Do as Sonographers Think: Contrast-enhanced Ultrasound for Thyroid Nodules Diagnosis via Microvascular Infiltrative Awareness

Dynamic contrast-enhanced ultrasound (CEUS) imaging can reflect the microvascular distribution and blood flow perfusion, thereby holding clinical significance in distinguishing between malignant and benign thyroid nodules. Notably, CEUS offers a meticulous visualization of the microvascular distribution surrounding the nodule, leading to an apparent increase in tumor size compared to gray-scale ultrasound (US). In the dual-image obtained, the lesion size enlarged from gray-scale US to CEUS, as the microvascular appeared to be continuously infiltrating the surrounding tissue. Although the infiltrative dilatation of microvasculature remains ambiguous, sonographers believe it may promote the diagnosis of thyroid nodules. We propose a deep learning model designed to emulate the diagnostic reasoning process employed by sonographers. This model integrates the observation of microvascular infiltration on dynamic CEUS, leveraging the additional insights provided by gray-scale US for enhanced diagnostic support. Specifically, temporal projection attention is implemented on time dimension of dynamic CEUS to represent the microvascular perfusion. Additionally, we employ a group of confidence maps with flexible Sigmoid Alpha Functions to aware and describe the infiltrative dilatation process. Moreover, a self-adaptive integration mechanism is introduced to dynamically integrate the assisted gray-scale US and the confidence maps of CEUS for individual patients, ensuring a trustworthy diagnosis of thyroid nodules. In this retrospective study, we collected a thyroid nodule dataset of 282 CEUS videos. The method achieves a superior diagnostic accuracy and sensitivity of 89.52% and 93.75%, respectively. These results suggest that imitating the diagnostic thinking of sonographers, encompassing dynamic microvascular perfusion and infiltrative expansion, proves beneficial for CEUS-based thyroid nodule diagnosis.

Small extracellular vesicles facilitate epithelial-mesenchymal transition in chronic rhinosinusitis with nasal polyps via the miR-375-3p/QKI axis

BACKGROUND

Epithelial-mesenchymal transition (EMT) plays a crucial role in the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP). However, the involvement of small extracellular vesicles (sEVs) in EMT and their contributions to CRSwNP has not been extensively investigated.

METHODS

SEVs were isolated from nasal mucosa through ultracentrifugation. MicroRNA sequencing and reverse-transcription quantitative polymerase chain reaction were employed to analyze the differential expression of microRNAs carried by sEVs. Human nasal epithelial cells (hNECs) were used to assess the EMT-inducing effect of sEVs/microRNAs. EMT-associated markers were detected by western blotting and immunofluorescence. Dual-luciferase reporter assay was performed to determine the target gene of miR-375-3p. MicroRNA mimic, lentiviral, and plasmid transduction were used for functional experiments.

RESULTS

In line with the greater EMT status in eosinophilic CRSwNP (ENP), sEVs derived from ENP (ENP-sEVs) could induce EMT in hNECs. MiR-375-3p was elevated in ENP-sEVs compared to that in control and nonENP. MiR-375- 3p carried by ENP-sEVs facilitated EMT by directly targeting KH domain containing RNA binding (QKI) at seed sequences of 913-919, 1025-1033, and 2438-2444 in 3'-untranslated region. Inhibition of QKI by miR-375-3p overexpression promoted EMT, which could be reversed by restoration of QKI. Furthermore, the abundance of miR-375-3p in sEVs was closely correlated with the clinical symptom score and disease severity.

CONCLUSIONS

MiR-375-3p-enriched sEVs facilitated EMT by suppressing QKI in hNECs. The association of miR-375-3p with disease severity underscores its potential as both a diagnostic marker and a therapeutic target for the innovative management of CRSwNP.

First-line Palliative Chemotherapy for Colorectal Cancer: a Population-based Analysis of Delivery and Outcomes in a Single-payer Health System

AIMS

Clinical practice guidelines recommend palliative chemotherapy for most patients with metastatic colorectal cancer. However, outcomes observed in the real world compared with patients enrolled in clinical trials have not been sufficiently described. The objective of this study was to evaluate the delivery and outcomes of first-line palliative chemotherapy administered to patients with colorectal cancer in routine clinical practice compared with clinical trials.

