Maximum Follow-up Research Articles

Baseline right ventricular-pulmonary artery uncoupling and mortality following transcatheter aortic valve replacement: a meta-analysis

Abstract Background In severe aortic stenosis (AS) patients, elevated left-sided filling pressures can lead to pulmonary hypertension and right ventricular (RV) systolic dysfunction. These conditions signal advanced disease and predict poor outcomes in transcatheter aortic valve replacement (TAVR) cases. However, recent studies indicate potential recovery post-TAVR, with improved prognosis. The newly recognized index, RV to pulmonary artery (RV-PA) coupling, reflects the RV's ability to handle pulmonary afterload and is associated with adverse outcomes. Purpose This study aimed to delineate the prognostic role of baseline RV-PA uncoupling in patients undergoing TAVR. Methods We conducted a systematic literature search for studies assessing RV-PA coupling indices at baseline in patients undergoing TAVR. We recorded the year of publication, method of RV-PA assessment, the proposed cutoffs, patients’ age-sex, and follow-up duration. The primary outcome of interest was all-cause mortality at maximal follow-up and the adjusted hazard ratios of RV-PA uncoupling for all-cause mortality were extracted. Pooling of the hazard ratios was conducted according to a random effects model. I2 was chosen as the measure of between-study heterogeneity, with values exceeding 50% being significant. Results We identified a total of 316 studies, of which 5 were ultimately selected for data extraction and inclusion in the meta-analysis after screening of title/abstract/full-text. All but one study utilized the Tricuspid Annular Plane Systolic Excursion/Pulmonary artery systolic pressure (TAPSE/PASP) as the method of RV-PA assessment. The mean age of the participants across the studies was approximately 81 years old, with a balanced male:female ratio. The median follow-up duration was 23 months (range: 6-40 months). According to the results of the meta-analysis, the presence of baseline RV-PA uncoupling was associated with a 2.8-fold increased risk of all-cause mortality at maximal follow-up (Figure). Significant between-study heterogeneity was detected. An asymmetric funnel plot was inspected, indicative of publication bias (Egger’s test intercept: 6.76, 95% confidence interval 5.07-8.44, p=0.004). The results, although attenuated, remained significant even after a trim-and-fill analysis (3 studies added, hazard ratio: 1.27, 95% confidence interval: 0.03-2.51, p=0.04). Furthermore, the results were unaffected following a sensitivity analysis with the leave-one-out method. Conclusion This meta-analysis suggests that baseline RV-PA uncoupling prior to TAVR is associated with all-cause mortality and it could serve as an imaging biomarker of prognosis in this patient population.Figure

Right ventricular-pulmonary artery coupling and clinical outcomes after mitral transcatheter edge-to-edge repair: A meta-analysis

Abstract Introduction Mitral transcatheter edge-to-edge repair (TEER) has gained prominence in the realm of cardiovascular care, as it has been proven to improve patient prognosis and quality of life. While the primary focus of such interventions is the mitral valve itself, understanding the broader impact of right ventricular function and pulmonary artery dynamics is crucial for a comprehensive assessment of clinical efficacy and patient outcomes. A newly recognized index, right ventricular-pulmonary artery (RV-PA) coupling, reflects the RV's ability to handle pulmonary afterload and is associated with adverse outcomes. Purpose This meta-analysis consolidates findings from diverse studies to systematically evaluate the association between RV-PA coupling parameters and the success of mitral TEER. Methods We conducted a systematic literature search for studies assessing RV-PA coupling indices at baseline in patients undergoing mitral TEER. We recorded the year of publication, method of RV-PA assessment, and the proposed cutoffs. The primary outcome of interest was the combined primary endpoint of included studies at maximal follow-up and the adjusted hazard ratios of RV-PA uncoupling were extracted if they were available. Secondary outcomes included mortality and post-operative mitral regurgitation at follow-up. Pooling of the hazard ratios was conducted according to a random effects model. I2 was chosen as the measure of between-study heterogeneity, with values exceeding 50% being significant. Results We identified a total of 316 studies, of which 8 were ultimately selected for data extraction and inclusion in the meta-analysis after screening of title/abstract/full-text. All but one study utilized the Tricuspid Annular Plane Systolic Excursion/Pulmonary artery systolic pressure (TAPSE/PASP) as the method of RV-PA assessment. According to the results of the meta-analysis, the presence of baseline RV-PA uncoupling was associated with a 2.3-fold increased risk of facing the combined primary endpoint at maximal follow-up (Figure, Panel A). All-cause mortality was also approximately 2.2-fold higher in cases of RV-PA uncoupling (Figure, Panel B). Finally, post-operative MR was 1.4-fold higher in cases of RV-PA uncoupling (Figure, Panel C). Significant between-study heterogeneity was detected in all the examined endpoints. Conclusion: This meta-analysis indicates that RV-PA uncoupling at baseline represents an important prognostic marker in patients undergoing mitral TEER.Figure

