On the Material Constitutive Behavior of the Aortic Root in Patients with Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat patients with severe aortic valve stenosis. However, there is limited knowledge on the material properties of the aortic root in TAVI patients, and this can impact the credibility of computer simulations. This study aimed to develop a non-invasive inverse approach for estimating reliable material constituents for the aortic root and calcified valve leaflets in patients undergoing TAVI.

METHODS

The identification of material parameters is based on the simultaneous minimization of two cost functions, which define the difference between model predictions and cardiac-gated CT measurements of the aortic wall and valve orifice area. Validation of the inverse analysis output was performed comparing the numerical predictions with actual CT shapes and post-TAVI measures of implanted device diameter.

RESULTS

A good agreement of the peak systolic shape of the aortic wall was found between simulations and imaging, with similarity index in the range in the range of 83.7% to 91.5% for n.20 patients. Not any statistical difference was observed between predictions and CT measures of orifice area for the stenotic aortic valve. After TAVI simulations, the measurements of SAPIEN 3 Ultra (S3) device diameter were in agreement with those from post-TAVI angio-CT imaging. A sensitivity analysis demonstrated a modest impact on the S3 diameters when altering the elastic material property of the aortic wall in the range of inverse analysis solution.

CONCLUSIONS

Overall, this study demonstrates the feasibility and potential benefits of using non-invasive imaging techniques and computational modeling to estimate material properties in patients undergoing TAVI.

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.

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.

Safety of pregnancy after breast cancer in young women with hormone receptor-positive disease: a systematic review and meta-analysis

BACKGROUND

Despite increasing evidence on the safety of pregnancy after anticancer treatments in breast cancer survivors, many physicians and patients remain concerned about a potential risk of pregnancy specifically in the case of hormone receptor-positive breast cancer.

MATERIALS AND METHODS

A systematic literature search of Medline, Embase and Cochrane library with no language or date restriction up to 31 March 2023 was carried out. To be included, articles had to be retrospective and prospective case-control and cohort studies as well as clinical trials comparing survival outcomes of premenopausal women with or without a pregnancy after prior diagnosis of hormone receptor-positive breast cancer. Disease-free survival (DFS) and overall survival (OS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Study protocol is registered in PROSPERO (n. CRD42023394232).

RESULTS

Out of 7796 screened studies, 8 were eligible to be included in the final analysis. A total of 3805 patients with hormone receptor-positive invasive early breast cancer were included in these studies, of whom 1285 had a pregnancy after breast cancer diagnosis. Median follow-up time ranged from 3.8 to 15.8 years and was similar in the pregnancy and non-pregnancy cohorts. In three studies (n = 987 patients) reporting on DFS, no difference was observed between patients with and those without a subsequent pregnancy (HR 0.96, 95% CI 0.75-1.24, P = 0.781). In the six studies (n = 3504 patients) reporting on OS, patients with a pregnancy after breast cancer had a statistically significant better OS than those without a pregnancy (HR 0.46, 95% CI 0.27-0.77, P < 0.05).

CONCLUSIONS

This systematic review and meta-analysis of retrospective cohort studies provides updated evidence that having a pregnancy in patients with prior history of hormone receptor-positive invasive early breast cancer appears safe without detrimental effect on prognosis.

Parametric analysis of transcatheter aortic valve replacement in transcatheter aortic valve replacement: evaluation of coronary flow obstruction

