Association and the International Cardio-Oncology Society) four-category risk stratification tool to predict risk of heart failure (HF) and other cardiovascular disease (CVD) complications during and after cancer therapy. However, the actual risk associated with assignment to these categories is unknown. Purpose We aimed to assess the prognostic performance the HFA-ICOS risk stratification tool in a large cancer subpopulation of a general health survey linked to Norwegian health registries. Methods Participants in a large-scale population study diagnosed with cancer between 2006 and 2012 were included (n=2290) and followed for CVD endpoints until Sept 2023. CVD risk factors were measured at baseline between 2006 and 2008. The Norwegian Cancer Registry provided detailed information about cancer characteristics and therapy. We retrieved CVD endpoints from the local hospitals’ registries and the national causes of death registry. Kaplan Meier survival curves were used to estimate the risk of the combined endpoint of HF hospitalization, myocardial infarction (MI), stroke and CVD death, as well as HF hospitalization alone and non-CVD death. Harrel’s C-statistic was used to validate the discriminative abilities. Results Mean (SD) age was 65.8 (12.4) years, 48% were female, cancer types and cardiovascular risk factors are shown in Table 1. During a median (interquartile range) follow-up of 6.9 (1.4 to 12.2) years, there were 460 first CVD events (HF hospitalizations 87 (19%), MIs 161 (35%), strokes 130 (28%), CVD deaths 82 (18%)) and 1003 (44%) non-CVD deaths. When applying the HFA-ICOS tool, 649 (28%) were assigned to the low-risk category, 912 (40%) to medium, 661 (29%) to high-risk and 68 (3%) to the very high-risk category. Between the HFA-ICOS risk categories, there were clear differences in the observed risk of CVD events, HF hospitalizations and non-CVD mortality (Figure 1). CVD incidence was highest in the highest HFA-ICOS risk categories (7% in the low risk group, 21% in the medium risk group, 31% in the high risk group and 37% in the very high-risk group (p-value &amp;lt;0.001)). C-statistics for predicting CVD events was 0.696 (95% CI, 0.674 to 0.718). When only assessing patients with HF hospitalizations as (first) outcome (n=116), the risk of HF was higher in the high and very high-risk groups (0% in the low risk group, 4% in the medium, 9% in high and 21% in the very high risk group (C-statistics 0.794 (95% CI, 0.762 to 0.827)). Conclusion The HFA-ICOS baseline risk assessment was useful to identify patients at risk of both clinical overt heart failure and other major CV complications and non-CV death in a population with a variety of cancers. These results can help communicate absolute risks to cancer patients, which may be helpful in the shared decision-making for cardioprotective treatment and intensified follow-up.

Comparative discontinuation and non-bleeding side effects of Clopidogrel, Prasugrel and Ticagrelor in patients with acute coronary syndromes; a Network Meta-analysis of Randomized Controlled Trials

Abstract Background P2Y12 receptor inhibitors are highly effective treatment options following ACS. However, premature discontinuation compromises their effectiveness. Although extensive literature exists, the clinical assessment of their adherence remains controversial, requiring definitive investigation. Purpose To evaluate treatment discontinuation and non-bleeding adverse effects associatedwith platelet P2Y12 receptor inhibitors in individuals post-ACS through network meta-analysis. Methods Data Sources: MEDLINE, Embase, Cochrane, and clinicaltrials.gov to May 2021 and later updated to October 2022. Study Selection and Outcomes: Reviewers identified RCTs that enrolled patients post-ACS taking Clopidogrel, Ticagrelor, and Prasugrel. Exclusions included non-ACS indications, anticoagulation therapy, observational studies, and crossover designs. The primary outcomesincludedoverall treatment discontinuation, treatment discontinuation attributed to side effects, and dyspnea. Secondary outcomes included bradycardia and atrial fibrillation. Data Extraction and Synthesis:This network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, employing frequentist random-effects models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework was utilized to assess the certainty of evidence. Results With 139,343 participants in 32 RCTs, the overall treatment discontinuation rate across all studies was 16.57% out of a total of 137,897 participants. Ticagrelor was associated with increased risk for overall treatment discontinuation compared to Clopidogrel (RR, 1.34; 95% CI, 1.19 to 1.49; P&amp;lt;0.0001), Prasugrel (RR, 1.23; 95% CI, 1.07 to 1.41; P=0.0031) and placebo (RR, 1,40; 95% CI, 1.19 to 1.65; P&amp;lt;0.0001). In compatibility to overall treatment discontinuation, Ticagrelor was associated with increased risk for treatment discontinuation due to side effects compared to Clopidogrel (RR, 1.80; 95% CI, 1.36 to 2.38; P&amp;lt;0.0001), Prasugrel (RR, 1.49; 95% CI, 1.06 to 2.10; P=0.0216) and placebo (RR, 1.85; 95% CI, 1.21 to 2.83; P=0.0044). Ticagrelor, Prasugrel and Clopidogrel were associated with an increased risk for dyspnea in comparison to placebo (RR, 2.86; 95% CI, 2.57 to 3.17; P&amp;lt;0.0001; RR, 1.61; 95% CI, 1.35 to 1.91; P&amp;lt;0.0001; RR, 1.60; 95% CI, 1.41 to 1.82; P&amp;lt;0.0001) respectively. Ticagrelor was associated with increased risk for dyspnea compared to Clopidogrel (RR, 1.78; 95% CI, 1.65 to 1.92; P&amp;lt;0.0001) and prasugrel (RR, 1.78; 95% CI, 1.55 to 2.05; P&amp;lt;0.0001). Conclusions The findings of this study suggest that Ticagrelor presents the highest risk for premature discontinuation compared to Clopidogrel and Prasugrel. Additionally, P2Y12 receptor inhibitors, in general, are notably associated with dyspnea, with Ticagrelor showing the highest risk. These results provide health professionals with valuable information for making treatment decisions in patients post-ACS.NMA netgraphsNMA of Overall treatment discontinuation