Symptomatic patients without coronary artery disease do not have excess cardiovascular risk compared to the general population

Abstract Background Patients with stable angina with no coronary atherosclerosis by coronary computed tomography angiography (CCTA) have a lower cardiovascular risk compared to CCTA patients with greater atherosclerotic burden. However, it remains unknown whether these symptomatic patients have excess cardiovascular risk when compared to the general population and if any excess risk is sex or age dependent. Purpose To examine the 10-year cardiovascular risk and mortality in patients with no coronary atherosclerosis by CCTA compared to a matched general population comparison cohort. Methods We included every symptomatic CCTA patient with no coronary artery disease (CAD), defined as no coronary plaques and Agatston calcium score of 0, in Western Denmark from 2008-2021. Each patient was matched by age and sex with 5 individuals with no previous history of ischemic heart disease from the Western Danish general population. Maximum follow-up was 10 years. Outcomes were myocardial infarction, ischemic stroke, and all-cause death. We estimated 10-year risk difference (RD) and incidence rate ratios (IRR) using a conditional Poisson regression, comparing patients with no CAD to the general population cohort. Additionally, we performed age- (<45 year, 45-65 years, and ≥65 years) and sex stratified analyses. Results We included 39,223 patients with no CAD who were matched with 196,115 individuals from the general population. Median age was 54 and 60% were women. Baseline use of anti-thrombotic agents, statins, and anti-hypertensive drugs was higher in patients with no CAD than the general population. Median follow-up was 6.1 years. CCTA patients with no CAD had lower risk of myocardial infarction [RD -0.2%, IRR 0.75 (95% CI 0.65-0.85)] and death [RD -3.3%, IRR 0.51 (95% CI 0.48-0.55)], but similar risk of ischemic stroke [RD 0.0%, IRR 0.93 (95% CI 0.84-1.02)] compared to the general population (Figure 1). However, patients <45 years had higher 10-year risk of both myocardial infarction and ischemic stroke despite absence of CAD by CCTA compared the general population (Figure 2). Conclusions Symptomatic patients without CAD by CCTA do not have excess cardiovascular risk when compared to a general population cohort without known ischemic heart disease. Future cardiovascular risk management of these patients should therefore follow primary prevention guidelines. However, patients <45 years did exhibit higher risk of ischemic outcomes and may require intensified preventative treatment.Figure 1Figure 2

Antithrombotic treatment in univentricular heart

Abstract Background Univentricular heart (UVH) corrected with Fontan surgery may be associated with an increased risk of thrombosis. Data regarding optimal thrombotic prevention strategy after Fontan surgery in patients with UVH is scarce, and guidelines for antithrombotic treatment are not yet available. Purpose The aim was to evaluate the prevalence of antithrombotic treatments and their relation to mortality in patients with Fontan circulation. Methods A total of 5,075 patients with UVH were identified using data from the Swedish National Patient Register, the Cause of Death Register, and the National Prescribed Drug Register. Patients with UVH born in Sweden between 1970 and 2017 who underwent Fontan surgery were included. The study population was divided into three groups based on medication: anticoagulation therapy, antiplatelet therapy, and no therapy. Incidence rate (IR) was reported per 1000 person-years and calculated as the total number of deaths divided by total follow-up time. Confidence interval (CIs) for IR was estimated with Poisson regression. Kaplain-Meier was used to estimate the survival probability of 95% for UVH. The Stratified Cox proportional hazards model was used to estimate hazard ratios (HR) with 95% CI. Results The total cohort consisted of 864 patients of which 280 individuals (32%) had hypoplastic left heart syndrome (HLHS). The median follow-up time was 14.4 (IQR 3.9;24.9) years, maximum follow-up time was 47 years. Out of all the patients, 36% received no anticoagulation or antiplatelet therapy. Among those who did receive therapy, 75% were treated with antiplatelets. The patients who had no therapy had a higher mortality rate. During long-term follow-up, patients with UVH had higher survival rates when treated with antiplatelets. Conclusion Antithrombotic therapy, in particular antiplatelet therapy, was associated with the highest survival in patients with UVH as compared to no treatment. Our data suggest that antithrombotic treatment, and in particular antiplatelet treatment, could be considered in patients with UVH.Survival with Antithrombotic treatment

