Successful Catheter-Directed Thrombolysis of Massive Bilateral Upper Extremity DVT Presenting as Superior Vena Cava Syndrome

Superior vena cava syndrome (SVCS) is traditionally associated with malignancy. However, approximately one-third of SVCS cases are due to intravascular devices and pacemakers. No specific guidelines exist for managing catheter-associated SVCS. We present catheter-associated SVCS resistant to anticoagulation, angioplasty, and thrombectomy but resolved with ultrasound-assisted catheter directed thrombolysis. (Level of Difficulty: Intermediate.).

An Optical Filter-Less CMOS Image Sensor with Differential Spectral Response Pixels for Simultaneous UV-Selective and Visible Imaging

This paper presents a complementary metal-oxide-semiconductor (CMOS) image sensor (CIS) capable of capturing UV-selective and visible light images simultaneously by a single exposure and without employing optical filters, suitable for applications that require simultaneous UV and visible light imaging, or UV imaging in variable light environment. The developed CIS is composed by high and low UV sensitivity pixel types, arranged alternately in a checker pattern. Both pixel types were designed to have matching sensitivities for non-UV light. The UV-selective image is captured by extracting the differential spectral response between adjacent pixels, while the visible light image is captured simultaneously by the low UV sensitivity pixels. Also, to achieve high conversion gain and wide dynamic range simultaneously, the lateral overflow integration capacitor (LOFIC) technology was introduced in both pixel types. The developed CIS has a pixel pitch of 5.6 µm and exhibits 172 µV/e- conversion gain, 131 ke- full well capacity (FWC), and 92.3 dB dynamic range. The spectral sensitivity ranges of the high and low UV sensitivity pixels are of 200-750 nm and 390-750 nm, respectively. The resulting sensitivity range after the differential spectral response extraction is of 200-480 nm. This paper presents details regarding the CIS pixels structures, doping profiles, device simulations, and the measurement results for photoelectric response and spectral sensitivity for both pixel types. Also, sample images of UV-selective and visible spectral imaging using the developed CIS are presented.

Tetralogy of Fallot: Pushing Through Despite Long Odds

The natural history of tetralogy of Fallot depends on whether a transannular pulmonary valve patch or shunt surgery was necessary in infancy. This case illustrates the feasibility of cardiac rest on extracorporeal membranous oxygenation for a very ill adult with conduit endocarditis who received a right ventricle–to–pulmonary artery valveless conduit for later transcatheter pulmonary valve replacement. (Level of Difficulty: Advanced.)

Real-time optical vascular imaging: a method to assess the microvascular circulation of myofascial free flaps used in the head and neck region

Microvascular free flaps are considered the gold standard in head and neck reconstructive surgery. Myofascial flaps, in particular, are useful in certain oral and maxillofacial reconstruction cases, where mucosal regeneration over the transplanted tissue is planned. Despite high success rates, 1-6% of free flaps fail. A plethora of methods are available to assess transplanted tissue viability after reconstruction, including clinical observational monitoring, surface Doppler, implantable Doppler probe, colour Doppler sonography, laser Doppler flowmeter, surface temperature and indocyanine green angiography. However, no method has demonstrated adequate reliability or has proven to be cost-effective. The authors tested a technique called real-time optical vascular imaging to evaluate the microvascular circulation of myofascial free flaps. This technique was develop at Guy's Hospital, London to observe the microvascular anatomy of the oral cavity in vivo, non-invasively and without the need for patient preparation, with the aim of detecting and monitoring oral diseases. This technology detects the red blood cells flowing inside the microvasculature at a depth of approximately 2mm, allowing the microvascular architecture and blood flow to be determined. This study showed that RTOVI may prove to be beneficial for the early detection of vascular compromise due to its immediacy and the feasibility of assessing multiple graft tissue regions.

