Severe Grade Research Articles

Automatic knee osteoarthritis severity grading based on X-ray images using a hierarchical classification method

Automatic knee osteoarthritis severity grading based on X-ray images using a hierarchical classification method

Risk Factors for Postoperative Intra-Abdominal Abscess in Pediatric Perforated Appendicitis Following Laparoscopic Appendectomy: A Multicenter Analysis

Background: Perforated appendicitis in children is a frequently encountered and significant surgical condition. The treatment of choice is laparoscopic appendectomy, but this carries a risk of postoperative intra-abdominal abscess (IAA). The purpose of this study was to determine risk factors linked to the occurrence of IAA following laparoscopic surgery in pediatric perforated appendicitis. Methods: This retrospective cohort study analyzed 137 children with perforated appendicitis who received laparoscopic appendectomy at four tertiary hospitals between March 2018 and December 2022. Data on patient demographics, preoperative clinical characteristics, and surgical details were collected. Independent risk factors for IAA formation were determined using logistic regression analysis. Results: The overall incidence of postoperative IAA was 10.9%. Prolonged symptom duration and elevated CRP levels were associated with higher IAA rates. Patients who developed IAAs experienced prolonged postoperative fevers and longer hospital stays. Significant risk factors for IAA identified through multivariable analysis included a higher severity grade of appendicitis (≥Grade IV, OR 5.9, p = 0.034) and the presence of a free appendicolith during surgery (OR 5.549, p = 0.01). Of the patients who developed IAAs, nine (60%) improved with conservative treatment, while six (40%) required invasive procedures. Conclusions: A higher severity grade of appendicitis (≥Grade IV) and the presence of a free appendicolith are significant predictors of postoperative IAAs in pediatric perforated appendicitis. Recognizing these factors can help guide clinical management and postoperative care, potentially reducing the incidence of this complication.

HPB SO30 - Evaluation of efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis

Abstract Background Acute cholecystitis is associated with considerable mortality. The risk of mortality ranges between 2.4% to 8.4% according to severity. The main line of managing patient presenting with grade II/ III acute cholecystitis is source control through insertion of cholecystostomy drain (if patient is not suitable for emergency cholecystectomy) and anti-microbial treatment. Tokyo 2018 guidelines recommends against use of Co-Amoxiclav as an empiric antimicrobial therapy for cases of acute cholecystitis as most common organism isolated is E. Coli. The aim of this study is to evaluate the efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis. Method The medical records were searched retrospectively for patient presented with acute severe cholecystitis grade II/ III who treated with cholecystostomy drain insertion as a temporary measure during 2020 and 2021. The culture and sensitivity (C&S) of cholecystostomy drain aspirate at time of insertion of the drains were reviewed to determine the type of appropriate antimicrobial therapy. The results were analysed using both best and worst case scenario to find about the efficacy of Co-Amoxiclav as an empiric antimicrobial treatment. Results 105 sample of cholecystostomy drain aspirate sent for culture and sensitivity, 27 samples were resistant to co-amoxiclav (25%), while 22 samples were sensitive to co-amoxiclav(20.9%) . 56 of samples (53.1%) showed no mention of testing of Co-Amoxiclav. On further analysis on best case scenario basis, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are sensitive to co-amoxiclav. While on worst case scenario, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are resistant to co-amoxiclav. Conclusion Use of co-amoxiclav as an empirical antimicrobial treatment for cases of grade II/ III acute cholecystitis is associated with considerable antimicrobial resistance ranges from 25% in the best case scenario and 79% in worst case scenario. The most common organism isolated from these samples was E.coli. These results are in complete agreement with Tokyo 2018 guidelines, which states that Co-amoxiclav is associated with more than 20% resistance.

