Retrospective Observational Study Research Articles

Ablate and pace with conduction system pacing, Rovigo's experience

Abstract Background Several clinical data demonstrate that atrio ventricular junction (AVJ) ablation, followed by cardiac pacing, in atrial fibrillation (AF) with uncontrollable heart rate is beneficial. There are still limited data about conduction system pacing (CSP) in that setting. Aims To analyse if this “ablate and pace” strategy is feasible with good electrical results (ECG and parameters) and clinical outcomes (heart failure (HF) admission, ejection fraction (EF) and NYHA class). To analyse also differences between his bundle pacing (HBP) and left bundle branch area pacing (LBBAP) in this setting. Methods. This is an observational retrospective single center study involving 30 patients of which 11 had a HBP and 19 a LBBAP from March 2019 to June 2023 (medium follow up 33 ± 18 month). The implant procedure was performed with both stylet driven or lumenless lead. After 2 ± 2 weeks was performed the AVJ ablation. The electrical parameters were measured at the implant and every 6 – 12 months. The patients had an echocardiographic and clinical evaluation every 6 – 12 months. There was nobody with a NYHA class IV. Results The procedure was performed without complication in all patients. There were a rising in the EF (49,9 ± 14,6 vs 54,2 ± 10,4% p = 0.004). There weren’t HF admission and only 2 patients died (not for cardio–vascular causes) during follow up. There were also a decrease in NYHA class in every patient (at least one NYHA class less). 17 (57%) patients had normal ventricular conduction, only 4 (13%) had LBBB, 4 (13%) RBBB. There were not statistical difference between the QRS duration pre and after implant (129 ± 35 vs 125 ± 24 ms p = 0,06). The threshold measured at the implant were stable both in the HBP (0,75 ± 0,34 vs 1,3 ± 0,8 V @ 0,4 ms p = 0,14) and in the LBBAP (0,93 ± 0,3 vs 0,89 ± 0,3 V @ 0,4 ms p = 0,49). The LBBAP presented higher values of sensing compared with HBP (17,5 ± 7,4 vs 6,3 ± 3,3 mV p = 0,04) and less procedural (63 ± 32 vs 95 ± 41 min, p = 0,02) and fluoroscopic time (2,6 ± 2,4 vs 7,5 ± 4,1 min, p = 0,04) compared with HBP. Conclusion The CSP is feasible and safe in the setting of “ablate and pace” and results in a clear increasing in EF and clinical status of patients with good and stable ECG features and electrical parameters during follow up; the CSP indeed represent a valuable alternative to BVP in this setting. LBBAP performed better than HBP in terms of procedural and fluoroscopic time and of higher sensing values.

Profiling the acceleration and deceleration components in elite futsal players

ABSTRACT This retrospective observational study explores the acceleration and deceleration demands of elite male futsal players (age: 28.8 ± 2.4 years, weight: 73.7 ± 6.2 kg, height: 175.9 ± 5.9 cm) in official matches. Utilising a local positioning system, tracking data from twelve matches involving two elite teams with nineteen players was analysed. Physical demands were assessed at various thresholds, considering standing and rolling efforts based on initial and final velocities. The most prevalent efforts were rolling accelerations (32.4%) and decelerations (31.3%), along with standing accelerations (18.7%) and decelerations (17.6%). A majority of efforts occurred within small distances (less than 10 metres), representing 27.9% to 71.1% of cases. Intensity comparisons revealed that larger distances consistently had significantly higher velocities (d = 0.67 to d = 5.91). High-intensity efforts over large distances were notably shorter than their low-intensity counterparts, both in standing (d = 1.75 to d = 1.98) and rolling (d = 0.64 to d = 0.82) effort types. In essence, elite futsal players predominantly engage in rolling accelerations and decelerations within short distances, exhibiting average speeds below 3 m·s−2. This insight into the nuanced dynamics of player movements provides valuable information for optimising training regimens and enhancing performance in elite futsal competitions.

