Management Options Research Articles

Economic Analysis, Yield Optimization, and Competition Dynamics of Groundnut/Cereal Fodder Intercropping Systems in Pakistan's Semi Arid Tropics

This research focuses on the intercropping management options including aspects of yield performance, nitrogen contribution to groundnut and economical considerations through the usage of intercrop Maize, Sorghum and Pearl Millet under varying cuttings treatments. Intercropping is effective in increasing land productivity and efficiency in nutrient use and provides economic returns yet the best combinations have not been well explored. Randomised complete block design was used to assess the growth characteristics of plant height, modulation and nitrogen in sole cropping and intercropping treatments in which they make cuts. For sole crop, both, maize and pearl millet produced the highest green fodder yields of 13.40 t ha⁻¹ and 19.10 t ha⁻¹, respectively, and intercropping reduced the productivity for both crops but it was statistically significant, yield recorded in Maize (one cut) groundnut = 3.10 t ha⁻¹. Both nodulation and nitrogen content were maximum in sole groundnut, but they were lower when groundnut was grown in association with other crops. Among all competitive indices, the LER was the highest on maize (LER=1.72), pearl millet and sorghum indicated that intercropping enhances land use efficiency. This was facilitated by the Monetary Advantage Index (MAI) that provided much support to maize-groundnut intercrop, which was easily identified as the most appropriate option for inter-crop revenue generation with an MAI of Rs. 17,800. These results provide evidence for the suitability of maize as the best intercrop for the enhancement of productivity and profitability in groundnut based intercropping systems. This study adds valuable input to sustainable agriculture, particularly in that it expresses the yields and profits from distinct intercrop associations as numeral digits deemed useful by both the scientific and agricultural communities.

Dermoscopy Training Course Improves Ophthalmologists’ Accuracy in Diagnosing Atypical Pigmented Periorbital Skin Lesions

Background/Objectives: Facial pigmented skin lesions are extremely common, starting from the fourth to fifth decades, especially in South-European countries, often located in the periorbital region. These include malignant forms, Lentigo maligna (LM) and lentigo maligna melanoma (LMM), characterized by growing incidence, and a series of benign simulators, including solar lentigo (SL), pigmented actinic keratosis (PAK), seborrheic keratosis (SK) and lichen planus-like keratosis (LPK). The clinical differential diagnosis of atypical pigmented skin lesions (aPFLs) can be difficult, even for dermatologists, leading to inappropriate skin biopsies with consequent aesthetic impacts. Dermoscopy of the facial area is a specific dermoscopic field that requires dedicated training and proved to increase diagnostic accuracy in dermatologists. Since these lesions are often seen by ophthalmologists at first, we aimed to evaluate the effect of a focused dermoscopy training course on a group of ophthalmologists naïve to the use of a dermatoscope. Methods: A set of 80 periorbital pigmented skin lesions with both clinical and dermoscopic images was selected and evaluated by six ophthalmologists before and after a one-day intensive dermoscopic training course. They were required to evaluate 80 periorbital lesions one month before and after a one-day intensive dermoscopic training course, illustrating second-level diagnostic options such as reflectance confocal microscopy (RCM), obtaining a total of 480 evaluations. Specifically, they had to provide, for each case, a punctual diagnosis and a management option among dermoscopic follow-up/skin biopsy/RCM/LC-OCT. Descriptive statistics were carried out, and the accuracy (ACC), sensitivity (SE), and specificity (SP), with their 95% confidence interval (95% CI), were estimated. Results: In the pre-course test, ophthalmologists achieved 84.0% SP, 33.3% SE and 63.7% ACC, while after the course, SE increased by +9% (i.e., 41.7%), SP decreased by 4%, and ACC remained comparable, i.e., 64.6%. In the management study, the percentage of benign lesions for which a close dermoscopic follow-up was suggested significantly decreased (51.6% versus 22.2%), in parallel with an increase in the number of lesions referred for RCM. As for malignant cases, the reduction in responses “close dermoscopic follow-up” decreased from 37.0% to 9.9%, (−27%), in favor of RCM (+15%) and skin biopsy (+12%). Conclusions: The ophthalmologists proved to be very receptive in quickly metabolizing and putting into practice the concepts learned during the one-day intensive dermoscopy training course. Indeed, after only a one-day lesson, they were able to increase their SE by 9% and to improve their management strategy. The present findings highlight the importance of providing training ophthalmologists in dermoscopy during residency programs, in terms of benefits for the correct patient care.

Spinal Cord Stimulation vs Medical Management for Chronic Back and Leg Pain: A Systematic Review and Network Meta-Analysis.