Transcatheter aortic valve replacement (TAVR) is increasingly being considered for use in younger patients having longer life expectancy than those who were initially treated. The TAVR-in-TAVR procedure represents an appealing strategy to treat failed transcatheter heart valves (THV) likely occurring in young patients. However, the permanent displacement of first THV can potentially compromise the coronary access and ultimately inhibit the blood flow circulation. The objective of this study was to use finite-element analysis (FEA) to quantify coronary flow in a patient who underwent TAVR-in-TAVR. A parametric investigation was carried out to determine the impact of both the implantation depth and device size on coronary flow for several deployment configurations. The FEAs consisted of first delivering the SAPIEN 3 Ultra THV and then positioning the Evolut PRO device. Findings indicates that high implantation depth and device undersize of the second THV could significantly reduce coronary flow to 20% of its estimated level before TAVR. Additionally, a positive correlation was observed between coronary flow and the valve-to-coronary distance (R = 0.86 and p = 0.032 for the left coronary artery, and R = 0.93 and p = 0.014 for the right coronary artery). This study demonstrated that computational modeling can provide valuable insights to improve the pre-procedural planning of TAVR-in-TAVR.

Effects of Sacubitril/Valsartan on Exercise Capacity in Patients with Heart Failure with Reduced Ejection Fraction and the Role of Percentage of Delayed Enhancement Measured by Cardiac Magnetic Resonance in Predicting Therapeutic Response: A Multicentre Study

Background: This study aims to evaluate the cardiopulmonary effects of sacubitril/valsartan therapy in patients with heart failure with reduced ejection fraction (HFrEF), investigating a possible correlation with the degree of myocardial fibrosis, as assessed by cardiac magnetic resonance. Methods: A total of 134 outpatients with HFrEF were enrolled. Results: After a mean follow-up of 13.3 ± 6.6 months, an improvement in ejection fraction and a reduction in E/A ratio, inferior vena cava size and N-terminal pro-B-type natriuretic peptide levels were observed. At follow-up, we observed an increase in VO₂ peak of 16% (p<0.0001) and in O₂ pulse of 13% (p=0.0002) as well as an improvement in ventilatory response associated with a 7% reduction in the VE/VCO₂ slope (p=0.0001). An 8% increase in the ΔVO₂/Δ work ratio and an 18% increase in exercise tolerance were also observed. Multivariate logistic regression analysis showed that the main predictors of events during follow-up were VE/VCO₂ slope >34 (OR 3.98; 95% CI [1.59-10.54]; p=0.0028); ventilatory oscillatory pattern (OR 4.65; 95% CI [1.55-16.13]; p=0.0052); and haemoglobin level (OR 0.35; 95% CI [0.21-0.55]; p<0.0001). In patients who had cardiac magnetic resonance, when delayed enhancement >4.6% was detected, a lower response after sacubitril/valsartan therapy was observed as expressed by improvement in ΔVO₂ peak, O₂ pulse, LVEF and N-terminal pro-B-type natriuretic peptide. No significant differences were observed in ΔVO₂/Δ work and VE/VCO₂ slope. Conclusion:Sacubitril/valsartan improves cardiopulmonary functional capacity in HFrEF patients. The presence of myocardial fibrosis on cardiac magnetic resonance is a predictor of response to therapy.

Biomechanical performance of the Bicaval Transcatheter System for the treatment of severe tricuspid regurgitation

Introduction: Tricuspid regurgitation (TR) is a relatively common valvular disease, which can result from structural abnormalities of any anatomic part of the tricuspid valve. Severe TR is linked to congestive heart failure and hemodynamic impairment, resulting in high mortality when repaired by elective surgery. This study was undertaken to quantify the structural and hemodynamic performance of the novel Transcatheter Bicaval Valves System (TricValve) percutaneously implanted in the superior vena cava (SVC) and inferior vena cava (IVC) of two patients with severe TR and venous congestion. Methods: After developing the SVC and IVC device models, the contact pressure exerted on the vena cava wall was obtained by computational analysis. Both smoothed-particle hydrodynamics (SPH) and computational fluid dynamics were carried out to quantify caval reflux in the right atrium and the pressure field of pre- and post-TricValve scenarios, respectively. Results: Analysis of contact pressure highlighted the main anchoring area of the SVC device occurring near the SVC device belly, while the IVC device exerted pronounced forces in the device's proximal and distal parts. SPH-related flow velocities revealed the absence of caval reflux, and a decrease in time-averaged pressure was observed near the SVC and IVC after TricValve implantation. Discussion: Findings demonstrated the potential of computational tools for enhancing our understanding of the biomechanical performance of structural tricuspid valve interventions and improving the way we design next-generation transcatheter therapies to treat the tricuspid valve with heterotopic caval valve implantation.