Immunohistochemistry and real-time Polymerase Chain Reaction: importance in the diagnosis of intestinal tuberculosis in a Peruvian population

IntroductionThe diagnosis of intestinal tuberculosis is challenging even nowadays. This study aims to report the positivity rates of new diagnostic methods such as immunohistochemistry and Real-Time Polymerase Chain Reaction in patients with intestinal tuberculosis, as well as describe the pathological and endoscopic features of intestinal tuberculosis in our population.MethodsThis was a retrospective observational study conducted in patients diagnosed with intestinal tuberculosis, between 2010 to 2023 from the Hospital Nacional Daniel Alcides Carrion and a Private Pathology Center, both located in Peru. Clinical data was obtained, histologic features were independently re-evaluated by three pathologists; and immunohistochemistry and real-time Polymerase Chain Reaction evaluation were performed. The 33 patients with intestinal tuberculosis who fulfilled the inclusion criteria were recruited.ResultsImmunohistochemistry was positive in 90.9% of cases, while real-time Polymerase Chain Reaction was positive in 38.7%. The ileocecal region was the most affected area (33.3%), and the most frequent endoscopic appearance was an ulcer (63.6%). Most of the granulomas were composed solely of epithelioid histiocytes (75.8%). Crypt architectural disarray was the second most frequent histologic finding (78.8%) after granulomas, but most of them were mild.ConclusionSince immunohistochemistry does not require an intact cell wall, it demonstrates higher sensitivity compared to Ziehl–Neelsen staining. Therefore, it could be helpful for the diagnosis of paucibacillary tuberculosis.

The psychedelic call: analysis of Australian Poisons Information Centre calls associated with classic psychedelics

Introduction The global use of certain classical psychedelics has increased in recent years, but little is known about their spectrum of toxicity within Australia. We aim to describe calls to New South Wales Poisons Information Centre relating to exposures to classical psychedelics including lysergic acid diethylamide, psilocybin, N,N-dimethyltryptamine, ayahuasca, mescaline and ibogaine. Methods This is a retrospective observational study of calls to New South Wales Poisons Information Centre between January 2014 and December 2022. We identified exposures to classical psychedelics within New South Wales Poisons Information Centre database and measured the annual number of exposures, source of call (hospital, health care worker, member of the public), co-ingested substances, clinical features and advice given. Results There were 737 calls related to relevant psychedelic exposures; 352 (47.8 per cent) to lysergic acid diethylamide, 347 (47.0 per cent) to psilocybin, 28 (3.8 per cent) to N,N-dimethyltryptamine, 4 (0.5 per cent) to ayahuasca, 4 (0.5 per cent) to mescaline and 2 (0.3 per cent) to ibogaine. Cases were predominantly male (77.2 per cent) and aged between 20 and 74 years (65.6 per cent). Psychedelic calls more than doubled from 45 in 2014 to 105 in 2022 and 625 (85 per cent) of all calls were either from or referred to hospital. Co-ingestion of psychedelics with another substance occurred in 249 (33.8 per cent) of calls and the most frequent clinical features related to single substance psychedelic exposures were hallucinations (27.6 per cent), gastrointestinal symptoms (21.7 per cent) and tachycardia (18.1 per cent). Seizures occurred in 2.9 per cent of single substance psychedelic exposures. Discussion Increasing incidence of psychedelic exposure calls, including those reporting significant toxicity, likely reflects increasing community use. This may in part be driven by increasing interest in psychedelic assisted psychotherapy trials subsequently increasing public awareness. Conclusion Relatively high poisoning severity contrasts with safety within clinical trials of psychedelic assisted psychotherapy that may relate to the uncontrolled nature of community use which is mitigated within clinical trial environments. Education about safe use may be useful.

Risk of epilepsy after a first epileptic seizure with unknown etiology in elderly patients

Patients whose epilepsy begins with seizures with unknown etiology in old age have been studied to a limited extent. The aim is to clinically characterise these patients, and predict their risk of developing epilepsy in the long term. This is a retrospective observational study of patients over 55 years old experiencing a first epileptic seizure with unknown etiology. The data were collected from their clinical history, including electroencephalogram (EEG) and brain magnetic resonance imaging (MRI) results. Eighty-seven patients (58.6% male; 71.5 ± 8.1 years) were included. The mean follow-up was 7.3 ± 4.9 years. The most common vascular risk factor was arterial hypertension (77%; n = 67). Focal seizures with altered consciousness were the most frequent type of seizure (44.8%; n = 39), followed by focal seizures evolving to bilateral tonic-clonic seizures (39.1%; n = 34). Brain MRI showed cortical atrophy (50%; n = 42) and signs of small-vessel vascular disease (SVVD) (67.8%; n = 57). Interictal epileptiform EEG abnormalities were observed in 43.7% (n = 38) of the patients, mostly with temporal localisations (94.7%; n = 36). 44.8% (n = 39) had mild cognitive impairment at baseline. Recurrence of seizures, which was observed in 49 patients (56.1%), occurred after a median of 12 months (interquartile range: 4.4-25.9). Finally, 71 patients (81.6%) developed epilepsy. The risk of epilepsy in the long term following a single seizure of unknown etiology in elderly patients is greater than 80%. Arterial hypertension and mild cognitive impairment at baseline are the most common clinical features. Cortical atrophy and the presence of SVVD are frequent in MRI, and routine EEGs do not usually show epileptiform alterations.