Chronic back and lower extremity pain is one of the leading causes of disability worldwide. Spinal cord stimulation (SCS) aims to improve symptoms and quality of life. To evaluate the efficacy of SCS therapies compared with conventional medical management (CMM). MEDLINE, Embase, and Cochrane Library were systematically searched from inception to September 2, 2022. Selected studies were randomized clinical trials comparing SCS therapies with sham (placebo) and/or CMM or standard treatments for adults with chronic back or leg pain who had not previously used SCS. Evidence synthesis estimated odds ratios (ORs) and mean differences (MDs) and their associated credible intervals (CrI) through bayesian network meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for network meta-analyses was followed. The primary outcomes were pain-related end points, including pain intensity (measured by visual analog scale) and proportion of patients achieving at least 50% pain relief (responder rate) in the back or leg. Quality of life (measured by EQ-5D index score) and functional disability (measured by the Oswestry Disability Index score) were also considered. A total of 13 studies of 1561 patients were included in the network meta-analysis comparing conventional and novel SCS therapies with CMM across the 6 outcomes of interest at the 6-month follow-up. Both conventional and novel SCS therapies were associated with superior efficacy compared with CMM in responder rates in back (conventional SCS: OR, 3.00; 95% CrI, 1.49 to 6.72; novel SCS: OR, 8.76; 95% CrI, 3.84 to 22.31), pain intensity in back (conventional SCS: MD, -1.17; 95% CrI, -1.64 to -0.70; novel SCS: MD, -2.34; 95% CrI, -2.96 to -1.73), pain intensity in leg (conventional SCS: MD, -2.89; 95% CrI, -4.03 to -1.81; novel SCS: MD, -4.01; 95% CrI, -5.31 to -2.75), and EQ-5D index score (conventional SCS: MD, 0.15; 95% CrI, 0.09 to 0.21; novel SCS: MD, 0.17; 95% CrI, 0.13 to 0.21). For functional disability, conventional SCS was superior to CMM (MD, -7.10; 95% CrI, -10.91 to -3.36). No statistically significant differences were observed for other comparisons. This systematic review and network meta-analysis found that SCS therapies for treatment of chronic pain in back and/or lower extremities were associated with greater improvements in pain compared with CMM. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management.

Newly Established Bermudagrass Response to Topramezone and Photosystem II-Inhibitor Herbicides

Abstract Bermudagrass is the most troublesome and difficult-to-control perennial grass weed in Florida sugarcane. Once established, it is only controlled effectively during the sugarcane fallow period using nonselective herbicides and tillage combinations. It is important to evaluate options for selective management of bermudagrass that escape sugarcane fallow period management programs to mitigate its progressive increase as the crop cycle increases from plant cane to ratoon crops. Greenhouse and field studies were conducted in Belle Glade, Florida, from 2017 to 2018 to determine the response of newly established bermudagrass from sprigs with stolons to two or three sequential applications of topramezone (25 and 50 g ha-1) every 14 d and the combinations of topramezone (25 and 50 g ha-1 ) with photosystem II (PS II)-inhibitor herbicides atrazine (2,240 g ha-1), ametryn (440 g ha-1), and metribuzin (2,240 g ha-1). Two or three sequential applications of topramezone with a cumulative total of 75 to 100 g ha-1 provided >93% bermudagrass control 42 d after the first sequential application under greenhouse and field conditions. These treatments had 12% chance of survival 70 d after the first sequential application. There was an additive effect of PS-II inhibitor herbicides on bermudagrass control in mixtures with topramezone. The mixture of topramezone (50 g ha-1) with metribuzin and atrazine provided more than 87% and 92% bermudagrass control under greenhouse and field conditions, respectively, 42 d after treatment. Bermudagrass treated with topramezone (50 g ha-1) mixture with metribuzin had 23% chance of survival 70 d after treatment. The results show good efficacy of sequential topramezone applications every 14 d or mixtures with PS-II inhibitor herbicides atrazine and metribuzin for control of newly established bermudagrass which typically escape control measures during the sugarcane fallow management period.

Abstract A027: Systematic review of real-world adherence to blood-based laboratory tests for average-risk disease screening: potential implications for emerging colorectal cancer screening modalities

