Symptomatic Patients Research Articles

Artificial intelligence-based automated plaque quantification from CCTA to predict acute coronary syndrome on top of obstructive or ischemic coronary artery disease

Abstract Background Artificial intelligence (AI)-based quantitative computed tomography (AI-QCT) is a novel tool for automated plaque characterization and quantification from coronary computed tomography angiography (CCTA). The prognostic value of various AI-QCT plaque types on top of the presence of obstructive or ischemic coronary artery disease (CAD) is unknown. Purpose To investigate the added prognostic value for acute coronary syndrome (ACS) of AI-QCT total plaque burden (percent atheroma volume (PAV) %), and its subcomponents non-calcified plaque burden (NCPB), low-attenuation plaque burden (LAP), and calcified plaque burden (CPB) (%) on top of obstructive or ischemic CAD. Methods A cohort of 2007 symptomatic patients having undergone CCTA and selective downstream PET perfusion for suspected CAD was analyzed. Patients with prior or early elective revascularization within 6 months from CCTA were excluded. Obstructive CAD was defined as ≥1 vessel with >50% visual stenosis, and ischemic CAD as absolute hyperemic myocardial blood flow ≤2.3 ml/g/min in ≥2 adjacent segments on 15O-H2O PET. Multivariable Cox regressions adjusted for clinical confounders (age, sex hypertension, typical angina) including each plaque type separately (per 1.0%) on top of obstructive or ischemic CAD, respectively, were performed. The amount of LAP was <1% and therefore pooled together with NCPB. Results Throughout a median follow-up of 7 years, 72/2007 patients experienced ACS (50 myocardial infarction, 22 unstable angina). On top of obstructive CAD, all plaque types were independent predictors of ACS (Figure 1A), however according to the C-indexes (p-value vs. obstructive CAD), only PAV (C-index=0.814, p=0.010) and NCPB+LAP (C-index=0.818, p=0.014), but not CPB (C-index=0.800, p=0.066) significantly improved the prediction of ACS on top of obstructive CAD (C-index=0.790) (Figure 2A). On top of ischemic CAD (1967 patients, 66 events), all plaque types were also independent predictors of ACS (Figure 1B). But, similarly, according to the C-indexes (p-value vs. ischemic CAD), only PAV (C-index=0.818, p=0.003), and NCPB+LAP (C-index=0.818, p=0.005), but not CPB (C-index=0.798, p=0.054) significantly improved the prediction of ACS on top of ischemic CAD (C-index=0.776) (Figure 2B). NCPB+LAP alone performed similarly as PAV on top of obstructive (p=0.554) and ischemic CAD (p=0.991) (Figure 2). Conclusions Among patients with native coronary arteries treated medically, AI-based plaque quantification significantly improved the prediction of ACS on top of obstructive or ischemic CAD. The risk of ACS was largely related to NCPB+LAP, whereas CPB did not significantly improve risk stratification.Adjusted HR for ACS per plaque typeC-indexes for ACS

C-C motif chemokine ligand 3 is associated with atherosclerotic plaque vulnerability and increased risk of mortality

Abstract Background and Purpose Chemokines play a crucial role in the inflammatory process underlying atherosclerotic plaque formation, progression and subsequent cardiovascular events. However, the specific role of C-C motif chemokine ligand 3 (CCL3) in atherosclerosis remains largely unexplored. This study aims to explore associations between intra-plaque levels of CCL3 and plaque vulnerability as well as to investigate the prognostic role of circulating CCL3 levels in patients undergoing carotid endarterectomy. Methods The CCL3 protein expression was measured using a proximity extension assay in 207 human carotid plaques and 558 plasma samples from patients undergoing carotid endarterectomy, all enrolled in the Carotid Plaque Imaging Project (CPIP) cohort. Protein expression is quantified as normalized protein expression (NPX), an arbitrary unit on a log2-scale. Plaque components and extracellular matrix including smooth muscle cells, macrophages, neutral lipids, intraplaque hemorrhage, collagen (by histology), and matrix metalloproteinases (assessed biochemically), were quantified. Plaque vulnerability index was calculated as the sum percentage of plaque areas stained for lipids, macrophages and hemorrhage, divided by the sum percentage of smooth muscle cells and collagen. Patients were followed up to 10.2 years to record cardiovascular events and mortality. Results Plaque and circulating levels of CCL3 were higher in symptomatic patients compared to asymptomatic patients (plaque, median NPX (interquartile range, IQR): 18.2 (17.4–19.1) vs 17.2 (16.4–18.0), P<0.001; plasma, median NPX (IQR): 1.78 (1.42–2.21) vs 1.56 (1.28–1.97), P<0.001). Plaque levels of CCL3 showed positive correlations with neutral lipids, macrophages, intraplaque hemorrhage, plaque vulnerability index and matrix metalloproteinases including MMP1, MMP2, MMP9, MMP10 and TIMP1, but inversely with smooth muscle cells. Among 511 patients with complete follow-up and circulating CCL3 measures, 144 (28.2%) patients developed cardiovascular events and 123 (24.1%) patients died. Elevated circulating CCL3 levels were associated with increased risk of cardiovascular events (hazard ratio (HR) per standard deviation (SD) = 1.40, 95% CI 1.06–1.84) and mortality (HR per SD=1.77, 95% CI 1.34–2.33), respectively. Higher levels of circulating CCL3 remained independently associated with an increased risk of mortality (HR per SD=1.50, 95% CI 1.09–2.04) even after adjustment for potential confounders. Conclusions Plaque levels of CCL3 are associated with plaque vulnerability features. Circulating levels of CCL3 predict higher risk of cardiovascular events and mortality among carotid endarterectomy patients.