Navigating the Maze: Exploring Non-Oncological Complexities in Non-Small-Cell Lung Cancer.

Pulmonary oncological pathologies are an important public health problem and the association with other pulmonary lesions may pose difficulties in diagnosis and staging or require different treatment options. To address this complexity, we conducted a retrospective observational study at the Marius Nasta Institute of Pneumophthisiology, Bucharest, Romania. Our study focused on patients admitted in 2019 with non-small-cell lung carcinoma and associated pulmonary lesions identified through surgical resection specimens. Among the 314 included patients, multiple pulmonary nodules were observed on macroscopic examination, with 12% (N = 37) exhibiting nonmalignant etiologies upon microscopic examination. These findings underscore the challenge of preoperative staging. Patients with coexisting nonmalignant lesions were similar in age, smoking habits, and professional or environmental exposure by comparison with those who presented only malignant lesions. The presentation of coexisting malignant and nonmalignant lesions may pose difficulties in diagnosing and staging pulmonary cancer.

Predictors of futile recanalization in nonagenarians treated with mechanical thrombectomy: a multi-center observational study.

There is a lack of data regarding patients aged 90years or older undergoing mechanical thrombectomy and their predictors of futile recanalization. We sought to evaluate the predictors of futile recanalization in patients ≥ 90years with large vessel occlusion undergoing mechanical thrombectomy. This multi-center observational retrospective study included patients ≥ 90years consecutively treated with mechanical thrombectomy in four thrombectomy capable centers between January 1st, 2016 and 30th March 2023. Futile recanalization was defined as large vessel occlusion patients experiencing a 90-day poor outcome (mRS 3-6) despite successful recanalization (mTICI ≥ 2b) after mechanical thrombectomy. Our cohort included 139 patients ≥ 90years with acute ischemic stroke due to anterior circulation large vessel occlusion treated with mechanical thrombectomy. One hundred seventeen of one hundred thirty-nine patients ≥ 90years who achieved successful recanalization were included in the analysis (seventy-six female (64.9%)), of whom thirty-one (26.49%) experienced effective recanalization and eighty-six (73.51%) experienced futile recanalization. Patients with futile recanalization had higher NIHSS on admission (p < 0.001); they were less frequently treated with intravenous thrombolysis (p = 0.048), had more often general anesthesia (p = 0.011), and longer door to groin puncture delay (p = 0.002). Univariable regression analysis showed that use of intravenous thrombolysis (0.29, 95% CI 0.02-0.79, p = 0.034) and site of occlusion distal vs proximal (0.34, 95% CI 0.11-0.97, p = 0.044) were associated with reduced probability of futile recanalization while NIHSS on admission (1.29, 95% CI 1.16-1.45, p < 0.001), NIHSS at 24h (1.15, 95% CI 1.07-1.25, p = 0.002), type of anesthesia used (4.18, 95% CI 1.57-11.08, p = 0.004), and door to groin puncture time (1.02, 95% CI 1.00-1.05, p = 0.005) were associated with increased probability of futile recanalization. Multivariable regression analysis showed that use of intravenous thrombolysis (0.44, 95% CI 0.09-0.88, p = 0.039) was associated with reduced probability of futile recanalization. Our study seems to suggest that mechanical thrombectomy with intravenous thrombolysis is associated with reduced probability of futile recanalization in a multi-center cohort of patients aged 90years or older.