Abstract Introduction: Blood-based tests represent a compelling option for early detection and management of cancers and other chronic diseases. While blood-based tests may offer potential to increase patient engagement, the assumption of greater adherence in clinical practice requires further evaluation. This systematic review aimed to evaluate the real-world adherence to established blood-based tests for commonly recommended screening indications, to better inform expectations for proposed application to average-risk colorectal cancer (CRC) screening. Methods: A systematic search of PubMed, Embase, and citations was performed to identify literature published from 2010 to 2023. Studies examined adherence to routine blood-based laboratory tests with a Grade A or B recommendation per the United States Preventive Services Task Force (USPSTF) for diabetes, dyslipidemia, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) in an average-risk patient population were included. In addition, prostate-specific antigen (PSA) testing adherence for prostate cancer screening (Grade-C USPSTF recommendation), the only commonly accessible blood-based single-cancer screening test for average-risk adults, was also included. Studies without venipuncture-derived blood were excluded. Results: Of 53,067 articles screened, 69 were included in the analysis. Overall, adherence rates of blood-based tests were highly variable, with median values (interquartile range, IQR) of 66.3% (11.8%), 67.8% (18.0%), 34% (28.7%), and 36.8% (30%) for diabetes, dyslipidemia, HCV, and HIV, respectively. PSA testing adherence was 37.2% (18.4%). Beyond disease type, adherence varied by study design, data source, patient characteristics, clinical setting, and study country. Information and selection bias were the most common risks of bias. Conclusions: Based on data from this comprehensive systematic review, real-world adherence to currently recommended, blood-based screening strategies is suboptimal. Future research is needed to identify the extent to which these data are generalizable to blood-based CRC screening, and to determine if/how this candidate strategy would impact clinical, economic, and health equity outcomes. Citation Format: Quang A. Le, Takako Kiener, Heather A. Johnson, Rukaiyya S. Khan, Joyce Kong, Kevin H. Li, Gina Thompson, A. Burak Ozbay, Mallik Greene, Paul J. Limburg, A. Mark Fendrick, John B. Kisiel, Derek W. Ebner. Systematic review of real-world adherence to blood-based laboratory tests for average-risk disease screening: potential implications for emerging colorectal cancer screening modalities [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr A027.

HPB SO35 - Outcomes of Transcystic Laparoscopic Common Bile Duct Exploration at the time of Laparoscopic Cholecystectomy in patients with small common bile duct diameter

Abstract Background Laparoscopic Cholecystectomy with Laparoscopic Common Bile Duct Exploration (LC+LCBDE) is a single stage therapeutic option for management of choledocholithiasis. There have been limited publications regarding the feasibility of transcystic LCBDE in patients with small (≤8mm) common bile ducts (CBD). This study seeks to examine the outcomes for patients with small ducts who underwent LC+LCBDE via a transcystic approach (LCBDE-t) in a district general hospital over a thirty-month period. Method Prospectively collected data regarding all patients who underwent LC+LCBDE-t over a period from January 2022 to June 2024 was retrospectively reviewed. Data including indication for surgery, CBD diameter, length of stay, complication rate, and readmission rate were determined from Electronic Care Records. Data were analysed using Microsoft Excel. Results 76 patients were identified. CBD diameter (almost all as measured at pre-operative Magnetic Resonance Cholangiopancreatography [MRCP]) ranged from 3.5mm to 8mm (average 6.32). One patient required conversion to open surgery due to difficulties with the LC element of the operation. Median postoperative length of stay was 1 day (range 0-32 days) and readmission rate was 5.33%. Five patients experienced a complication beyond Clavien-Dindo Grade II, with the most serious two being a bile leak and a postoperative bleed, both of which required further surgery. One patient required subsequent Endoscopic Retrograde Cholangiopancreatography (ERCP) for retained CBD stones. Conclusion LCBDE is a safe and effective management option for patients in the setting of choledocholithiasis with small CBD diameter. Small CBD should not necessarily be a deterrent to consideration of transcystic LCBDE as a therapeutic option in appropriately selected patients.

Investigating the Role of Inositol: Myo-inositol and D-Chiro-inositol in Diabetes: A Review

The sugar alcohol known as inositol and its derivatives are becoming more and more interesting in metabolism-related research studies due to its physiological roles. Inositol derivatives mainly myoinositol and d-chiroinositol have gained so much attention these days in the context of managing and treating metabolic issues such as diabetes and polycystic ovarian syndrome. For a long time, it was considered as the vitamin B, but later we got to know it is produced from glucose so considered non-essential. Nowadays rising rates of obesity which are further linked with diabetes and polycystic ovarian syndrome have fuelled demand for artificial sweeteners. Many people are searching for options to maintain their weight, which has led to the widespread usage of sucrose and fructose substitutes in the food industry. Sugar alcohols such as myoinositol and d chiroinositol (which are not been commonly used) in particular can be metabolized without the need for insulin control and have little effect on blood sugar levels. These sugar substitutes have the potential to provide sweetness without raising blood sugar levels and adding calories. These have half of the sweetness of sucrose. This paper aims to thoroughly investigate and understand the various roles played by inositol in the complex field of managing metabolic diseases. To find out the eligible papers for review paper screening has been performed through PubMed, Science Direct, Web of Science and Google Scholar. Different sets of keywords such as inositol, d chiro inositol, myo-inositol, insulin-resistance, diabetes, insulin sensitivity, DCI and type 2 diabetes mellitus were used. Studies which full text article were present used for the review. Research articles have been included the studies specifically to find out the relation between myoinositol and diabetes or any metabolic disease. The development of many diseases, such as PCOS and diabetes, is linked with inositol deficiency. Myoinositol is derived from the food we eat as well as from within. The low levels of MI can be the result of several factors, including decreased dietary intake, increased catabolism, alterations in the gut and reduced biosynthesis. These two forms, myoinositol and d-chiroinositol play significant roles in regulating lipid metabolism and glycaemic control. glycaemic metabolism and this are also supported by many research studies. Therefore, it can be a possible treatment or management option for people suffering from metabolic issues such as diabetes and PCOS. Future studies should focus on how we can increase the intake of myoinositol through diet and dietary food products.