BN SO51 - Complications from operative cholangiogram during emergency laparoscopic cholecystectomy: A retrospective, observational cohort study in a UK single centre

Abstract Background Laparoscopic cholecystectomy (LC) is a common surgical procedure, with >60,000 undertaken annually in the UK. One serious complication of cholecystectomy is bile-duct-injury (BDI), with an incidence of 0.28–1.5%. The use of intraoperative-cholangiogram (OTC) has been shown to aid in earlier diagnosis and treatment of BDI. Although advocated as routine by many, no studies have assessed the morbidity caused by OTC. With newer modalities available, such as indocyanine-green-fluorescent-cholangiography (ICGC) and three-dimensional laparoscopy, it is important to consider each method's risks and benefits, including OTC. We decided to investigate the morbidity caused by OTC with an emphasis on post-OTC acute pancreatitis. Method We conducted a retrospective cohort study of a prospectively collected cohort of patients aged 18 and over who have undergone emergency LC, defined as LC within seven days from admission with acute cholecystitis, over three years in a UK district general hospital. The primary outcome studied was the incidence of complications following OTC, including acute pancreatitis (AP), acute cholangitis, extra-hepatic biliary tree injury and hepatic abscess. The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist was utilised. We used GraphPad Prism 10.2.3. for statistical analysis. Results 472 cases were analysed. Median age was 54(A), BMI 31(C), ASA grade 2(D), clinical frailty score 2(E), Charlson Comorbidity Index 1(F), Tokyo severity grade 1(K) and female-to-male ratio 0.83(B). 14.31% of cases had pre-op CBD dilatation, 0.42% CBD stones and 6.19% both, with most having ultrasound pre-op (J-I). The median Nassar score was 3(L). 24.57 % of cases had an OTC done, with a median volume of contrast-media used of 11(6;24.5) mls, with 17 cases having CBD stones diagnosed(M-O). Four cases, or 3.44% of the total OTCs, developed acute pancreatitis (P). Conclusion Emergency laparoscopic cholecystectomy with intraoperative cholangiogram may increase the risk of postoperative acute pancreatitis.

MRI variables and peripheral inflammatory response biomarkers predict severity and prognosis in patients with acute cervical traumatic spinal cord injury.

Traumatic spinal cord injury (TSCI) stands as one of the most profoundly damaging and debilitating conditions. This study aims to explore the potential of magnetic resonance imaging (MRI) variables and peripheral inflammatory indicators as promising biomarkers. It aims to understand their significance in evaluating the severity and predicting the prognosis of TSCI. Furthermore, the study aims to ascertain whether combining these indicators could enhance the accuracy of injury assessment and predictive prognostic ability. A multicentre retrospective cohort study was conducted to assess the severity and prognostic value of MRI variables and peripheral inflammatory response biomarkers in patients with acute cervical TSCI. The study involved 374 patients with acute cervical TSCI drawn from the First Affiliated Hospital of Nanchang University and the Second Affiliated Hospital of Nanchang University. The severity and prognosis of patients with acute cervical TSCI were assessed using the American Spinal Injury Association Impairment Scale (AIS). The correlation between MRI variables, peripheral inflammatory response biomarkers, admission severity, and the 1-year follow-up prognosis was analysed. After the initial assessment using the AIS grade system, 169 (49.2%) patients fell into the severe category for cervical TSCI (AIS A-B), while 205 (50.8%) patients were classified as non-severe cases (AIS C-E). The MRI variables (intramedullary lesion length [IMLL], Brain and Spinal Injury Centre [BASIC], maximum spinal cord compression [MSCC], and maximum canal compromise [MCC]) and inflammatory response biomarkers (white blood cells [WBCs], neutrophils, and C-reactive protein [CRP]) exhibited a consistent decrease correlating with the severity grades noted upon admission. Among the 374 patients assessed, 147 (39.3%) experienced a poor prognosis, as indicated by the AIS grade during the 1-year follow-up. MRI variables and peripheral inflammatory response biomarkers declined in correspondence with the follow-up AIS grades. Sex (p < 0.001), IMLL (p < 0.001), MSCC (p < 0.001), MCC (p < 0.001), BASIC (p < 0.001), WBC (p < 0.001), neutrophils (p < 0.001), and CRP (p < 0.001) were statistically significant in predicting poor outcomes. Through multivariate logistic regression analysis, BASIC score and CRP emerged as independent predictors of poor prognosis. Notably, the model combining the BASIC score and CRP yielded a larger area under the curve compared to models using only the BASIC score or CRP individually. The BASIC score and CRP are crucial biomarkers for evaluating the severity of cervical TSCI and predicting prognosis. Their combination proved to be a more robust determinant of injury severity and a better predictor of neurological recovery.