Free fatty acids: independent predictors of long-term adverse cardiovascular outcomes in heart failure patients

BackgroundThe association between plasma free fatty acid (FFA) and the outcomes in the heart failure (HF) patients remains unclear.MethodsA cohort study among HF patients was performed. Plasma FFA was analyzed as both a continuous and a categorical variable (grouped by tertiles) to assess its association with composite cardiovascular (CV) death and HF hospitalization (CV death & HHP), CV death alone, and all-cause mortality (ACM) using Cox regression models. Subgroup analyses of HF patients with preserved ejection fraction (HFpEF) and mildly reduced/reduced ejection fraction (HFmrEF/HFrEF) were performed. This work also assessed the effectiveness of combining FFA and NT-pro BNP biomarkers for risk stratification by calculating the concordance index (C-index).ResultsAmong the 4,109 HF patients, FFA levels exceeding 0.4–0.42 mmol/L were associated with increased risks of the three outcomes. Patients in the highest FFA tertile faced greater risks than those in the lowest tertile. Adjusted hazard ratios were 1.32 (95% CI: 1.11–1.58) for CV death & HHP, 1.45 (95% CI: 1.16–1.82) for CV death, and 1.39 (95% CI: 1.15–1.68) for ACM, with a maximum follow-up of 8 years (median: 25 months). Subgroup analyses revealed that elevated FFA levels consistently predicted worse outcomes in both HFmrEF/HFrEF and HFpEF patients. The C-index for predicting outcomes was significantly greater when NT-pro BNP and FFA were combined than when NT-pro BNP was used alone (P < 0.01).ConclusionIncreased plasma FFA concentrations were independently associated with greater risks of CV death & HHP, CV death, and ACM among HF patients, irrespective of the ejection fraction. The combination of FFA and NT-pro BNP biomarkers significantly improved risk stratification in HF patients.

Survival and longevity among male Australian elite athletes: A retrospective cohort study.

To quantify and compare survival and longevity in three populations of male Australian elite athletes, relative to sex- and age-matched referents from the general population. Retrospective cohort study. This study comprised a census of three populations of male Australian elite athletes (i.e. N = 10,502 Australian Football League players, N = 803 national team rugby union players, and N = 1527 Olympic athletes) who debuted from 1-JAN-1921 to 31-DEC-2023. Nonparametric relative survival analysis was conducted using the Kaplan-Meier estimator to generate survival curves, the Pohar Perme method and a log-rank type test to estimate and compare net survival, and the life years difference measure to estimate longevity gains or losses. Olympic athletes had a continuous gain in net survival post-debut, with an average life years difference of 3.40 (95 % confidence interval 2.30 to 4.49) years at the maximum follow-up time. Australian football and rugby union players initially had modest gains in net survival post-debut, followed by a gradual decline in net survival, with average life years differences of 0.31 (95 % confidence interval -0.03 to 0.65) and -0.67 (95 % confidence interval -1.87 to 0.53) years at the maximum follow-up time, respectively. Net survival was significantly different across the three cohorts (test statistic 21.8; degrees of freedom = 2; p < 0.001). Expected survival benefits were offset in elite male Australian football and rugby union players. Further research examining cause-specific mortality is warranted to elucidate the underlying reasons for the observed lack of expected survival benefit in Australian football and rugby union players.

Early outcomes with a fully retrievable SinoCrown transcatheter heart valve in patients with severe aortic stenosis.

This study summarizes and analyzes data from patients suffering from symptomatic aortic stenosis who successfully underwent transcatheter aortic valve implantation (TAVI) using a novel, completely retrievable transcatheter heart valve. We included patients who underwent a TAVI procedure with SinoCrown valves at our center between December 2021 and September 2022. We collected 1-year follow-up data on survival, complications, echocardiographic results, New York Heart Association functional class in heart failure, and patient-reported health-related quality of life outcomes. Eight successive patients (73.3 ± 4.3 years) were included in the study, with a median Society of Thoracic Surgery risk score of 4.26%. The procedure had a 100% success rate. Median postoperative discharge time was 7 days, with no 30-day hospital readmissions. Postoperative aortic valve hemodynamics improved, indicated by decreased transvalvular flow velocity compared with preoperative values (1.9 ± 0.2 vs. 4.9 ± 0.2 m/s, p < 0.0001). The median and maximum follow-up times were 8 and 12 months, respectively. During the follow-up period, there were no serious complications such as death, stroke, valve embolization, or high-grade atrioventricular block. The results from eight initial TAVI cases performed with the SinoCrown valve demonstrated promising safety and efficacy.

