Procedural Guidance Research Articles

Extracting organs of interest from medical images based on convolutional neural network with auxiliary and refined constraints

Accurately extracting organs from medical images provides radiologist with more comprehensive evidences to clinical diagnose, which offers up a higher accuracy and efficiency. However, the key to achieving accurate segmentation lies in abundant clues for contour distinction, which has a high demand for the network architecture design and its practical training status. To this end, we design auxiliary and refined constraints to optimize the energy function by supplying additional guidance in training procedure, thus promoting model’s ability to capture information. Specifically, for the auxiliary constraint, a set of convolutional structures are involved into a conventional network to act as a discriminator, then adversarial network is established. Based on the obtained architecture, we further build adversarial mechanism by introducing a second discriminator into segmentor for refinement. The involvement of refined constraint contributes to ameliorate training situation, optimize model performance, and boost its ability of collecting information for segmentation. We evaluate the proposed framework on two public databases (NIH Pancreas-CT and MICCAI Sliver07). Experimental results show that the proposed network achieves comparable performance to current pancreas segmentation algorithms and outperforms most state-of-the-art liver segmentation methods. The obtained results on public datasets sufficiently demonstrate the effectiveness of the proposed model for organ segmentation.

Point-of-Care Ultrasound and Critical Care Ultrasound use Among Providers in Neurocritical Units: A National Survey.

Point-of-care ultrasound (POCUS)/critical care ultrasound (CCU) use in medical and surgical intensive care units has surged over the last few decades. It is unclear if this has similarly translated in neurocritical care (NCC) units. We designed a survey to describe the current state of POCUS/CCU use and training among NCC providers. An online 13-question survey was distributed nationally through newsletters and social media after endorsement by the Neurocritical Care Society. Participation was voluntary, and responses were anonymous. The survey queried respondent demographics, training, clinical use, confidence in POCUS/CCU, and barriers to POCUS/CCU use. Overall, 119 NCC providers responded to the survey. Most respondents were attending neurointensivists (52.1%) and had completed neurology residency training (62.2%). Approximately 23% of respondents did not have training in POCUS/CCU, and 71% of respondents had not completed POCUS/CCU board-certified training. Fifty-five percent of respondents used POCUS/CCU in their practice frequently, and 37% used it rarely on a weekly basis. Thirty-six percent and 42% of respondents felt moderately skilled at acquiring and interpreting POCUS/CCU images, respectively. Ultrasound guidance for procedures was the most common technique used by respondents. Most respondents felt that using ultrasound for volume status, procedural guidance, and evaluation of shock influenced clinical decision-making. Lack of confidence in interpreting data/imaging and comfort in performing POCUS/CCU were the most common barriers to ultrasound use. Respondents agreed with incorporation of POCUS/CCU training in NCC fellowship milestones and creating resources for credentialing providers in POCUS/CCU to increase use of POCUS/CCU in NCC. This national survey indicated that POCUS/CCU is moderately used among NCC providers. However, more formalized and robust training in POCUS/CCU is needed for trainees and practitioners in NCC to enhance comfortability with using ultrasound for clinical assessments.

Best-practice recommendations for campus-based suicide postvention intervention at a South African university in the Western Cape: An expert consensus study

The suicide of students on university campuses has significant impacts for students and staff. South African universities are not excluded from this impact. This study aimed to identify best-practice recommendations for a suicide postvention intervention programme at a South African university. In a single-round consensus study, suicide-bereaved students (N = 25) and staff (N = 21) at the university rated 126 statements in an online questionnaire on a 5-point Likert scale from “essential” to “should not be included.” Agreement between the two groups was significant regarding the most highly rated statements. The most highly rated statements for both groups generated six core themes: providing culturally competent and religiously sensitive support to bereaved families; respecting family’s wishes while meeting the university’s needs; connecting students to available support; staff training needs; clear procedural guidance for staff and mourning and remembering the deceased student.

Transcatheter closure of a right pulmonary artery to left atrium fistula using multi-modality image fusion guidance.

We present the case of 53-year-old woman with a late diagnosis of an right pulmonary artery-left atrium fistula who underwent transcatheter device closure using multi-modality imaging for pre-procedural planning and procedural guidance.