Edge-to-edge repair for tricuspid valve regurgitation: 1-year follow up and clinical implications from the TR- Interventional Study (TRIS)

Abstract Background Tricuspid regurgitation (TR) affects 7% of the population, contributing significantly to heart failure-related hospitalizations. Traditional treatments have several limitations, prompting the exploration of innovative interventions. Purpose The present study aims to investigate the efficacy of tricuspid valve transcatheter edge-to-edge repair (T-TEER) in real-world patients with severe and symptomatic TR deemed at high surgical risk. Primary objectives focus on assessing T-TEER-induced TR reduction and reverse structural remodeling of the RV. Secondary objectives include assessment of functional status, quality of life, and residual regurgitation during the 12-month follow-up period. Methods The TR-Interventional study (TRIS) is a prospective, single-arm study. From January 2021 to December 2023, we enrolled 44 symptomatic patients with at least severe TR referred for TEER. Outcomes included safety and effectiveness along with assessment of clinical status. Results The study cohort had a mean age of 78.3±7 years, with 77.3% women and a mean TRISCORE of 5.1±1.9. Seventeen patients (38.6%) had massive, 7 (15.9%) had torrential, and 20 (45.5%) patients had severe TR. Etiologies included functional (40.9%), degenerative (13.64%), lead-induced (15.9%), and mixed (29.54%) origin. The primary efficacy endpoint, which assesses the successful implantation and performance of the device at the 30-day mark, was attained in 82.9% of patients. The secondary efficacy endpoint, assessing the stability of TR reduction at the 12-month, was achieved in 82,3% of patients. Post-procedural TR reduction of at least 2 degrees was achieved in 84% of patients. Echocardiographic assessments indicate ongoing beneficial remodeling over the one-year follow-up (Figure 1). Effects on RV remodeling also became apparent at the one-year follow-up, including reductions in the RV end-diastolic basal (p<0.01) and medium (p= 0.04) diameters of the TA septal-lateral diameter (p< 0.01). Significant reduction in vena contracta width (9 mm to 3 mm; p=<0.01), regurgitant volume (58 ml to 30 ml; p<0.01), and effective regurgitant orifice area (EROA) (0.6 cm2 to 0.3 cm2; p<0.01), occurred between baseline and one-year follow-up (Figure 2). The NYHA Functional Class and KCCQ scores were improved from 30 days to 1 year (Figure 2). Conclusion TRIS suggests that T-TEER is a durable, effective, and safe therapeutic option for high-risk patients with severe TR. The enduring nature of TR reduction at one year correlates with sustained clinical benefits and reverse structural remodeling of the right ventricle.TR reductionNYHA and functional status

A nurse-led intervention improves quality of life and reduces arrhythmic recurrences in patients undergoing atrial fibrillation ablation. Results of the NURSECAT-AF randomized clinical trial

Abstract Background/Introduction Atrial fibrillation (AF) is a prevalent condition that can lead to a decrease in quality of life and frequent re-hospitalizations. Some data suggest that integrated care nurse-led may blunt these consequences in unselected patients with AF, but not all studies support this. While AF ablation is becoming a cornerstone treatment for symptomatic patients with AF, it is unclear what impact a nurse-led intervention would have on these, quite likely, more receptive patients. Purpose To assess the impact of nurse-led intervention on quality of life among AF patients undergoing ablation. Methods We conducted a single-centre prospective randomised clinical trial to test the effect of an expert nurse-based intervention consisting of an educational programme on AF, support for the patient undergoing cardiac ablation to ensure its success, and management of risk factors associated with this arrhythmia. The control group underwent standard medical follow-up. Patient selection was based on chronological order. Only patients who underwent their first ablation and did not have heart failure were included. The primary endpoint was quality of life at 12 months post-ablation using the Arrhythmia-Specific Scale in Tachycardia and Arrhythmia (ASTA) questionnaire (higher values denote impaired quality of life). Secondary endpoints were AF knowledge and satisfaction at 15 days post-ablation using validated instruments, symptoms using the ASTA questionnaire as well, and readmissions rates, emergency room visits, and AF recurrence rates over a one-year period. Results 116 patients were screened (50 were excluded mostly because were re do). A total of 66 patients were eventually included and randomized (33 per arm; mean age [mean±SD] 63±10 years; 44 men [67%]). At 12 months, quality of life was significantly better in the intervention group than in the control group (4.5 ± 6.1 vs 0.57 ± 2.3, respectively, p=0.001)(Figure). Furthermore, satisfaction levels (17 ± 4.1 vs 12.7 ± 5.4, p>0.001) and disease knowledge (20.5 ± 5.1 vs 15.9 ± 4.5, p<0.001) were higher in the intervention group. Patients in the control group experienced a higher symptom burden during the first year (0.6 ± 1.5 vs 3.8 ± 4.5, p<0.001. Relevant clinical endpoints such as readmissions (3% vs 18.2%, p=0.046), emergency room visits (21.2% vs 57.5%, p=0.021), and arrhythmia recurrences (15.2% vs 45.5%, p=0.02) were all significantly lower in the intervention group. Conclusion(s) Nurse-led integrated care for patients undergoing AF ablation yields substantial improvements in quality of life and symptomatic relief at one year post-procedure. Additionally, it enhances patient knowledge of AF and satisfaction levels, and reduces readmissions, emergency room visits, and arrhythmia recurrences.