Outcomes of Conservative Treatments Evaluations for Lumbar Radiculopathy

Background: Lumbar Radiculopathy (LR) is a condition characterized by motor, reflex and sensory changes, often causing significant pain and disability. Conservative treatments are commonly recommended as initial management options. This study aims to evaluate the outcomes of various conservative treatments for LR. Materials and methods: This prospective cohort study involved 100 patients diagnosed with LR who underwent conservative treatments between January 2023 and December 2023 at our Physical Medicine Department, Institute of Applied Health Sciences (IAHS). Treatments included physical therapy, NSAIDs, epidural steroid injections and activity modification. Baseline data, including demographic information, pain intensity (VAS) functional status (ODI) and quality of life (SF-36), were collected. Follow-up assessments were conducted at 6 weeks, 3 months and 6 months. Primary outcomes were changes in VAS, ODI and SF-36 scores. Secondary outcomes included patient satisfaction and the need for additional interventions. Data were analyzed using descriptive statistics, paired t-tests and ANOVA. Results: The mean age of participants was 45.3 years, with a slight male predominance (56%). At baseline, mean VAS was 7.8, ODI was 45.6 and SF-36 was 62.5. Significant reductions in VAS (2.6), ODI (18.7), and improvements in SF-36 physical (80.3) and mental (81.7) scores were observed at 6 months (p<0.05). Patient satisfaction at 6 months was highest for epidural injections (90%), followed by NSAIDs (85%), physical therapy (80%) and activity modification (70%). The need for additional interventions decreased to 8%. The incidence of adverse events was low, with physical therapy showing the lowest rates. Initial ODI score was a significant predictor of positive outcomes (p=0.03). Conclusion: Conservative treatments for LR are effective in reducing pain and disability and improving quality of life. All treatment modalities showed comparable efficacy, with low adverse event rates, supporting their use as first-line treatments. Initial disability levels should be considered in treatment planning to optimize outcomes. Further research is needed to refine predictive models and enhance individualized treatment strategies. IAHS Medical Journal Vol 7(1), June 2024; 80-85

Abstract 4134345: Diastolic Dysfunction And The Risk Of Stroke And Major Bleeding

Background: Diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident ischemic stroke/transient ischemic attack (TIA) and with bleeding events is not well established. Aims: To examine the association of presence and severity of DD with the risk of incident ischemic stroke/TIA and major bleeding. Methods: A total of 219,667 patients who underwent at least one echocardiogram between 2010 and 2022 at a large academic institution and were followed for at least 3 months were included. Patients with prior history of stroke or TIA (n=21,505, 10%) were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups, based on the most severe DD assessment: Normal (n=113,265), grade I (n=21,981), grade II (n=7,215), and grade III (n=1,627). Patients in whom the presence of DD could not be determined (n=54,074) were excluded. The final study cohort (n=144,088) was followed to the endpoint of hospital admission for ischemic stroke/TIA or for major bleeding. Results: Over a median follow-up of 3.4 years, 3482 (2.4%) patients were hospitalized for stroke/TIA and 6994 (4.9%) for major bleeding. After adjusting for several confounding variables (Table), DD remained a strong predictor of incident stroke/TIA (hazard ratio (HR)=1.34 per grade increase in DD, p<0.001, Figure) and of major bleeding (HR=1.32 per grade increase in DD, p<0.001, Figure). These results were similar in patients with (n=11,508, 8%) or without prior history of atrial fibrillation. Conclusions: Patients with DD have a heightened risk of ischemic cerebrovascular accidents and major bleeding independent of the presence of atrial fibrillation. These risks escalate with the severity of DD. DD should be considered when counseling patients regarding their risk profile and management options.

Management of Sacrocolpopexy Mesh Complications-A Narrative Review and Clinical Experience from a Large-Volume Center.