The use of generative artificial intelligence in surgical education: a narrative review

The introduction of generative artificial intelligence (AI) has revolutionized healthcare and education. These AI systems, trained on vast datasets using advanced machine learning (ML) techniques and large language models (LLMs), can generate text, images, and videos, offering new avenues for enhancing surgical education. Their ability to produce interactive learning resources, procedural guidance, and feedback post-virtual simulations makes them valuable in educating surgical trainees. However, technical challenges such as data quality issues, inaccuracies, and uncertainties around model interpretability remain barriers to widespread adoption. This review explores the integration of generative AI into surgical training, assessing its potential to enhance learning and teaching methodologies. While generative AI has demonstrated promise for improving surgical education, its integration must be approached cautiously, ensuring AI input is balanced with traditional supervision and mentorship from experienced surgeons. Given that generative AI models are not yet suitable as standalone tools, a blended learning approach that integrates AI capabilities with conventional educational strategies should be adopted. The review also addresses limitations and challenges, emphasizing the need for more robust research on different AI models and their applications across various surgical subspecialties. The lack of standardized frameworks and tools to assess the quality of AI outputs in surgical education necessitates rigorous oversight to ensure accuracy and reliability in training settings. By evaluating the current state of generative AI in surgical education, this narrative review highlights the potential for future innovation and research, encouraging ongoing exploration of AI in enhancing surgical education and training.

Transesophageal Echocardiography-Guided Transseptal Puncture Reduces Pericardial Tamponade in Electrophysiological Procedures.

Background: Transseptal puncture (TSP) is a critical step in electrophysiological (EP) procedures, as a misdirected TSP can result in life-threatening complications. Although TSP is predominantly performed under fluoroscopic guidance in EP procedures, transesophageal echocardiography (TEE) offers more precision and certainty in the localization of the transseptal needle at the interatrial septum. Despite the widespread use of TSP, evidence supporting the added value of TEE-guided TSP in EP procedures remains limited. This study evaluates the impact of additional TEE guidance on TSP-associated complications during EP procedures. Methods: This study enrolled patients who underwent left atrial or left ventricular procedures with TSP, performed either without (fluoroscopy group) or with additional TEE guidance (TEE group), at the University Heart Center Ulm, Germany. Results: A total of 932 patients were included: 443 in the TEE group (mean age 68.1 ± 11.8 years, 40.6% female) and 489 in the fluoroscopy group (mean age 68.8 ± 11.0 years, 38.2% female). The mean number of transseptal accesses per patient was 1.18 ± 0.38 in the TEE group and 1.14 ± 0.34 in the fluoroscopy group (p = 0.101). Pericardial tamponade occurred significantly less in the TEE group (0.5%) than in the fluoroscopy group (1.8%; p = 0.046). Logistic regression revealed a 91.8% lower risk of pericardial tamponade with TEE-guided TSP compared to fluoroscopy guidance alone. The overall TEE complication rate was low (0.9%). Conclusions: TEE guidance during TSP significantly reduces the risk of pericardial tamponade in EP procedures, indicating that TSP should be performed with additional sonographic guidance to increase patient safety.

High-fidelity pose estimation for real-time extended reality (XR) visualization for cardiac catheterization

Extended reality (XR) technologies are emerging as promising platforms for medical training and procedural guidance, particularly in complex cardiac interventions. This paper presents a high-fidelity methodology to perform real-time 3D catheter tracking and visualization during simulated cardiac interventions. A custom 3D-printed setup with mounted cameras enables biplane video capture of a catheter. A computer vision algorithm processes the biplane images in real-time to reconstruct the 3D catheter trajectory represented by any designated number of points along its length. This method accurately localizes the catheter tip within 1 mm and can reconstruct any arbitrary catheter configuration. The tracked catheter data is integrated into an interactive Unity-based scene rendered on the Meta Quest 3 headset. The visualization seamlessly combines a reconstructed 3D patient-specific heart model with the dynamically tracked catheter, creating an immersive extended reality training environment. Our experimental study, involving six participants, demonstrated that the 3D visualization provided by the proposed XR system significantly outperformed 2D visualization in terms of speed and user experience. This suggests that the XR system has the potential to enhance catheterization training by improving spatial comprehension and procedural skills. The proposed system demonstrates the potential of XR technologies to transform percutaneous cardiac interventions through improved visualization and interactivity.

Initial Experience with the 4D Mini-TEE Probe in the Adult Population.