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients.

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection. In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact. 897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties. We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

Risk and causes of hospital admission in patients with atrial fibrillation on treatment with oral anticoagulants

Abstract Background Atrial fibrillation (AF) is associated with an increased risk of hospitalisation, although the main reasons for hospital admission and the role of antiarrhythmic drugs are not clarified. Objective The aim of our study was to assess the incidence rate and the factors associated with all-cause, cardiovascular and AF-related causes of hospitalisation in patients suffering from AF. Methods This is a prospective single-centre ongoing study (ATHERO-AF cohort) which included 2782 patients affected by non-valvular AF on oral anticoagulants. The primary endpoints were all-cause, cardiovascular and AF-related hospitalisation. Cardiac hospitalizations were defined as (non-AF) arrhythmias, acute coronary syndromes, heart failure (HF), systemic embolism, hypertensive urgency, vascular/cardiac surgery. The AF-related hospitalisation was defined as a recurrence of AF in paroxysmal pattern or as a high-rate symptomatic AF episode in persistent/permanent patterns. Multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratio (HR) with 95% Confidence interval (95%CI) for each factor in relation to risk of hospitalisation. Results Overall, 43.5% of patients were women with a mean age of 74.6±9.1year. Patients were followed for a mean of 31±26.8 months. We registered 1205 (12.1%/year) hospitalisations for any reason, 533 (5.7%/year) for cardiovascular causes and 180 (2.0%/year) were AF-related hospitalisations (Central illustration). Among the anti-arrhythmic drug use, we highlighted that flecainide and propafenone were associated with AF-related hospitalisations in paroxysmal and in persistent/permanent patterns (HR 1.861, 95%CI 1.116-3.101 and HR 1.947, 95%CI 1.069-3.548, respectively). Amiodarone (HR 3.012, 95%CI 1.835-4.943) and verapamil or diltiazem (HR 2.067, 95%CI 1.117-3.825) were associated with an increased risk of AF-related hospitalisations in persistent/permanent AF pattern. Furthermore, cancer was associated (HR 1.802, 95%CI 1.057-3.070) with increased risk of hospitalisation due to AF-related causes. Conversely, beta-blockers and digoxin were not associated with increased risk of hospital admission. Conclusions Hospitalisations of patients with AF are frequent for both cardiovascular and non-cardiovascular causes. Among the AF-related ones, the use of antiarrhythmic drugs emerged as associated with increased risk of hospitalisations, hypothesizing their poor effect in preventing AF episodes. For these reasons, we suggest carefully considering their use, reserving them for symptomatic patients with frequent AF recurrences.Central Illustration

Fractional flow reserve in saphenous vein grafts for the detection of myocardial ischemia determined by perfusion imaging

Abstract Background Fractional flow reserve (FFR) is recommended to guide revascularization of native coronary arteries. Revascularization decision-making for saphenous vein grafts (SVGs), however, is based on angiographic estimation of lesion severity, as studies exploring the value of FFR to detect perfusion imaging defined myocardial ischemia in SVGs are scarce. Purpose We aimed to define an optimal FFR threshold and compare its diagnostic performance with the traditional FFR cutoff and with percentage diameter stenosis (%DS) in patients evaluated for SVG disease using myocardial perfusion imaging (MPI) as the reference standard. Methods Symptomatic patients with prior coronary artery bypass grafting (CABG) who underwent single-photon emission computed tomography, positron emission tomography or stress perfusion cardiac magnetic resonance imaging, and had FFR measurements of one or more SVGs were included. Angiographic lesion severity of the SVG was measured using 2D quantitative invasive coronary angiography. We allocated and matched the myocardial territory subtended by the SVG to compare the values of FFR and %DS with ischemia determined by MPI. Results Included were 77 patients (mean age 72 ± 7 years; 86% male) with 91 SVGs. A total of 38 SVGs (42%) supplied an ischemic coronary territory. FFR and %DS correlated moderately (r= -0.51, P<0.001). The optimal cutoff value of FFR was ≤0.94, resulting in a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 63%, 75%, 65%, 74% and 70%, respectively (Figure 1). Corresponding values of FFR≤0.80 and DS%≥50 are shown in Figure 1 as well. Sensitivity, NPV and accuracy of FFR ≤0.94 outperformed that of FFR≤0.80, whereas specificity was lower. FFR≤0.94 outperformed %DS≥50 only in terms of sensitivity. Conclusions The optimal cutoff value of FFR for the detection of MPI-defined disease in SVGs is higher than the traditional FFR cutoff used to guide native coronary artery revascularization. Importantly, the increased sensitivity led to a higher diagnostic performance of the adjusted cutoff. However, the high prevalence of ischemia in post-CABG patients questions whether the optimal cutoff reflects ischemia caused by SVG obstruction.Diagnostic performance of FFR and %DS