MATERIALS AND METHODS

Using linked health administrative data, we carried out a retrospective population-level cohort study on patients diagnosed with colorectal cancer in Ontario, Canada from 2010 to 2019. Patient, disease and treatment characteristics were summarised. The primary outcome was median overall survival, stratified by treatment prescribed and age. Demographics and outcomes in this real-world population were compared with those from pivotal clinical trials. A multivariable Cox regression model reporting hazard ratios and 95% confidence intervals was used to determine factors associated with survival in patients receiving systemic treatment.

RESULTS

We identified 70 987 patients with a new diagnosis of colorectal cancer, of which 4613 received first-line chemotherapy for unresectable locally advanced or metastatic disease and formed the study cohort. Fifty-eight per cent were male and the mean age was 63 years. Most had colon cancer (69%), at least one comorbidity (73%) and lived in an urban location (79%). Less than half (47%) had surgery after diagnosis. The most common regimen prescribed was folinic acid, 5-fluorouracil and irinotecan (FOLFIRI) with bevacizumab or epidermal growth factor receptor inhibitors (EGFRi; n = 2784, 60%). Among all treated patients, the median overall survival was 17.1 months, with survival difference by regimen [median overall survival 18.3 for FOLFIRI with bevacizumab or EGFRi, 19.6 for folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX)/capecitabine, oxaliplatin (XELOX) with bevacizumab or EGFRi, 13.6 for FOLFIRI alone and 7.8 for 5-fluorouracil or capecitabine]. Patients aged >80 years were most likely to have received single-agent 5-fluorouracil or capecitabine, and had inferior overall survival compared with their younger counterparts. Compared with pivotal clinical trials, patients in the real world had inferior overall survival outcomes despite similar demographic characteristics (including age and sex).

CONCLUSIONS

In this real-world population-based analysis of patients receiving first-line chemotherapy for unresectable locally advanced or metastatic colorectal cancer, survival outcomes were inferior to those reported in randomised trials despite similarities in age and sex. This information can be used when counselling patients in routine practice about expected outcomes.

Deep learning radiomics based prediction of axillary lymph node metastasis in breast cancer

This study aimed to develop and validate a deep learning radiomics nomogram (DLRN) for the preoperative evaluation of axillary lymph node (ALN) metastasis status in patients with a newly diagnosed unifocal breast cancer. A total of 883 eligible patients with breast cancer who underwent preoperative breast and axillary ultrasound were retrospectively enrolled between April 1, 2016, and June 30, 2022. The training cohort comprised 621 patients from Hospital I; the external validation cohorts comprised 112, 87, and 63 patients from Hospitals II, III, and IV, respectively. A DLR signature was created based on the deep learning and handcrafted features, and the DLRN was then developed based on the signature and four independent clinical parameters. The DLRN exhibited good performance, yielding areas under the receiver operating characteristic curve (AUC) of 0.914, 0.929, and 0.952 in the three external validation cohorts, respectively. Decision curve and calibration curve analyses demonstrated the favorable clinical value and calibration of the nomogram. In addition, the DLRN outperformed five experienced radiologists in all cohorts. This has the potential to guide appropriate management of the axilla in patients with breast cancer, including avoiding overtreatment.

Design of a single-center, phase II trial to explore the efficacy and safety of 'R-ISV-RO' treatment in advanced tumors

Background: The authors' preclinical study has confirmed that RO adjuvant (composed of TLR 7 agonists [imiquimod/R837] and OX40 agonists) injected into local lesions induces the regression of both primary tumor and distant metastasis. The authors propose to realize local control and exert abscopal effect through an 'R-ISV-RO' in situ strategy plus anti-PD-1 monoclonal antibody in advanced tumors. Methods: This study is a single-center, exploratory, phase II trial to evaluate the efficacy and safety of R-ISV-RO plus anti-PD-1 monoclonal antibody in advanced tumors. 30 patients with one or more measurable extracerebral lesions that are accessible for radiation or injection will be enrolled. The primary endpoint is the objective response rate of target lesions. Discussion/Conclusion: The efficacy and safety of the novel strategy will be further validated through this clinical trial. Clinical trial registration: ChiCTR2100053870 (www.chictr.org.cn/).