Single-residue physicochemical characteristics kinetically partition membrane protein self-assembly and aggregation

Ninety-five percent of all transmembrane proteins exist in kinetically trapped aggregation-prone states that have been directly linked to neurodegenerative diseases. Interestingly, the primary sequence almost invariably avoids off-pathway aggregate formation, by folding reliably into its native, thermodynamically stabilized structure. However, with the rising incidence of protein aggregation diseases, it is now important to understand the underlying mechanism(s) of membrane protein aggregation. Micromolecular physicochemical and biochemical alterations in the primary sequence that trigger the formation of macromolecular cross-β aggregates can be measured only through combinatorial spectroscopic experiments. Here, we developed spectroscopic thermal perturbation with 117 experimental variables to assess how subtle protein sequence variations drive the molecular transition of the folded protein to oligomeric aggregates. Using the Yersinia pestis outer transmembrane β-barrel Ail as a model, we delineated how a single-residue substitution that alters the membrane-anchoring ability of Ail significantly contributes to the kinetic component of Ail stability. We additionally observed a stabilizing role for interface aliphatics, and that interface aromatics physicochemically contribute to Ail self-assembly and aggregation. Moreover, our method identified the formation of structured oligomeric intermediates during Ail aggregation. We show that the self-aggregation tendency of Ail is offset by the evolution of a thermodynamically compromised primary sequence that balances folding, stability, and oligomerization. Our approach provides critical information on how subtle changes in protein primary sequence trigger cross-β fibril formation, with insights that have direct implications for deducing the molecular progression of neurodegeneration and amyloidogenesis in humans.

Economic implications of localization strategies for cerebrospinal fluid rhinorrhea

BACKGROUND

The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described.

METHODS

A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters.

RESULTS

Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values.

CONCLUSION

This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

Nanomedicine in organ transplantation and regenerative surgery: an interview with Vijay Gorantla and Jelena Janjic

Discussing the recently published Special Focus Issue 'Nanomedicine in Organ Transplantation and Regenerative Surgery - Advances, Applications and Future Directions', highlighting the applications of nanomedicines for therapeutic, diagnostic and monitoring strategies in solid organ transplantation as well covering biocompatibility and nanopharmaceutics.

Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis

BACKGROUND

functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods, including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of wireless motility capsules, and emerging magnetic resonance imaging (MRI) approaches.

OBJECTIVES

to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs.

METHODS

a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI.

CONCLUSIONS

emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs.

Mechanism of fluid leak in non-traumatic corneal perforations: an anterior segment optical coherence tomography study

AIM

Non-traumatic corneal perforations (CPerfs) may present with shallow/flat or formed anterior chamber (AC). This study uses anterior segment optical coherence tomography (ASOCT) to ascertain these differences.

METHOD

The study included 14 eyes of 13 patients. They underwent high-resolution ASOCT scans at multiple time points, prior to and after cyanoacrylate glueing, between January 2016 and July 2018. A retrospective analysis of over 2500 ASOCT sections and AS photographs was conducted by two independent observers. The findings were correlated with clinical features and diagnoses.

RESULT

All patients had documented Seidel's positive sign at the outset. Two groups with distinctive features were identified. In group 1, 'formed' AC, there was hydration of the cornea with lamellar separation of the stroma, intrastromal pockets of fluid, epithelial bullae and an indirect communication between AC and the exterior. In group 2, 'flat' AC, the corneal hydration was less obvious, there were no pockets of intrastromal fluid, no epithelial bullae and a direct communication of the AC with the exterior. After glueing, the stromal hydration resolved, and healing occurred beneath the glue. The glue and corneal blood vessels consistently cast a dense shadow posteriorly on ASOCT.

CONCLUSION

ASOCT demonstrates that leaking CPerfs can be indirect or direct. The former is associated with a 'formed' AC and the latter with a very shallow/flat AC. The valvular nature of the communication in indirect perforations allows the AC to maintain its volume despite a continuous leak.

Recent advances in understanding the phenotypes of osteoarthritis

Recent research in the field of osteoarthritis (OA) has focused on understanding the underlying molecular and clinical phenotypes of the disease. This narrative review article focuses on recent advances in our understanding of the phenotypes of OA and proposes that the disease represents a diversity of clinical phenotypes that are underpinned by a number of molecular mechanisms, which may be shared by several phenotypes and targeted more specifically for therapeutic purposes. The clinical phenotypes of OA supposedly have different underlying etiologies and pathogenic pathways and they progress at different rates. Large OA population cohorts consist of a majority of patients whose disease progresses slowly and a minority of individuals whose disease may progress faster. The ability to identify the people with relatively rapidly progressing OA can transform clinical trials and enhance their efficiency. The identification, characterization, and classification of molecular phenotypes of rapidly progressing OA, which represent patients who may benefit most from intervention, could potentially serve as the basis for precision medicine for this disabling condition. Imaging and biochemical markers (biomarkers) are important diagnostic and research tools that can assist with this challenge.