Low UKA implantation volume, comorbidities, male sex, and implantation of constrained TKA are risk factors for septic revision after knee arthroplasty implantation : A register-based study from the German Arthroplasty Register

Periprosthetic joint infection (PJI) is one of the main causes of revision surgeries after total knee arthroplasty (TKA) and unicondylar knee replacement. Patient- and hospital-related risk factors must be evaluated to prevent PJI. This study identifies influencing factors and differences in infection rates between various types of implant. The basis for the data is the German Arthroplasty Register (EPRD). Septic revisions were calculated with the aid of Kaplan-Meier estimates, with septic revision surgery defined as the primary endpoint. Patients with constrained and unconstrained TKA or UKA were analysed using the Holm multiple log-rank test and the Cox proportional hazard model. The 300,998 cases of knee arthroplasty analysed included 254,144 (84.4%) unconstrained TKA, 9993 (3.3%) constrained TKA and 36,861 (12.3%) UKA, with a maximum follow-up of 7 years. After 1 year, the PJI rate was 0.5% for UKA and 2.8% for TKA, whereas after 7 years it was 4.5% for UKA and 0.9% for TKA (p < 0.0001). In constrained TKA, the PJI rate was significantly increased compared with unconstrained TKA (p < 0.0001). After 1 year, the PJI rate was 2.0% for constrained TKA and 0.8% for unconstrained TKA, as well as 3.1% and 1.4% respectively after 7 years. Implantation of a constrained TKA (HR = 2.55), male sex (HR = 1.84), an increased Elixhauser Comorbidity Index score (HR = 1.18-1.56) and an implantation volume of less than 25 UKA per year (HR = 2.15) were identified as risk factors for revision surgeries; an Elixhauser Comorbidity Index score of0 (HR = 0.80) was identified as a preventive factor. A reduced implantation volume and constrained knee arthroplasty are linked to a higher risk of PJI. Comorbidities (increased Elixhauser Comorbidity Index score), male sex and a low UKA-implantation volume were identified as risk factors for PJI. Patients who fulfil these criteria need specific infection prevention measures. Further analyses are required to investigate the potential influence of prevention and risk factor modification. III.

Perceived discrimination and type 2 diabetes incidence: Findings from the Health and Retirement Study.

To examine the prospective association between perceived everyday discrimination and Type 2 diabetes incidence in a large population-based sample. Data were from the Health and Retirement Study of 14,900 individuals aged ≥ 50 years without a diabetes diagnosis. Participants self-reported experiences of everyday discrimination and diabetes status. Associations between baseline perceived everyday discrimination (one time point) and incident diabetes in the following 10 years were modeled using Cox regression, adjusting for potential confounders. Exploratory analyses assessed the association between repeated reports of perceived everyday discrimination (reports of everyday discrimination at more than one time point) and later diabetes onset. A total of 917 (6.15%) of the 14,900 participants developed Type 2 diabetes over a maximum 10-year follow-up (Mdn = 6). Baseline perceived everyday discrimination was prospectively associated with an increased risk of diabetes (hazard ratio = 1.37, 95% confidence interval [1.15, 1.63], p < .001) independent of age, sex, wealth, race and ethnicity, and education. This association was robust to further adjustment for body mass index, hypertension, physical activity, smoking, alcohol consumption, and depression. In exploratory analyses, repeated reports of everyday discrimination were not significantly associated with incident diabetes. Individuals who perceive everyday discrimination are more likely to develop Type 2 diabetes than those who do not perceive everyday discrimination. Further research is needed to investigate the potential pathways linking discrimination and diabetes onset. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Risk predictive model for the development of hepatocellular carcinoma before initiating long-term antiviral therapy in patients with chronic hepatitis B virus infection.

It is generally acknowledged that antiviral therapy can reduce the incidence of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), there remains a subset of patients with chronic HBV infection who develop HCC despite receiving antiviral treatment. This study aimed to develop a model capable of predicting the long-term occurrence of HCC in patients with chronic HBV infection before initiating antiviral therapy. A total of 1450 patients with chronic HBV infection, who received initial antiviral therapy between April 2006 and March 2023 and completed long-term follow-ups, were nonselectively enrolled in this study. Least absolute shrinkage and selection operator (LASSO) and Cox regression analysis was used to construct the model. The results were validated in an external cohort (n = 210) and compared with existing models. The median follow-up time for all patients was 60 months, with a maximum follow-up time of 144 months, during which, 32 cases of HCC occurred. The nomogram model for predicting HCC based on GGT, AFP, cirrhosis, gender, age, and hepatitis B e antibody (TARGET-HCC) was constructed, demonstrating a good predictive performance. In the derivation cohort, the C-index was 0.906 (95% CI = 0.869-0.944), and in the validation cohort, it was 0.780 (95% CI = 0.673-0.886). Compared with existing models, TARGET-HCC showed promising predictive performance. Additionally, the time-dependent feature importance curve indicated that gender consistently remained the most stable predictor for HCC throughout the initial decade of antiviral therapy. This simple predictive model based on noninvasive clinical features can assist clinicians in identifying high-risk patients with chronic HBV infection for HCC before the initiation of antiviral therapy.