Background: Transesophageal echocardiography (TEE) is a vital diagnostic tool in clinical practice, particularly in transcatheter interventions where it aids in both pre-operative planning and intra-operative guidance. Traditional TEE probes often require general anesthesia due to patient discomfort. However, the development of miniaturized TEE probes presents a promising alternative, enabling routine examinations and interventions with minimal sedation. This study evaluates the feasibility of performing a complete 2D/4D TEE protocol with the new 4D mini-TEE probe in the echocardiography department and its application in transcatheter interventions. Methods: This is a retrospective study that included 30 consecutive patients from two high-volume European hospitals (Interbalkan Medical Center, Thessaloniki, Greece, and Rennes University, France) that underwent TEE or transcatheter interventions. The new 4D mini-TEE 9VT-D probe (GE Healthcare) was utilized. The quality of the images and the tolerance of the probe were assessed in the cath lab during interventions and in the echocardiography department during routine TEE examinations. Results: Direct comparison of the 4D mini-TEE probe with the standard 6VT-D probe confirmed the excellent image quality of this new pediatric probe. Most of the patients required minimal sedation or local oropharyngeal anesthesia, with satisfactory tolerance reported. Most of the transcatheter procedures did not require general anesthesia and intubation, resulting in shorter procedural time. Both 2D and 4D imaging modalities offered adequate intra-operative guidance for transcatheter procedures. Conclusions: The 4D mini-TEE probe delivers exceptional imaging capabilities for routine examinations and transcatheter interventions without needing sedation. Its use reduces esophageal trauma and the need for general anesthesia, enhancing patient comfort and safety.

Evacuation efficiency and survival rate of bent-over walking during horizontal cabin fire evacuation

Bent-over walking is a common and neglected fire evacuation behavior. To provide bent-over walking data for evacuation research, bent-over walking speed under different deck environment was obtained through experiments. In addition, to compare the differences of walking, bent-over walking and crawling in cabin fire evacuation, we used numerical simulations to test the impacts of fire location, distribution of persons at day and night, personnel evacuation to the nearest point, and directional movement on evacuation efficiency. Fire and personnel evacuation were simulated using the Fire Dynamics Simulator model. The numerical simulation results confirm that bent-over walking has a higher evacuation efficiency and survival rate as compared with walking and crawling. In addition, by comparing experimental data with the numerical simulation results, we identified a critical impact of the interaction between personnel evacuation behaviour and fire environmental factors on evacuation efficiency and mortality rate. The speed data of different evacuation behaviors obtained by the experiment is a very important factor in the study of ship evacuation, and the simulation results will provide guidance for ship fire evacuation procedures.

Minimalist approach to left atrial appendage occlusion through three-dimensional intracardiac echocardiography: Procedural steps and single-center experience

Atrial fibrillation (AF), the most prevalent arrhythmia worldwide, is associated with an annual risk of ischemic stroke of up to 5%, with approximately 98% of thrombi originating from the left atrial appendage (LAA). Direct oral anticoagulants or vitamin K antagonists remain the gold standard for preventing systemic thromboembolism in patients with AF. LAA occlusion (LAAO) is an alternative stroke prevention technique for patients with AF who cannot tolerate long-term anticoagulation. Percutaneous LAAO typically employs a multimodal imaging approach with contrast fluoroscopy and transesophageal echocardiography (TEE) for visualization, device selection and deployment, and complication monitoring. TEE is also used for follow-up imaging. However, it necessitates general anesthesia or deep sedation and is associated with a high risk of adverse events. Three-dimensional intracardiac echocardiography (3D ICE) has been proposed as a viable alternative to TEE for LAAO procedures. In this review, we summarized the current evidence regarding ICE guidance in LAAO procedures. We also presented a case series of consecutive patients presenting at our center who underwent LAAO, which was performed by a single operator using a minimalist approach of moderate sedation, 3D ICE, and same-day discharge. We also presented a summary of the minimalist approach to LAAO using 3D ICE and detailed procedural steps of 3D ICE catheter manipulation for successful LAAO intervention.