Changes in the OCT angiographic appearance of type 1 and type 2 CNV in exudative AMD during anti-VEGF treatment

Objective

Optical coherence tomography angiography (OCT-A) enables detailed visualisation of the vascular structure of choroidal neovascularisation (CNV). The aim of this study was to determine whether mathematically ascertained OCT-A vascular parameters of type 1 and type 2 CNV in exudative age-related macular degeneration (AMD) change during antivascular endothelial growth factor (anti-VEGF) treatment. The OCT-A vascular parameters were also compared with previously obtained activity parameters (fluid distribution on spectral domain OCT (SD-OCT)) to establish whether they could potentially be used as further ‘activity parameters’ for assessment of anti-VEGF treatment.

Methods and Analysis

We evaluated 27 eyes of 27 patients (mean follow-up 9.8 months) with type 1, type 2 or mixed CNV who had received anti-VEGF treatment (IVAN scheme). The parameters analysed were area (aCNV), total length of all vessels (tlCNV), overall number of vascular segments (nsCNV) and fractal dimension (FD) of the CNV. The changes in each of these parameters were correlated with the central foveal thickness (CFT).

Results

Regression and renewed perfusion of the CNV corresponded with the decrease or increase, respectively, of macular fluid distribution on SD-OCT. The increase and decrease of CFT during anti-VEGF treatment were highly significantly correlated with changes in FD (p<0.00001), aCNV (p<0.00001), tlCNV (p<0.00001) and nsCNV (p<0.00001).

Conclusion

OCT-A enables detailed analysis of AMD with regard to FD, aCNV, tlCNV and nsCNV. As the changes in these parameters correlate closely with changes on SD-OCT, they can be used as new activity parameters, alongside fluid distribution, for assessment of treatment effect and as parameters of stabilisation or the need for repeated treatment.

Acute Respiratory Distress Syndrome (ARDS): Pathophysiological Insights and Lung Imaging

Acute respiratory distress syndrome (ARDS) is in the center of the scientific debate both for its complex pathophysiology and for the discussion about the remedies that could contribute to its healing. The intricate interplay of different body systems that characterizes ARDS is mirrored by two main research threads, one centered on the pathophysiological mechanisms of the disease and the other on the new approaches to lung imaging. In this Special Issue of the Journal of Clinical Medicine are presented studies using imaging technologies based on electrical impedance tomography, synchrotron radiation computed tomography and intravital probe-based confocal laser endomicroscopy. The studies on the pathophysiological mechanisms pertain to the evaluation of the biomarkers of the disease and the platelet disfunction during extracorporeal membrane oxygenation. These contributions witness the intensity of ARDS research as many of the key problems of the disease are only in part resolved.

Development and validation of a prediction model for identifying men with intermediate- or high-risk prostate cancer for whom bone imaging is unnecessary: a nation-wide population-based study

Objective: To develop and validate a nomogram that identifies men for whom bone scan is unnecessary.Material and methods: The study datasets were derived from the National Prostate Cancer Register (NPCR) of Sweden. All men in the NPCR ≤80 years of age who were diagnosed with intermediate- or high-risk prostate cancer and who had pretreatment bone imaging (^99mTc MDP scintigraphy, plain x-ray, computed tomography, magnetic resonance imaging, and/or positron emission tomography fused with computed tomography) were included. Men diagnosed from 2015-2016 formed a development dataset and men diagnosed in 2017 formed a validation dataset. Outcome was metastasis on bone imaging as registered in NPCR. Multivariable logistic regression was used to develop a nomogram.Results: In the development dataset 482/5084 men (10%) had bone metastasis, the corresponding percentage in the validation dataset was 282/2554 (11%). Gleason grade group, clinical T stage, and prostate-specific antigen were included in the final model. Discrimination and calibration were satisfactory in both the development (AUC 0.80, 95% CI 0.78-0.82) and validation dataset (AUC 0.80, 95% CI, 0.77-0.82). Compared with using the EAU guidelines' recommendation for selecting men for imaging, using the nomogram with a cut-off at 4% chance of bone metastasis, would have avoided imaging in 519/2068 men (25%) and miss bone metastasis in 10/519 (2%) men in the validation dataset.Conclusion: By use of our nomogram, bone scans of men with prostate cancer can be avoided in a large proportion of men.