Long-term Results of Endoscopic Percutaneous Suture Lateralization for Newborns with Bilateral Vocal Cord Paralysis.

Bilateral vocal fold paralysis (BVFP) is a critical condition in newborns, which may present with significant airway distress necessitating tracheostomy. The purpose of this study is to report the safety and effectiveness of endoscopic percutaneous suture lateralization (EPSL) for newborns with BVFP, and evaluated the long-term results and the stability of the lateralization. A review of patients undergoing EPSL for BVFP at our institutions was performed between October 2018 and June 2023. Preoperative and postoperative clinical information was collected. The functional outcomes of the surgery in terms of breathing, voice, and swallowing were evaluated and recorded. Twenty seven patients were included, with a median age at diagnosis of 12 days (range, 1-33 days). The maximum follow-up is for 5 years. EPSL was successful in 77.8% of cases, effectively avoiding the need for tracheostomy. Dyspnea was relieved within a month after surgery, enabling patients to tolerate oral feeds within 2 months after surgery. Notably, some patients experienced a return of vocal fold function, particularly in successful EPSL cases, underlining the procedure's efficacy. Minor complications, including granulation tissue and wound infection, were observed but were manageable. Major complications were notably absent. The results are durable and stable at long-term follow-up. EPSL for BVFP is a relatively simple, minimally invasive, non-destructive, safe, and effective procedure in newborns, which may avoid the need for a tracheostomy, preserves the laryngeal framework, and does not affect the natural recovery of vocal cords. Level 3: retrospective case series Laryngoscope, 2024.

Nonlinear dynamics of multi-omics profiles during human aging.

Aging is a complex process associated with nearly all diseases. Understanding the molecular changes underlying aging and identifying therapeutic targets for aging-related diseases are crucial for increasing healthspan. Although many studies have explored linear changes during aging, the prevalence of aging-related diseases and mortality risk accelerates after specific time points, indicating the importance of studying nonlinear molecular changes. In this study, we performed comprehensive multi-omics profiling on a longitudinal human cohort of 108 participants, aged between 25 years and 75 years. The participants resided in California, United States, and were tracked for a median period of 1.7 years, with a maximum follow-up duration of 6.8 years. The analysis revealed consistent nonlinear patterns in molecular markers of aging, with substantial dysregulation occurring at two major periods occurring at approximately 44 years and 60 years of chronological age. Distinct molecules and functional pathways associated with these periods were also identified, such as immune regulation and carbohydrate metabolism that shifted during the 60-year transition and cardiovascular disease, lipid and alcohol metabolism changes at the 40-year transition. Overall, this research demonstrates that functions and risks of aging-related diseases change nonlinearly across the human lifespan and provides insights into the molecular and biological pathways involved in these changes.

Vitamin D deficiency and its impact on outcomes in myocardial infarction patients: a prospective observational study

