EVALUATION OF GLASS STAGE IN PATIENTS WITH CHRONIC LIMB THREATENING ISCHEMIA TREATED WITH AUTOGENOUS BYPASS GRAFTS

OBJECTIVE

To evaluate the relationship of GLASS stages with clinical outcomes in patients with chronic limb threatened ischemia (CLTI) submitted to distal bypasses using venous graft.

METHODS

A single-center retrospective analysis of patients with CLTI submitted to distal bypasses with vein graft between January 2012 and December 2019 were included. The primary end point was freedom from CLTI (amputation-free survival, with complete wound healing and without ischemic rest pain). Secondary end points included a composite outcome of recurrence (patients that achieved freedom from CLTI but developed a new wound or ischemic rest pain), major limb amputation, amputation free-survival, overall survival, major adverse limb events (MALE), limb-based patency (LBP) and primary and secondary patency rates.

RESULTS

A total of 190 patients were submitted to 211 distal bypasses with a median follow up of 30 months. Eighty percent of the cases had diabetes or end-stage kidney disease requiring dialysis. Most patients (63%) had major or extensive tissue loss (Wound class ≥ 2) with more than half of these with some degree of infection of the foot. Severe anatomic pattern (GLASS stage III) was predominant with a prevalence of 78%. There were no significant differences between GLASS I-II and GLASS III stage groups for all the outcomes analysed. About 80% of the 211 revascularized limbs were free from CLTI at 12 months. At 4 years of follow up we observed that 25% of the cases had recurrence of CLTI, 83% were free from major amputation and 61% were free from MALE. LBP, primary patency, and secondary patency were 79%, 80% and 93% at one year, and 64%, 65% and 81% at four years, respectively.

CONCLUSIONS

GLASS stage was not related with patency and clinical outcomes after distal bypasses with vein graft. Distal open revascularization presents excellent rates of freedom from CLTI with low rates of recurrence of CLTI, two key time-integrated outcomes of clinical disease severity in patients with CLTI.

Exploring the selective gray matter profile of autism spectrum disorder through Bayes Factor Modeling

Introduction

Despite decades of brain MRI research demonstrating atypical neuroanatomical substrate in patients with autism spectrum disorder (ASD), it remains unclear whether and to what extent disorder-selective neuroanatomical abnormalities occur in this spectrum. This, and the fact that multiple brain disorders report a common neuroanatomical substrate, makes transference and the application of neuroimaging findings into the clinical setting an open challenge.

Objectives

To investigate the selective neuroanatomical alteration profile of the ASD brain, we employed a meta-analytic, data-driven, and reverse inference-based approach (i.e.; Bayes fACtor mOdeliNg).

Methods

Eligible voxel-based morphometry data were extracted by a standardized search on BrainMap and MEDLINE databases (849 published experiments, 131 brain disorders, 22747 clinical subjects, 16572 x-y-z coordinates). Two distinct datasets were generated: the ASD dataset, composed of ASD-related data; and the non-ASD dataset, composed of all other clinical conditions data. Starting from the two unthresholded activation likelihood estimation (ALE) maps, the calculus of the Bayes fACtor mOdeliNg was performed. This allowed us to obtain posterior probability distributions on the evidence of brain alteration specificity in ASD.

Results

We revealed both cortical and cerebellar areas of neuroanatomical alteration selectivity in ASD. Eight clusters showed a selectivity value ≥ 90%, namely the bilateral precuneus, the right inferior occipital gyrus, left lobule IX, left Crus II, right Crus I, and the right lobule VIIIA (Fig. 1).

Conclusions

The identification of this neuroanatomical pattern provides new insights into the complex pathophysiology of ASD, opening attractive prospects for future neuroimaging-based interventions.

Disclosure

No significant relationships.

The burden associated with, and management of, difficult-to-treat depression in patients under specialist psychiatric care in the United Kingdom

BACKGROUND

Major depressive disorder (MDD) is common and often has sub-optimal response to treatment. Difficult-to-treat depression (DTD) is a new concept that describes 'depression that continues to cause significant burden despite usual treatment efforts'.