Despite the reputation of sacrocolpopexy as a highly durable reconstructive surgery for pelvic organ prolapse, mesh-related complications remain a significant deterrent for patients. This review discusses the incidence, presentation, diagnosis, management and prevention of sacrocolpopexy mesh complications. We reviewed the literature on sacrocolpopexy focusing on long-term mesh complications and their management. As the literature is not specifically robust, we also give our recommendations based on experience from a large-volume center. Intraoperative videos and images are provided to illustrate findings and management techniques. Sacrocolpopexy mesh complications include vaginal mesh exposure; bladder or bowel erosions; inflammatory and infectious conditions including spondylodiscitis; and mesh-related pain. Presentation ranges from overt symptoms such as mesh palpated in the vagina to insidious-like spondylodiscitis manifesting as back pain and malaise. Diagnosis relies on methodical history taking, review of operative reports, and a physical examination, with office-based endoscopy studies and imaging as indicated. Various management options have been described in the literature. We recommend an expectant approach for asymptomatic patients; For symptomatic vaginal exposure, we encourage removal of entire mesh arm(s) via an abdominal approach; however, many prefer to utilize a transvaginal or partial excisional approach first. Spondylodiscitis is managed with long-term antibiotics and often requires mesh removal. Prevention strategies include using a lightweight polypropylene mesh attached to well- vascularized vaginal walls, avoiding direct placement on any sutured vaginotomy or cystotomy. Delayed absorbable monofilament suture is non-inferior to permanent suture. Sacrocolpopexy mesh complications can be challenging to diagnose and manage. Symptomatic cases often require a proactive approach; listening to patients when they describe persistent symptoms with postoperative onset; a low threshold for further evaluation; and upfront discussion of management options.

Alternatively activated macrophages are associated with faster growth rate in vestibular schwannoma

Abstract The variability in vestibular schwannoma growth rates greatly complicates clinical treatment. Management options are limited to radiological observation, surgery, radiotherapy and, in specific cases, bevacizumab therapy. As such, there is a pressing requirement for growth restricting drugs for vestibular schwannoma. This study explored potential predictors of vestibular schwannoma growth in depth, highlighting differences between static and growing vestibular schwannoma to identify potential therapeutic targets. High dimensional imaging was used to characterise the tumour microenvironment of four static and five growing vestibular schwannoma (indicated by volumetric change < 20% or ≥ 20% per year, respectively). Single cell spatial information and protein expression data from a panel of 35 tumour immune-targeted antibodies identified specific cell populations, their expression profiles, and their spatial localisation within the tumour microenvironment. Growing vestibular schwannoma contained significantly more proliferative and non-proliferative alternatively activated tumour-associated macrophages per mm2 compared to static vestibular schwannoma. Furthermore, two additional proliferative cell types were identified in growing and static vestibular schwannoma: transitioning monocytes and Programmed Cell Death Ligand 1 (PD-L1+) Schwann cells. In agreement, growing vestibular schwannoma were characterised by a tumour microenvironment composed of immune-enriched, proliferative neighbourhoods, whereas static vestibular schwannoma were composed of tumour-enriched, non-proliferative neighbourhoods. Finally, classically activated macrophages significantly co-localised with alternatively activated macrophages in static vestibular schwannoma, but this sequestration was reduced in growing vestibular schwannoma. This study provides a novel, spatial characterisation of the immune landscape in growing vestibular schwannoma, whilst highlighting the need for new therapeutic targets that modulate the tumour immune microenvironment.

Comparing the Effect of Topical Lignocaine and Bupivacaine in Nasal Packs for Pain Relief in Post Operative Nasal Surgery Patients

This randomized controlled trial compared the analgesic efficacy of lignocaine, bupivacaine, and placebo nasal packs in patients undergoing nasal surgeries, including septoplasty and functional endoscopic sinus surgery (FESS). A total of 100 patients, aged 18–60 years, were randomly assigned into three groups: lignocaine (n=34), bupivacaine (n=33), and placebo (n=33). Postoperative pain was assessed using the Visual Analog Scale (VAS) over 24 hours. Additional analgesic requirements, side effects, recovery time, and length of hospital stay were recorded. Bupivacaine provided significantly lower pain scores at all intervals compared to lignocaine and placebo (p < 0.05). The bupivacaine group had a lower need for additional analgesics (39.4%) compared to lignocaine (76.5%) and placebo (81.8%) (p = 0.041). Side effects such as nausea and vomiting were similar across all groups. The bupivacaine group experienced a shorter hospital stay (2.0 days) compared to the lignocaine (2.5 days) and placebo (3.0 days) groups (p = 0.038). In conclusion, bupivacaine-soaked nasal packs offer superior pain relief, reduce the need for additional analgesics, and shorten hospital stays, making it a preferable option for postoperative pain management in nasal surgeries.