Objectives: Vitamin D deficiency has been linked to cardiovascular diseases, but its impact on outcomes in myocardial infarction (MI) patients remains unclear. This study investigated the relationship between serum vitamin D levels and short-term and medium-term outcomes in patients with myocardial infarction. Ischemic heart diseases (IHD) are the most common cause of death in the world. Identifying risk factors and predictors can play a critical role in identifying high-risk people in screenings, identifying high-risk patients during admission to the hospital, and adjusting these risk factors in patients to improve prognosis. Methods: This prospective observational study was conducted on 212 patients diagnosed with myocardial infarction at Seyed al-Shohada Hospital in Urmia, Iran. Having been admitted, the patients had their serum vitamin D levels measured using the same blood sample for routine tests. Levels of vitamin D were categorized as normal (&gt;30 ng/ml), insufficient (21-29 ng/ml), or deficient (&lt;20 ng/ml). The patient's files provided the demographic, clinical, and biomedical information, echocardiography, and angiography data. The patients were followed for at least six months post-MI, with a maximum follow-up of 11 months. Follow-up occurred through monthly phone calls and outpatient clinic visits as needed. Primary outcomes included in-hospital complications (such as death, significant bleeding, acute pulmonary edema, cardiogenic shock, and arrhythmias), cardiac readmissions, and mortality. Logistic regression and Cox regression analyses were used to examine the connection between outcome variables and vitamin D levels, adjusting for potential confounders including age, gender, blood pressure, diabetes, blood lipids, creatinine, disease severity (SYNTAX score*), and left ventricular ejection fraction. The mean serum level of vitamin D in patients on admission was 33. 62 ng/dL. The average number of hospitalization days was 4.8 days, and the rate of re-hospitalization was 26.6% in the six-month follow-up and 30.3% in the 9-month follow-up. The hospital mortality rate was equal to 1.4%, and the mortality rate at the end of the follow-up period was equal to 8.3%. The most common complication during hospitalization among the patients was ventricular tachycardia. However, in follow-up, re-hospitalization due to previous issues was the most common complication. Results: The mean serum vitamin D level was 33. 62 ng/ml,with 52.8% of patients having insufficient or deficient levels. The most common in-hospital complication was ventricular tachycardia (11.5%). Vitamin D deficiency was not significantly associated with in-hospital complications. However, during the follow-up period, vitamin D deficiency was significantly related to increased risk of readmission to hospital (HR: 6.984, 95% CI: 3.500-13.936, p&lt;0.001). The 6-month readmission rate was 26.6%, increasing to 30.3% at 9 months. Vitamin D deficiency was also associated with increased cardiac mortality (HR: 12.936, 95% CI: 1.494- 112.016, p=0.020) during follow-up. The 9-month mortality rate was 8.3%. Other factors contributing to cardiac mortality included disease severity (SYNTAX score) and female gender. Conclusions: While vitamin D deficiency did not impact short-term complications, it was associated with increased risk of hospitalreadmission and mortality in MI patients during medium-term follow-up. These findings suggest that vitamin D status can significantly impact long-term outcomes for MI patients

TO EVALUATE THE FUNCTIONAL OUTCOME IN PATIENTS WITH FLOATING KNEE WHO UNDERWENT MAGNETIC RESONANCE IMAGING

Objective: The incidence of floating knee injuries has traditionally been underestimated. However, with the increased use of magnetic resonance imaging (MRI) and arthroscopy, their frequency has risen. There is a crucial need to classify this complex injury pattern by also considering associated soft-tissue injuries. Soft-tissue injuries might be missed during clinical examination due to tenderness and swelling but can be detected through immediate MRI scans. This study aimed to evaluate the functional outcomes of patients with floating knee injuries who underwent MRI for soft tissue injuries. Methods: This study was conducted at a tertiary care center from February 2021 to January 2024. The study involved 100 patients with floating knee injuries who underwent MRI assessments for soft-tissue injuries. Follow-ups were scheduled at 1 month, 3 months, 6 months, and 1 year, with a maximum follow-up duration of 2½ years. The outcomes of floating knee injuries were assessed using the Karlstrom Olerud criteria. Results: Among 100 patients with floating knee injuries who underwent MRI, 72 had meniscus or ligament injuries, and nine had patellar fractures with extensor mechanism rupture. According to the Karlstrom Olerud criteria, seven patients had excellent outcomes, 46 had good outcomes, 33 had fair outcomes, and six had poor outcomes. Eight patients were lost to follow-up. Conclusion: Our aim is to ensure timely and accurate treatment by thoroughly addressing all associated injuries, including often-overlooked ligament damage around the knee. To improve clinical outcomes, we recommend a multidisciplinary approach involving various specialists in the care of these patients.

Radiofrequency ablation via catheter and transpapillary access in patients with cholangiocarcinoma (ACTICCA-2 trial) – a multicenter, randomized, controlled, open-label investigator-initiated trial