CTNI-30. A PHASE 2 DOUBLE-BLIND, RANDOMIZED, PROSPECTIVE, PLACEBO CONTROLLED STUDY OF NANO₂TM COMBINED WITH RADIATION AND TEMOZOLOMIDE IN PATIENTS WITH NEWLY-DIAGNOSED GLIOBLASTOMA: RESTORE

Abstract INTRODUCTION Glioblastoma (GBM) commonly has extensive hypoxic regions, possibly due to thrombosis from tumor-produced pro-coagulant factors. Radiation-induced cell death relies on oxygen free radicals and oxygen fixation of DNA-strand breaks. In the absence of oxygen tumor cells can repair the DNA strand breaks leading to treatment resistance. Hypoxic cells also exhibit chemoresistance due to decreased drug efficacy, limited drug diffusion, and poor delivery to distant cells. This study hypothesizes that increasing oxygen delivery to hypoxic GBM tissue using NanO₂ (2% w/v dodecafluoropentane emulsion) infusion will enhance the effectiveness of radiation therapy (RT) and chemotherapy (CT). METHODS Patients diagnosed with GBM per CNS5-WHO criteria receive standard chemoradiation: 30 fractions of focal RT with 60 Gy, delivered as 2 Gy fractions five days per week for six weeks with concurrent oral TMZ at 75 mg/m²/day for six weeks. Patients are randomized in a 1:2 ratio to receive either a placebo (0.9% Sodium Chloride) or NanO₂ infusion administered immediately prior to each RT dose. Patients continuously breathe oxygen during infusion and RT. Following six weeks of RT with temozolomide, patients have a four-week break before starting adjuvant temozolomide. RESULTS Ten patients have been enrolled in the RESTORE trial. Seven continue to be followed through maintenance treatment and long term follow up. There have been 23 non-hematologic adverse events described as CTCAE severity grade 3 and above. Grade 4, hematologic toxicity occurred in two patients, with one patient experiencing prolonged pancytopenia necessitating hematologic support and discontinuation of temozolomide. Two patients discontinued therapy due to early tumor progression. CONCLUSION This study is ongoing, assessing the safety and potential efficacy of NanO₂ in improving treatment outcomes for GBM by enhancing oxygen delivery to hypoxic tumor regions.

Development of a nomogram for predicting pancreatic portal hypertension in patients with acute pancreatitis: a retrospective study

IntroductionPancreatic portal hypertension (PPH) is a rare complication of acute pancreatitis (AP) that can lead to severe gastrointestinal bleeding. The risk factors associated with PPH, as well as the overall...

Diagnosis and Management of Drug-Induced Interstitial Lung Disease in the context of Anti-Cancer Therapy: a Multidisciplinary Viewpoint by Portuguese Experts.

Drug-induced interstitial lung disease (DI-ILD) is a significant complication in patients undergoing treatment with certain anti-cancer therapies, with incidence rates rising, particularly with newer drugs such as trastuzumab-deruxtecan, which may impact their safe and effective use. Although the exact pathophysiological mechanisms remain unknown, and different drugs may induce lung damage through different pathways, the most recognized mechanisms are cytotoxic- and immune-mediated effects. Multidisciplinary teams play a crucial role in the diagnosis, management, and prevention of DI-ILD. Given the wide variability in the onset of DI-ILD, which may occur within the first few days of treatment or months after, patient education and clinician training are essential for early detection and improved outcomes. Moreover, the diagnostic confirmation requires the exclusion of alternative causes through clinical, imaging and bronchoscopy evaluation. Treatment strategies largely depend on the grade of severity of the clinical manifestations of DI-ILD, ranging from interruption or discontinuation of the offending drug to corticosteroid therapy and hospitalization for appropriate monitoring. Nonetheless, further research is needed to better understand the impact of emerging anti-cancer drugs on DI-ILD and to establish standardized management protocols.

In vivo lacrimal gland imaging artefact assessment based on swept-source optical coherence tomography for dry eye disease.