Exercise postcapillary pulmonary hypertension in patients with chronic thromboembolism. Role of multimodal resting and exercise assessment

Abstract Introduction Chronic thromboembolic pulmonary disease refers to the presence of thrombotic material after a pulmonary embolism (PE), exercise limitation and the absence of resting pulmonary hypertension (PH) but impaired right ventricular and pulmonary vascular reserve during exercise causing exercise precapillary PH (exprecapPH). However, in some patients, PH arises from an abnormal increase in pulmonary arterial wedge pressure (PAWP) with exercise in relation to underlying diastolic dysfunction, with thrombotic material not playing a substantial role. Whether these patients present distinct non-invasive and resting invasive parameters remains largely unknown. Purpose To compare the different exercise hemodynamic profiles of patients with chronic thromboembolism to identify clinical, echocardiographic, functional and hemodynamic parameters associated with exercise postcapillary PH (expostcapPH). Methods Data come from a prospective cohort of 71 symptomatic patients with perfusion defects in lung scintigraphy and computed tomographic confirmation of chronic thrombi despite anticoagulation ≥3 months after PE without or mild resting PH, undergoing exercise cardiac catheterization via supine cycle ergometry. A multipoint mean pulmonary artery pressure (mPAP)/cardiac output (CO) and mean PAWP/CO slope were calculated. Simultaneous stress echocardiography was available in 43 patients. Cardiopulmonary exercise test (CPET) was performed 24 hours before catheterization. Results Mean age was 53±13.9 years, 46 (64.8%) were males. 37 patients showed normal exercise hemodynamics, while 26 developed exprecapPH and 8 expostcapPH. Mean mPAP/CO slope was 3.1±1.6 mmHg/L/min, mean PAWP/CO slope 1.5±0.9 mmHg/L/min. Patients with expostcapPH were older, had a higher body mass index and hypertension. Comparison of hemodynamics, CPET and resting echocardiography is depicted in the table. Patients with expostcapPH, similar to those without exercise PH, had significantly lower resting pulmonary pressures and pulmonary vascular resistance than those with exprecapPH. These differences remained at peak exercise; however, while resting PAWP did not differ between groups, a significant increase in PAWP was unmasked in patients with expostcapPH compared to the other groups, and accordingly a significant difference in the PAWP/CO slope. Regarding CPET, patients with expostcapPH had higher baseline systolic blood pressure and lower functional capacity (VO2 max, VO2 at VT1, O2 pulse, OUES). Resting TAPSE/PASP was higher in patients with expostcapPH compared to those with exprecapPH. Conclusions Patients with chronic thromboembolism and expostcapPH exhibit distinct clinical features and have lower functional capacity, while resting PAWP did not allow differentiation between groups. Further studies are warranted to delineate characteristic elements of patients with underlying diastolic dysfunction due to its distinct prognosis and treatment.

Socio-economic profile and prevalence of hypertension among type 2 newly diagnosed diabetes mellitus patients attending a tertiary hospital in Dhaka

Introduction: Untreated coexistence of hypertension and diabetes mellitus (DM) may result in more severe complications. The implementation of earlier intervention to prevent these complications can be facilitated by earlier identification of the conditions and their associated factors. Methods: This cross-sectional research was conducted at Sir Salimullah Medical College, Dhaka, between June 2020 and July 2021. Following the diagnosis of DM in the symptomatic patients, SPSS V 25 was utilized to collect socioeconomic history and blood pressure data for further analysis. Results : 271 (40 %) of the 542 diabetic patients were between 33 to 47 years of age. Most (332, 60.9%) were females. A majority of the patients (302.55.7%) belonged to lower socioeconomic classes, with incomes ranging from 1 thousand to 14 thousand taka. 253 patients (46.7%) had a familial predisposition to diabetes. Concurrent hypertension was observed in 193 (35.6%) diabetic patients; this was substantially correlated with advancing age, lower socioeconomic status, and higher body mass index (p< 0.05). Result: Diabetic hypertensive patients were more prevalent among those with lower socioeconomic status, a demographic that is least likely to pursue and adhere to treatment. Therefore, it is necessary to develop and execute policies that guarantee their appropriate treatment and avert subsequent complications. Conclusion A significant percentage of the participants simultaneously presented with diabetes mellitus and hypertension, both of which are life-threatening conditions if left untreated. The majority of patients belonged to the lower socioeconomic class, which increases the likelihood of inadequate diagnosis and treatment. It is imperative to develop policies that facilitate their convenient access to healthcare services, thereby enabling them to obtain appropriate treatment and prevent any subsequent complications. J Shaheed Suhrawardy Med Coll 2023; 15(1): 55-58