AIMS

To identify patients with likely DTD in UK secondary care and examine demographic, disease and treatment data as compared with 'non-DTD' MDD patients.

METHODS

Anonymised electronic health records (EHRs) of five specialist mental health National Health Service (NHS) Trusts in the United Kingdom were analysed using a natural language processing model. Data on disease characteristics, comorbidities and treatment histories were extracted from structured fields and using natural language algorithms from unstructured fields. Patients with MDD aged ⩾18 years were included in the analysis; those with presumed DTD were identified on the basis of MDD history (duration and recurrence) and number of treatments prescribed.

RESULTS

In a sample of 28,184 patients with MDD, 19% met criteria for DTD. Compared to the non-DTD group, patients with DTD were more likely to have severe depression, suicidal ideation, and comorbid psychiatric and/or physical illness, as well as higher rates of hospitalisation. They were also more likely to be in receipt of unemployment and sickness/disability benefits. More intensive treatment strategies were used in the DTD group, including higher rates of combination therapy, augmentation, psychotherapy and electroconvulsive therapy.

CONCLUSION

This study demonstrates the feasibility of identifying patients with probable DTD from EHRs and highlights the increased burden associated with MDD in these patients.

Photo2Video: Semantic-Aware Deep Learning-Based Video Generation from Still Content

Applying machine learning (ML), and especially deep learning, to understand visual content is becoming common practice in many application areas. However, little attention has been given to its use within the multimedia creative domain. It is true that ML is already popular for content creation, but the progress achieved so far addresses essentially textual content or the identification and selection of specific types of content. A wealth of possibilities are yet to be explored by bringing the use of ML into the multimedia creative process, allowing the knowledge inferred by the former to influence automatically how new multimedia content is created. The work presented in this article provides contributions in three distinct ways towards this goal: firstly, it proposes a methodology to re-train popular neural network models in identifying new thematic concepts in static visual content and attaching meaningful annotations to the detected regions of interest; secondly, it presents varied visual digital effects and corresponding tools that can be automatically called upon to apply such effects in a previously analyzed photo; thirdly, it defines a complete automated creative workflow, from the acquisition of a photograph and corresponding contextual data, through the ML region-based annotation, to the automatic application of digital effects and generation of a semantically aware multimedia story driven by the previously derived situational and visual contextual data. Additionally, it presents a variant of this automated workflow by offering to the user the possibility of manipulating the automatic annotations in an assisted manner. The final aim is to transform a static digital photo into a short video clip, taking into account the information acquired. The final result strongly contrasts with current standard approaches of creating random movements, by implementing an intelligent content- and context-aware video.

Case report: primary ciliary dyskinesia associated with Kartagener syndrome

INTRODUCTION: Primary ciliary dyskinesia is a ciliary mobility disorder, which is characterized by reduced or uncoordinated mobility of the cilia present in the respiratory epithelium. Consequently, mucociliary transport is impaired in the patient’s respiratory tract, making him susceptible to infections and stasis of recurrent secretions, and later to a hyperplasia of secretory cells. CASE REPORT: This article describes the case of a patient with primary ciliary dyskinesia associated with Kartagener syndrome. All the significant points that led to its early diagnosis (less than 3 years of age) will be highlighted, including clinical status, imaging tests, and genetic study. DISCUSSION: It is an autosomal recessive disease, and in half of the cases it is associated with Kartagener syndrome, which manifests classic signs of chronic sinusitis, situs inversus and bronchiectasis. Furthermore, it is also common to find persistent cough, dyspnea, otitis media, mouth breathing, nasal polyp, and even cardiac malformations in patients with the disease. The differential diagnosis for ciliary dyskinesia is important in order to investigate possible additional damage to the patient due to his clinical condition. Therefore, clinical investigation in conjunction with radiographs, CT scans and cytological exams are the main method for analyzing structural variations. Overall, this dysfunction is usually identified in late stages, so its study is necessary enough to help the early diagnosis of the pathology, contributing to the preservation of the pulmonary function of these patients.