Volumetric B-mode ultrasound and Doppler Imaging: Automatic Tracking With One Single Camera

Vascular diseases may occur in the upper extremities, and the lesions can span the entire length of the blood vessel. One of the most popular methods to identify vascular disorders is ultrasound Doppler imaging. However, traditional two-dimensional (2D) ultrasound Doppler imaging cannot capture the entire length of a long vessel in one image. Medical professionals often have to painstakingly reconstruct three-dimensional (3D) data using 2D ultrasound images to locate the lesions, especially for large blood vessels. 3D ultrasound Doppler imaging can display the morphological structure of blood vessels and the distribution of lesions more directly, providing a more comprehensive view compared to 2D imaging. In this work, we propose a wide-range 3D volumetric ultrasound Doppler imaging system with dual modality, in which a high-definition camera is adopted to automatically track the movement of the ultrasound transducer, simultaneously capturing a corresponding sequence of 2D ultrasound Doppler images. We conducted experiments on human arms using our proposed system and separately with X-ray computerized tomography (X-CT). The comparison results prove the potential value of our proposed system in the diagnosis of arm vascular diseases.

SISS-MCO: large scale sparsity-induced spot selection for fast and fully-automated robust multi-criteria optimisation of proton plans

Objective.Intensity modulated proton therapy (IMPT) is an emerging treatment modality for cancer. However, treatment planning for IMPT is labour-intensive and time-consuming. We have developed a novel approach for multi-criteria optimisation (MCO) of robust IMPT plans (SISS-MCO) that is fully automated and fast, and we compare it for head and neck, cervix, and prostate tumours to a previously published method for automated robust MCO (IPBR-MCO, van de Water 2013).Approach.In both auto-planning approaches, the applied automated MCO of spot weights was performed with wish-list driven prioritised optimisation (Breedveld 2012). In SISS-MCO, spot weight MCO was applied once for every patient after sparsity-induced spot selection (SISS) for pre-selection of the most relevant spots from a large input set of candidate spots. IPBR-MCO had several iterations of spot re-sampling, each followed by MCO of the weights of the current spots.Main results.Compared to the published IPBR-MCO, the novel SISS-MCO resulted in similar or slightly superior plan quality. Optimisation times were reduced by a factor of 6 i.e. from 287 to 47 min. Numbers of spots and energy layers in the final plans were similar.Significance.The novel SISS-MCO automatically generated high-quality robust IMPT plans. Compared to a published algorithm for automated robust IMPT planning, optimisation times were reduced on average by a factor of 6. Moreover, SISS-MCO is a large scale approach; this enables optimisation of more complex wish-lists, and novel research opportunities in proton therapy.

Correlation between choroidal vascularity and retrobulbar ocular blood flow changes and thyroid-associated ophthalmopathy activity: a cross-sectional study

OBJECTIVE

To evaluate the alterations in retrobulbar color Doppler imaging (CDI) parameters and retinal/choroidal optical coherence tomography angiography (OCTA) parameters and their association with the clinical activity and severity in thyroid-associated orbitopathy (TAO) patients.

METHODS

In this study, the retrobulbar flow parameters including resistance index (RI), Pulsatile Index(PI), peak systolic velocity (PSV) and end diastolic velocity (EDV) in posterior ciliary artery (PCA), central retinal artery (CRA) and ophthalmic artery (OA) were determined by CDI. Moreover, the retina and choroidal vascularity including the superficial vessel density (SVD), deep vessel density (DVD), choroidal thickness (ChT) and choroidal vascularity, including total choroidal area (TCA), luminal area (LA), stromal area (SA) and Choroidal Vascularity Index (CVI), were determined by OCTA. All patients grouped as active TAO and inactive TAO based on Clinical activity score (CAS). We picked the severe eye among the subjects and compared all parameters between two groups. We analyzed the correlations among those parameters.