Comparative Assessment of the Incidence of Unilateral and Bilateral Lower Limb Deep Venous Thrombosis in Symptomatic and Clinically Suspected Patients

Objective: Deep vein thrombosis (DVT) is a familiar coagulation pathology that can be diagnosed through Doppler ultrasonography. This is a highly specific and sensitive method for the assessment of thrombosis. The present study aims to assess the incidence of lower limb DVT in a cohort of symptomatic and clinically suspected Saudi Arabian patients. Methods: This is a retrospective study that incorporated 1051 DVT patients over three years between January 2015 and December 2017 which presented with signs and symptoms of single or bilateral disease. Data were collected on the history of oedema, swelling, pain, tenderness, weakness, hotness, redness, fever, and vomiting. Possible risk factors that may increase the probability of developing DVT were also recorded. Results: The incidence of bilateral lower limb DVT in suspected patients was 84.5% negative and 15.5% positive. Old age was found to be the most common risk factor that resulted in DVT. The incidence of DVT is more common among females, whereas males were with all the bilateral cases. Conclusions: Screening tests are needed for DVT in symptomatic and asymptomatic patients.

The impact of updated national guidelines for managing unintentional paediatric liquid paracetamol exposures: a retrospective poisons centre study

Introduction In 2015, Australia and New Zealand treatment guidelines recommended a 2 h paracetamol serum concentration for risk assessment of unintentional paracetamol liquid exposures. We assess our experience with this approach. Methods Retrospective case review of children <6 years-old with liquid paracetamol overdoses referred to a regional poisons information centre January 2017 to August 2022. We extracted data on the exposure and management from the poisons information centre and hospital medical records. We identified additional cases with two paracetamol concentrations obtained from September 2022 to June 2024. Results Of 437 paediatric poisonings, 271 were eligible for inclusion. The median age was 24 months, the median time to presentation was 120 min, and paracetamol was the sole ingestant in 92% of cases. Blood testing was recommended in 131 patients (48.3%), occurring at 2 h post-ingestion in 62 patients (47.3%). Testing at a later time was mostly due to delayed presentation, including to hospitals unable to measure paracetamol concentrations. Eighteen patients (16.7%) had repeat blood testing, and five additional cases were identified in the subsequent period. Overall, the concentration decreased in 19 patients (83%), but in three patients it increased, from 73 mg/L to 81 mg/L (0.49–0.54 mmol/L), from 154 mg/L to 179 mg/L (1.03–1.19 mmol/L), and from 56 mg/L to 115 mg/L (0.37–0.77 mmol/L. Symptomatic patients were more likely to receive a second blood test or acetylcysteine while awaiting investigations. Of 19 patients administered acetylcysteine, it was discontinued in five due to low paracetamol serum concentrations. All patients recovered. Discussion Guidelines were followed in >90% of patients and this testing regimen shortened length of stay. Based on these data, Australian treatment guidelines now recommend repeat testing for 2 h paracetamol serum concentrations >100 mg/L (0.67 mmol/L). Conclusion A paracetamol serum concentration between 2 h and 4 h post-ingestion in children <6 years-old with unintentional poisonings of paracetamol liquid can facilitate medical discharge.

Diagnosis and Treatment of Tethered Spinal Cord: A Systematic Review.

Tethered cord syndrome is associated with motor and sensory deficits. Our objective was to summarize evidence regarding the diagnosis, prophylactic surgery, symptomatic treatment, and repeat surgery of tethered spinal cord in a systematic review (CRD42023461296). We searched 13 databases, reference-mined reviews, and contacted authors to identify diagnostic accuracy studies and treatment studies published until March 2024. One reviewer abstracted data, and a content expert checked the data for accuracy. We assessed the risk of bias, strength of evidence (SoE), and applicability. The evidence base includes 103 controlled studies, many with risk of bias and applicability concerns, and 355 case series providing additional clinical information. We found moderate SoE for MRI diagnosing tethered spinal cord, with medium to high diagnostic sensitivity and specificity. A small number of prophylactic surgery studies suggested motor function benefits and stability of neurologic status over time, but also complications such as surgical site infection (low SoE). A larger body of evidence documents treatments for symptomatic patients; studies revealed improvement in neurologic status after surgical detethering (low SoE), but also postoperative complications such as cerebrospinal fluid leakage (moderate SoE). A small body of evidence exists for retethering treatment (low or insufficient SoE for all outcomes). There was insufficient evidence for key outcomes (eg, over- or undertreatment, clinical impact of diagnostic modalities, ambulation, quality of life). This comprehensive overview informs difficult clinical decisions that parents and their children with tethered spinal cords, as well as their health care providers, face.