Effect of exercise on phase angle in cancer patients: a systematic review

INTRODUCTION

Body composition is one of the main variables of interest in clinical practice in cancer patients. Specific markers from bioelectrical impedance analysis, such as phase angle (PhA), have been assuming increasing relevance in this population. The aim of the present systematic review was to study and systematise the effect of exercise on PhA in cancer survivors, as compared to control conditions, namely usual care, with no exercise. The effect of exercise on PhA in the population of cancer survivors is not yet established. EVIDENCE ACQUISITIONː This systematic review was conducted on October 13, 2021, through PubMed, Web of Science, Wiley Online Library, Directory of Open Access Journals, Science Direct and JSTOR, following PRISMA guidelines and PICOS model that include: cancer survivors with ≥18 years; intervention of any exercise program for the target group; comparison between intervention group and control group that followed control conditions, namely usual care, with no exercise; outcome related to PhA; and studies of randomized control trials.

EVIDENCE SYNTHESIS

We founded a total of 1244 publications, using selected keywords. Eight studies were included in this systematic review, after inclusion/exclusion criteria considered. Compared with the control conditions, exercise training programs seem associated with a positive effect on PhA, both in solid tumours and haematologic cancer types, but only when using resistance exercise alone. According to the best evidence synthesis criteria, we could not conclude the superiority of any exercise program analysed in the value of the PhA.

CONCLUSIONS

There were several exercise details that may have potential to be beneficial for PhA in cancer patients, including an early start of the exercise intervention (during treatment and immediately after discharge from hospital), the use of resistance exercise or/and aerobic exercise, and mainly a long follow-up period (≥ 4 months) to verify the structural effects of exercise on the PhA. However, there were no effects on the PhA value immediately after the intervention, regardless of the type of protocol and the intervention time.

RECURRENT VARICOSE VEINS FOLLOWING SMALL SAPHENOUS VEIN SURGERY: A 5-YEAR FOLLOW-UP DUPLEX ULTRASOUND STUDY

INTRODUCTION

Chronic venous disease (CVD) of the lower limbs is a very prevalent medical condition with important socioeconomic repercussions. Small saphenous vein (SSV) incompetence, although less frequent than great saphenous vein (GSV) incompetence, presents a more challenging treatment, with higher rates of complication and recurrence.

OBJECTIVES

To determine the incidence and associated risk factors of varicose veins recurrence in patients submitted, for the first time and exclusively, to SSV surgery with 5 years of follow-up.

METHODS

Retrospective analysis of all exclusively first-time SSV surgeries, at Angiology and Vascular Surgery Service of Hospital Beatriz Ângelo, between January 1st, 2013, and December 31st, 2014. In March 2019, the authors performed clinical and venous doppler ultrasound reassessment of all included patients.

RESULTS

A total of 23 limbs were evaluated, 56.5% were female and the mean age was 51.8 years. All patients were symptomatic and underwent ligation of the saphenopopliteal junction (SPJ), 26.1% and 43.5% had total and partial SSV stripping, respectively. After venous doppler ultrasound at 5-year follow-up, we found that 21.7% did not present a correct SPJ ligation due to failure to identify its location, with a statistically significant association between SPJ ligation and varicose vein recurrence. In follow-up, we also diagnosed GSV incompetence in 21.7% for the first time, which is in agreement with the fact that this is a chronic disease. Finally, we found that all patients with symptomatic recurrence at 5-year follow-up had CVD, however, some asymptomatic patients also had ultrasound changes.

CONCLUSION

Routine preoperative localization of the SPJ by doppler ultrasound guidance could have an impact in minimizing varicose vein recurrence. Imaging recurrence does not always translate into clinical recurrence. Because this is a chronic disease, patients should keep general care to prevent disease progression, even after surgery.

Direct tissue-sensing reprograms TLR4+ Tfh-like cells inflammatory profile in the joints of rheumatoid arthritis patients

CD4⁺ T cells mediate rheumatoid arthritis (RA) pathogenesis through both antibody-dependent and independent mechanisms. It remains unclear how synovial microenvironment impinges on CD4⁺ T cells pathogenic functions. Here, we identified a TLR4⁺ follicular helper T (Tfh) cell-like population present in the blood and expanded in synovial fluid. TLR4⁺ T cells possess a two-pronged pathogenic activity whereby direct TLR4⁺ engagement by endogenous ligands in the arthritic joint reprograms them from an IL-21 response, known to sponsor antibody production towards an IL-17 inflammatory program recognized to fuel tissue damage. Ex vivo, synovial fluid TLR4⁺ T cells produced IL-17, but not IL-21. Blocking TLR4 signaling with a specific inhibitor impaired IL-17 production in response to synovial fluid recognition. Mechanistically, we unveiled that T-cell HLA-DR regulates their TLR4 expression. TLR4⁺ T cells appear to uniquely reconcile an ability to promote systemic antibody production with a local synovial driven tissue damage program.

