Workflow Time Research Articles

End-to-End Throughput Chemical Proteomics for Photoaffinity Labeling Target Engagement and Deconvolution.

Photoaffinity labeling (PAL) methodologies have proven to be instrumental for the unbiased deconvolution of protein-ligand binding events in physiologically relevant systems. However, like other chemical proteomic workflows, they are limited in many ways by time-intensive sample manipulations and data acquisition techniques. Here, we describe an approach to address this challenge through the innovation of a carboxylate bead-based protein cleanup procedure to remove excess small-molecule contaminants and couple it to plate-based, proteomic sample processing as a semiautomated solution. The analysis of samples via label-free, data-independent acquisition (DIA) techniques led to significant improvements on a workflow time per sample basis over current standard practices. Experiments utilizing three established PAL ligands with known targets, (+)-JQ-1, lenalidomide, and dasatinib, demonstrated the utility of having the flexibility to design experiments with a myriad of variables. Data revealed that this workflow can enable the confident identification and rank ordering of known and putative targets with outstanding protein signal-to-background enrichment sensitivity. This unified end-to-end throughput strategy for processing and analyzing these complex samples could greatly facilitate efficient drug discovery efforts and open up new opportunities in the chemical proteomics field.

A semiautomated microfluidic ELISA for the detection of hemophagocytic lymphohistiocytosis biomarkers.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by a massive overactivation of the immune system. Because the clinical findings are nonspecific, the development of assays to facilitate rapid diagnosis is critical for patient care. The objectives of this study were to evaluate the performance of a microfluidic enzyme-linked immunosorbent assay (ELISA) for HLH biomarkers and investigate the impact of insourcing this testing on workflow, cost, and turnaround time in a tertiary-care cancer hospital. Trends in order volume were evaluated for C-X-C motif chemokine ligand 9 (CXCL9) and soluble interleukin 2 receptor ɑ (sIL2R), and a microfluidic ELISA was used to measure these analytes in serum samples. Analyte values, turnaround time, and costs were compared for this assay relative to reference laboratory testing. Test ordering has increased from 187 to 1030 requests annually over the past 5 years. Insourcing these analytes on a semiautomated ELISA can decrease time to result by approximately 2 days and generate a cost savings of roughly $140,000 annually within our laboratory. Using a semiautomated ELISA for sIL2R and CXCL9 may help physicians arrive at a diagnosis and monitor therapy for patients with HLH while decreasing turnaround time and costs within the clinical laboratory.

High-throughput rapid amplicon sequencing for multilocus sequence typing of Mycoplasma ovipneumoniae from archived clinical DNA samples.

Spillover events of Mycoplasma ovipneumoniae have devastating effects on the wild sheep populations. Multilocus sequence typing (MLST) is used to monitor spillover events and the spread of M. ovipneumoniae between the sheep populations. Most studies involving the typing of M. ovipneumoniae have used Sanger sequencing. However, this technology is time-consuming, expensive, and is not well suited to efficient batch sample processing. Our study aimed to develop and validate an MLST workflow for typing of M. ovipneumoniae using Nanopore Rapid Barcoding sequencing and multiplex polymerase chain reaction (PCR). We compare the workflow with Nanopore Native Barcoding library preparation and Illumina MiSeq amplicon protocols to determine the most accurate and cost-effective method for sequencing multiplex amplicons. A multiplex PCR was optimized for four housekeeping genes of M. ovipneumoniae using archived DNA samples (N = 68) from nasal swabs. Sequences recovered from Nanopore Rapid Barcoding correctly identified all MLST types with the shortest total workflow time and lowest cost per sample when compared with Nanopore Native Barcoding and Illumina MiSeq methods. Our proposed workflow is a convenient and effective method for strain typing of M. ovipneumoniae and can be applied to other bacterial MLST schemes. The workflow is suitable for diagnostic settings, where reduced hands-on time, cost, and multiplexing capabilities are important.

Subcutaneous vs Intravenous Trastuzumab/Pertuzumab: A Time and Motion Substudy of a Phase II Trial of Adjuvant Trastuzumab/Pertuzumab for Stage I HER2+ Breast Cancer (ADEPT trial).