Abstract 4134417: Cardiotoxicity Conundrum: Distinguishing Immune Checkpoint Inhibitor Myocarditis from Fluorouracil Cardiotoxicity in Concurrent Therapy

Case Description: The patient is a 37-year-old male with metastatic gastroesophageal junction adenocarcinoma presenting with chest pain and dyspnea two days after initiation of leucovorin, fluorouracil, oxaliplatin (FOLFOX), and nivolumab therapy. He was tachycardic and hypotensive with elevated cardiac biomarkers and globally reduced left ventricular systolic function. Suspecting immune checkpoint inhibitor (ICI) myocarditis versus fluorouracil (5-FU) cardiotoxicity, he was treated simultaneously for both. After starting high-dose steroids and before uridine triacetate, he had improved symptoms, cardiac function, biomarkers, and invasive hemodynamics. Though his endomyocardial biopsy did not show inflammatory cell infiltrates, his CMR demonstrated increased T1 and T2 relaxation times consistent with myocarditis. Testing revealed normal dihydropyrimidine dehydrogenase (DPD) activity. He completed uridine triacetate and was discharged on a steroid taper. At follow-up, he remained clinically stable, tolerating oxaliplatin and docetaxel (FLOT) initiation and nivolumab rechallenge without 5-FU. Discussion: This case is challenging as the presentation does not conclusively identify a causative agent. The patient’s symptom severity suggests ICI myocarditis, while the early onset points to 5-FU cardiotoxicity. His quick recovery of cardiac function after medication cessation suggests 5-FU-associated Takotsubo cardiomyopathy. His improvement after steroids raises concern for an adverse immunologic response as in ICI myocarditis or idiosyncratic reactions to oxaliplatin with 5-FU. This patient received ICI therapy and chemotherapy, increasing his risk for cardiac immune-related adverse events. His protracted 5-FU infusion increased his risk for 5-FU cardiotoxicity, but his normal DPD activity mitigates this risk. Although his biopsy was negative, it cannot exclude ICI myocarditis. By the IC-OS 2021 consensus, he meets the criteria for ICI myocarditis presenting 48 hours after nivolumab exposure with cardiogenic shock, elevated cardiac biomarkers, decline in cardiac function, and CMR with elevated T1 and T2 relaxation times. Yet, his biomarkers remained normal with nivolumab rechallenge, arguing against ICI myocarditis and suggesting 5-FU as the culprit. Early recognition and differentiation of the culprit in concurrent therapies impact management and future treatment options. Rechallenge carries risk and requires interdisciplinary collaboration to ensure patient safety.

Using a behaviour-change approach to support uptake of population genomic screening and management options for breast or prostate cancer.

As the possibility of implementing population genomic screening programs for the risk of developing hereditary cancers in health systems increases, understanding how to support individuals who wish to have genomic screening is essential. This qualitative study aimed to link public perceived barriers to a) taking up the offer of population genomic screening for breast or prostate cancer risk and b) taking up risk-management options following their result, with possible theory-informed behaviour-change approaches that may support implementation. Ten focus groups were conducted with a total of 25 members of the Australian public to identify and then categorise barriers within the behaviour-change Capability, Opportunity, Motivation - Behaviour (COM-B) model. Ten COM-B categorised barriers were identified as perceived influences on an individual's intentions to take-up the offer, including Capability (e.g., low public awareness), Opportunity (e.g., inconvenient sample collection procedure) and Motivation (e.g., genomic screening not perceived as relevant to an individual). Ten barriers for taking up risk-management options included Motivation (e.g., concerns about adverse health impact) and Opportunity (e.g., social opportunity and cost incurred to the individual). Our findings demonstrate that a nuanced approach is required to support people to take-up the offer of population genomic screening and, where appropriate, to adopt risk-management options. Even amongst participants who were enthusiastic about a population genomic screening program, needs were varied, demanding a range of implementation strategies. Promulgating equitable uptake of genomic screening and management options for breast and prostate cancer risk will require a needs-based approach.