BackgroundDespite the recent advances in cancer treatment, the therapeutic options for patients with biliary tract cancer are still very limited and the prognosis very poor. More than 50% of newly diagnosed patients with biliary tract cancer are not amenable to curative surgical treatment and thus treated with palliative systemic treatment. Malignant bile duct obstructions in patients with perihilar and/or ductal cholangiocarcinoma (CCA) represents one of the most important challenges in the management of these patients, owning to the risk represented by developing life-threatening cholangitis which, in turn, limits the use of systemic treatment. For this reason, endoscopic stenting and/or bile duct decompression is the mainstay of treatment of these patients. Data on efficacy and safety of adding radiofrequency ablation (RFA) to biliary stenting is not conclusive. The aim of this multicenter, randomized trial is to evaluate the effect of intraductal RFA prior to bile duct stenting in patients with unresectable perihilar or ductal CCA undergoing palliative systemic therapy.Methods/DesignACTICCA-2 is a multicenter, randomized, controlled, open-label, investigator-initiated trial. 120 patients with perihilar or ductal CCA with indication for biliary stenting and systemic therapy will be randomized 1:1 to receive either RFA plus bile duct stenting (interventional arm) or bile duct stenting alone (control arm). Patients will be stratified by trial site and tumor location (perihilar vs. ductal). Both arms receive palliative systemic treatment according to the local standard of care determined by a multidisciplinary tumorboard. The primary endpoint is time to first biliary event, which is determined by an increase of bilirubin to > 5 mg/dl and/or the occurrence of cholangitis leading to premature stent replacement and/or disruption of chemotherapy. Secondary endpoints include overall survival, safety according to NCI CTCAE v5, quality of life assessed by questionnaires (EORTC QLQ-C30 and QLQ-BIL21), clinical event rate at 6 months after RFA and total days of over-night stays in hospital. Follow-up for the primary endpoint will be 6 months, while survival assessment will be continued until end of study (maximum follow-up 30 month). All patients who are randomized and who underwent endoscopic stenting will be used for the primary endpoint analysis which will be conducted using a cause-specific Cox proportional hazards model with a frailty for trial site and fixed effects for the treatment group, tumor location, and stent material.DiscussionACTICCA-2 is a multicenter, randomized, controlled trial to assess efficacy and safety of adding biliary RFA to bile duct stenting in patients with CCA receiving palliative systemic treatment.Trial registrationThe study is registered with ClinicalTrials.gov (NCT06175845) and approved by the local ethics committee in Hamburg, Germany (2024-101232-BO-ff). This manuscript reflects protocol version 1 as of January 9th, 2024.Graphical

Impact of the pre-biologic treatment journey on biologic drug survival in psoriasis: A nationwide cohort study.

It is unknown whether the pre-biologic treatment journey affects subsequent biologic drug survival. To examine the potential impact of a complex treatment journey on subsequent biologic drug survival in patients with psoriasis. The study utilized longitudinal data from Danish national registries and included all patients who, for the first time, initiated a biological treatment for psoriasis. Maximum follow-up was 5 years and patients were included from 1 January 2010 to 30 June 2021. The study used three definitions of exposure to a complex treatment journey and the following conventional systemic treatments: acitretin, cyclosporine, dimethyl fumarate and methotrexate. The first definition was the cumulative number of treatment series. The second definition comprised the number of unique treatments. The third definition was time from the first conventional systemic treatment to biological therapy. Drug survival for the three definitions were illustrated using Kaplan-Meier curves and compared using log-rank test. The sensitivity analysis largely confirmed these findings by grouping patients according to pharmacotherapy. A total of 2496 patients were included in the study, with 1380 (55.3%) receiving adalimumab, 608 (24.4%) receiving ustekinumab, 271 (10.9%) receiving secukinumab, 166 (6.7%) receiving etanercept and 71 (2.8%) receiving infliximab. The mean age at initiation of biologics was 43.6 years (standard deviation (SD) 15.2 years), and most patients were male (62.9%). During the follow-up of 5477 patient years, 1953 patients (78.2%) reached the main endpoint of discontinuation. Using a log-rank test, the probability of remaining on treatment was unaffected by the three definitions of complexity of the treatment journey. None of the three exposures used to assess the complexity of the pre-biologic treatment journey appeared to impact drug survival. As long as patients experience adequate disease control, these results suggest that conventional systemic treatment do not negatively impact the drug survival of subsequent biologics.

Uric acid elevation in pediatric patients with dilated cardiomyopathy and prediction of mortality.

Pediatric dilated cardiomyopathy (DCM) is a primary cause of heart failure, highlighting the urgent need for effective prognostic markers. We performed a single-center retrospective study involving 145 children diagnosed with DCM, with a median follow-up period of 4.0 months (interquartile range: 6.2-108.4 months). The relationship between serum uric acid (SUA) levels and all-cause mortality was assessed using Kaplan-Meier survival curves, multivariate Cox proportional hazard models, and restricted cubic spline (RCS) models. Of the 145 children with DCM (median age 5.7 years; 61.4% male), 45 (31%) died within 1 year, and 65 (44.8%) died during the maximum follow-up period. In adjusted multivariate Cox regression models, each log2 SUA increase was linked to a higher risk of 1-year mortality [hazard ratio (HR), 2.66; 95% confidence interval (CI), 1.41-5.01] and overall mortality (HR, 1.97; 95% CI, 1.15-3.37). The highest SUA tertile showed a greater risk of mortality at 1 year (HR, 4.26; 95% CI: 1.5-12.06) and during the maximum follow-up (HR, 2.56; 95% CI: 1.06-6.16) compared with the lowest tertile. RCS models indicated an inverted L-shaped association between baseline SUA levels and overall mortality risk, with age-stratified analyses revealing a linear and U-shaped relationship in children ≤10 and >10 years, respectively. Further age-stratified analyses highlighted the modifying effect of age on this association. Elevated SUA levels are a significant predictor of mortality in pediatric DCM, with a pronounced impact on children under 10 years of age. Therefore, SUA levels could serve as potential biomarkers for risk stratification in this population.