The time required for in-clinic drug administration can substantially affect breast cancer patients' quality of life. Subcutaneous (SC) drug administration, as opposed to intravenous (IV), may reduce this time commitment. This study sought to estimate the difference in time burden between IV and SC administration of trastuzumab and pertuzumab (HP). We prospectively enrolled a subcohort of patients participating in the ADEPT trial (ClinicalTrials.gov identifier: NCT04569747, investigating adjuvant HP plus endocrine therapy for stage I human epidermal growth factor receptor 2-positive breast cancer) to this single-arm crossover time and motion substudy. Patients received two cycles of IV HP followed by two cycles of SC HP. During each cycle, time points in drug preparation and administration were captured. The primary end point was total patient time in the treatment chair. Additional end points included total patient treatment experience time and total pharmacy workflow time. A sample size of 22 patients was estimated to provide 90.7% power with two-sided alpha .05 to detect a difference of 70 minutes in the primary end point by treatment arm (IV v SC). Twenty-two patients were enrolled. The mean total patient time in the treatment chair was 61.8 minutes shorter with SC versus IV HP (22.5 v 84.3 minutes; P < .0001). The mean total patient treatment experience time (incorporating time spent waiting for treatment initiation and time spent in the treatment chair) was 81.8 minutes shorter for SC administration (96 v 177.8 minutes; P < .0001). The pharmacy workflow time was 78.2 minutes shorter for SC versus IV formulation (41 v 119.2 minutes; P < .0001). SC administration of HP shortened patient time burden by approximately 1 hour. SC drug administration can facilitate faster workflows for health care professionals and improve patients' breast cancer treatment experience.

Investigation of intra-fractionated range guided adaptive proton therapy (RGAPT): II. Range-shift compensated on-line treatment adaptation and verification

We previously proposed range-guided adaptive proton therapy (RGAPT) that uses mid-range treatment beams as probing beams and intra-fractionated range measurements for online adaptation. In this work, we demonstrated experimental verification and reported the dosimetric accuracy for RGAPT. A STEEV phantom was used for the experiments, and a 3 × 3 × 3 cm3 cube inside the phantom was assigned to be the treatment target. We simulated three online range shift scenarios: reference, overshoot, and undershoot, by placing upstream Lucite sheets, 4, 0, and 8 that corresponded to changes of 0, 6.8, and −6.8 mm, respectively, in water-equivalent path length. The reference treatment plan was to deliver single-field uniform target doses in pencil beam scanning mode and generated on the Eclipse treatment planning system. Different numbers of mid-range layers, including single, three, and five layers, were selected as probing beams to evaluate beam range (BR) measurement accuracy in positron emission tomography (PET). Online plans were modified to adapt to BR shifts and compensate for probing beam doses. In contrast, non-adaptive plans were also delivered and compared to adaptive plans by film measurements. The mid-range probing beams of three (5.55MU) and five layers (8.71MU) yielded accurate range shift measurements in 60 s of PET acquisition with uncertainty of 0.5 mm while the single-layer probing (1.65MU) was not sufficient for measurements. The adaptive plans achieved an average gamma (2%/2 mm) passing rate of 95%. In contrast, the non-adaptive plans only had an average passing rate of 69%. RGAPT planning and delivery are feasible and verified by the experiments. The probing beam delivery, range measurements, and adaptive planning and delivery added a small increase in treatment delivery workflow time but resulted in substantial dose improvement. The three-layer mid-range probing was most suitable considering the balance of high range measurement accuracy and the low number of probing beam layers.

Training and assessing convolutional neural network performance in automatic vascular segmentation using Ga-68 DOTATATE PET/CT