Toward objective monitoring of Parkinson's disease motor symptoms using a wearable device: wearability and performance evaluation of PDMonitor®

Parkinson's disease (PD) is characterized by a variety of motor and non-motor symptoms. As disease progresses, fluctuations in the response to levodopa treatment may develop, along with emergence of freezing of gait (FoG) and levodopa induced dyskinesia (LiD). The optimal management of the motor symptoms and their complications, depends, principally, on the consistent detection of their course, leading to improved treatment decisions. During the last few years, wearable devices have started to be used in the clinical practice for monitoring patients' PD-related motor symptoms, during their daily activities. This work describes the results of 2 multi-site clinical studies (PDNST001 and PDNST002) designed to validate the performance and the wearability of a new wearable monitoring device, the PDMonitor^®, in the detection of PD-related motor symptoms. For the studies, 65 patients with Parkinson's disease and 28 healthy individuals (controls) were recruited. Specifically, during the Phase I of the first study, participants used the monitoring device for 2-6 h in a clinic while neurologists assessed the exhibited parkinsonian symptoms every half hour using the Unified Parkinson's Disease Rating Scale (UPDRS) Part III, as well as the Abnormal Involuntary Movement Scale (AIMS) for dyskinesia severity assessment. The goal of Phase I was data gathering. On the other hand, during the Phase II of the first study, as well as during the second study (PDNST002), day-to-day variability was evaluated, with patients in the former and with control subjects in the latter. In both cases, the device was used for a number of days, with the subjects being unsupervised and free to perform any kind of daily activities. The monitoring device produced estimations of the severity of the majority of PD-related motor symptoms and their fluctuations. Statistical analysis demonstrated that the accuracy in the detection of symptoms and the correlation between their severity and the expert evaluations were high. As a result, the studies confirmed the effectiveness of the system as a continuous telemonitoring solution, easy to be used to facilitate decision-making for the treatment of patients with Parkinson's disease.

Imaging of hepatocellular carcinoma recurrence after liver transplantation

Liver transplantation (LT) provides the highest survival benefit to patients with unresectable hepatocellular carcinoma (HCC). The Milan criteria have been developed for the selection of LT candidates with the goal of improving survival and maintaining an acceptable risk of HCC recurrence. Despite this, recurrence of HCC after LT occurs in up to 20% of cases and represents a major concern due to the poor prognosis of these patients. Furthermore, several extended criteria for the selection of LT candidates have been proposed to account for the growing demand for organs and the resultant increase in the risk of HCC recurrence. Radiologists should be aware that HCC can recur after LT with multiple organ involvement. Knowledge of the location and radiologic appearance of recurrent HCC is necessary to ensure the choice of the most appropriate therapy. This paper aims to comprehensively summarize the spectrum of HCC recurrence after LT and to examine and discuss the imaging features of these lesions. CRITICAL RELEVANCE STATEMENT: This paper aims to share a review of imaging findings of HCC recurrence after LT and to make radiologists familiar with the spectrum of this disease.

Modulation of Motor Vigor by Expectation of Reward Probability Trial-by-Trial Is Preserved in Healthy Ageing and Parkinson's Disease Patients