Abstract 4147610: Efficacy and Safety of Selective Cardiac Myosin Inhibitors in Symptomatic Hypertrophic Obstructive Cardiomyopathy: A Meta-Analysis of Randomized Controlled Trials

Background: Hypertrophic Obstructive Cardiomyopathy (HOCM) is an autosomal dominant inherited condition with limited management options, primarily focusing on symptom improvement through beta blockers. A novel selective cardiac myosin inhibitor, Mavacamten has been shown to improve exercise tolerance and NYHA functional class as compared to placebo in multiple randomized controlled trials (RCTs). A recent RCT from 2024 studied another oral cardiac myosin inhibitor, Aficamten which potentially decreases left ventricular outflow tract obstruction (LVOTO) in symptomatic HOCM. One limitation of all these RCTs, for obvious reasons, is the small sample size, which poses a challenge in its actual clinical significance. Aims: To analyze the efficacy and safety of novel selective cardiac myosin inhibitors in symptomatic HOCM patients Methods: We included 4 RCTs, comparing the efficacy and safety of selective cardiac myosin inhibitors and placebo groups. These studies were selected through a detailed search of the MEDLINE, COCHRANE, and PUBMED databases. We compared various common primary and secondary endpoints between both the groups: changes in exercise tolerance, NYHA functional class, and Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS). The results were reported as Odds Ratios (OR) with 95% confidence intervals (CI), using a random effects model. Results: The outcomes from 704 HOCM patients, which consisted of 361 patients who received a myosin inhibitor and 343 who received a placebo were analyzed. The primary endpoint in all the studies was improvement in exercise tolerance [measured as 1.5 mL/kg per min or greater increase in peak oxygen consumption (pVO2)], which was not statistically significant in our study (OR: 1.75, 95% CI: 0.89-3.43, p:0.1). There was a statistically significant improvement in ≥1 NYHA functional Class (OR: 3.9, 95% CI:2.49-6.12 p<0.05). There was no significant change seen in KCCQ-CSS (OR: 1.26, 95% CI: 0.75-2.12, p:0.3) and1 or more Serious Adverse Events (OR: 0.75, 95% CI: 0.42-1.32, p:0.3). (Figures A-D) Conclusion: Novel cardiac myosin inhibitors have shown statistically significant results in improving NYHA functional class, but not much difference in objective criteria like pVO2 with no significant adverse events. While these results appear promising and 2024 ACC/AHA guidelines have Class 1 Recommendation regarding their use for symptomatic HOCM, further analysis from a large population is needed.

Risk Factors and Management of Portal Vein Thrombosis after Hepatectomy: A Single-Center Experience

Objective: This study investigated the risk factors and management of portal vein thrombosis (PVT) after hepatectomy. Background: PVT after hepatectomy can cause liver dysfunction and portal hypertension, and may be fatal. However, it has not been sufficiently investigated. Methods: The study included 1403 consecutive patients who underwent elective hepatectomy at our department from January 2010 to July 2022. The patients were divided into PVT and non-PVT groups based on the presence or absence of PVT, and relevant risk factors were analyzed. The management and prognosis of patients with PVT were investigated. Results: Among the 1403 patients, PVT occurred in 33 cases, giving a frequency of 2.4%. In univariate analyses, female sex (P = 0.03), portal vein reconstruction (P = 0.01), and left lateral sectionectomy (P < 0.001) were significant risk factors for PVT. On multivariate analysis, portal vein reconstruction (P = 0.01) and left lateral segmentectomy (P < 0.001) remained significant risk factors for PVT. The management options for PVT were thrombectomy, antithrombotic therapy, and observation. With antithrombotic therapy, 96.4% of patients achieved PVT resolution. Among patients who underwent hepatectomy with portal vein reconstruction, the PVT site was the main trunk of the portal vein in all 3 cases, and thrombectomy was performed in 2 cases. No perioperative mortality was observed. Conclusions: In the present study, portal vein reconstruction and left lateral sectionectomy were identified as risk factors for PVT after hepatectomy. As PVT can be fatal, early detection and appropriate treatment according to the status of PVT are important.

Current Concepts of the Management of Painful Traumatic Peripheral Nerve Neuromas

Painful neuromas are a complex clinical condition that results in notable disability and functional impairment after injury to a peripheral nerve. When regenerating axons lack a distal target, they form a stump neuroma. Up to 60% of neuromas are painful because of mechanical sensitivity and crosstalk between nerve fibers. Clinical evaluation includes a thorough history and physical examination followed by directed diagnostic imaging and procedures to assess pain generators and their effect on quality of life. Nonsurgical management options may include pharmacological interventions, desensitization strategies, injections, and therapies to reduce pain perception and improve function. Surgical interventions, such as nerve reconstruction by direct repair or grafting, redirection to alternative targets, and containment of regenerating axons by relocation into innervated tissues or in grafts, are considered when conservative measures fail. A comprehensive and individualized treatment plan is crucial for optimizing patient outcomes with painful neuromas. The plan should consider the underlying pathology, pain generators, and psychosocial factors contributing to the patient's pain.

Diastolic Dysfunction and the Risk of Stroke and Major Bleeding.