Quantitative magnetic resonance imaging of paraspinal muscles for assessing chronic non-specific low back pain in young adults: a prospective case-control study.

This study aimed to investigate the application of quantitative magnetic resonance imaging of paraspinal muscles in assessing the young CNLBP with unilateral symptom. This prospective study enrolled 107 young individuals with unilateral symptomatic CNLBP (56 cases) and a normal cohort (51 cases). All subjects underwent conventional lumbar sequences, T2 mapping, and IDEAL-IQ scans at 3T. T2 values and fat fraction (FF) of bilateral multifidus (mid-levels of L2-L5 vertebrae) and erector spinae (mid-levels of L1-L4 vertebrae) were measured. CNLBP severity, Japanese Orthopedic Association (JOA) score, and Visual Analogue Scale (VAS) score were recorded. Wilcoxon signed-rank tests were used to compare parameter differences between painful and non-painful sides in the case group. Mann-Whitney U tests were employed to evaluate differences between the case and normal group. Logistic regression analysis was conducted to identify predictive factors and to establish a combined model. In the case group, erector spinae FF values (L4 level), erector spinae T2 values (L1, L2, and L4 levels), and multifidus T2 values (L4 and L5 levels) were higher on the painful side (P<0.05). Multifidus T2 values (L5 level) and FF values (L2-L5 levels) were higher in the case group compared to the normal group (P<0.05). The optimal performance in differentiating young CNLBP was the combination of L5 level multifidus T2 value with FF (AUC = 91.81%). Negative correlation existed between T2 values and FF of multifidus at L5 level and JOA scores (r=-0.41, P < 0.05), and positive correlation with VAS scores (r = 0.46, P < 0.05). The combination of T2 value and FF may provide deeper insights into the pathological alterations of paraspinal muscles in young CNLBP, providing an important imaging basis for clinical judgment and preventive treatment of non-painful side in unilateral symptomatic patients.

3D transesophageal echocardiographic assessment of acute reverse remodeling of the tricuspid annulus after transcatheter edge-to-edge repair.

Our study aims to evaluate the acute remodeling of the tricuspid valve annulus immediately after the T-TEER by using intraprocedural transesophageal three-dimensional (3D) echocardiography. We prospectively enrolled 62 consecutive symptomatic patients with at least severe TR, who underwent T-TEER with the TriClip System between March 2021 and June 2024. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D dataset: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter and eccentricity index.The acute procedural success was achieved in 85,5%. We observed an acute reduction in SL (from a median of 43 to 38 mm, p<0,0001), AP (from a median of 46 to 45 mm, p<0,0001), area (from a median of 17,9 to 15,95 cm2, p<0,0001), perimeter (from a median of 145,5 to 137 mm, p<0,0001) and eccentricity index (from 0,92 to 0,87, p<0,0001). The TV annulus was progressively larger in patients with higher residual TR. Analysis of the subgroups according to procedural success showed an acute inverse remodeling of the TV annulus independent of the acute procedural success. The TV geometry necessitates the use of 3D echocardiography for accurate assessment of annular remodeling post T-TEER. The reduction in TR grade and TV annulus dimensions begins immediately after TriClip implantation. Concurrently, the baseline TV geometry influences the procedural results.

CT-FFR by expanding coronary tree with Newton–Krylov–Schwarz method to solve the governing equations of CFD

Abstract Background A new model of computational fluid dynamics (CFD)-based algorithm for coronary CT angiography (CCTA)-derived fractional flow reserve (FFR) (CT-FFR) analysis by expanding the coronary tree to smaller-diameter lumen (0.8mm) using Newton–Krylov–Schwarz (NKS) method to solve the three-dimensional time-dependent incompressible Navier-Stokes equations has been developed; however, the diagnostic performance of this new method has not been sufficiently investigated. Objectives The aim of this study was to determine the diagnostic performance of a novel CT-FFR technique by expanding the coronary tree in the CFD domain. Methods Six centers enrolled 338 symptomatic patients with suspected or known coronary artery disease (CAD) who were prospectively underwent CCTA and FFR. Stenosis assessment in CCTA and CT-FFR analysis were performed in independent core laboratories. Hemodynamically significant stenosis was defined by an CT-FFR and FFR ≤0.80, and anatomically obstructive CAD was defined as a CCTA with stenosis ≥50%. Diagnostic performance of CT-FFR was evaluated against invasive FFR using receiver operator characteristic (ROC) curve analysis. The correlation between CT-FFR and invasive FFR was analyzed using the Spearman correlation coefficient and Bland-Altman analysis. Intra-observer and inter-observer agreement were evaluated utilizing the intraclass correlation coefficient (ICC). Results In this study, 338 patients with 422 targeted vessels were investigated, revealing hemodynamically significant stenosis in 31.1% (105/338) of patients and anatomically obstructive stenosis in 54.1% of patients. On a per-vessel basis, the area under the receiver-operating characteristic curve for CT-FFR was 0.94 versus 0.76 for CCTA (p &amp;lt; 0.001). Per-vessel accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 89.8%, 89.3%, 90.0%, 79.0%, and 99.2%, respectively, for CT-FFR and were 68.4%, 82.8%, 62.3%, 48.1%, and 89.6%, respectively, for CCTA stenosis. CT-FFR and FFR were well correlated (r = 0.775, p &amp;lt; 0.001) with a Bland-Altman bias of 0.0011, and limits of agreement from -0.1509 to 0.1531 (p = 0.770). The intraclass correlation coefficients with CT-FFR for intro- and inter-observer agreement were 0.919 (95% CI: 0.866 to 0.952) and 0.909 (95% CI: 0.851 to 0.945), respectively. The average computation time for CT-FFR analysis was maintained at 11.7 minutes. Conclusion This novel CT-FFR model with the inclusion of smaller lumen provides high diagnostic accuracy in detecting hemodynamically significant CAD. Furthermore, the integration of the NKS method ensures that the computation time remains within an acceptable range for potential clinical applications in the future.