Motor improvements, such as faster movement times or increased velocity, have been associated with reward magnitude in deterministic contexts. Yet whether individual inferences on reward probability influence motor vigor dynamically remains undetermined. We investigated how dynamically inferring volatile action-reward contingencies modulated motor performance trial-by-trial. We conducted three studies that coupled a reversal learning paradigm with a motor sequence task and used a validated hierarchical Bayesian model to fit trial-by-trial data. In Study 1, we tested healthy younger [HYA; 37 (24 females)] and older adults [HOA; 37 (17 females)], and medicated Parkinson's disease (PD) patients [20 (7 females)]. We showed that stronger predictions about the tendency of the action-reward contingency led to faster performance tempo, commensurate with movement time, on a trial-by-trial basis without robustly modulating reaction time (RT). Using Bayesian linear mixed models, we demonstrated a similar invigoration effect on performance tempo in HYA, HOA, and PD, despite HOA and PD being slower than HYA. In Study 2 [HYA, 39 (29 females)], we additionally showed that retrospective subjective inference about credit assignment did not contribute to differences in motor vigor effects. Last, Study 3 [HYA, 33 (27 females)] revealed that explicit beliefs about the reward tendency (confidence ratings) modulated performance tempo trial-by-trial. Our study is the first to reveal that the dynamic updating of beliefs about volatile action-reward contingencies positively biases motor performance through faster tempo. We also provide robust evidence for a preserved sensitivity of motor vigor to inferences about the action-reward mapping in aging and medicated PD.SIGNIFICANCE STATEMENT Navigating a world rich in uncertainty relies on updating beliefs about the probability that our actions lead to reward. Here, we investigated how inferring the action-reward contingencies in a volatile environment modulated motor vigor trial-by-trial in healthy younger and older adults, and in Parkinson's disease (PD) patients on medication. We found an association between trial-by-trial predictions about the tendency of the action-reward contingency and performance tempo, with stronger expectations speeding the movement. We additionally provided evidence for a similar sensitivity of performance tempo to the strength of these predictions in all groups. Thus, dynamic beliefs about the changing relationship between actions and their outcome enhanced motor vigor. This positive bias was not compromised by age or Parkinson's disease.

Feasibility of Ultra-Low Volume Contrast-Saline Mixture Injection With Dual-Flow Technique in a Pre-TAVI Computed Tomography Angiography

BACKGROUND

To explore the feasibility and image quality of ultra-low volume contrast-saline mixture injection with dual-flow injection technique in a computed tomography angiography (CTA) protocol in patients scheduled for transcatheter aortic valve implantation (TAVI).

METHODS

Forty (40) TAVI candidates underwent investigation with CTA using a third-generation dual-source CT scanner between September and November 2020. Different volumes of a monophasic contrast-saline mixture at an 80:20 ratio were administered at an infusion rate of 3 mL/s in 20 patients (group A). The injected volume was based on patient body mass index (BMI): 50 mL if BMI <29 kg/m² and 63 mL if BMI >29 kg/m². The other 20 patients (group B)-the control cases-received a total of 65 mL of contrast medium (CM), in multiphasic injections at different flow rates, followed by 10 mL of saline. The images that were obtained were prospectively evaluated for image quality, vessel attenuation (HU), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and estimated radiation dose.

RESULTS

Image quality of the aortic root and ilio-femoral vessels was diagnostic in all patients. Vascular attenuation was >200 HU and CNR >3 at any vessel level.

CONCLUSIONS

Data from this study suggest that a monophasic ultra-low volume contrast-saline mixture injection with a dual-flow technique can provide clear visualisation of the aortic root and ilio-femoral vessels in pre-TAVI CTA, which is comparable with a standard multiphasic volume injection protocol.

Polystyrene nanoplastics affect the human ubiquitin structure and ubiquitination in cells: a high-resolution study

Humans are estimated to consume several grams per week of nanoplastics (NPs) through exposure to a variety of contamination sources. Nonetheless, the effects of these polymeric particles on living systems are still mostly unknown. Here, by means of CD, NMR and TEM analyses, we describe at an atomic resolution the interaction of ubiquitin with polystyrene NPs (PS-NPs), showing how a hard protein corona is formed. Moreover, we report that in human HeLa cells exposure to PS-NPs leads to a sensible reduction of ubiquitination. Our study overall indicates that PS-NPs cause significant structural effects on ubiquitin, thereby influencing one of the key metabolic processes at the base of cell viability.