Ultrasonographic appearance of the coelomic cavity organs in healthy veiled chameleons (Chamaeleo calyptratus) and panther chameleons (Furcifer pardalis)

Veiled chameleons (Chamaeleo calyptratus) and panther chameleons (Furcifer pardalis) are the most popular chameleons over the world, and consequently, two of the most frequent species presenting to veterinary practices. However, published studies on normal ultrasonographic anatomy for these lizards are currently lacking. The objectives of this prospective anatomic study were to develop an ultrasound protocol for evaluation of the coelomic cavity in these species and describe the normal ultrasonographic anatomy of the coelomic organs. Seventeen healthy veiled chameleons and 15 healthy panther chameleons were included. A linear 18 MHz transducer was used. Chameleons were sedated and restrained in right lateral recumbency by an assistant. Longitudinal and transverse images were acquired, and authors recorded qualitative and quantitative ultrasonographic characteristics of the coelomic structures. The kidneys, liver, caudal vena cava, hepatic veins, portal vein, gallbladder, wall of the stomach and intestine, gonads and, when distended, urinary bladder could be visualized during ultrasonography of the coelomic cavity in both species. The spleen, pancreas, and adrenal glands could not be identified. Findings from the current study supported the use of ultrasonography for veiled chameleons (Chamaeleo calyptratus) and panther chameleons (Furcifer pardalis) with suspected intracoelomic diseases and provided normal reference information for future studies of these chameleon species.

Noninvasive Assessment of Exosome Pharmacokinetics In Vivo: A Review

Exosomes, intraluminal vesicles that contain informative DNA, RNA, proteins, and lipid membranes derived from the original donor cells, have recently been introduced to therapy and diagnosis. With their emergence as an alternative to cell therapy and having undergone clinical trials, proper analytical standards for evaluating their pharmacokinetics must now be established. Molecular imaging techniques such as fluorescence imaging, magnetic resonance imaging, and positron emission tomography (PET) are helpful to visualizing the absorption, distribution, metabolism, and excretion of exosomes. After exosomes labelled with a fluorescer or radioisotope are administered in vivo, they are differentially distributed according to the characteristics of each tissue or lesion, and real-time biodistribution of exosomes can be noninvasively monitored. Quantitative analysis of exosome concentration in biological fluid or tissue samples is also needed for the clinical application and industrialization of exosomes. In this review, we will discuss recent pharmacokinetic applications to exosomes, including labelling methods for in vivo imaging and analytical methods for quantifying exosomes, which will be helpful for evaluating pharmacokinetics of exosomes and improving exosome development and therapy.

A Review of the Role of Breast Arterial Calcification for Cardiovascular Risk Stratification in Women

Cardiovascular disease continues to be the leading cause of death among women in the United States. One of the barriers to improving cardiovascular disease outcomes in women is the lack of reliable, effective screening modalities. Breast arterial calcification has emerged as a potential risk stratification tool. Localized deposition in the media of the artery, known as Mönckeberg medial calcific sclerosis, is notably different from the intimal atherosclerotic process commonly associated with coronary artery disease. Nonetheless, studies favor a correlation between breast arterial calcification and cardiovascular risk factors or coronary artery disease, defined as coronary artery calcification on computed tomography scan or both nonobstructive and obstructive lesions on angiography. Since a majority of women over the age of 40 undergo yearly breast cancer screening with mammography, measurement of breast arterial calcification may offer a personalized, noninvasive approach to risk-stratify women for cardiovascular disease at no additional cost or radiation. Mammography has the potential to alter the course of the leading cause of death in women, heart disease, through the evaluation of breast arterial calcification and identification of opportunities for prevention. Current evidence supports the universal reporting of breast arterial calcifications and personalized patient-provider discussions to more aggressively treat cardiac risk factors through targeted medical therapies or healthy lifestyle changes.