Complications of placenta previa: A retrospective observational study at tertiary care hospital

: Placenta previa (PP) is condition where the placenta is inserted completely or partially into the lower uterine segment, at or after 28 weeks of gestation. Maternal and fetal risks are antepartum haemorrhage (APH), postpartum haemorrhage (PPH), abnormal adherence of placenta, low birth weight (LBW), intra uterine growth restriction (IUGR), preterm births and congenital malformations. The purpose of this study was to determine the proportion of placenta previa, the demographics of patients, types- severity, complications and the feto-maternal outcome in patients of placenta previa.: After due permission of Institutional Review Board, this retrospective observational study was carried out at tertiary care teaching hospital from July 2020 to November 2022.Proportion of pregnancies with placenta previa was 0.3%. Majority 44(91.7%) patients were registered, 38(79.2%) of patients were in age group of 21-30 years, 38(79.1%) patients were multigravida, 41 (85.4%) had major degree of placenta previa, 29(60.4%) patients admitted after 37 weeks of gestation and 47(97.9%) of patients were delivered by caesarean section. Majority of patients, 20 (41.7%) had mild anemia. Major complications were bleeding episodes during antenatal period/APH in 23 (47.9%) and PPH in 22 (45.8%) patients. Maternal mortality occurred in 1 (2.1%) patient. All babies were live at time of birth and 44(91.7%) babies were alive at the time of discharge and neonatal death occurred in 4 (8.3%) preterm babies (28-33 week gestation). Majority of patients were multigravida. No patient was severely anaemic. Majority of patients were delivered by CS. APH and PPH were major complications. About two third of patients required blood transfusion in ante/intra/post-natal period. Obstetric hysterectomy was required in about one tenth of patients. Majority of babies were alive at the time of discharge due to higher number of registered patients who took regular antenatal care, hospital delivery and good NICU facilities. Once diagnosed, placenta previa and morbidly adherent placenta should be managed at tertiary care centre with multidisciplinary approach so as to lessen the feto-maternal morbidity and mortality. Prevention is better than cure. Multiparity increases the risk of placenta previa. Hence, family planning with an aim to reduce unwanted pregnancies and abortions will help to reduce the chances placenta previa. CS increases the risk of development of placenta previa. Efforts should be made to reduce the primary caesarean section rate as it poses more risk of placenta previa, morbidly adherent placenta and its related complications in subsequent gestations.

2023 catastrophic Turkey earthquake: clinical outcomes of pediatric patients rescued under the rubble

ABSTRACT Objectives Children are the most vulnerable population affected by the earthquake. We aimed to examine the characteristics, morbidity, mortality, and the factors affecting these pediatric earthquake victims to guide the follow-up of pediatric patients who were rescued under the rubble in possible future disasters. Methods This is a retrospective observational study. The files of pediatric earthquake victims aged 0-18 years who were admitted to Adana City Training and Research Hospital between 6 February-30 April 2023 were analyzed. 318 patients were included in the study. Results Of all patients 48.7% (n = 155) were female and 51.3% (n = 163) were male. The mean age of the patients was 114.8 months. 65.4% (n = 208) of the patients were discharged from our hospital, eighteen patients (5.7%) died. Information on the hour when the patients were rescued under the rubble could be reached in 117 (36.8%) patients. The mean rescue time of these patients was 50.5 hours. 62 (53%) victims were rescued in the first 24 hours after the earthquake. There were 111 patients (34.9%) with fractures. There were 118 patients (37.1%) who underwent fasciotomy surgery. The total number of patients with amputation was 48 (15.1%). There were 36 patients (11.3%) with one limb amputated, 12 patients (%3.7) with more than one limb amputation. Internal organ injury was present in 30.5% (n = 97) of the patients. Of these patients, 85.6% (n = 83) had single organ trauma and 14.4% (n = 14) had multiple organ trauma. There were 58 patients (18.2%) with acute renal failure in follow-up. The mean rescue time for patients with amputation was 83.65 ± 62.9 hours, and for patients without amputation was 36.44 ± 50.6 hours. This difference was statistically significant (p = 0.001). No statistically significant difference was found when the ages of the patients were compared to fasciotomy, amputation, and fracture status. Conclusion While evaluating earthquake-induced trauma, pediatric patients should be approached carefully.

The association between prehospital post-return of spontaneous circulation core temperature and survival after out-of-hospital cardiac arrest.