91-month follow-up of solitary punctate chorioretinitis in a Chinese patient

BackgroundSolitary Punctate Chorioretinitis (SPC) is a recently identified form of punctate inner choroidopathy (PIC) characterized by a single lesion in the fovea of the macula. Previous studies with a maximum follow-up of 48 months were insufficient. Our review uncovered a case sustained for 91 months.Case presentationA 28-year-old young woman experienced with sudden visual loss in her right eye. Comprehensive examinations, including assessment of best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, noncontact tonometry, fundus fluorescein angiography (FFA), fundus autofluorescence (FAF), optical coherence tomography angiography (OCTA), perimetry, and microperimetry, were conducted. Over 91 months, the lesion slightly enlarged, remained yellow-white and punctate, and stayed in the central macula of the posterior pole. OCT images depicted subsidence in the inner nuclear layer (INL), the outer plexiform layer (OPL), photoreceptor layer, and disruption of the external limiting membrane (ELM), ellipsoid zone, and retinal pigment epithelium (RPE)/Bruch’s membrane complex. Retinal herniation, focal choroidal excavation (FCE), and abnormal vessels in the choriocapillaris were noted. At the slab of the choriocapillaris, OCTA demonstrated that the lesion resembled a linear vascular structure, distinct from the structure of normal choriocapillaris. This confirmed the lesion as an abnormal vascular formation. FAF revealed a punctate hypo-autofluorescence lesion and abnormal hyper-autofluorescence near the optic disc and macula. FFA demonstrated a punctate hyper-fluorescent lesion inferotemporal to the fovea. The vascular structure remained stable without fluid exudation on OCT images, hence anti-vascular endothelial growth factor (anti-VEGF) treatment was not administered. Visual acuity improved from counting fingers to 0.07 in 52 days, reached 0.6 after 15 months, remained at 0.6 from 56 to 80 months, and returned to 0.8 after 91 months, although accompanied by local scotomas. The lesion pattern slightly enlarged without scarring.ConclusionsThroughout long-term follow-up, we had long suspected the presence of choroidal neovascularization (CNV) and found the FCE in the last visit. Eventually, we concluded that SPC could potentially constitute a distinct subtype of PIC. The patient received no treatment, and vision recovered to 0.8. If CNV is suspected in SPC, anti-VEGF treatment may not be necessary without activity on OCT, but close monitoring is essential.

Real-world effectiveness of belimumab in patients with lupus in China: RELIABLE observational cohort study protocol

IntroductionThe efficacy of belimumab in SLE has been demonstrated in randomised clinical trials, and its real-world effectiveness has been shown in studies in several countries. While belimumab was approved for...

Clinical Course of Bio Naive Ulcerative Colitis Patients Five Years After Initiation of Adalimumab in a Nationwide Cohort.

There is limited data on the long-term clinical outcomes of bio-naïve ulcerative colitis (UC) patients who are initiated on adalimumab (ADA). Our study aims to evaluate the clinical course of a nationwide cohort of bio naïve UC patients who were started on ADA, and then followed for 5 years after initiation of the drug. We conducted a retrospective cohort study using the US Veteran Affairs Healthcare System (VAHS). Bio naïve UC patients were followed for 5 years after initiation of ADA. The primary outcome was to determine the time to discontinuation of ADA and if patients achieved endoscopic remission by the end of follow-up. A total of 387 patients were included among whom 193 (49.87%) had pancolitis. The highest rate of ADA discontinuation was within the first year, with the elderly having a higher rate of discontinuation (HR 1.67, 95% CI: 1.14-2.45) and those on concomitant immunomodulators having a lower rate of discontinuation (HR 0.70, 95% CI: 0.48-1.03). In total, 125 (32.30%) patients remained on ADA at the end of their maximum follow-up. 54 (43.90%) achieved endoscopic remission. Among bio-naive UC patients who were started on ADA, a third were still on the drug at the end of 5 years and half had endoscopic remission. The rate of discontinuation was highest within the first year of initiation, but patients continued to stop the drug over the course of follow-up.