To evaluate a convolutional neural network’s performance (nnU-Net) in the assessment of vascular contours, calcification and PET tracer activity using Ga-68 DOTATATE PET/CT. Patients who underwent Ga-68 DOTATATE PET/CT imaging over a 12-month period for neuroendocrine investigation were included. Manual cardiac and aortic segmentations were performed by an experienced observer. Scans were randomly allocated in ratio 64:16:20 for training, validation and testing of the nnU-Net model. PET tracer uptake and calcium scoring were compared between segmentation methods and different observers. 116 patients (53.5% female) with a median age of 64.5 years (range 23–79) were included. There were strong, positive correlations between all segmentations (mostly r > 0.98). There were no significant differences between manual and AI segmentation of SUVmean for global cardiac (mean ± SD 0.71 ± 0.22 vs. 0.71 ± 0.22; mean diff 0.001 ± 0.008, p > 0.05), ascending aorta (mean ± SD 0.44 ± 0.14 vs. 0.44 ± 0.14; mean diff 0.002 ± 0.01, p > 0.05), aortic arch (mean ± SD 0.44 ± 0.10 vs. 0.43 ± 0.10; mean diff 0.008 ± 0.16, p > 0.05) and descending aorta (mean ± SD < 0.001; 0.58 ± 0.12 vs. 0.57 ± 0.12; mean diff 0.01 ± 0.03, p > 0.05) contours. There was excellent agreement between the majority of manual and AI segmentation measures (r ≥ 0.80) and in all vascular contour calcium scores. Compared with the manual segmentation approach, the CNN required a significantly lower workflow time. AI segmentation of vascular contours using nnU-Net resulted in very similar measures of PET tracer uptake and vascular calcification when compared to an experienced observer and significantly reduced workflow time.

Clinical diagnostic value of targeted next‑generation sequencing for infectious diseases (Review).

As sequencing technology transitions from research to clinical settings, due to technological maturity and cost reductions, metagenomic next‑generation sequencing (mNGS) is increasingly used. This shift underscores the growing need for more cost‑effective and universally accessible sequencing assays to improve patient care and public health. Therefore, targeted NGS (tNGS) is gaining prominence. tNGS involves enrichment of target pathogens in patient samples based on multiplex PCR amplification or probe capture with excellent sensitivity. It is increasingly used in clinical diagnostics due to its practicality and efficiency. The present review compares the principles of different enrichment methods. The high positivity rate of tNGS in the detection of pathogens was found in respiratory samples with specific instances. tNGS maintains high sensitivity (70.8‑95.0%) in samples with low pathogen loads, including blood and cerebrospinal fluid. Furthermore, tNGS is effective in detecting drug‑resistant strains of Mycobacterium tuberculosis, allowing identification of resistance genes and guiding clinical treatment decisions, which is difficult to achieve with mNGS. In the present review, the application of tNGS in clinical settings and its current limitations are assessed. The continued development of tNGS has the potential to refine diagnostic accuracy and treatment efficacy and improving infectious disease management. However, further research to overcome technical challenges such as workflow time and cost is required.

Feasibility of simulation free abdominal stereotactic adaptive radiotherapy using an expedited pre-plan workflow

Background and PurposeImproved hounsfield-unit accuracy of on-board imaging may lead to direct-to-unit treatment approaches We aimed to demonstrate the feasibility of using only a diagnostic (dx) computed tomography (CT)-defined target pre-plan in an in silico study of simulation-free abdominal stereotactic adaptive radiotherapy (ART). Materials and MethodsEight patients with abdominal treatment sites (five pancreatic cancer, three oligometastases) were treated using an integrated adaptive O-Ring gantry system. Each patient’s target was delineated on a dxCT. The target only pre-plan served primarily to seed the ART process. During the ART session, all structures were delineated. All simulated cases were treated to 50 Gy in 5 fractions to a planning target optimization structure (PTV_OPT) to allow for dose escalation within the planning target volume. Timing of steps during this workflow was recorded. Plan quality was compared between ART treatment plans and a plan created on a CT simulation scan using the traditional planning workflow. ResultsThe workflow was feasible in all attempts, with organ-at-risk (OAR) constraints met in all fractions despite lack of initial OAR contours. Median absolute difference between the adapted plan and simulation CT plan for the PTV_Opt V95% was 2.0 %. Median absolute difference in the D0.5 cm3 between the adapted plan and simulation CT plan was −0.9 Gy for stomach, 1.2 Gy for duodenum, −5.3 Gy for small bowel, and 0.3 Gy for large bowel. Median end-to-end workflow time was 63 min. ConclusionThe workflow was feasible for a dxCT-defined target-only pre-plan approach to stereotactic abdominal ART.

Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry

BackgroundThe optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as...

Enhanced eMAGE applied to identify genetic factors of nuclear hormone receptor dysfunction via combinatorial gene editing

Technologies that generate precise combinatorial genome modifications are well suited to dissect the polygenic basis of complex phenotypes and engineer synthetic genomes. Genome modifications with engineered nucleases can lead to undesirable repair outcomes through imprecise homology-directed repair, requiring non-cleavable gene editing strategies. Eukaryotic multiplex genome engineering (eMAGE) generates precise combinatorial genome modifications in Saccharomyces cerevisiae without generating DNA breaks or using engineered nucleases. Here, we systematically optimize eMAGE to achieve 90% editing frequency, reduce workflow time, and extend editing distance to 20 kb. We further engineer an inducible dominant negative mismatch repair system, allowing for high-efficiency editing via eMAGE while suppressing the elevated background mutation rate 17-fold resulting from mismatch repair inactivation. We apply these advances to construct a library of cancer-associated mutations in the ligand-binding domains of human estrogen receptor alpha and progesterone receptor to understand their impact on ligand-independent autoactivation. We validate that this yeast model captures autoactivation mutations characterized in human breast cancer models and further leads to the discovery of several previously uncharacterized autoactivating mutations. This work demonstrates the development and optimization of a cleavage-free method of genome editing well suited for applications requiring efficient multiplex editing with minimal background mutations.

Influence of Time of Admission on Endovascular Thrombectomy (EVT): Comparison of Outcomes During Business Hours Versus Off-Business Hours.

Purpose:To investigate the differences in endovascular thrombectomy (EVT) outcomes of patients treated for acute ischaemic stroke (AIS) during business versus off-business hours. Methods: A single-centre retrospective cohort study of patients with AIS treated with EVT from February 1, 2015, to May 31, 2021, was performed at a comprehensive stroke centre (CSC). Patients were divided into business (Monday to Friday, 8 AM-5 PM) versus off-business hours groups. The primary outcome was functional neurological disability, scored using the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included the rate of successful reperfusion and procedural workflow time delays. Differences in proportions were assessed using Fisher's exact and Chi-Square tests as appropriate. For continuous variables, differences in medians between groups were assessed using Mann-Whitney U tests. Results: A total of 676 patients were included, with 399 patients (59%) comprising the off-business-hour group. No significant differences were seen in age, sex, ASPECTS score, or NIHSS at arrival. Off-business hours strokes had a longer delay between CSC arrival to groin puncture (minutes: 81 vs 44, P < .0001) and between imaging to groin puncture (minutes: 67 vs 32, P < .0001) compared to the business hours strokes. There were no differences in the rate of successful reperfusion (mTICI ≥2b) between groups (82% vs 83%, P = .61). At 90 days, 65% of patients in both groups had an mRS ≤2 (P = .91). Conclusion: Despite workflow delays in initiating EVT during off-business hours, there were no differences in the rate of successful reperfusion or functional outcomes.

Solvation Free Energies from Machine Learning Molecular Dynamics.

The present work proposes an extension to the approach of [Xi, C; et al. J. Chem. Theory Comput. 2022, 18, 6878] to calculate ion solvation free energies from first-principles (FP) molecular dynamics (MD) simulations of a hybrid solvation model. The approach is first re-expressed within the quasi-chemical theory of solvation. Then, to allow for longer simulation times than the original first-principles molecular dynamics approach and thus improve the convergence of statistical averages at a fraction of the original computational cost, a machine-learned (ML) energy function is trained on FP energies and forces and used in the MD simulations. The ML workflow and MD simulation times (≈200 ps) are adjusted to converge the predicted solvation energies within a chemical accuracy of 0.04 eV. The extension is successfully benchmarked on the same set of alkaline and alkaline-earth ions.

High in-vivo accuracy of a novel robotic-arm-assisted system for total knee arthroplasty.