Following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), a low body temperature on arrival at the hospital and on admission to the ICU is reportedly associated with increased mortality. Whether this association exists in the prehospital setting, however, is unknown. The objective of this study was to investigate whether the initial, prehospital core temperature measured post-ROSC is independently associated with survival to hospital discharge in adult patients following OHCA. This retrospective observational study was conducted at East Anglian Air Ambulance, a physician-paramedic staffed Helicopter Emergency Medical Service in the East of England, UK. Adult OHCA patients attended by East Anglian Air Ambulance from 1 February 2015 to 30 June 2023, who had post-ROSC oesophageal temperature measurements were included. The primary outcome measure was survival to hospital discharge. Core temperature was defined as the first oesophageal temperature recorded following ROSC. Multivariable logistic regression evaluated the adjusted association between core temperature and survival to hospital discharge. Resuscitation was attempted in 3990 OHCA patients during the study period, of which 552 patients were included in the final analysis. The mean age was 61 years, and 402 (72.8%) patients were male. Among them, 194 (35.1%) survived to hospital discharge. The mean core temperature was lower in nonsurvivors compared with those who survived hospital discharge; 34.6 and 35.2 °C, respectively (mean difference, -0.66; 95% CI, -0.87 to -0.44; P < 0.001). The adjusted odds ratio for survival was 1.41 (95% CI, 1.09-1.83; P = 0.01) for every 1.0 °C increase in core temperature between 32.5 and 36.9 °C. In adult patients with ROSC following OHCA, early prehospital core temperature is independently associated with survival to hospital discharge.

Endovascular Therapy in Large Core Ischemic Strokes: Real-World Indian Experience

Abstract Background: Large core acute ischemic strokes have predominantly been excluded from endovascular therapy (EVT) studies due to perceived higher risks of hemorrhage and poorer functional outcomes. However, recent randomized controlled trials (RCTs) indicate that EVT for large vessel occlusion (LVO) strokes improves functional outcomes compared to medical management alone, despite higher hemorrhagic transformation rates, with no corresponding increase in symptomatic intracerebral hemorrhage (sICH) rates. The real-world outcomes of this intervention in Indian patients remain underexplored. Objectives: To evaluate the real-world outcomes of EVT for large core acute ischemic strokes with LVO in an Indian population. Methods: We conducted a single-center, retrospective observational study using a 7 years prospective database of EVT in anterior circulation stroke patients. Patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3–5 were included. Clinical and radiologic data were analyzed, with the primary endpoint being 90-day modified Rankin scale (mRS) scores. Safety outcomes included rates of sICH and mortality. Descriptive statistical analysis was done using Microsoft Excel. Results: The study included 25 patients who met the inclusion criteria. Mean age of patients was 52.9 ± 14.3 years, and there were 13 (52%) males. Median ASPECTS was 5 (interquartile range 4–5). Successful recanalization, classified by modified Thrombolysis in Cerebral Infarction score, was 92%. Good functional recovery, that is, 90-day mRS 0–3, was achieved in nine (36%) patients. Safety outcomes: sICH was seen in four (16%) and mortality was reported in nine (36%) patients. Conclusions: Our results reaffirm findings from RCTs, provide updated real-world evidence, and suggest that EVT is a viable option to be considered in selected patients with large core ischemic infarcts.

A Two-Step Approach to the Surgical Treatment of Soft-Tissue Sarcomas.

Background: Nowadays, limb-sparing procedures are the gold standard in the treatment of soft-tissue sarcomas of the limbs. Wide tumor resection with appropriate oncological margins, reconstruction, and stabilization of the involved bone and joint and restoration of the soft tissue lost are essential in order to obtain good clinical and functional outcomes. Tumor excision and soft-tissue reconstruction performed in one-step surgery is chosen by many centers as the preferred approach; however, according to our experience in some selected patients, two-step surgery performed using a dermal regeneration template first and then a margin revision, taking into account the definitive results of the anatomopathological exam conducted over the surgical specimen from the previous surgery, associated with definitive reconstruction surgery over a healthy bed of granulated tissue, showed many potential benefits. Methods: A retrospective observational study was conducted on thirteen patients who underwent a two-step reconstruction procedure using dermal substitution after soft-tissue sarcoma excision. Results: Clinically, the enrolled patients achieved excellent contour and cosmesis of their surgical wounds, with a mean VSS value of 3.07. During the follow-up period, no local recurrences were observed in any patient. Conclusions: Two-step surgery represents the most suitable solution to allow surgical radicality with minimal recurrency and adequate soft-tissue reconstruction, avoiding the possibility of wasting autologous tissue. Our patients generally embraced this approach and the management that followed.