Partisan Impacts and Determinants for Internationalization of Ethiopian Pharmaceutical Products

<i>Background</i>: The pharmaceutical and related commodities manufacturing industry in Ethiopia is long-lived because the country is well-endowed with basic raw materials and local ownership and to some extent with machinery and technological know-how. The pharmaceutical industry, both globally and in Africa, encounters challenges in internationalizing products. In Ethiopia, challenges like regulatory complexities and limited government support hinder international market access for pharmaceutical products. This aim is to explore the barriers and understand why Ethiopian pharmaceuticals struggle to enter global markets. <i>Method</i>: The study adopted a mixed research approach, integrating qualitative and quantitative methods. It focuses on 15 pharmaceutical industries in Ethiopia, particularly those in Addis Ababa and the Oromia Special Zone, using probability and none probability sampling technique. The total study participants involved in the quantitative and qualitative studies were 373 and 15, respectively. Data collection comprises questionnaires, key informant interviews, and observation checklists, supplemented by secondary data from official and theoretical sources. Ethical considerations underscore obtaining verbal consent and ensuring confidentiality. Analysis entails descriptive statistics and qualitative synthesis, with numerical analysis conducted using STATA 14.1 software. <i>Results</i>: Out of the expected 384 study participants, 373 (97.13%) participated in our study, while the entire group of participants proposed in the qualitative study (15) also participated in this study. Key findings include resource constraints, regulatory issues, and biased perceptions against local products, hindering their global recognition. While strong political commitment and effective policy enforcement at the top government level are crucial, inadequate collaboration across government tiers undermines these efforts. Despite existing policies, inadequate implementation and procedural guidance diminish industry interest. There's uncertainty about government support for local pharmaceutical production, with persistent challenges like resource shortages and policy inconsistencies impeding progress. Perceptions vary on the effectiveness of policies promoting local production, and concerns about taxation issues impact the industry. Nevertheless, most respondents’ express confidence in the quality of domestically produced pharmaceuticals. <i>Conclusion</i>: Despite crucial government commitment, weak collaboration across levels impedes progress. Respondents note deficient policy implementation and doubt government support. Persistent issues like resource shortages persist, along with taxation concerns, despite locally produced products being perceived as equal in quality. To advance, better policy implementation, regulatory harmony, financial support, infrastructure enhancement, increased awareness, and improved collaboration are essential.

REALIZATION OF THE FUNCTIONS OF THE PROSECUTOR’S OFFICE AS AN ELEMENT OF THE MECHANISM OF ENSURING NATIONAL SECURITY OF UKRAINE

The article is devoted to the study of the peculiarities of exercising the functions of the Prosecutor’s Office of Ukraine in the context of ensuring the national security of the State in the current conditions. Attention is focused on the procedural guidance of pre-trial investigation and support of public prosecution in court in criminal proceedings on crimes against the foundations of national security of Ukraine. The author notes that the main regulatory documents defining the main directions of the state policy in the field of national security do not mention the prosecutor’s office and its activities. At the same time, the work demonstrates that, as a key criminal justice body, the prosecutor’s office is actively involved in ensuring the national security of Ukraine within its competence. The author emphasizes the importance of the prosecutor’s office’s coordination activities in the area of combating crime, primarily crimes against the foundations of national security of Ukraine, cybercrime, corruption criminal offenses, offenses in the budgetary and economic security spheres, as well as organized crime, which have a destructive impact on the proper functioning of the national security of the State. The author provides examples of skillful use of coordination powers by the heads of individual prosecutor’s offices, which helped to orient law enforcement agencies to further effective counteraction to separatism, encroachment on the territorial integrity and inviolability of the State and other crimes against the foundations of national security of Ukraine. The author emphasizes the need to improve the mechanisms of interaction between the prosecutor’s office and other law enforcement agencies, which is crucial for a comprehensive approach to protecting national interests and citizens’ rights, which is the basis of a strong and stable state. The author substantiates the importance of timely and high-quality coverage of the work of the prosecutor’s office in the area of ensuring the national security of Ukraine using the capabilities of modern communication tools, such as the official Telegram channel of the Prosecutor General’s Office, the official pages of the Office on Facebook, Twitter and YouTube.

From classroom to bedside: The role of point‐of‐care ultrasound in undergraduate medical education