This study aimed to characterise imaging artefacts in the lacrimal gland using swept-source optical coherence tomography (SS-OCT) in patients with dry eye disease (DED) and healthy participants and identify risk factors for these artefacts. In total, 151 eyes, including 104 from patients with DED and 47 from non-DED participants, were analysed. Demographic data collection, comprehensive ocular examinations and SS-OCT imaging of the palpebral lobe of the lacrimal gland were performed. Artefacts were classified into distinct categories with different severities. Univariate and multivariate logistic regression analyses were performed to evaluate the association of age, gender, best-corrected visual acuity, intraocular pressure (IOP) and the presence of DED with the presence of artefacts. Eight artefact types and severity grading were defined by analysing 1208 lacrimal SS-OCT images. The three most prevalent artefacts were defocus (75.83%), cliff (67.47%) and Z-off (58.44%). The presence of artefacts was significantly associated with the presence of DED (OR=9.13; 95% CI, 2.39 to 34.88; p=0.001) and higher IOP (OR=1.34; 95% CI, 1.14 to 1.58; p<0.001). Furthermore, multivariate logistic analyses showed that lower tear film breakup time (OR=0.71; 95% CI, 0.55 to 0.92; p=0.009) and higher meibum quality score (OR=2.86; 95% CI, 1.49 to 5.48; p=0.002) were significantly associated with higher odds for the presence of artefacts. DED eyes had more SS-OCT image artefacts than normal eyes. Stringent standardised image quality control should be implemented before further image analysis when using SS-OCT to assess lacrimal gland image.

Correlation of safety and efficacy of atezolizumab therapy across indications

BackgroundThe association between safety and efficacy of immune checkpoint inhibitors is known, but the correlation between severity and impact of specific organ involvement by immune-related adverse events (irAE) and cancer...

Surgical Technique for Performing Endoscopic Carpal Tunnel Release without Converting to an Open Technique, and Analysis of the Reasons for Conversion

IntroductionEndoscopic carpal tunnel release (ECTR) has advantages over open carpal tunnel release (OCTR); however, complications with ECTR are more likely to occur if the surgeon continues the procedure despite encountering difficulties. Techniques to minimize the need for conversion to OCTR have been infrequently discussed in the literature. This study aims to present a technique for performing ECTR without conversion to the open approach and to analyze the reasons for such conversions. MethodsA total of 1,160 hands in 771 patients who underwent single-portal ECTR between January 2001 and December 2020 were analyzed. We evaluated the rate and reasons for conversion and compared clinical severity and electrodiagnostic grades between the ECTR and OCTR conversion groups to identify patient characteristics associated with conversion. ResultsA total of 18 hands in 17 patients required conversion to OCTR (1.56%). In the first 5 years, 9 out of 251 ECTRs (3.59%) were converted, but since then, the conversion rate significantly decreased with increasing surgical experience. The most common reasons for conversion were poor visualization of the transverse carpal ligament (TCL) due to the transbursal approach with a hypertrophic synovial membrane. As the preoperative clinical grade worsened, the conversion rate significantly increased. The OCTR conversion rate also tended to rise with more severe electrodiagnostic grades. Outcomes for all 18 wrists were successful at the 6-month follow-up. ConclusionA thorough subligamentous extrabursal approach is essential for achieving a clear endoscopic view of the TCL and performing ECTR without the need for conversion to open surgery.

Lessons learned: Risk factors and clinical impact of severe pneumothorax after endoscopic lung volume reduction with endobronchial valves

BackgroundPneumothorax is a major complication following endoscopic lung volume reduction with valves with a prevalence of up to 34%. While some patients benefit from valve implantation despite pneumothorax, others are significantly impaired after lung collapse. Research questionWhat are the differences in the severity grades of pneumothorax and how does that affect our clinical practice? Study design and MethodsThis single-center retrospective study analyzed patients undergoing endoscopic valve implantation with and without post-interventional pneumothorax. Emphysema characteristics, collateral ventilation, management, and outcome of patients with pneumothorax 3 months after valve implantation were assessed. Pneumothorax was categorized as “severe pneumothorax” (chest tube insertion, prolonged air leak requiring valve removal), “moderate pneumothorax” (chest tube, no valve removal), and “mild pneumothorax” (no chest tube). ResultsPneumothorax occurred in 102/532 patients (19%) and was significantly more common after valve placement in the upper lobes (31.3%) compared to the lower lobes (11.3%, p < 0.001). Fissure integrity was significantly higher in patients with pneumothorax (mean 96.6 ± 6.3 % vs. 93.4 ± 10.3 %, p = 0.002). Of all pneumothoraces, 30.4% were mild, 30.4% moderate, 39.2% severe. Severe pneumothorax caused multiple complications and prolonged hospitalization. Valve placement in the left upper lobe and a larger size of the target lobe were identified as risk factors for severe pneumothorax. Patients with pneumothorax developed complete lobar atelectasis in >60% as a sign of therapeutic success, but obviously only when valves could be left in place or re-implanted. However, valve re-implantation resulted in re-pneumothorax in 42.9%. InterpretationPatients could be more individually informed about their risk of pneumothorax, which varies with target lobe location, fissure integrity and re-implantation. The poor outcome and high complication rate of severe pneumothorax calls for future research into the prediction of severe pneumothorax.