Prevalence of intra-abdominal adhesions in patients undergoing repeat cesarean section: An observational retrospective study

: To study the prevalence of intraabdominal adhesion in repeat CS and evaluate the maternal and fetal outcome.: CS is a lifesaving procedure for the mother and fetus, but have multiple complications like adhesions, abdominal pain, prolonged duration of surgery, postoperative bleeding, and identification of these can help improve maternal and fetal outcome and care.: This retrospective study reviewed 70 pregnant women undergoing repeat CS. Data was tabulated and analyzed and adhesions were scored based on a system into dense and flimsy, and its dimensions. Chi Square test was used to observe association. P-value&amp;#60;0.05 was taken as significant.: Adhesions were noted in 30(42.9%) of the subjects and 40(57.1%) patients had no adhesions. Dense adhesions were noted in 19(27.1%) and flimsy in 11(15.7%) patients. Among those with adhesions – 6(20%) had atonic postpartum hemorrhage (PPH). No association was noted with fetal outcome. There was a statistically significant increase in duration of surgery in those with adhesions – 126.83 minutes +/- 19.85 than in those without adhesions – 82.35 minutes +/-12.82. Those patients with dense adhesions, the duration of surgery was – 132.63 minutes +/-21.88 and with flimsy adhesions – 116.82 minutes +/-82.: Repeat CS with adhesions increased the duration of surgery, increased the chances of PPH and had no statistically significant effect on neonatal outcome. Furthermore, duration of surgery was prolonged with dense adhesions. Further research can be done including post operative complications, details of prior CS and interpregnancy interval and thereby adhesion prevalence.

Radiomics analysis of ultrasound images to discriminate between benign and malignant adnexal masses with solid ultrasound morphology.

Our primary aim was to identify radiomic ultrasound features that can distinguish benign from malignant adnexal masses with solid ultrasound morphology, and primary invasive from metastatic solid ovarian masses, and to develop ultrasound-based machine learning models that include radiomics features to discriminate between benign and malignant solid adnexal masses. Our secondary aim was to compare the diagnostic performance of our radiomics models with that of the ADNEX model and subjective assessment by an experienced ultrasound examiner. This is a retrospective observational single center study. Patients with a histological diagnosis of an adnexal tumor with solid morphology at preoperative ultrasound examination performed between 2014 and 2021 were included. The patient cohort was split into training and validation sets with a ratio of 70:30 and with the same proportion of benign and malignant (borderline, primary invasive and metastatic) tumors in the two subsets. The extracted radiomic features belonged to two different families: intensity-based statistical features and textural features. Models to predict malignancy were built based on a random forest classifier, fine-tuned using 5-fold cross-validation over the training set, and tested on the held-out validation set. The variables used in model building were patient's age, and those radiomic features that were statistically significantly different between benign and malignant adnexal masses (Wilcoxon-Mann-Whitney Test with Benjamini-Hochberg correction for multiple comparisons) and assessed as not redundant based on the Pearson correlation coefficient. We describe discriminative ability as area under the receiver operating characteristics curve (AUC) and classification performance as sensitivity and specificity. 326 patients were identified and 775 preoperative ultrasound images were analyzed. 68 radiomic features were extracted, 52 differed statistically significantly between benign and malignant tumors in the training set, and 18 features were selected for inclusion in model building. The same 52 radiomic features differed statistically significantly between benign, primary invasive malignant and metastatic tumors. However, the values of the features manifested overlap between primary malignant and metastatic tumors and did not differ statistically significantly between them. In the validation set, 25/98 tumors (25.5%) were benign, 73/98 (74.5%) were malignant (6 borderline, 57 primary invasive, 10 metastases). In the validation set, a model including only radiomics features had an AUC of 0.80, and 78% sensitivity and 76% specificity at its optimal risk of malignancy cutoff (68% based on Youden's index). The corresponding results for a model including age and radiomics features were 0.79, 86% and 56% (cutoff 60% based on Youden's method), while those of the ADNEX model were 0.88, 99% and 64% (at 20% malignancy cutoff). Subjective assessment had sensitivity 99% and specificity 72%. Even though our radiomics models had discriminative ability inferior to that of the ADNEX model, our results are promising enough to justify continued development of radiomics analysis of ultrasound images of adnexal masses. This article is protected by copyright. All rights reserved.