AbstractIntroductionPoint‐of‐Care Ultrasound (POCUS) has become an indispensable tool for diagnosis, monitoring, and procedure guidance in various medical specialties. Structured POCUS training is essential to provide users with the knowledge and skills needed for clinical practice. Many medical schools have integrated POCUS into their curriculum to familiarize their students with this technology early on in their medical careers.ObjectiveThis review aims to explore the integration of POCUS into the undergraduate medical education curriculum, discussing its benefits, challenges, barriers, and strategies for effective implementation.DiscussionThe POCUS educational framework uses various methods that combine the delivery of theoretical knowledge with practical skills training. It is highly recommended that medical schools include the fundamentals of ultrasound physics and knobology, structural anatomy, physiology, basic pathology of various organs, and basic instructions on ultrasound needle guidance for procedures in their POCUS curriculum. Importantly, the curriculum should include a comprehensive plan for assessing competency. The integration of POCUS into undergraduate medical education offers several benefits, including facilitating the teaching of basic sciences, enhancing physical examination skills, improving clinical problem‐solving abilities, preparing students for future clinical work, and enhancing the overall educational experience. However, there are challenges associated with this integration, such as a limited availability of qualified instructors, the high financial and logistical investment required, and the complexities of incorporating POCUS into an already compact medical curriculum. With the advancements in ultrasound technology and the integration of artificial intelligence, future research studies are needed to assess how these developments influence the integration of POCUS in undergraduate medical education.

Pulsed Field Ablation to Treat Paroxysmal Atrial Fibrillation: Safety and Effectiveness in the AdmIRE Pivotal Trial.

Evidence from clinical trials of early pulsed field ablation (PFA) systems in treating atrial fibrillation has demonstrated their promising potential to reduce complications associated with conventional thermal modalities while maintaining efficacy. However, the lack of a fully integrated mapping system, a staple technology of most modern electrophysiology procedures, poses limitations in lesion creation and workflow options. A novel variable-loop PFA catheter integrated with an electroanatomic mapping system has been developed that allows for real-time nonfluoroscopic procedural guidance and lesion indexing as well as feedback of tissue-to-catheter proximity. AdmIRE (Assessment of Safety and Effectiveness in Treatment Management of Atrial Fibrillation With the Bosense-Webster Irreversible Electroporation Ablation System), a multicenter, single-arm, Food and Drug Administration investigational device exemption study, evaluated the long-term safety and effectiveness of this integrated PFA system in a large United States-based drug-refractory symptomatic paroxysmal atrial fibrillation patient population. Using the PFA catheter with a compatible electroanatomic mapping system, patients with drug-refractory symptomatic paroxysmal atrial fibrillation underwent pulmonary vein isolation. The primary safety end point was primary adverse event within 7 days of ablation. The primary effectiveness end point was a composite end point that included 12-month freedom from documented atrial tachyarrhythmia (ie, atrial fibrillation, atrial tachycardia, atrial flutter) episodes, failure to achieve pulmonary vein isolation, use of a nonstudy catheter for pulmonary vein isolation, repeat procedure (except for one redo during blanking), taking a new or previously failed class I or III antiarrhythmic drug at higher dose after blanking, or direct current cardioversion after blanking. At 30 centers, 277 patients with paroxysmal atrial fibrillation (61.5±10.3 years of age; 64.3% male) in the pivotal cohort underwent PFA. More than 25% of the procedures were performed without fluoroscopy. Median (Q1, Q3) pulmonary vein isolation procedure, fluoroscopy, and transpired PFA application times were 81.0 (61.0, 112.0), 7.1 (0.00, 14.3), and 31.0 (24.8, 40.9) minutes, respectively. The primary adverse event rate was 2.9% (8 of 272), with the most common complication being pericardial tamponade. The 12-month primary effectiveness end point was 74.6%. The 1-year freedom from atrial fibrillation, atrial tachycardia, or atrial flutter recurrence rate after blanking was 75.4%. Substantial improvements in quality of life were observed as early as 3 months after the procedure, concurrent with a reduction in multiple health care use measures. AdmIRE confirmed the safety and effectiveness of the variable-loop PFA catheter, with short procedure and PFA application times and low fluoroscopy exposure. URL: https://www.clinicaltrials.gov; Unique identifier: NCT05293639.

Development and Implementation of a Multicenter Registry for Resuscitation-Focused Transesophageal Echocardiography