A Novel Method for Correcting Pelvic Tilt on Anteroposterior Pelvic Radiographs

Background Anteroposterior (AP) pelvic radiographs remain the standard for pre- and postoperative imaging during total hip arthroplasty (THA), despite the known limitation of plain films, including the inability to adequately account for distortion caused by variations in pelvic orientation such as pelvic tilt. The purpose of this study was to develop a reliable method for correcting pelvic tilt on AP pelvic radiographs in patients undergoing THA. Methods CT scans from 20 patients/cadaver specimens (10 male, 10 female) were used to create 3D renderings, from which synthetic radiographs of each pelvis were generated. For each pelvis, 13 synthetic radiographs were generated, showing the pelvis at between -30° and 30° of pelvic tilt, in 5° increments. On each image, eight unique parameters/distances were measured to determine the most appropriate parameters for the calculation of pelvic tilt. The most reliable and accurate of these parameters was determined via regression analysis and used to create gender-specific nomograms from which pelvic tilt measurements could be calculated. The accuracy and reliability of the nomograms and correction method were subsequently validated using both synthetic radiographs (n=50) and stereoradiographic images (n=58). Results Of the eight parameters measured, the vertical distance between the superior margin of the pubic symphysis and the transischial line (PSTI) was determined to be the most reliable (r=-0.96, ICC=0.94). Using that parameter and applying the associated nomograms to 50 synthetic radiographs of random pelvic tilt, the mean difference between the actual pelvic tilt and that calculated using the correction method was 0.1°±5.1° (p=0.98, r=0.96). In 58 stereoradiographic images, the mean difference between actual and measured pelvic tilt was -0.2°±6.4° (p=0.74, r=0.77). The pooled results indicate no significant difference between actual (2.2°±13.9°) and measured pelvic tilt (2.1°±14.3°, p=0.93, r=0.91). No significant differences were noted based on gender. Conclusions Our method of correcting for pelvic tilt using the vertical distance from the pubic symphysis to the transischial line provides a reliable method for correcting for pelvic tilt on AP pelvic radiographs.

Synthesis and Characterization of ROSA Dye - A Rhodamine B-type Fluorophore, Suitable for Bioconjugation and Fluorescence Studies in Live Cells

BACKGROUND

Herein we report the multigram-scale synthesis, characterization and application of a rhodamine B-based fluorophore (ROSA) suitable for fluorescent studies in biological applications. This fluorophore is devoid of rhodamine spirolactone formation and furthermore characterized by a high molar extinction coefficient (ϵ=87250 ± 1630 M-1cm-1) and quantum yield (φ) of 0.589 ± 0.070 in water. Reported here is also the application of ROSA towards synthesis of a ROSA-PEG-GRGDS-NH2 fluorescent probe suitable for live cell imaging of αvβ3 integrins for in vitro assays.

OBJECTIVES

The main objective of this study is to efficiently prepare rhodamine B derivative, devoid of spirolactone formation that would be suitable for bioconjugation and subsequent bioimaging.

METHODS

Rhodamine B was transformed into rhodamine B succinimide ester (RhoB-OSu) using N-hydroxysuccinimide. RhoB-OSu was further coupled to sarcosine to obtain rhodamine Bsarcosine dye (ROSA) in good yield. The ROSA dye was then coupled to a αvβ3 integrin binding sequence using standard solid-phase conditions. Resulting ROSA-PEG-GRGDS-NH2 probe was used to image integrins on cancer cells.

RESULTS

The rhodamine B-sarcosine dye (ROSA) was obtained in multigram scale in good total yield of 47%. Unlike rhodamine B, the ROSA dye does not undergo pH-dependent spirolactone/spirolactam formation as compared with rhodamine B-glycine. It is also characterized by excellent quantum yield (φ) of 0.589 ± 0.070 in water and high molar extinction coefficient of 87250 ± 1630 M-1cm-1. ROSA coupling to the RGD-like peptide was proved to be efficient and straightforward. Imaging using standard filters on multimode plate reader and confocal microscope was performed. The αvβ3 integrins present on the surface of live WM-266-4 (melanoma) and MCF- 7 (breast cancer) cells were successfully imaged.