Delineating three distinct spatiotemporal patterns of brain atrophy in Parkinson's disease.

The clinical manifestation of Parkinson's disease exhibits significant heterogeneity in the prevalence of non-motor symptoms and the rate of progression of motor symptoms, suggesting that Parkinson's disease can be classified into distinct subtypes. In this study, we aimed to explore this heterogeneity by identifying a set of subtypes with distinct patterns of spatiotemporal trajectories of neurodegeneration. We applied Subtype and Stage Inference (SuStaIn), an unsupervised machine learning algorithm that combined disease progression modelling with clustering methods, to cortical and subcortical neurodegeneration visible on 3 T structural MRI of a large cross-sectional sample of 504 patients and 279 healthy controls. Serial longitudinal data were available for a subset of 178 patients at the 2-year follow-up and for 140 patients at the 4-year follow-up. In a subset of 210 patients, concomitant Alzheimer's disease pathology was assessed by evaluating amyloid-β concentrations in the CSF or via the amyloid-specific radiotracer 18F-flutemetamol with PET. The SuStaIn analysis revealed three distinct subtypes, each characterized by unique patterns of spatiotemporal evolution of brain atrophy: neocortical, limbic and brainstem. In the neocortical subtype, a reduction in brain volume occurred in the frontal and parietal cortices in the earliest disease stage and progressed across the entire neocortex during the early stage, although with relative sparing of the striatum, pallidum, accumbens area and brainstem. The limbic subtype represented comparative regional vulnerability, which was characterized by early volume loss in the amygdala, accumbens area, striatum and temporal cortex, subsequently spreading to the parietal and frontal cortices across disease stage. The brainstem subtype showed gradual rostral progression from the brainstem extending to the amygdala and hippocampus, followed by the temporal and other cortices. Longitudinal MRI data confirmed that 77.8% of participants at the 2-year follow-up and 84.0% at the 4-year follow-up were assigned to subtypes consistent with estimates from the cross-sectional data. This three-subtype model aligned with empirically proposed subtypes based on age at onset, because the neocortical subtype demonstrated characteristics similar to those found in the old-onset phenotype, including older onset and cognitive decline symptoms (P < 0.05). Moreover, the subtypes correspond to the three categories of the neuropathological consensus criteria for symptomatic patients with Lewy pathology, proposing neocortex-, limbic- and brainstem-predominant patterns as different subgroups of α-synuclein distributions. Among the subtypes, the prevalence of biomarker evidence of amyloid-β pathology was comparable. Upon validation, the subtype model might be applied to individual cases, potentially serving as a biomarker to track disease progression and predict temporal evolution.

44 Spotting the clotting: a 3-year national surveillance study of paediatric pulmonary thromboembolism

Abstract Background Pulmonary thromboembolism (PE) is a rare event in the paediatric population but can be acutely life-threatening and result in chronic complications. Awareness of contemporary patterns of clinical presentation, diagnostic modalities, and management may aid clinicians in ensuring that patients are promptly identified and treated. Objectives To describe the risk factors, symptoms, diagnostic modalities, therapeutic interventions, and short-term outcomes in paediatric patients (neonate up to 18 years) with PE through national surveillance. Design/Methods Between January 2020 and December 2022, monthly surveillance was conducted with over 2,800 paediatricians and sub-specialists through the Canadian Paediatric Surveillance Program. Voluntary reporting of cases meeting a standardized definition of PE was followed up with a detailed questionnaire. Results 58 confirmed cases were reported; 33 (57%) were females age 15 to 18 years. Detailed information was available for 31 (53%) of 58 cases. At least 1 risk factor was identified in 28 (90%) cases and 12 (39%) patients had 2 or more risk factors. The most common risk factors were oral contraceptive use (n=10 of 31; 32%) and obesity (n=9 of 31; 29%). Presentation was symptomatic in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. The most common symptoms were chest pain (n=18; 58%), dyspnea (n=13; 42%) and tachycardia (n=13; 42%). The most common diagnostic modality utilized was computed tomography pulmonary angiography (n=25; 81%). Initiation of systemic anticoagulation was reported for 24 (77%) of 31 cases; thrombolysis and surgical interventions were uncommon (&amp;lt; 5 cases). Treatment complications were common (n=8; 29%). Mortality was reported, but in fewer than 5 cases. Conclusion PE in children often presents with non-specific symptoms, but usually occurs in patients with known risk factors. Clinicians should maintain a high index of suspicion in symptomatic patients, particularly those with risk factors and in cases when other diagnoses that may explain symptoms have been excluded. Anticoagulation is the mainstay of treatment; complications can occur. Prompt recognition and management presumably reduce morbidity and mortality, but this cannot be inferred from our data.