RESULTS

There was a significant difference in CAS score, proptosis value, ChT, LA, CVI between patients with active TAO and inactive TAO. In the active group, PSV and EDV of PCA were significantly higher than the inactive group. On logistic regression analysis, CAS was closely associated with PSV-PCA. On multiple linear regression, proptosis value was closely associated with ChT, LA, SA and CVI.

CONCLUSION

Choroidal vascularization and retrobulbar blood flow were concurrently higher in active TAO patients and several variables in choroid circulation was closely related to TAO clinical features.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Factors influencing the detection rate of fumarate peak in 1H MR spectroscopy of fumarate hydratase-deficient renal cell carcinoma at 3 T MRI

AIM

To identify factors that may be associated with fumarate detection rate in 1H-magnetic resonance spectroscopy (MRS) in fumarate hydratase-deficient renal cell carcinoma (FH-RCC).

MATERIALS AND MEHODS

Between February 2018 and March 2022, 16 FH-RCC patients with 30 lesions underwent 1H-MRS. Detection results were classified as having a detected fumarate peak (n=12), undetected peak (n=10), or technical failure (n=8). Factors including tumour size, tumour location, treatment history, and metastasis status were collected and analysed. A Bayesian logistic regression model was applied to evaluate the association between these factors and the detection result.

RESULTS

Bayesian analysis demonstrated significant associations between fumarate detection results and the following factors: long-axis diameter (odds ratio [OR] of 1.64; 95% confidence interval [CI] of 1.07-2.53), short-axis diameter (OR of 1.90; 95% CI of 1.19-3.06), voxel size (OR of 2.85; 95% CI of 1.70-4.75), treatment history (OR of 0.35; 95% CI of 0.21-0.58), non-metastatic state (OR of 2.45; 95% CI of 1.48-4.06), and lymph node metastasis (OR of 0.35; 95% CI of 0.21-0.58). Technical failure results were associated with factors such as treatment history (OR of 2.59; 95% CI of 1.37-4.66), non-metastatic state (OR of 0.36; 95% CI of 0.19-0.66), and lymph node metastasis (OR of 2.61; 95% CI of 1.39-4.74).

CONCLUSION

Tumour size, treatment history, and metastasis character were associated with the detection of abnormal fumarate accumulation. This finding will serve as a reference for interpreting 1H-MRS results and for selecting suitable scenarios to evaluate FH-RCC.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Deep Semi-Supervised Ultrasound Image Segmentation by Using a Shadow Aware Network With Boundary Refinement

Accurate ultrasound (US) image segmentation is crucial for the screening and diagnosis of diseases. However, it faces two significant challenges: 1) pixel-level annotation is a time-consuming and laborious process; 2) the presence of shadow artifacts leads to missing anatomy and ambiguous boundaries, which negatively impact reliable segmentation results. To address these challenges, we propose a novel semi-supervised shadow aware network with boundary refinement (SABR-Net). Specifically, we add shadow imitation regions to the original US, and design shadow-masked transformer blocks to perceive missing anatomy of shadow regions. Shadow-masked transformer block contains an adaptive shadow attention mechanism that introduces an adaptive mask, which is updated automatically to promote the network training. Additionally, we utilize unlabeled US images to train a missing structure inpainting path with shadow-masked transformer, which further facilitates semi-supervised segmentation. Experiments on two public US datasets demonstrate the superior performance of the SABR-Net over other state-of-the-art semi-supervised segmentation methods. In addition, experiments on a private breast US dataset prove that our method has a good generalization to clinical small-scale US datasets.