CONCLUSION

We successfully derivatized rhodamine B to create an inexpensive, stable and convenient to use fluorescent probe. The obtained derivative has excellent photochemical properties and it is suitable for bioconjugation and many imaging applications.

Evaluation of Osseous Morphology of the Hip Using Zero Echo Time Magnetic Resonance Imaging

BACKGROUND

Femoroacetabular impingement syndrome (FAIS) is a common disorder of the hip resulting in groin pain and ultimately osteoarthritis. Radiologic assessment of FAI morphologies, which may present with overlapping radiologic features of hip dysplasia, often requires the use of computed tomography (CT) for evaluation of osseous abnormality, owing to the difficulty of direct visualization of cortical and subchondral bone with conventional magnetic resonance imaging (MRI). The use of a zero echo time (ZTE) MRI pulse sequence may obviate the need for CT by rendering bone directly from MRI.

PURPOSE/HYPOTHESIS

The purpose was to explore the application of ZTE MRI to the assessment of osseous FAI and dysplasia morphologies of the hip. It was hypothesized that angular measurements from ZTE images would show significant agreement with measurements obtained from CT images.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Thirty-eight hips from 23 patients were imaged with ZTE MRI and CT. Clinically relevant angular measurements of hip morphology were made in both modalities and compared to assess agreement. Measurements included coronal and sagittal center-edge angles, femoral neck-shaft angle, acetabular version (at 1-, 2-, and 3-o'clock positions), Tönnis angle, alpha angle, and modified-beta angle. Interrater agreement was assessed for a subset of 10 hips by 2 raters. Intermodal agreement was assessed on the complete cohort and a single rater.

RESULTS

Interrater agreement was demonstrated in both CT and ZTE, with intraclass correlation coefficient values ranging from 0.636 to 0.990 for ZTE and 0.747 to 0.983 for CT, indicating "good" to "excellent" agreement. Intermodal agreement was also shown to be significant, with intraclass correlation coefficients ranging from 0.618 to 0.904.

CONCLUSION

Significant agreement of angular measurements for hip morphology exists between ZTE MRI and CT imaging. ZTE MRI may be an effective method to quantitatively evaluate osseous hip morphology.

EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: Challenges in the diagnosis and management of valve disease: the case for the specialist valve clinic

Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients' outcomes.

2-D Shear Wave Elastography for Focal Lesions in Liver Phantoms: Effects of Background Stiffness, Depth and Size of Focal Lesions on Stiffness Measurement

The aim of this study was to determine the factors influencing stiffness and conspicuity of focal lesions in deep organs by focusing on target properties using 2-D shear wave elastography (SWE). Two normal (4 ± 1 kPa) and cirrhotic (16 ± 2 kPa) liver-mimicking phantoms with spherical inclusions (23 ± 3 kPa) were used. Inclusions of three sizes (20, 15 and 10 mm in diameter) were arranged in a row at depths of 3, 5 and 7 cm. Two observers acquired quantitative stiffness values and a qualitative five-grade morphologic score at each inclusion using SWE. The coefficients of variation (CVs) of stiffness were calculated to assess measurement reliability. The generalized estimating equation was used to identify whether stiffness, CV and morphologic score were independent of background stiffness, depth and size of inclusions and observer. In the quantitative assessment, stiffness of the inclusion and CV were dependent on the type of phantom and depth of inclusion (p < 0.001). There were no significant differences in stiffness and CV according to the observer. Morphologic score differed significantly only in the size of the inclusion (p < 0.001). When the depth of the inclusion was 7 cm, the stiffness was the highest, and the 10 mm-sized inclusions had lower morphologic scores than the other inclusions (all p values < 0.001). In conclusion, 2-D SWE assessment of focal lesions could be affected by background stiffness and depth of focal lesions, and may be limited in evaluating focal hepatic lesions.

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain

Background  Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions  Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods  A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results  A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion  Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence  This is a Level III study.