International Society for Diseases of the Esophagus consensus on management of the failed fundoplication.

Fundoplication is a durable, effective, and well-accepted treatment for gastroesophageal reflux disease. Nonetheless, troublesome postoperative symptoms do occasionally occur with management varying widely among centers. In an attempt to standardize definition and management of postfundoplication symptoms, a panel of international experts convened by the Guidelines Committee of the International Society for Diseases of the Esophagus devised a list of 33 statements across 5 domains through a Delphi approach, with at least 80% agreement to establish consensus. Eight statements were endorsed for the domain of Definitions, four for the domain of Investigations, nine for Dysphagia, nine for Heartburn, and four for Revisional surgery. This consensus defined as the treatment goal of fundoplication the resolution of symptoms rather than normalization of physiology or anatomy. Required investigations of all symptomatic postfundoplication patients were outlined. Further management was standardized by patients' symptomatology. The appropriateness of revisional fundoplication and the techniques thereof were described and the role of revisional surgery for therapies other than fundoplication were assessed. Fundoplication remains a frequently-performed operation, and this is the first international consensus on the management of various postfundoplication problems.

Hepatocellular Carcinoma in Acute Hepatic Porphyria: A Meta-Analysis of Observational Studies.

Hepatocellular carcinoma (HCC) is a long-term complication of acute hepatic porphyria (AHP) inclusive of acute intermittent porphyria [AIP], variegate porphyria [VP], or hereditary coproporphyria [HCP]. Data on HCC risk in AHP patients are limited and heterogeneous. We performed this meta-analysis with aims to (a) determine incidence of HCC in AHP and specific subtypes of AHP and (b) examine high-risk groups for HCC. Data from studies reporting HCC development in AHP patients were pooled and reported per 100 person years with 95% confidence intervals (CI). 12 observational (5 prospective) studies (11 Europe and 1 US) on 2735 patients (mean age 54.8 yrs., 62% females) with AHP (80% AIP) were analyzed. 115 HCC cases were observed with HCC incidence per 100 person years of 0.3 (0.2-0.5) in AHP, 0.4 (0.2-0.6) in AIP, 0.3 (0-0.4) in VP, and 0.2 (0.1-0.6) in HCP. The risk was 0.4 (0.2-0.6) in females, 0.3 (0.1-0.5) in males, 0.9 (0.1-1.7) in symptomatic, and 0.5 (0-1.6) in asymptomatic patients. Analyses were heterogeneous with publication bias. AHP patients with HCC were older females with a higher prevalence of cirrhosis, alcohol use, and viral hepatitis. The annual incidence of HCC in AHP patients is 0.3%, with higher risk in AIP, older females, symptomatic patients, and those with other risk factors of liver disease. Future studies pooling individual patient data and overcoming limitations of the current meta-analysis are needed as a basis for deriving a effective screening and surveillance approach for HCC in patients with AHP.

Serological and bacterial prevalence of Brucella spp. in suspected patients: a risk factor analysis in North Khorasan, Iran

Background and Objectives: Brucellosis, a zoonotic bacterial disease caused by Brucella, affects humans and domestic animals, leading to significant economic loss. This study examined suspected cases in North Khorasan, Iran, to understand the prevalence of infection and its characteristics in this region. Materials and Methods: Blood specimens were collected from 200 patients suspected of brucellosis after obtaining in- formed consent. Serum samples were tested using RBPT, Wright, and 2-ME agglutination tests. Blood samples were cul- tured on Brucella agar, and positive cultures underwent biotyping and PCR assays. A questionnaire identified correlated risk factors. Results: RBPT, Wright, and 2-ME tests showed 25% brucellosis seroprevalence in symptomatic patients. In contrast, the prevalence was 2.5% among those with positive blood cultures. Notably, all culture-positive patients were also serologically positive, with titers exceeding 1:320 in Wright and 2-ME tests. Most positive cases were in people in their 30s, with B. mel- itensis biovar 1 identified as the causative agent, and the results were confirmed by multiplex PCR. Significant risk factors include contact with livestock and consumption of raw milk (P &lt; 0.0001). Conclusion: The findings highlighted the importance of comprehensive diagnostic approaches for accurate identification of brucellosis. Furthermore, education regarding close contact with animals and pasteurization of dairy products is essential for controlling human brucellosis.