Case 305: Loeffler Endocarditis

HISTORY

A 27-year-old man was admitted to the emergency department with fever and thoracic pain. In the previous 6 months, the patient lost a substantial amount of weight (12 kg). His family history was negative for cardiac disease. Electrocardiography revealed sinus rhythm and diffuse T-wave inversion. Two-dimensional echocardiography was performed and revealed normal left systolic function (ejection fraction, 60%). Laboratory tests showed elevated levels of high-sensitivity cardiac troponin (1.07 ng/mL; normal value, <0.015 ng/mL), high levels of C-reactive protein (16 mg/dL; normal range, 0-5 mg/dL), and leukocytosis with an eosinophilia level of 8710/μL (normal level, <400/μL). Parasitic and infectious diseases (Toxocara canis, strongyloides, filariasis, cysticercosis, fasciola, trichinella, echinococcosis) were excluded based on blood and fecal test results. Corticosteroid therapy was started, and the patient was dismissed. A few days later, he was readmitted to the emergency department with a headache and suddenly blurred vision. Neurologic and ophthalmologic findings were normal, and MRI of the brain was performed. Cardiac MRI was performed 2 days later and revealed the following quantitative results: (a) left ventricular end-diastolic volume (LVDV) of 165 mL (LVDV/body surface area [BSA], 89 mL/m²; normal range, 64-100 mL/m²), left ventricular end-systolic volume (LVSV) of 80 mL (LVSV/BSA, 43 mL/m²; normal range, 17-39 mL/m²), stroke volume (SV) of 85 mL (SV/BSA, 46 mL/m²; normal range, 43-67 mL/m²), and ejection fraction of 52% and (b) right ventricular end-diastolic volume (RVDV) of 163 mL (RVDV/BSA, 88 mL/m²; normal range, 63-111 mL/m²), right ventricular end-systolic volume (RVSV) of 81 mL (RVSV/BSA, 44 mL/m²; normal range, 32-92 mL/m²), stroke volume (SV) of 82 mL (SV/BSA, 44 mL/m²; normal range, 39-71 mL/m²), and ejection fraction of 50%.

Hybrid Graphenene Oxide/Cellulose Nanofillers to Enhance Mechanical and Barrier Properties of Chitosan-Based Composites

Chitosan-based hybrid nanocomposites, containing cellulose nanocrystals (CNCs), graphene oxide (GO), and borate as crosslinking agents, were successfully prepared by solution-casting technique. The synergistic effect of the two fillers, and the role of the cross-linker, in enhancing the structural and functional properties of the chitosan polymer, was investigated. XPS results confirm the chemical interaction between borate ions and hydroxyl groups of chitosan, GO, and CNCs. The morphological characterization shows that the GO sheets are oriented along the casting surface, whereas the CNC particles are homogenously distributed in the sample. Results of tensile tests reveal that the presence of graphene oxide enhances the elastic modulus, tensile strength, elongation at break, and toughness of chitosan, while cellulose and borate induce an increase in the elastic modulus and stress at the yield point. In particular, the borate-crosslinked chitosan-based sample containing 0.5 wt% of GO and 0.5 wt% of CNCs shows an elongation at a break value of 30.2% and a toughness value of 988 J*m⁻³ which are improved by 124% and 216%, respectively, compared with the pristine chitosan. Moreover, the water permeability results show that the presence of graphene oxide slightly increases the water barrier properties, whereas the borate and cellulose nanocrystals significantly reduce the water vapor permeability of the polymer by about 50%. Thus, by modulating the content of the two reinforcing fillers, it is possible to obtain chitosan-based nanocomposites with enhanced mechanical and water barrier properties which can be potentially used in various applications such as food and electronic packaging.