Robotic-assisted total knee arthroplasty (TKA) has been shown to improve the accuracy and precision of bony resections and implant position. However, the in vivo accuracy of the full surgical workflow has not been widely reported. The primary objective of this study is to determine the accuracy and precision of a robotic-arm-assisted system throughout the intraoperative workflow. This was a retrospective cohort study of adult patients who underwent primary TKA with various workflows and alignment targets by three arthroplasty-trained surgeons with previous experience using the ROSA® Knee System (Zimmer Biomet) over a 3-month follow-up period. Accuracy and precision were determined by measuring the difference between various workflow time points, including the final preoperative plan (PP), robot-validated (RV) resection angleand postoperative radiographs (PR). The absolute mean difference between the measurements determined accuracy, and the standard deviation represented precision. The lateral distal femoral angle, medial proximal tibial angle, femoral flexion angle and tibial slope were measured on postoperative coronal long-leg radiographs and true short-leg lateral radiographs. A total of 77 patients were included in the final analyses. The accuracy for the coronal femoral angle was 1.62 ± 1.11°, 0.75 ± 0.79°and 1.96 ± 1.29° for the differences between PP and PR, PP and RVand RV and PR. The tibial coronal accuracy was 1.44 ± 1.03°, 0.81 ± 0.67°and 1.57 ± 1.14° for PP/PR, PP/RVand RV/PR, respectively. Femoral flexion accuracy was 1.39 ± 1.05°, 0.83 ± 0.59°and 1.81 ± 1.21° for PP/PR, PP/RVand RV/PR, respectively. Tibial slope accuracy was 0.99 ± 0.72°, 1.19 ± 0.87°and 1.63 ± 1.11°, respectively. The proportion of patients within 3° was 93.2%, 95.3%, 97.3%and 94.6% for the distal femur, proximal tibia, femoral flexionand tibial slope angles when the final intraoperative plan was compared to PRs. No patients had a postoperative complication at the final follow-up. The ROSA Knee System has acceptable accuracy and precision of coronal and sagittal plane resections with few outliers at various steps throughout the platform's entire workflow in vivo. Level III.

Clinical Application of Optical Genome Mapping for Molecular Diagnosis of Facioscapulohumeral Muscular Dystrophy.

Facioscapulohumeral muscular dystrophy (FSHD) is a common form of muscular dystrophy that mainly affects skeletal muscle. FSHD1 accounts for 95% of all FSHD cases and can be diagnosed based on the pathogenic contraction of the D4Z4-repeat array on chromosome 4q35. Genetic diagnosis of FSHD1 is challenging because of the large size and repetitive nature of the D4Z4 region. We evaluated the clinical applicability of optical genome mapping (OGM) for the genetic diagnosis of FSHD1. We included 25 individuals with clinically confirmed or suspected/probable FSHD and their families. Ultra-high-molecular-weight DNA from peripheral blood was labeled, stained, and imaged using a single-molecule OGM platform (Bionano Genomics Saphyr system). D4Z4 repeat size and haplotype information were analyzed using the manufacturer's dedicated pipeline. We also compared the workflow and test time between Southern blot analysis and OGM. We obtained concordant OGM and Southern blot results with 10 samples from patients with clinically confirmed FSHD. The D4Z4 repeat size differed within 1 unit between the Southern blot analysis and OGM. Among nine patients with clinically suspected or probable FSHD, six patients were confirmed to have pathogenic contractions by OGM. In our cohort, one de novo mosaic FSHD1 patient was successfully diagnosed with OGM. Moreover, OGM has a more straightforward and less time-consuming workflow than Southern blot analysis. OGM enables accurate and reliable detection of pathogenic contraction of the D4Z4-repeat array and is a valuable tool for the genetic diagnosis of FSHD1.