Antimicrobial resistance in intensive care patients hospitalized with SEPSIS: a comparison between the COVID-19 pandemic and pre-pandemic era

IntroductionCoronavirus disease 2019 (COVID-19) is a highly contagious viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has had a dramatic effect on the world, resulting in millions of deaths worldwide and causing drastic changes in daily life. A study reported that septic complications were associated with high mortality in COVID-19 patients. This study aimed to evaluate how the COVID-19 pandemic changed the pre-pandemic and post-pandemic prevalence of sepsis in ICUs and to evaluate the different risk factors associated with mortality and the different diffusion of microorganisms and their resistance.Materials and methodsWe conducted a single-center retrospective observational clinical study, observing all patients in the ICU of the SS Annunziata Hospital in Chieti (Italy) who were diagnosed with sepsis and had a bacterial isolate from their blood culture. Sepsis was diagnosed by SEPSIIS III criteria. We enrolled all in-patients in the ICU from January 2018 to December 2021. We divided the patients into three groups: (1) non-pandemic period (Np) hospitalized in 2018–2019, (2) pandemic period (Pp)-COVID hospitalized in 2020–2021 with a diagnosis of COVID-19, and (3) Pp-non-COVID patients hospitalized in 2020–2021 without a diagnosis of COVID-19.ResultsFrom January 2018 to December 2021, 1,559 patients were admitted to the ICU, of which 211 patients [36 (17.1%) in 2018, 52 (24.6%) in 2019, 73 (34.6%) in 2020, and 50 (23.7%) in 2021, respectively] met the selection criteria: 88 patients in period Np, 67 patients in Pp without COVID-19, and 56 patients Pp with COVID-19. The overall mortality of these patients was high (65.9% at 30 days in Np), but decreased during the Pp (60.9%): Pp-non-COVID was 56.7% vs. Pp-COVID 66.1%, with a statistically significant association with APACHE III score (OR 1.08, 95%CI 1.04–1.12, p &amp;lt; 0.001), SOFA score (OR 1.12, 95%CI 1.03–1.22, p = 0.004), and age (OR 1.04, 95%CI 1.02–1.07, p &amp;lt; 0.0001). Between the Np vs. Pp periods, we observed an increase in a few Gram-positive bacteria such as S. capitis (1 pt. −0.9% vs. 14 pt. −7.65%- p = 0.008), S. epidermidis, Streptococcus spp., and E. faecalis, as well as a decrease in a case of blood culture positive for S. aureus, S. hominis, and E. faecium. In Gram-negative bacteria, we observed an increase in cases of Acinetobacter spp. (Np 6 pt. −5.1%- vs. Pp 20 pt. −10.9%, p = 0.082), and Serratia spp., while cases of sepsis decreased from E. faecium (Np 11 pt. −9.4%- vs. Pp 7 pt. −3.8%, p = 0.047), and Enterobacter spp., S. haemolyticus, S. maltophilia, Proteus spp., and P. aeruginosa have not changed. Finally, we found that resistance to OXA-48 (p = 0.040), ESBL (p = 0.002), carbapenems (p = 0.050), and colistin (p = 0.003) decreased with time from Np to Pp, particularly in Pp-COVID.ConclusionThis study demonstrated how the COVID-19 pandemic changed the prevalence of sepsis in the ICU. It emerged that the risk factors associated with mortality were APACHE and SOFA scores, age, and, above all, the presence of ESBL-producing bacteria. Despite this, during the pandemic phase, we have observed a significant reduction in the emergence of resistant germs compared to the pre-pandemic phase.

Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Diverting ostomy prior to neoadjuvant treatment in rectal cancer should be used selectively: A retrospective single-center cohort study.

Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered, despite the absence of conclusive evidence when a diversion is advantageous. This is a retrospective observational single-center study on a 4-year consecutive rectal cancer cohort undergoing neoadjuvant therapy, aiming at improving the understanding of risks and benefits associated with ostomy diversion. Baseline characteristics, tumor-specific data, clinical events, and outcomes were collected using the Swedish Colorectal Cancer Registry and medical records. Thirty-two (30.2%) of the 106 included patients presented with endoscopic impassable tumors at diagnosis, of which 18 (56.2%) had diverting ostomy. Three out of 14 with impassable tumor and no diversion developed a bowel obstruction. None of the patients with an endoscopically passable tumor at diagnosis (n = 74) experienced a bowel obstruction. The elective diversions (n = 40) were not associated with serious complications (Clavien-Dindo grade ⩾ 3b). Patients with a diverting ostomy (n = 30) had similar time intervals from diagnosis to neoadjuvant treatment and to definite tumor resection as those without diversion but experienced more complex primary tumor resections in terms of blood loss and operation time. An elective diverting ostomy is a relatively safe procedure in rectal cancer patients requiring neoadjuvant therapy. More than one out of five non-diverted patients with endoscopically impassable rectal tumors developed bowel obstruction and would potentially have benefited from an elective diversion.

A nation-wide medical record database study: Value of hepatitisB surface antigen loss in chronic hepatitisB patients in Japan.

HepatitisB surface antigen (HBsAg) seroclearance is considered to be one of the best surrogate endpoints of functional cure for hepatitisB virus (HBV) infection. However, evidence regarding the relationship between achieving HBsAg seroclearance or a low baseline HBsAg level, and long-term clinical outcomes in Japanese patients with chronic HBV infection remains to be confirmed in a real-world setting. A retrospective observational cohort study was performed with an electronic medical record database, including data from 230 hospitals across Japan. Chronic HBV infection was defined as two consecutive, positive HBsAg laboratory measurements for HBV infection. The date of the second positive was used as a baseline to identify subsequent HBsAg seroclearance and liver disease progression. In the database, 2523 patients with chronic HBV infection were identified as the chronic hepatitisB (CHB) cohort. Among the CHB cohort with an average observational period of 5.19±3.87years, 202 patients (8%) achieved HBsAg seroclearance after baseline. They had a lower risk of developing hepatocellular carcinoma (HCC) (adjusted hazard ratio [aHR] 0.206, p<0.01) and cirrhosis (aHR 0.361, p<0.01). When the CHB cohort was stratified into two groups based on baseline HBsAg levels (<100IU/mL and ≥100IU/mL), patients with a lower baseline level of HBsAg (<100IU/mL) had a lower risk of developing liver disease (HCC aHR 0.600, p<0.01; cirrhosis aHR 0.618, p<0.05). These results confirm the clinical significance of HBsAg seroclearance and low HBsAg level at baseline with respect to long-term outcomes of patients with CHB in the Japanese population.

The Association between Low Fetal Fraction of Non-Invasive Prenatal Testing and Adverse Pregnancy Outcomes for Placental Compromise

(1) Background: Non-invasive prenatal testing (NIPT) is a screening test for fetal aneuploidy using cell-free fetal DNA. The fetal fragments (FF) of cell-free DNA (cfDNA) are derived from apoptotic trophoblast of the placenta. The level of fetal cfDNA is known to be influenced by gestational age, multiple pregnancies, maternal weight, and height. (2) Methods: This study is a single-center retrospective observational study which examines the relationship between the fetal fraction (FF) of cell-free DNA in non-invasive prenatal testing (NIPT) and adverse pregnancy outcomes in singleton pregnancies. A total of 1393 samples were collected between 10 weeks and 6 days, and 25 weeks and 3 days of gestation. (3) Results: Hypertensive disease of pregnancy (HDP) occurred more frequently in the low FF group than the normal FF group (5.17% vs. 1.91%, p = 0.001). Although the rates of small for gestational age (SGA) and placental abruption did not significantly differ between groups, the composite outcome was significantly higher in the low FF group (7.76% vs. 3.64%, p = 0.002). Furthermore, women who later experienced complications such as HDP or gestational diabetes mellitus (GDM) had significantly lower plasma FF levels compared to those without complications (p &lt; 0.001). After adjustments, the low FF group exhibited a significantly higher likelihood of placental compromise (adjusted odds ratio: 1.946). (4) Conclusions: Low FF in NIPT during the first and early second trimesters is associated with adverse pregnancy outcomes, particularly HDP, suggesting its potential as a predictive marker for such outcomes.

Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period.

(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.