OSCE RELATED ANXIETY IN ASSOCIATION WITH PERCEIVED VS ACTUAL PERFORMANCE

Objectives: The study investigates the impact of anxiety on medical students performance in Objective Structured Clinical Examinations (OSCEs), focusing on the relationship between self-perceived and actual performance. Methods: Conducted among 5th-year medical students at Taif University, the study used an online questionnaire with the PHQ-4 scale to measure anxiety and depression. The aim was to correlate these levels with students self-assessment and actual performance in OSCEs. Results: The study analyzed responses from 62 students. The average self-reported anxiety level was 8.95 ± 1.348 on a 10-point scale, with 64.5% of students reporting severe anxiety and depression. No significant gender differences in anxiety and depression severity were noted (p=0.308). Higher levels of anxiety and depression were reported by students who perceived their grades as lower, although this was not statistically significant (p=0.431). There was no statistically significant correlation between anxiety/depression severity and actual grades (p=0.280). Conclusions: The study underscores the prevalent issue of anxiety among medical students and its potential influence on their self-perceived performance in critical evaluations like OSCEs. It suggests the necessity for targeted interventions to manage student anxiety, which could enhance self-assessment accuracy and overall performance.

FOLFOXIRI for First-Line Treatment of Unresectable Colorectal Cancer with Liver Metastases in a Resource-Limited Setting.

FOLFOXIRI is a standard treatment for unresectable colorectal cancer (CRC) liver metastases. However, limited data exists on its safety and effectiveness in low-to-middle-income countries (LMICs). This prospective study addresses this gap in a Vietnamese LMIC setting. We enrolled 92 patients with unresectable CRC liver metastases between 2022 and 2023. All patients received FOLFOXIRI every 2 weeks, with routine G-CSF prophylaxis to prevent neutropenia. A multidisciplinary team (MDT) assessed diagnoses and treatment responses. Outcomes were R0/R1 resection rate, progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), adverse events (AEs), and recurrence-free survival (RFS) for surgical patients. The median patient age was 56 years, with a male predominance (70.7%). The primary tumors were located in the left colon (42.4%), rectum (37%), and right colon (20.7%). Thirty-two patients (34.8%) experienced severe (grade 3 or higher) AEs, with thrombocytopenia (13.1%) and anemia (9.8%) being the most frequent. Most patients (72/87, 82.9%) achieved a partial response. The ORR and DCR were 85.1% and 95.4%, respectively. Fifty-seven patients (62%) achieved resectability, and 54 (58.7%) underwent radical surgery. The R0/R1 resection rate was 88.9%. The median PFS and OS for all patients were 13 and 22 months, respectively. The median RFS of surgical patients was 14 months. FOLFOXIRI improves the response rates, R0/R1 resection rates, and survivals for patients with CRC liver metastases. Future research is necessary to improve the prognosis of patients while minimizing toxicities. NCT05362825 dated 5 May 2022.

Quality of life of patients with neurofibromatosis 1-Physical disability does not necessarily result in poor mental health.