IN VIVO ACCURACY OF A NEW ROBOTICALLY ASSISTED SYSTEM FOR TOTAL KNEE ARTHROPLASTY: A PROSPECTIVE COHORT STUDY

IntroductionRecent technological advancements have led to the introduction of robotic-assisted total knee arthroplasty to improve the accuracy and precision of bony resections and implant position. However, the in vivo accuracy is not widely reported. The primary objective of this study is to determine the accuracy and precision of a cut block positioning robotic arm.MethodSeventy-seven patients underwent total knee arthroplasty with various workflows and alignment targets by three arthroplasty-trained surgeons with previous experience using the ROSA® Knee System. Accuracy and precision were determined by measuring the difference between various workflow time points, including the final pre-operative plan, validated resection angle, and post-operative radiographs. The mean difference between the measurements determined accuracy, and the standard deviation represented precision.ResultsThe accuracy and precision for all angles comparing the final planned resection and validated resection angles was 0.90° ± 0.76°. The proportion within 3° ranged from 97.9% to 100%. The accuracy and precision for all angles comparing the final intra- operative plan and post-operative radiographs was 1.95 ± 1.48°. The proportion of patients within 3° was 93.2%, 95.3%, 96.6%, and 71.4% for the distal femur, proximal tibia, femoral flexion, and tibial slope angles when the final intra-operative plan was compared to post-operative radiographs. No patients had a postoperative complication requiring revision at the final follow-up.ConclusionsThis study demonstrates that the ROSA Knee System has accurate and precise coronal plane resections with few outliers. However, the tibial slope demonstrated decreased accuracy and precision were measured on post-operative short-leg lateral radiographs with this platform.

Evaluation of the Efficiency of a Digital Workflow for Cataract Planning in Patients with Astigmatism.

To evaluate the efficiency and associated costs of a digital cataract workflow system and manual cataract workflow system for patients, with astigmatism presenting for cataract surgery in Brisbane, Australia. Sixty patients with bilateral cataract requiring toric intraocular lenses (IOL) were sequentially assigned to a manual cataract workflow (n = 30) or digital workflow (n = 30) using EQ Workplace (SW v1.7.0) running on FORUM (SW v.4.2.1.66) (Carl Zeiss Meditec, Jena, Germany). Each step of preoperative data acquisition and analysis was timed. Steps in each workflow were divided into presurgical planning time and total workflow time, the latter including the time required to input toric data into CALLISTO eye (Carl Zeiss Meditec). Secondary outcomes included staff costs within each workflow. Median presurgical planning time using a digital workflow process was 6.51 ± 0.65 minutes, and using a manual workflow process, 12.32 ± 0.56 minutes (p < 0.001). Similarly, median total workflow time using a digital workflow process was 6.93 ± 0.57 minutes and using a manual workflow process, 13.49 ± 0.47 minutes (p < 0.001). Evaluating the staff remuneration during presurgical planning and the operating costs associated with running EQ Workplace, there was a cost-reduction of 35% per patient when using the digital cataract workflow process. Using a digital cataract workflow process is more efficient and provides staff cost-savings compared to a manual workflow process when planning for toric IOL implantation.

Optimization of hepatological clinical guidelines interpretation by large language models: a retrieval augmented generation-based framework

Large language models (LLMs) can potentially transform healthcare, particularly in providing the right information to the right provider at the right time in the hospital workflow. This study investigates the integration of LLMs into healthcare, specifically focusing on improving clinical decision support systems (CDSSs) through accurate interpretation of medical guidelines for chronic Hepatitis C Virus infection management. Utilizing OpenAI’s GPT-4 Turbo model, we developed a customized LLM framework that incorporates retrieval augmented generation (RAG) and prompt engineering. Our framework involved guideline conversion into the best-structured format that can be efficiently processed by LLMs to provide the most accurate output. An ablation study was conducted to evaluate the impact of different formatting and learning strategies on the LLM’s answer generation accuracy. The baseline GPT-4 Turbo model’s performance was compared against five experimental setups with increasing levels of complexity: inclusion of in-context guidelines, guideline reformatting, and implementation of few-shot learning. Our primary outcome was the qualitative assessment of accuracy based on expert review, while secondary outcomes included the quantitative measurement of similarity of LLM-generated responses to expert-provided answers using text-similarity scores. The results showed a significant improvement in accuracy from 43 to 99% (p < 0.001), when guidelines were provided as context in a coherent corpus of text and non-text sources were converted into text. In addition, few-shot learning did not seem to improve overall accuracy. The study highlights that structured guideline reformatting and advanced prompt engineering (data quality vs. data quantity) can enhance the efficacy of LLM integrations to CDSSs for guideline delivery.

Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis.

We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.