Measuring Health-Related Quality of Life With Multimodal Data: Viewpoint

The ability to objectively measure aspects of performance and behavior is a fundamental pillar of digital health, enabling digital wellness products, decentralized trial concepts, evidence generation, digital therapeutics, and more. Emerging multimodal technologies capable of measuring several modalities simultaneously and efforts to integrate inputs across several sources are further expanding the limits of what digital measures can assess. Experts from the field of digital health were convened as part of a multi-stakeholder workshop to examine the progress of multimodal digital measures in two key areas: detection of disease and the measurement of meaningful aspects of health relevant to the quality of life. Here we present a meeting report, summarizing key discussion points, relevant literature, and finally a vision for the immediate future, including how multimodal measures can provide value to stakeholders across drug development and care delivery, as well as three key areas where headway will need to be made if we are to continue to build on the encouraging progress so far: collaboration and data sharing, removal of barriers to data integration, and alignment around robust modular evaluation of new measurement capabilities.

P309 A CASE OF POST COVID VACCINE MYCARDITIS

Background

Myocarditis is an inflammatory disease of the heart muscle commonly caused by viral infections. Vaccines can also cause myocarditis although the occurrence of this side effect is very rare. In the course of the Sars Cov 2 pandemic, there have been myocarditis both related to the virus and related to the anti–virus vaccine (especially related to RNA vaccines).

We present a case of myocarditis from Comirnaty. 23 year old sportsman. In anamnesis only frequent tonsillitis in school age leading him to tonsillectomy at 18 years old. June 2021 1st dose Pfizer vaccine. Next day in ER for fever, headache, nausea, dizziness, abdominal pain. Brain CT: neg; Blood tests: slight increase in Gb 14,200 (109 / L) (neutrophils 88%) which drop the next day to 9,000 and a slight increase in CRP which from 0.19 mg / dl (nv < 0.5) reaches the value of 1.5. Of note a slight increase in CPKs stable in the two samples (CPK 602 U / l –> 652); August 2021 2nd dose of Pfizer vaccine. From 6th to 12th day post vaccine intense headache. Chest pain on the 13th day. In ER ECG with diffuse elevated ST. Trop I 12888 (vn < 50); Echocardium: normal. Trop I peak 45795 ng / l; Bisoprolol 1.25 mg started for a 6–beat TVNS. CardiacMRI: FE 67%, T2–weighted sequences: anterior and lateral intramural hyperintensity, sequences after contrast medium: large areas of late intramural enhacement in the apical and middle anterior wall and in the lateral wall, suggestive for myocarditis. In discharge recommended suspension of competitive physical activity. 3 months later inspection: pz in excellent condition. Echocardium: normal. CardiacMRI: reduction of ventricular volumes (EDV Vsx 187 ml –> 136) (EDV Vdx 227 ml –> 195) areas of intramural fibrosis reduced at the level of the lateral wall.

Discussion

Post vaccine myocarditis cases are rare but more frequent than reported in pivotal studies. The incidence varies according to the different registers. There seems to be an increase in incidence compared to the general population but not compared to the population affected by Sars Cov2. As confirmed by our case, this pathology is more frequent in young men and appears mainly after the 2nd dose. The pathogenetic mechanism of this reaction is still uncertain. The short–term prognosis of the disease is generally benign even if a longer follow–up is necessary in order to observe the evolution of the clinical status over time