Neurofibromatosis 1 (NF1) is a chronic neurocutaneous disease known to profoundly affect quality of life (QoL). We have performed an analysis of disease severity, mental and physical QoL and compare the different subclasses among patients with neurofibromatosis 1 (NF1). We conducted a prospective analysis of 89 NF1 patients between January 2016 and March 2018. Data sourced from local records including demographic information, employment status, education level, and marital status. All patients completed 36-Item Short Form Health Survey (SF-36) and additionally the numerical pain rating scale (NPS). Patients were stratified based on severity of NF1, visibility and disease severity. Among 89 patients, severity was classified as grade 4 was identified in 42 (47.2%), moderate in 17 (19.1%), mild in 23 (25.8%) and minimal in 7 (7.9%) cases. According to visibility scale, severe grade 3 was found in 28 (31.5%), moderate grade 2 in 26 (29.2%) and mild grade in 35 (39.3%) cases. SF-36 data, except for pain, showed significantly lower values, if compared to the standard German population (P < 0.001, physical component summary P = 0.045). Sex, marital status and education level did not significantly influence results. Employment was significantly associated with better mental and physical status (P = 0.028 and P = 0.01 respectively) and age >40 was linked to lower physical (P = 0.027) but not mental component scores (P = 0.362). The numerical pain rating scale indicated pain levels of 7-10 in 9 cases (10,1%), 5-6 in 10 patients (11.2%), 1-4 in 26 patients (29.2%) and no pain in 44 cases (49.4%). Physical component scores significantly differed across different NPS grades (P < 0.001) but not in mental component scores (P = 0.06). Finally, no significant differences were found in mental component scores across severity or visibility grades. Severity and visibility grades of patients with NF1 may not necessarily result in poor mental health. Symptomatic treatment should be considered even for severely disabled patients as they may have comparable QoL to less severely affected patients with NF1. Employment was linked to better quality of life outcomes in our findings.

A Cross Sectional Study of the Prevalence of Retinopathy in Patients with Chronic Kidney Disease on Hemodialysis in a Tertiary Care Centre in Chengalpattu District, South India

Context: Many studies have reported varying proportions of retinopathy among cases with chronic kidney disease (CKD). Cases with severe grades of CKD were more likely to develop ocular complications, especially diseases which occurs due to small vessel pathology. Aim: To estimate the prevalence of various types of retinopathies in patients with CKD undergoing hemodialysis in a tertiary care centre in South India. Settings and Design: The outpatient Department of Ophthalmology and Hemodialysis unit of Nephrology, Karpaga Vinayaga Institute of Medical Sciences from January 2022 to June 2023 A cross-sectional hospital-based observational study in a low resource setting. Methods and Material: The study consists of 28 patients who were known cases of CKD on hemodialysis. Patients underwent complete ocular evaluation and findings were noted. The pre hemodialysis values of blood urea and serum creatine, hemoglobin, liver function tests and vital parameters were also noted. Data analysis was done utilising version 20 of Statistical Packages for the Social Sciences (SPSS). Results: 56 eyes of 28 patients on hemodialysis were studied. The mean age was 53 years + 10.9 with a male preponderance. 31.6% had retinopathy of which 26.3% had hypertensive retinopathy and 5.3% had diabetic retinopathy. This is contrary to the previous studies that have reported a higher incidence of diabetic retinopathy in patients with end stage CKD. Hypertension resulted in CKD earlier than diabetes. Conclusion: The results emphasize the importance of frequent eye examination in patients with CKD to identify retinopathy earlier, thus potentially averting permanent vision impairment.

Validation of a hand-held ultrasound device in the evaluation of aortic stenosis

Abstract Introduction Hand-held Ultrasound devices (HHUD) are increasingly used in routine clinical practice, although until recently they did not have continuous Doppler. There is no evidence on the usefulness of an HHUD for the assessment of aortic stenosis (AS) in real life. Objective To validate the use of a new HHUD device in a real-life scenario. Material and methods Observational, single-center and prospective study, including patients diagnosed with AS with a previous standard echocardiography. Patients were randomly recruited from a tertiary cardiac imaging laboratory. Immediately after the reference echocardiography performed by an imaging expert, a Cardiology trainee with ASE level II repeated the study blindly with an HHUD. Agreement between the two tests was evaluated by measuring the mean aortic valve gradient (mAG). An intraclass correlation coefficient (ICC) test, linear regression, and Bland-Altman test were performed to compare the two methods. Results 101 patients were recruited. The reference test calculated a mAG of 29 mmHg (19.8 - 42.2) versus a mAG of 27.2 mmHg (16.2 - 43.9) in HHUD. The statistical analysis showed a good correlation between both tests (ICC: 0.87 (95% CI: 0.79 -0.94) and r=0.89 (95% CI: 0.85-0.94) (Figure). The Bland-Altman test showed a non-significant underestimation (1.61 ± 0.9 mmHg; p= 0.09). The HHUD classified 29 cases as severe or major AS compared to 31 in the reference test (kappa= 0.81; 95% CI: 0.68 - 0.94). The HHUD showed an excellent agreement for classification of AS in at least severe AS grade. The kappa analysis had a value of 0.81 (95% CI 0.68 – 0.94) with a global agreement of 92.1%. The positive predictive value was 89.6%. The negative predictive value was 93.1%. Sensitivity and specificity were 83.8% and 95.7%. The rest of the variables evaluated showed poorer agreement. In those patients with obesity, worse acoustic window, atrial fibrillation and critical AS, the agreement was worse. Conclusions The new HHUD evaluated by an operator with limited experience showed good agreement with the reference echocardiographic device in determining the mean aortic gradient.Central picture