In order to identify how the synovial microenvironment impinges on CD4+ T cells pathogenic functions in Rheumatoid Arthritis (RA), Amaral-Silva examined RA patient blood and synovial fluif and identified the presence of a TLR4+ follicular helper T (Tfh) cell-like population. They provided mechanistic insight into how TLR4⁺ T cells uniquely reconcile an ability to promote systemic antibody production with a local synovial driven-tissue damage program.

Relationship between Heart Rate Variability and Functional Fitness in Breast Cancer Survivors: A Cross-Sectional Study

Background: Breast cancer is the most common malignancy among women worldwide. The treatments may also cause neuromuscular and skeletal disorders; therefore, the aim of this study was to verify the existence of a relationship between heart rate variability and different functional fitness parameters in women survivors of breast cancer. Methods: This cross-sectional study included 25 women survivors of breast cancer, with a mean ± SD age, height, and body mass of 50.8 ± 8.8 years, 1.6 ± 0.7 m, and 67.1 ± 12.3 kg, respectively. Patients underwent measurements of heart rate variability with time and frequency domain analyses, as well as a “30 s chair-stand test”, “6 min walking test”, “timed up and go test”, and “ball throwing test”. Results: A multiple linear regression analysis showed that from the heart rate variability frequency domain, high frequency explained 21% (R² = 0.21) of the “30 s chair-stand test” performance. Conclusion: The findings of this study highlight high frequency as a predictor of “30 s chair-stand test” performance, regardless of age and time after diagnosis, suggesting its usefulness as a clinical indicator of functionality in breast cancer survivors. This study presents a straightforward and non-invasive methodology predicting functional fitness in women breast cancer survivors potentially applicable to clinical practice.

Pancreaticopleural fistula: An insidious cause of pleural effusion –case report

Pancreaticopleural fistulas (PPF) are a rare etiology of pleural effusions. We describe a case of a 61-year-old man, with left chest pain with six months of progression who presented with a large volume unilateral pleural effusion. A thoracentesis was performed, which showed a dark reddish fluid(exudate) and high content of pancreatic amylase. After that an abdominal computed tomography (CT)and magnetic resonance cholangiopancreatography (MRCP) was done, revealing fistulous pathways that originated in the pancreas. The patient was admitted for conservative and endoscopic treatment by Endoscopic Retrograde Cholangiopancreatography (ERCP) and a prosthesis was placed on a fistulous path. He was discharged without complications, with the resolution of the pleural effusion and fistula.The interest of this case lies in the rarity of the event and absence of symptoms of the probable primary event (acute pancreatitis). The possible iatrogenic association with several drugs of his usual medication makes it even more complex.

The Impact of SARS-CoV-2 Viral Load on the Mortality of Hospitalized Patients: A Retrospective Analysis

Introduction

Coronavirus disease 2019 (COVID-19) has emerged worldwide since December 2019. The standard method for diagnosis is via nucleic acid amplification testing, usually with a reverse-transcription polymerase chain reaction (RT-PCR). Hospitalized infected individuals may require ventilation and may have higher mortality rates. We aim to evaluate the clinical impact of nasopharyngeal viral load on these outcomes.

Materials and methods

We conducted a retrospective cohort study of patients hospitalized with COVID-19 from 17 March 2020 to 1 June 2020 at a tertiary care hospital. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load was assessed using cycle threshold (Ct) values from an RT-PCR assay applied to nasopharyngeal swab samples. We compared the clinical characteristics of survivors vs. non-survivors and assessed whether the viral load was independently associated with in-hospital 30-day mortality.