Case 305

HISTORY

A 27-year-old man was admitted to the emergency department with fever and thoracic pain. In the previous 6 months, the patient lost a substantial amount of weight (12 kg). His family history was negative for cardiac disease. Electrocardiography revealed sinus rhythm, and diffuse T-wave inversion. Two-dimensional echocardiography was performed (Fig 1) and revealed normal left systolic function (ejection fraction, 60%). Laboratory tests showed elevated levels of high-sensitivity cardiac troponin (1.07 ng/mL; normal value, <0.015 ng/mL), high levels of C-reactive protein (16 mg/dL; normal range, 0-5 mg/dL), and leukocytosis with an eosinophilia level of 8710/μL (normal level, <400/μL). Parasitic and infectious diseases (Toxocara canis, strongyloides, filariasis, cysticercosis, fasciola, trichinella, echinococcosis) were excluded based on blood and fecal test results. Corticosteroid therapy was started, and the patient was dismissed. A few days later, he was readmitted to the emergency department with a headache and suddenly blurred vision. Neurologic and ophthalmologic findings were normal, and MRI of the brain was performed (Fig 2). Cardiac MRI (Fig 3) was performed 2 days later and revealed the following quantitative results: (a) left ventricular end-diastolic volume (LVDV) of 165 mL (LVDV/body surface area [BSA], 89 mL/m²; normal range, 64-100 mL/m²), left ventricular end-systolic volume (LVSV) of 80 mL (LVSV/BSA, 43 mL/m²; normal range, 17-39 mL/m²); stroke volume (SV) of 85 mL (SV/BSA, 46 mL/m²; normal range, 43-67 mL/m²); and ejection fraction of 52% and (b) right ventricular end-diastolic volume (RVDV) of 163 mL (RVDV/BSA, 88 mL/m²; normal range, 63-111 mL/m²), right ventricular end-systolic volume (RVSV) of 81 mL (RVSV/BSA, 44 mL/m²; normal range, 32-92 mL/m²); stroke volume (SV) of 82 mL (SV/BSA, 44 mL/m²; normal range, 39-71 mL/m²); and ejection fraction of 50%.

Prognostic stratification of patients with low-risk hypertrophyc cardiomyopathy: the role of myocardial deformation imaging and myocardial fibrosis

Funding Acknowledgements

Type of funding sources: None.

Background

Hypertrophic cardiomyopathy (HCM) is associated with a high incidence of adverse cardiovascular events. Risk stratification for major cardiac events and management of HCM patients are still a serious challenge in cardiology. Current ESC guidelines recommend stratifying the risk of sudden cardiac death (SCD) at 5 years using a prediction model which evaluates clinical and echocardiographic criteria but this model does not include parameters of myocardial deformation at echocardiography and myocardial fibrosis at cardiac magnetic resonance.

Purpose

The aim of this study was to evaluate the predictive prognostic role of myocardial deformation imaging parameters derived by echocardiography (left ventricular global longitudinal strain GLS and PALS) and magnetic resonance parameters (extension of delayed enhancement DE) in a population of patients with HCM with low-risk of SCD, considering ESC prediction model.

Methods

We enrolled 166 patients, mean age 56.25 ± 16 with hypertrophic cardiomyopathy. A complete echocardiogram and a cardiac magnetic resonance were performed. After a period of 2.5 years, adverse cardiovascular events were evaluated: number of ICD shocks and ventricular arrhythmias, occurrence of atrial fibrillation (AF) or other supraventricular arrhythmias, symptoms of heart failure (HF) and or hospitalizations, heart transplant and death.

Results

7 heart transplants, 8 deaths, 29 patients developed AF, 6 patients developed ventricular arrhythmias and/or ICD shock, 17 patients were hospitalized, 16 patients developed HF. Patients with cardiovascular events had significantly lower PALS values than patients without events (PALS 4.6 ± 2.6 vs 17.5 ± 3.26, p-value &lt; 0.0001) and higher values left atrial volume (179 ± 81 vs 76 ± 37, p-value &lt; 0.001); significantly greater DE extension (57 ± 20 vs 17 ± 19, p-value 0.0082), lower GLS and EF values (GLS 10 ± 3 vs 15 ± 4, p value 0.0033; EF p-value 0,0001). Patients who developed ventricular arrhythmias, did not show significant changes in EF (p-value 0.26), left atrial volume (90 ± 17, p-value 0.36) and PALS (18 ± 1, p-value 0.7), but they had significantly lower GLS values (5.7 ± 12, p-value 0.02) and a greater extent of DE (p-value 0.04). Patients with AF showed a significantly increased left atrial volume (100 ± 43, p 0.0034) and the PALS (10.8+ 5.9, p-value &lt; 0.0001) was significantly reduced compared to patients without events; EF, GLS (-11.8 ± 8, p-value 0.08) and DE were not significantly reduced (14.8 ± 8, p-value 0.14). In patients who developed HF, both EF, GLS (p-value 0.035), left atrial volume , PALS (p-value &lt; 0.0001) and DE (65 ± 22.5 p-value &lt; 0.0001) were altered compared to patients without events.