Intra, short and long-term results of mitral VIV for the degenerated surgical mitral prosthesis from italian VIV registry (MIVIV registry)

Abstract Background/Introduction Reoperation of failed bioprosthetic mitral valves is associated with significant morbidity and mortality. Transcatheter mitral valve-in-valve (MViV) replacement was explored early in the development of THVs with transseptal/transfemoral (TS/TF) and transapical (TA) approaches. Purpose This is the first Italian Registry on mitral VIV and it was designed to explore contemporary MViV outcomes with all types of balloon expandable valves. The present study out of the registry aims to asses the &amp;gt;10 years follow-up outcomes in terms of mortality, gender diversity, and perioperative result. Methods Participating centers used standardized definitions to collect clinical information, including patient demographic characteristics, comorbidities, functional status, quality of life indexes, procedural details, and patient outcomes from consecutive MViV cases. Cohort of 265 patients was available for the primary analysis and follow-up too.The patients were grouped by 11 hospitals in Italy performing VIV for degenerated biological mitral prostheses. Results A total of 265 pts underwent mitral VIV due to bioprosthesis degeneration between January 2010 and January 2023. They have been subdivided by transfemoral (TF) with 117 (44%) pts and transapical (TA) with 148 (55,8%) pts. Most of the patients were of female sex (59,2%) and EuroScore II for surgical re-operation was 16.1%. Mixed disease (48%) was more common than mitral regurgitation (29%) and stenosis (22%). 69,8% of the total cohort was in class NYHA III and the mean LVEF was 54%.Otherwise, there were no significant demographic differences between patients undergoing TS and TA. In TF there was more severe PVL (5%)(p-value: 0,001) and much more cases of severe grade of stenosis (54,7%) and regurgitation (57%)(p-value&amp;lt; 0,0001). Considering intraoperative outcomes, technical success has been established in around 97,7% of the total cohort without difference btw groups. Only 3,3% died during hospitalization without difference between groups (P-value=0,735). LVOT obstruction has been seen in 3,4% in the case of TA and 0 for TF. Only 1,5% of the total cohort underwent surgical conversion as well as embolization in only 1,1%. Overall survival from the total cohort was 91,3% at &amp;gt;10 years, Figure 1. Concerning the freedom from cardiac death (CV death) was 96,6% in the total cohort at 13 years. Concerning the difference between access, the general survival is established at 97,4% in TF while 86,3% in TA (p-value =0,050)(Figure 2). Freedom from CV death was 99,1% in TF and 94,5 in TA (p-value=0,209). In gender analysis differentiation, the general survival in females was 98,5% in TF and 85,6% in TA at 13 years (p-value=0,056). Conclusion(s) Transcatheter MViV using a balloon-expandable valve is associated with high technical success, a low complication rate, and a solid long-term benefit in terms of survival. Transseptal access was associated with lower mortality compared with TA access.Figure 1Figure 2

Different right ventricular mechanics in atrial and ventricular secondary tricuspid regurgitation and their prognostic role. A multicentric three-dimensional echocardiography study