Results

We evaluated 197 patients. Thirty-day mortality was verified in 71 (36%) subjects. In the adjusted effects model, only the E-gene Ct value [odd ratio (OR) .873; confidence interval (CI) 95% .769-.992; p .037], age, the number of days of symptoms before admission, lactate dehydrogenase (LDH), and the oxygen saturation (SatO₂)-to-fraction of inspired oxygen (FiO₂) ratio remained significantly associated with 30-day mortality. There was no identified association between the viral loads and disease severity, the need for ventilation, or length of stay.

Discussion

Our results are, in part, concordant with previous papers. One possible limitation to our study is the fact that possibly included disproportionately more patients with poorer outcomes since hospitalization was required. Therefore, further research is required.

Conclusion

SARS-CoV-2 viral load on admission may be an independent predictor of 30-day mortality among hospitalized patients with COVID-19. Providing this information to clinicians could potentially be used to guide risk stratification. 

An Integrated 2D Ultrasound Phased Array Transmitter in CMOS With Pixel Pitch-Matched Beamforming

Emerging non-imaging ultrasound applications, such as ultrasonic wireless power delivery to implantable devices and ultrasound neuromodulation, require wearable form factors, millisecond-range pulse durations and focal spot diameters approaching 100 μm with electronic control of its three-dimensional location. None of these are compatible with typical handheld linear array ultrasound imaging probes. In this work, we present a 4 mm × 5 mm 2D ultrasound phased array transmitter with integrated piezoelectric ultrasound transducers on complementary metal-oxide-semiconductor (CMOS) integrated circuits, featuring pixel-level pitch-matched transmit beamforming circuits which support arbitrary pulse duration. Our direct integration method enabled up to 10 MHz ultrasound arrays in a patch form-factor, leading to focal spot diameter of ∼200 μm, while pixel pitch-matched beamforming allowed for precise three-dimensional positioning of the ultrasound focal spot. Our device has the potential to provide a high-spatial resolution and wearable interface to both powering of highly-miniaturized implantable devices and ultrasound neuromodulation.

Testing the plastic-wrapped composting system to dispose of swine mortalities during an animal disease outbreak

Composting has been used to dispose of animal mortalities and infected materials, such as manure and feed, during major animal disease outbreaks. In this study, we adapted the plastic-wrapped mortality composting system developed by the Canadian Food Inspection Agency during the 2004 highly pathogenic avian influenza outbreak to compost swine mortalities. The goals of the study were to evaluate the performance of the plastic-wrapped composting system to dispose of swine mortalities and to field test its ability to eliminate the spread of airborne pathogens through the aeration ducts. Two cover materials, ground cornstalks and woodchips, were tested using passively and actively aerated composting sheds. The mortalities were inoculated with Salmonella spp. and vaccine strains of Bovine herpesvirus-1 and Bovine viral diarrhea virus. Air samples collected from the upper aeration duct (air outlet) during the first 10 d of composting were negative for Salmonella and the viruses tested, which indicated that aerosol transmission of the pathogens was limited. The aeration plenum placed under the mortalities helped to keep conditions aerobic, as O₂ concentrations of both passively and actively aerated test units were above 11%. Actively aerated cornstalks had the highest degree-hours (1,462 °C h d^-1 ), which was followed by passively aerated cornstalks (1,312 °C h d^-1 ), actively aerated woodchips (1,303 °C h d^-1 ), and passively aerated woodchips (1,062 °C h d^-1 ). After a 7-wk composting period, all three pathogens were inactivated based on quantitative polymerase chain reaction test results. The mortalities were not inoculated with the African swine fever virus, but temperature data showed that if they were, the system had the potential to eliminate this virus.

MO647RENOPROTECTIVE EFFECT OF SGLT2 INHIBITORS AFTER FIVE YEARS OF TREATMENT: AN OBSERVATIONAL STUDY

Background and Aims

Sodium-glucose co-transporter 2 (SGLT2) inhibitors, the most recent glucose lowering oral agents, prevent glucose and sodium reabsorption at proximal tubules. These drugs have the potential of nephroprotection by their glucose lowering effects, but also through direct renal effects, such as reducing intraglomerular pressure and suppressing the production of pro-inflammatory and pro-fibrotic factors. Several randomized control trials have demonstrated these effects with slowing chronic kidney disease progression. The aim of our study was to evaluate the effect of SGLT2 inhibitors on estimated glomerular filtration rate throughout five years of treatment.