Anatomy preserving GAN for realistic simulation of intraoperative liver ultrasound images

In ultrasound-guided liver surgery, the lack of large-scale intraoperative ultrasound images with important anatomical structures remains an obstacle hindering the successful application of AI to ultrasound guidance. In this case, intraoperative ultrasound (iUS) simulation should be conducted from preoperative magnetic resonance (pMR), which not only helps doctors understand the characteristics of iUS in advance, but also expands the iUS dataset from various imaging positions, thereby promoting the automatic iUS analysis in ultrasound guidance. Herein, a novel anatomy preserving generative adversarial network (ApGAN) framework was proposed to generate simulated intraoperative ultrasound (Sim-iUS) of liver with precise structure information from pMR. Specifically, the low-rank factors based bimodal fusion was first established focusing on the effective information of hepatic parenchyma. Then, a deformation field based correction module was introduced to learn and correct the slight structural distortion from surgical operations. Meanwhile, the multiple loss functions were designed to constrain the simulation of the content, structures, and style. Empirical results of clinical data showed that the proposed ApGAN obtained higher Structural Similarity (SSIM) of 0.74 and Fr´echet Inception Distance (FID) of 35.54 compared to existing methods. Furthermore, the average Hausdorff Distance (HD) error of the liver capsule structure was less than 0.25 mm, and the average relative (Euclidean Distance) ED error for polyps was 0.12 mm, indicating the high-level precision of this ApGAN in simulating the anatomical structures and focal areas.

Frequency constraint-based adversarial attack on deep neural networks for medical image classification

The security of AI systems has gained significant attention in recent years, particularly in the medical diagnosis field. To develop a secure medical image classification system based on deep neural networks, it is crucial to design effective adversarial attacks that can embed hidden, malicious behaviors into the system. However, designing a unified attack method that can generate imperceptible attack samples with high content similarity and be applied to diverse medical image classification systems is challenging due to the diversity of medical imaging modalities and dimensionalities. Most existing attack methods are designed to attack natural image classification models, which inevitably corrupt the semantics of pixels by applying spatial perturbations. To address this issue, we propose a novel frequency constraint-based adversarial attack method capable of delivering attacks in various medical image classification tasks. Specially, our method introduces a frequency constraint to inject perturbation into high-frequency information while preserving low-frequency information to ensure content similarity. Our experiments include four public medical image datasets, including a 3D CT dataset, a 2D chest X-Ray image dataset, a 2D breast ultrasound dataset, and a 2D thyroid ultrasound dataset, which contain different imaging modalities and dimensionalities. The results demonstrate the superior performance of our model over other state-of-the-art adversarial attack methods for attacking medical image classification tasks on different imaging modalities and dimensionalities.

DWI-Based Radiomics Predicts the Functional Outcome of Endovascular Treatment in Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

Endovascular treatment is a reference treatment for acute basilar artery occlusion (ABAO). However, no established and specific methods are available for the preoperative screening of patients with ABAO suitable for endovascular treatment. This study explores the potential value of DWI-based radiomics in predicting the functional outcomes of endovascular treatment in ABAO.

MATERIALS AND METHODS

Patients with ABAO treated with endovascular treatment from the BASILAR registry (91 patients in the training cohort) and the hospitals in the Northwest of China (31 patients for the external testing cohort) were included in this study. The Mann-Whitney U test, random forests algorithm, and least absolute shrinkage and selection operator were used to reduce the feature dimension. A machine learning model was developed on the basis of the training cohort to predict the prognosis of endovascular treatment. The performance of the model was evaluated on the independent external testing cohort.

RESULTS

A subset of radiomics features (n = 6) was used to predict the functional outcomes in patients with ABAO. The areas under the receiver operating characteristic curve of the radiomics model were 0.870 and 0.781 in the training cohort and testing cohort, respectively. The accuracy of the radiomics model was 77.4%, with a sensitivity of 78.9%, specificity of 75%, positive predictive value of 83.3%, and negative predictive value of 69.2% in the testing cohort.

CONCLUSIONS

DWI-based radiomics can predict the prognosis of endovascular treatment in patients with ABAO, hence allowing a potentially better selection of patients who are most likely to benefit from this treatment.

Ultrasound fusion imaging for improving diagnostic and therapeutic strategies of focal liver lesions: A preliminary study

PURPOSE

To assess the effect of ultrasound (US) fusion imaging on the clinical diagnostic and therapeutic strategies of focal liver lesions, which are difficult to detect or diagnose by conventional US.