To evaluate the clinical effect, safety, and clinical outcomes of focused transesophageal echocardiography (TEE) in the evaluation of critically ill patients in the emergency department (ED) and ICUs. We established a prospective, multicenter, observational registry involving adult critically ill patients in whom focused TEE was performed for evaluation of out-of-hospital cardiac arrest (OHCA), inhospital cardiac arrest, evaluation of undifferentiated shock, hemodynamic monitoring, and/or procedural guidance in the ED, ICU, or operating room setting. The primary objective of the current investigation was to evaluate the clinical influence and safety of focused, point-of-care TEE in critically ill patients. Data elements included patient and procedure characteristics, laboratory values, timing of interventions, clinical outcomes, and TEE video images. A total of 1,045 focused TEE studies were collected among 916 patients from 28 hospitals, including 585 (64%) intraarrest and postarrest OHCA and inhospital cardiac arrest, 267 (29%) initial evaluation of undifferentiated shock, 101 (11%) procedural guidance, and 92 (10%) hemodynamic monitoring. TEE changed management in 85% of patients with undifferentiated shock, 71% of patients with inhospital cardiac arrest, and 62% of patients with OHCA. There were no reported esophageal perforations or oropharyngeal injuries, and other procedural complications were rare. A prospective, multicenter, and multidisciplinary TEE registry was successfully implemented, and demonstrated that focused TEE is safe and clinically impactful across multiple critical care applications. Further studies from this research network will accelerate the development of outcome-oriented research and knowledge translation on the use of TEE in emergency and critical care settings.

Percutaneous Cholecystostomy: Procedural Guidance and Future Directions for Clinical Management.

Percutaneous cholecystostomy (PC) is a recognized treatment option for the management of acute cholecystitis and is an integral component of the treatment algorithm in the 2018 Tokyo Guidelines. The utilization of PC has significantly increased over the past 30 years, particularly in the setting of critically ill patients and those with extensive comorbidities who are poor surgical candidates. The indications, complications, patient selection considerations, and technical complexities of the procedure will be discussed. Postprocedural drain management and the potential for shortened indwelling time are reviewed.

The Use of Point-of-Care Ultrasound (POCUS) in Anesthesiology: A Narrative Review.

Point-of-care ultrasound (POCUS) has become an essential tool in modern anesthesiology, offering real-time imaging that aids in diagnosis, treatment, and procedural guidance. Its applications have expanded significantly, from routine assessments to complex perioperative management, enhancing patient care across various domains. This study aimed to review and summarize the current literature on the applications of POCUS in anesthesiology, focusing on its utility in airway management, cardiac assessment, lung ultrasound (LUS), and abdominopelvic evaluations. Additionally, it discusses the challenges and strategies for overcoming barriers to its widespread adoption. A narrative literature review was conducted, encompassing studies on using POCUS in anesthesiology. Key databases were searched for relevant articles ("Point-of-care ultrasound,""Focused cardiac ultrasound,""Lung ultrasound"),and studies were selected based on their relevance to the main topics of interest: airway management, cardiac ultrasound, LUS, and abdominopelvic and gastric ultrasound. Both observational studies and randomized controlled trials were included. POCUS improves the safety and accuracy of regional anesthesia and airway procedures, enhancing patient outcomes by providing real-time visualization. Focused cardiac ultrasound is valuable in preoperative, intraoperative, and postoperative care, allowing for tailored anesthesia plans and timely interventions based on cardiac function. The US is an effective diagnostic tool for assessing pulmonary conditions, with specific signs and artifacts aiding in identifying pathologies such as pneumothorax, pleural effusions, and pulmonary congestion. Despite its benefits, POCUS faces barriers such as limited access to training, the need for standardized protocols, and the high equipment cost, especially in low-resource settings. While its integration into clinical practice continues to grow, overcoming challenges related to training, standardization, and equipment access is essential to realize its full potential. Continued efforts in education and research are needed to support the widespread adoption of POCUS in anesthesiology.

Thoracic ultrasound: a review of the state-of-the-art.

Thoracic ultrasound (TUS) is a tool that has become increasingly essential in the daily practice of thoracic medicine. Driven by the need to assess patients during the COVID-19 pandemic, there has been an increase in the use of point-of-care TUS, which has demonstrated several benefits, either as a complement to clinical decision-making for diagnosis or as a real-time guide for procedures, whether as a predictor or measure of treatment response. Here, we present a review of TUS, based on the most recent scientific evidence, from equipment and techniques to the fundamentals of pulmonary ultrasound, describing normal and pathological findings, as well as focusing on the management of lung disease and guidance for invasive thoracic procedures at the bedside. Finally, we highlight areas of perspective and potential lines of research to maintain interest in this valuable tool, in order to improve the diagnostic process and expand the treatment arsenal.

The value of multimodal imaging fusion in preoperative visualization assessment of neurovascular relationship in hemifacial spasm: a single-center retrospective study.