Method

This was a retrospective observational and longitudinal study that included patients diagnosed with DM2 and treated with an iSGLT2 in a Diabetic Clinic. Demographic and clinical variables were collected, including HbA1c, disease duration and cardiovascular risk factors (CVRF). Patient glucose-control therapy as well as RAAS inhibitor drugs were gathered. The estimated Glomerular Filtration Rate (eGFR) by the formula CKD-EPI and albuminuria, using the urinary albumin-to-creatinine ratio, were evaluated at the iSGLT2 introduction date and at 6, 12, 24, 36, 48 and 60 months of treatment. Categorical variables are presented as frequencies and percentages, and continuous variables as means or medians for variables with skewed distributions. All reported p values are two-tailed, with a p value of 0.05 indicating statistical significance. A paired Student’s t-test or paired-sample test were performed for continuous variables and a chi-squared test was performed for categorical variables.

Results

A total of 205 patients, 54,6 % male, mean age 65,4 years, median baseline HbA1c 8,4% and median duration of DM2 14 years were studied. Of all patients, 94,1% had at least 1 CVRF, 71,2% hypertensive, 83,4% dyslipidemia, 48,8% obese, and 25,4% had past/current smoking habits. Regarding glucose-control therapy 17,1% were treated with one drug class and the remaining patients were treated with 2 or more classes. Among the patients 82,0% of them were taking metformin and 51,2% were on insulin therapy. Also, 56,6 % were on a RAAS inhibitor. Overall, 129 (62,9 %) patients received dapaglifozin therapy (5 or 10mg) and 76 (37,1%) empaglifozin (10 or 25mg). Regarding albuminuria at baseline, 37 patients had normal albuminuria (<30mg/g), 18 patients had moderate albuminuria (30-300mg/g) and 6 patients had severe albuminuria (>300mg/g). As for eGFR, 15,6 % patients had an eGFR between 30 and 60 and 84,4% patients had an eGFR greater than 60 ml/min/1,73m2. These clinical features were similar between the patients that received either SGLT2 inhibitor, with the exception of obesity being more prevalent in the dapaglifozin group (55,8 % vs 36,8%, p=0,009). Assessing the eGFR during the 5 years of treatment, a significant decrease was noticed in the first 6 months from an 82,3 to 78,6 ml/min/1,73m2 (p=0,002), followed by a significant increase in the second semester to 82,9 ml/min/1,73m2 (p<0,001). Thereafter there is a slight increase in eGFR throughout the years, to a maximum of 84,1 ml/min/1,73m2 at 24 months and after a slow reduction to 80,6ml/min/1,73m2 in the end of the 5 years of SGLT2 inhibitor use.

Conclusion

This observational study shows that after an initial reduction in eGFR during the first 6 months of treatment, the use of iSGLT2 after five years slowed the decrease in eGFR, similar to what randomized control trials have demonstrated, promoting a renoprotective effect on type 2 diabetic patients.

Application of a sub-0.1-mm3 implantable mote for in vivo real-time wireless temperature sensing

There has been increasing interest in wireless, miniaturized implantable medical devices for in vivo and in situ physiological monitoring. Here, we present such an implant that uses a conventional ultrasound imager for wireless powering and data communication and acts as a probe for real-time temperature sensing, including the monitoring of body temperature and temperature changes resulting from therapeutic application of ultrasound. The sub-0.1-mm³, sub-1-nW device, referred to as a mote, achieves aggressive miniaturization through the monolithic integration of a custom low-power temperature sensor chip with a microscale piezoelectric transducer fabricated on top of the chip. The small displaced volume of these motes allows them to be implanted or injected using minimally invasive techniques with improved biocompatibility. We demonstrate their sensing functionality in vivo for an ultrasound neurostimulation procedure in mice. Our motes have the potential to be adapted to the distributed and localized sensing of other clinically relevant physiological parameters.