METHODS

From November 2019 to June 2022, 71 patients with invisible or undiagnosed focal liver lesions who underwent fusion imaging combining US with CT or MR were included in this retrospective study. The reasons for US fusion imaging were as follows: (1) lesions that were undetectable or inconspicuous on B-mode US; (2) post-ablation lesions that could not be assessed accurately by B-mode US; (3) to evaluate whether the lesions detected by B-mode US that were consistent with those presented on MRI/CT images.

RESULTS

Of the 71 cases, 43 cases were single lesions, and 28 cases were multiple lesions. Among the 46 cases which were invisible on conventional US, the display rate of lesions using US-CT/MRI fusion imaging was 30.8%, and that combined with CEUS was 76.9%. US-guided biopsy was performed in 30 patients after the detection and localization determined by fusion imaging, with a positive rate of 73.3%. Six patients with recurrence after ablation therapy were all detected and located accurately after fusion imaging, and 4 of them successfully underwent ablation therapy again.

CONCLUSION

Fusion imaging contributes to the understanding of the anatomical relationship between lesion location and blood vessels. Additionally, fusion imaging can improve the diagnostic confidence, be helpful to guide interventional operations, and hence be conducive to clinical therapeutic strategies.

Dynamic Perfusion Representation and Aggregation Network for Nodule Segmentation using Contrast-enhanced US

Dynamic contrast-enhanced ultrasound (CEUS) imaging has been widely applied in lesion detection and characterization, due to its offered real-time observation of microvascular perfusion. Accurate lesion segmentation is of great importance to the quantitative and qualitative perfusion analysis. In this paper, we propose a novel dynamic perfusion representation and aggregation network (DpRAN) for the automatic segmentation of lesions using dynamic CEUS imaging. The core challenge of this work lies in enhancement dynamics modeling of various perfusion areas. Specifically, we divide enhancement features into the two scales: short-range enhancement patterns and long-range evolution tendency. To effectively represent real-time enhancement characteristics and aggregate them in a global view, we introduce the perfusion excitation (PE) gate and cross-attention temporal aggregation (CTA) module, respectively. Different from the common temporal fusion methods, we also introduce an uncertainty estimation strategy to assist the model to locate the critical enhancement point first, in which a relatively distinguished enhancement pattern is displayed. The segmentation performance of our DpRAN method is validated on our collected CEUS datasets of thyroid nodules. We obtain the mean dice coefficient (DSC) and intersection of union (IoU) of 0.794 and 0.676, respectively. Superior performance demonstrates its efficacy to capture distinguished enhancement characteristics for lesion recognition. Code is available https://github.com/wanpeng16/DpRAN.

Effects of epicardial adipose tissue volume and thickness assessed by computed tomography and echocardiography on cardiovascular and cerebrovascular outcomes: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Epicardial adipose tissue (EAT) has garnered attention as a potential imaging biomarker for the risk stratification of cardiovascular diseases (CVD). However, the prognostic utility of EAT due to inter-ethnic differences and imaging modality (computed tomography (CT) or transthoracic echocardiography (TTE)) remains undetermined.

Purpose

To evaluate the effect of EAT volume and thickness on cardiovascular and cerebrovascular outcomes. We also aim to compare the prognostic utility between CT volumetric and TTE thickness quantification; and provide consolidated data on the heterogeneity in EAT measurements across different ethnic groups.

Methods

Medline and Embase databases were searched from inception till 16 May 2022 for studies that measured EAT volume or thickness of adult patients at baseline and reported follow-up data on outcomes of interest. Outcomes included MACE, all-cause mortality, cardiac death, myocardial infarction (MI), coronary revascularisation, atrial fibrillation (AF), and stroke. Statistical analyses were conducted on Review Manager 5.4.1 to obtain unadjusted and adjusted hazard ratios (HR) and odds ratios (OR) with the results presented on forest plots.