The neurovascular conflict (NVC) at the brainstem exit zone of the facial nerve is considered the primary etiology of primary hemifacial spasm (HFS). Therefore, microvascular decompression (MVD) has become the preferred treatment for HFS. Successful neurovascular decompression can achieve significant therapeutic effects, and accurately identifying the site of compression is crucial for the success of this surgery. Detailed diagnostic neuroimaging plays an important role in accurately identifying the site of compression.The purpose of this study is to explore the feasibility and predictive value of preoperative visualization assessment of the neurovascular relationship in HFS using 3D Slicer software based on multimodal imaging fusion. This aims to reduce the omission of responsible vessels and lower the incidence of postoperative complications, thereby potentially improving the efficacy and safety of the surgery. This study retrospectively analyzed 80 patients with HFS who underwent MVD surgery. All patients underwent preoperative cranial MRI scans, including the 3D-FIESTA and the 3D-TOF MRA sequences. Three-dimensional models were reconstructed from the multimodal MRI images using 3D Slicer software. Independent observers, who were blinded to the surgical outcomes, evaluated the neurovascular relationships using both the three-dimensional models and multimodal MRI images. The assessment results were compared with intraoperative findings, and statistical analysis was conducted using SPSS 22.0 software. The agreement between preoperative assessment using the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence and intraoperative findings was represented by a Kappa value of 0.343, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.637. There was a statistically significant difference between the two methods ( X2 = 18.852, P = 0.001 ). The sensitivity and specificity of the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence for evaluating neurovascular relationships were 92.4% and 100%, respectively, while for three-dimensional reconstruction, both were 100%. The Kappa value for agreement between preoperative the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence prediction of offending vessels and intraoperative findings was 0.625, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.938, showing a statistically significant difference ( X2 = 317.798, P = 0.000 ). The Kappa value for agreement between preoperative the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence assessment of the anatomical location of facial nerve involvement in neurovascular compression and intraoperative findings was 0.608, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.918, also showing a statistically significant difference ( X2 = 504.647, P = 0.000 ). The preoperative visualization assessment of neurovascular relationships in HFS using 3D Slicer software based on multimodal imaging fusion has been demonstrated to be reliable. It is more accurate than combining the 3D-TOF MRA sequence with the 3D-FIESTA sequence and shows higher consistency with intraoperative findings. This method provides guidance for surgical procedures and thereby potentially enhances the efficacy and safety of surgeries to a certain extent.

Zero-Contrast Transcatheter Aortic Valve Implantation vs. Standard Practice: Periprocedural and Long-Term Clinical Outcomes.

Background: We aimed to compare the procedural efficacy and long-term clinical results of a totally contrast-free Transcatheter Aortic Valve Implantation (TAVI) procedure (i.e., contrast dye was not used for either the pre-procedural assessment or during the procedure) to those of standard practice in patients with severe renal dysfunction. Methods: All consecutive patients with a glomerular filtration rate (GFR) ≤ 35 mL/min and severe aortic stenosis who were treated with transfemoral TAVI at our Institution were included in the registry. The zero-contrast patients underwent carbon dioxide angiography and a non-contrast CT scan for assessment of vascular access suitability, and aortic annulus sizing was performed by a TEE, and the procedural guidance was fluoroscopic and echocardiographic. Procedural outcomes were evaluated, and clinical long-term follow-up was performed for all included patients. Results: A total of 44 patients (median age, 85 (IQR, 80.75-87.00)) were included in the zero-contrast group (TEE guidance and general anesthesia in 37 (84%) patients), while 63 patients were included in the standard practice arm (82 ± 78 mL of contrast dye used). Procedural success was obtained in 100% of cases. There were no differences in procedural outcomes, including final mean aortic gradients (5.5 (IQR, 5.0-10.0) mmHg in the zero-contrast group vs. 6.0 (IQR, 5.0-10.0) mmHg in the standard practice group) and rate of at least a moderate paravalvular leak (0% vs. 1.6% in the zero-contrast and standard practice groups, respectively; p = 0.31). No differences in AKI during the hospital stay were observed. Over a median follow-up of 3.3 years, there was a significantly lower rate of AKI (1.2% vs. 25.9%, p < 0.001) and rehospitalizations (1.6% vs. 35.5%, p < 0.00) in standard practice group. Conclusions: We showed for the first time the feasibility and efficacy of a totally contrast-free strategy compared to standard practice in TAVI patients with severe renal dysfunction. Besides achieving comparable procedural results, the zero-contrast strategy showed a better long-term clinical outcome in reducing hospital readmissions for kidney function deterioration.