Impact of stent retriever size on clinical outcomes in the RECO registry

ObjectiveIn the RECO study, we investigated the impact of the operator's choice of stent retriever size on patients with internal carotid artery (ICA) occlusion. MethodsData from the RECO Registry, a prospective multicentre study, were utilized. Patients who underwent mechanical thrombectomy (MT) were divided according to the size of the stent into the RECO 4 × 20 group, the RECO 5 × 30 group and the RECO 6 × 30 group. The outcome measures assessed in the study were the 3-month modified Rankin Scale (mRS) score, occurrence of any intracranial haemorrhage (aICH), workflow timing, recanalization success rate, number of attempts, and all-cause mortality within a 3-month period. ResultsAnalysis was conducted on a total of 89 patients with ICA occlusion. RECO 4 × 20, 5 × 30, and 6 × 30 stent retrievers were used in 19 (21.3%), 52 (58.4%), and 18 (20.2%) patients, respectively. The demographic and baseline characteristics showed considerable similarity across the three groups. The puncture-to-recanalization time of the RECO 6 × 30 group [56.5 min (IQR, 41.5–80.8)] was significantly shorter than that of the RECO 4 × 20 group [110 min (IQR, 47–135)]. In 10 out of 18 patients (55.6%), the RECO 6 × 30 stent retriever achieved reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score 2b-3) after the initial attempt, surpassing the rates of 31.6% in the RECO 4 × 20 group and 32.7% in the RECO 5 × 30 group. In the RECO 4 × 20 group, the median number of passes was 2 (IQR, 1–3); in the RECO 5 × 30 group, it was 2 (IQR, 1–3); and in the RECO 6 × 30 groups, it was 1 (IQR, 1–2.5). There were no statistically significant differences observed among the three groups concerning aICH or good outcomes (mRS score 0–2). ConclusionOur study demonstrated the practical implications of stent-retriever size selection in the context of the MT for ICA occlusion. The routine use of a RECO 6 × 30 stent retriever holds the potential for early revascularization in clinical practice. The significant reduction in the puncture-to-reperfusion time and the greater first-pass effect associated with this stent size underscore its efficiency in treating ICA occlusion.

Just give the contrast? Appraisal of guidelines on intravenous iodinated contrast media use in patients with kidney disease

ObjectiveTo appraise the quality of guidelines on intravenous iodinated contrast media (ICM) use in patients with kidney disease, and to compare the recommendations among them.MethodsWe searched four literature databases, eight guideline libraries, and ten homepages of radiological societies to identify English and Chinese guidelines on intravenous ICM use in patients with kidney disease published between January 2018 and June 2023. The quality of the guidelines was assessed with the Scientific, Transparent, and Applicable Rankings (STAR) tool.ResultsTen guidelines were included, with a median STAR score of 46.0 (range 28.5–61.5). The guidelines performed well in “Recommendations” domain (31/40, 78%), while poor in “Registry” (0/20, 0%) and “Protocol” domains (0/20, 0%). Nine guidelines recommended estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 as the cutoff for referring patients to discuss the risk-benefit balance of ICM administration. Three guidelines further suggested that patients with an eGFR < 45 mL/min/1.73 m2 and high-risk factors also need referring. Variable recommendations were seen in the acceptable time interval between renal function test and ICM administration, and that between scan and repeated scan. Nine guidelines recommended to use iso-osmolar or low-osmolar ICM, while no consensus has been reached for the dosing of ICM. Nine guidelines supported hydration after ICM use, but their protocols varied. Drugs or blood purification therapy were not recommended as preventative means.ConclusionGuidelines on intravenous ICM use in patients with kidney disease have heterogeneous quality. The scientific societies may consider joint statements on controversial recommendations for variable timing and protocols.Critical relevance statementThe heterogeneous quality of guidelines, and their controversial recommendations, leave gaps in workflow timing, dosing, and post-administration hydration protocols of contrast-enhanced CT scans for patients with kidney diseases, calling for more evidence to establish a safer and more practicable workflow.Key points• Guidelines concerning iodinated contrast media use in kidney disease patients vary.• Controversy remains in workflow timing, contrast dosing, and post-administration hydration protocols.• Investigations are encouraged to establish a safer iodinated contrast media use workflow.Graphical