Left ventricular diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident stroke and transient ischemic attack (TIA) and with bleeding events is not known. We performed this observational cohort analysis to examine the impact of DD on the risk of stroke/TIA and major bleeding. Patients who underwent at least 1 cardiac echocardiogram and were followed for at least 3 months were included in this study. Patients with a prior history of stroke, TIA, or major bleeding, as determined by International Classifications of Diseases codes, were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups based on the most severe DD assessment. Patients in whom the presence of DD could not be determined were excluded. The final study cohort was followed to the end point of hospital admission for stroke/TIA and major bleeding, and independent predictors of these events were evaluated using the multivariable Cox proportional hazards method. The final study cohort (age, 56±18 years; 56% women) had 96 702 patients with no DD and 18 164, 5881, and 1340 patients with DD grades I, II, and III, respectively. Over a median follow-up of 3.4 years, 2938 (2.4%) patients were hospitalized for stroke/TIA and 5567 (4.6%) for major bleeding. After adjusting for age, the CHA2DS2-VASc score, chronic kidney disease, use of antiplatelet agents, use of anticoagulation agents, the year of echocardiographic testing, household income, and history of atrial fibrillation, DD remained a strong predictor of incident stroke/TIA (hazard ratio, 1.22 per grade increase in DD [95% CI, 1.16-1.29]; P<0.001) and major bleeding (hazard ratio, 1.20 per grade increase in DD [95% CI, 1.16-1.25]; P<0.001). DD is independently associated with a higher risk of cerebrovascular accidents and major bleeding. DD should be considered when counseling patients regarding their risk profile and management options.

Dumping syndrome: Update on pathophysiology, diagnosis, and management.

Dumping syndrome is a complex of gastrointestinal symptoms originally studied in peptic ulcer surgery patients. At present, it is most prevalent in patients who underwent bariatric, upper gastrointestinal cancer or anti-reflux surgery. The symptom pattern comprises early and late dumping symptoms. Several management options have been reported including nutritional, pharmacological and surgical approaches. In this study, we aimed to review the current evidence on dumping syndrome definition, diagnosis and treatment, including preliminary data from newer pharmacological studies. Current pathophysiological concepts and analyses of provocative tests has led to a clear definition of dumping syndrome, including both early and late dumping symptoms. The term postbariatric hypoglycemia represents a limited focus on late dumping only. The diagnosis relies on recognition of symptoms and signs in a patient with appropriate surgical history; and can be confirmed by provocative testing or registration of spontaneous hypoglycemia. The initial treatment focuses on dietary intervention, to which meal viscosity enhancers and/or the glycosidase inhibitor acarbose can be added. The most effective therapy is the use of short- or long-acting somatostatin analogues, which is however expensive and entails side effect issues. In case of refractory hypoglycemia, diazoxide or SGLT2 inhibitors can be considered, based on limited evidence. In refractory patients, continuous enteral feeding or (rarely) surgical reinterventions have been advocated, although not supported by solid evidence. Therapies under current evaluation include the broad-spectrum somatostatin analogue pasireotide, GLP-1 receptor antagonists, GLP-1 receptor agonists and administration of stable forms of glucagon are currently under study. Dumping syndrome is a well-defined but probably under-diagnosed complication of upper gastrointestinal, especially bariatric, and surgeries. Diagnosis is confirmed by a provocative test and incremental therapies starting with diet, adding meal viscosity enhancers or glycosidase inhibitors and adding somatostatin analogues in refractory cases. A number of emerging therapies targeting intestinal propulsion, peptide hormone effects and hypoglycemic events are under evaluation.

Calcium Release Deficiency Syndrome (CRDS): Rethinking “Atypical” Catecholaminergic Polymorphic Ventricular Tachycardia

Since the first description of catecholaminergic polymorphic ventricular tachycardia (CPVT) in the 1970s, new insights have progressively unraveled the understanding of this inherited arrhythmia syndrome. The identification of new distinct clinical entities related to RYR2, the gene encoding the cardiac ryanodine receptor, has allowed significant refinement in the diagnosis of previously labeled “atypical” CPVT cases. Among RYR2-ryanodinopathies, the characterization of calcium release deficiency syndrome (CRDS) is still in its infancy and represents a diagnostic challenge due to the need for functional studies which may confirm the loss-of-function nature of the RYR2 variant. The present review summarizes current evidence on CRDS. First, by providing an overview on RYR2 structure and function, we will elucidate the different pathophysiological underpinnings of CRDS and CPVT. Second, by retrieving in detail reported CRDS variants and their clinical phenotypes, we will provide, if any, genetic and clinical red flags that should raise suspicion for CRDS in daily clinical practice. Finally, we will discuss available therapies to provide clinicians with practical therapeutic options for CRDS management.