Results

Twenty-nine studies comprising 19709 patients were included in our analysis. Increased EAT thickness and volume were associated with higher risks of MACE (adjusted HR [aHR] 1.46, 95%CI 1.25–1.71, p&lt;0.001), cardiac death (OR 2.53, 95%CI 1.17–5.44, p=0.020), MI (OR 2.63, 95%CI 1.39–4.96, p=0.003), coronary revascularisation (OR 2.99, 95%CI 1.64–5.44, p&lt;0.001), AF (aOR 4.04, 95%CI 3.06–5.32, p&lt;0.001), and stroke (HR 1.02, 95%CI 1.01–1.03, p&lt;0.001). CT-volumetric quantification of EAT conferred a larger MACE risk (aHR 1.79, 95%CI 1.47–2.17, p&lt;0.001) compared to TTE thickness quantification (aHR 1.20, 95%CI 1.09–1.32, p&lt;0.001). Studies originating from North America (HR 1.91, 95%CI 1.26–2.89, p=0.002) and Asia (HR 1.60, 95%CI 1.09–2.36, p=0.020) demonstrated a significantly higher risk of MACE with increased EAT thickness and volume. However, this significance was not seen in European studies (HR 1.48, 95%CI 0.99–2.20, p=0.060). Subgroup differences were also noted across the studies’ countries of origin when analysing the association of EAT and MI (p=0.020). European studies reported a higher magnitude of MI risk associated with higher EAT thickness and volume (OR 5.28, 95%CI 2.34–11.95, p&lt;0.001) as compared to Asian studies (OR 1.75, 95%CI 1.05–2.92, p=0.030). No differences were noted across other outcomes in the subgroup comparisons by geographical region and between CT and TTE quantification of EAT.

Conclusion

The utility of EAT as an imaging biomarker for predicting and prognosticating CVD is promising. Future efforts to harmonise the EAT parameter thresholds, based on the type of imaging modality and the target population’s ethnic characteristics, will be the next important step before including EAT in CVD prediction models.

Soft hydrogel-shell confinement systems as bacteria-based bioactuators and biosensors

Genetically engineered (GE) bacteria were utilized for developing functional systems upon confinement within a restricted space. Use of natural soft hydrogel such as alginate, gelatin, and agarose, have been investigated as promising approaches to design functional architectures. Nevertheless, a challenge is to develop functional microenvironments that support biofilm-like confinement in a relevant three-dimensional (3D) format for long-term studies. We demonstrate a natural soft hydrogel bioactuator based on alginate core-shell structures (0.25-2 mm core and 50-300 μm shell thickness) that enables 3D microbial colonization upon confinement with high cell density. Specially, our study evaluates the efficiency of bacteria-functional system by recapitulating various GE bacteria which can produce common reporter proteins, to demonstrate their actuator functions as well as dynamic pair-wise interactions. The structural design of the hydrogel can endure continued growth of various bacteria colonies within the confined space for over 10 days. The total amount of cellular biomass upon hydrogel-shell confinement was increased 5-fold compared to conventional techniques without hydrogel-shell. Furthermore, the enzymatic activity increased 3.8-fold and bioluminescence signal by 8-fold compared to the responses from conventional hydrogel systems. The conceptualized platform and our workflow represent a reliable strategy with core-shell structures to develop artificial hydrogel habitats as bacteria-based functional systems for bioactuation.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Metabolic associated fatty liver disease increases risk of adverse events after acute coronary syndrome

 

Metabolic Associated Fatty Liver Disease (MAFLD) was recently introduced as an alternative definition for fatty liver, that has been linked to an increased risk of systemic end-organ damage. However, current studies have not examined the impact of MAFLD on patients presenting with acute coronary syndrome (ACS). Here, we present a retrospective analysis on the short and long-term outcomes of ACS patients with MAFLD.

Methods

A retrospective analysis was conducted in a tertiary care centre. Hepatic steatosis and fibrosis was examined with hepatic steatosis index and fibrosis-4 (FIB-4) index. The primary and secondary outcomes of the analysis were long term all-cause mortality, and in-hospital all-cause mortality, stroke, heart failure and cardiogenic shock respectively. Adjusted analysis was conducted for primary and secondary outcomes with covariates including age, sex, race, type of ACS and previous myocardial infarction.