Abstract Background/Introduction Secondary tricuspid regurgitation (STR) can develop from markedly different etiologies. Both progressive dilation and dysfunction of the right atrium (atrial phenotype, ASTR), and adverse right ventricular (RV) remodeling (ventricular phenotype, VSTR) may result in STR. RV function is a major determinant of outcome in patients with STR. However, data about how RV function adapts to ASTR and VSTR are scarce, and the prognostic implications of RV mechanics in ASTR and VSTR remain to be clarified. Purpose Accordingly, we aimed to investigate the RV mechanical patterns in ASTR and VSTR and to examine their prognostic role using three-dimensional (3D) echocardiography. Methods We enrolled 192 patients with STR (60% women) who underwent clinically indicated transthoracic echocardiography in a multicentric prospective observational study. The primary outcome was defined as a composite of heart failure hospitalization or cardiac death. STR etiology was assessed based on the TVARC criteria (ventricular STR n=134, atrial STR n=58). STR severity was categorized using STR effective regurgitant orifice area according to current guidelines. We assessed RV function by measuring the tricuspid annular plane systolic excursion (TAPSE) by M-mode echocardiography and RV ejection fraction (EF) by 3D echocardiography. In addition, we imported the 3D RV meshes into the ReVISION software package (Argus Cognitive, Inc, Lebanon, USA) to quantify the relative contribution of the longitudinal (LEFi), radial (REFi), and anteroposterior motion components (AEFi) to total RV EF. Results ASTR and VSTR patients had comparable TAPSE (17±5 mm vs. 18±5 mm, p=0.10), while RV EF was significantly higher in ASTR (54±7% vs. 47±10% p&amp;lt;0.001). Although LEFi (0.37±0.08 vs. 0.38±0.10, p=0.95) and AEFi (0.45±0.08 vs. 0.44±0.11, p=0.53) were comparable between ASTR and VSTR, REFi was significantly lower in VSTR (0.52±0.09 vs. 0.47±0.12, p&amp;lt;0.01). RF EF was comparable among STR severity grades (mild vs. moderate vs. severe: 50±11 vs. 49±9 vs. 50±10%, respectively, p=0.85). Conversely, LEFi was significantly higher in mild and moderate STR vs severe STR (0.39±0.08 vs. 0.39±0.09 vs. 0.35±0.10, respectively, p=0.04). Using multivariable Cox regression based on variables significant in the univariate analysis, REFi was a significant independent predictor of outcome in the entire cohort (hazard ratio: 0.978 [CI, 0.959-0.999], p= 0.037). Conclusions Using 3D echocardiographic assessment, ASTR and VSTR patients demonstrated significant differences in the RV mechanical pattern, with a lower contribution of the radial contraction in the case of ventricular STR etiology. While RV EF was comparable between STR severity grades, the relative importance of the longitudinal motion significantly differed. Notably, the relative contribution of radial motion to RV function demonstrated independent prognostic value in patients with STR.RV mechanics in STR severity stages

Use of respiratory signal analysis to assess severity of Brachycephalic Obstructive Airway Syndrome (BOAS) in dogs

Brachycephalic Obstructive Airway Syndrome (BOAS) is a potentially life-threatening condition that can be challenging to diagnose and grade objectively. The aim of this study was to investigate the use of respiratory signal analysis to assess severity of BOAS in dogs. Hundred and seventeen client-owned dogs of brachycephalic and non-brachycephalic breeds were enrolled. Respiratory sounds were recorded using an electronic stethoscope before and after a 3-minute exercise test (ET). Dogs were assigned a BOAS severity grade (BOAS 0–3) using a validated respiratory functional grading scheme. Signal analysis techniques were used to identify seven sound variables. Analysis of variance (ANOVA) was used to investigate associations between variables and BOAS severity and receiver operating characteristic (ROC) curves to assess the diagnostic efficacy of each sound variable. For each sound variable, there was a significant association with BOAS grade. An increase in BOAS grade resulted in greater sound magnitude in the frequency spectrum (0–1000 Hz), and in a greater contribution of lower frequencies (170–260 Hz). The variable “Peak 1” had the best performance in predicting BOAS negative (BOAS 0 +1) versus BOAS positive dogs (BOAS 2 + 3) before the ET; area under the curve (AUC) = 76.6 % (95 % confidence interval 67.4–85.8 %), whereas the variable “Valley 1” had the highest predictive value after the ET; AUC = 87.8 % (95 % confidence interval 81.4–94.3 %). Respiratory signal analysis has good potential for assessing BOAS severity and could be valuable for clinicians in clinical decision processes and for breeders when selecting suitable breeding dogs.