Results

A total of 5770 patients were included in the analysis, and 21% of ACS patients had concomitant MAFLD. MAFLD resulted in a 23% increase in long-term all-cause mortality compared to non-MAFLD (HR: 1.230, CI: 1.065 to 1.420, p=0.005). MAFLD increased the risk of in-hospital mortality, stroke, heart failure and cardiogenic shock compared to non-MAFLD. A sensitivity analysis conducted based on MAFLD with advance fibrosis, chronic kidney disease and diabetes also demonstrated significantly increased effect size magnitude of all-cause mortality, compared to non-MAFLD.

Conclusion

MAFLD represents an encapsulation of metabolism dysregulation and has been associated with increased risk of systematic disease. The present study shows that MAFLD is associated with significantly increased adverse prognostic outcomes after ACS compared to non-MAFLD. An increase in awareness of MAFLD is required beyond the field of hepatology for improvements in multidisciplinary care and management.

Funding Acknowledgement

Type of funding sources: None.

Higher long-term mortality in patients with concomitant acute coronary syndrome and aortic stenosis

Background

Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors, and their concomitant presentation is increasing in incidence with the aging population. Yet literature regarding the prognosis of patients with concomitant ACS and AS remains scarce.

Methods

This retrospective cohort study examined consecutive patients presenting with ACS (ST-segment elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and concomitant AS between 1 January 2011 and 31 March 2021 in a tertiary hospital. The cohort was divided into mild, moderate and severe AS based on index echocardiogram. The primary outcome was all-cause mortality. Kaplan-Meier curves were constructed to compare all-cause mortality among the three groups of patients, based on ACS type and left ventricular ejection fraction (LVEF). Multivariable Cox regression was performed to identify independent predictors of all-cause mortality.

Results

Of a total of 563 patients, 264 had mild (46.9%), 193 moderate (34.3%) and 106 severe AS (18.8%). The mean follow-up duration was 2.5 (± 2.4) years. Majority of patients (72.5%) presented with NSTEMI. Patients with moderate and severe AS had higher rates of all-cause mortality compared to those with mild AS (49.7% vs. 51.4% vs. 35.6% respectively, p=0.002). Concomitant moderate (HR 1.439, 95% CI 1.012–2.048, p=0.043) and severe AS (HR 1.844, 95% CI 1.159–2.933, p=0.010) were independent predictors of all-cause mortality after adjusting for age, gender, LVEF, ACS type, chronic kidney disease, diabetes, hypertension, coronary artery bypass grafting and aortic valve replacement as a time-dependent variable. The Kaplan-Meier curves demonstrated excess mortality in moderate and severe AS, compared to the mild AS group (p&lt;0.001), with similar survival trends observed in the STEMI and the NSTEMI groups, as well as those with preserved LVEF.

Conclusion

Regardless of the ACS presentation type, long-term excess mortality in those with concomitant moderate or severe AS was observed. The adverse prognosis typically observed in patients with concomitant severe AS, in the setting of ACS, extends to patients with moderate AS.

Funding Acknowledgement

Type of funding sources: None.

Prognostically distinct phenotypes of metabolic health beyond obesity in aortic stenosis

Background

Whilst current evidence are in favour of metabolic health and non-obesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) based on the presence of metabolic health and obesity.

Methods

This retrospective cohort on consecutive patients presenting with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups based on obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy non-obese (MHNO), metabolically unhealthy obese (MUO) and metabolically unhealthy non-obese (MUNO). Metabolic health was defined in accordance to Program Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, sex, chronic kidney disease and AVR as a time-dependent covariate.

Results

Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%) and MHO (6.9%) groups (p=0.001). Compared to MHNO, MHO (HR 0.159, 95% CI 0.038–0.668, p=0.012) and MUO (HR 0.614, 95% CI 0.403–0.937, p=0.024) were independently associated with lower all-cause mortality rates, after adjusting for confounders. In obese patients, metabolic health had favourable survival compared to metabolically unhealthy (p=0.015), but this protective impact of metabolic health was not observed in overweight or normal weight individuals. Obesity had favourable survival compared to overweight and normal weight, in both metabolically health (p=0.002) and unhealthy (p=0.007) patients,

Conclusion

MHO patients with AS have the most favourable prognosis whilst the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift towards prioritising metabolic health rather than weight reduction in patients with significant AS.

Funding Acknowledgement

Type of funding sources: None.