Conclusion

Low PALS, reduced EF and GLS and higher DE extension and left atrial volume, appear to be prognostic factors in patients with HCM. PALS and left atrial volume are predictors of death, heart failure and AF. Low GLS and DE are predictors of ventricular arrhythmias and heart failure.

Education on palliative care for Parkinson patients: development of the "Best care for people with late-stage Parkinson's disease" curriculum toolkit

BACKGROUND

Palliative care education among all stakeholders involved in the care of patients with late-stage Parkinson's disease is not adequate. In fact, there are many unmet educational and training needs as confirmed with a targeted, narrative literature review.

METHODS

To address these needs we have developed the "Best Care for People with Late-Stage Parkinson's Disease" curriculum toolkit. The toolkit is based on recommendations and guidelines for training clinicians and other healthcare professionals involved in palliative care, educational material developed in recent research efforts for patients and caregivers with PD and consensus meetings of leading experts in the field. The final version of the proposed toolkit was drafted after an evaluation by external experts with an online survey, the feedback of which was statistically analysed with the chi-square test of independence to assess experts' views on the relevance and importance of the topics. A sentiment analysis was also done to complement statistics and assess the experts positive and negative sentiments for the curriculum topics based on their free text feedback.

RESULTS

The toolkit is compliant with Kern's foundational framework for curriculum development, recently adapted to online learning. The statistical analysis of the online survey, aiming at toolkit evaluation from external experts (27 in total), confirms that all but one (nutrition in advanced Parkinson's disease) topics included, as well as their objectives and content, are highly relevant and useful.

CONCLUSIONS

In this paper, the methods for the development of the toolkit, its stepwise evolution, as well as the toolkit implementation as a Massive Open Online Course (MOOC), are presented. The "Best Care for People with Late-Stage Parkinson' s disease" curriculum toolkit can provide high-quality and equitable education, delivered by an interdisciplinary team of educators. The toolkit can improve communication about palliative care in neurological conditions at international and multidisciplinary level. It can also offer continuing medical education for healthcare providers.

How the health-related quality of life in geriatric patients is influenced?

Background

Health requires a multi-dimensional approach and not just a cure for illness. Health can be assessed from the point of view of the objective state, but also from its perception which influences the quality of life (QoL). Several tools have been used to measure QoL in many clinical contexts such as five-level EuroQol-5 dimension questionnaire (EQ-5D-5L). The aim of the study is to evaluate the perceived QoL in geriatric patients.

Methods

We conducted a cross-sectional study, using EQ-5D-5L from January to December 2019. EQ-5D-5L was self-administered to a sample of 187 geriatric patients from a private clinical (100 beds). We performed a descriptive and statistical analyses using the five dimensions: mobility (M), self-care (SC), usual activities (UA), pain/discomfort (PD), anxiety/depression (AD) in association with BMI, age, sex, length of stay (LoS). The analyses (Spearman correlation coefficient) was carried out with STATA software.

Results

In our sample the 66,8% was female, the mean age was 78,35 ±10,9, the LoS had an average of 22,37 ± 37,72. Only 170 patients responded to EQ-5D-5L. The mean score of the five dimension of EQ-5D-5L was 3 excepted for the AD that was 2. The mean of EQ index was 0.44 ± 0.29, and it is realted to LoS (p = 0,01; Rho=-0,18). Only UA was associated to BMI (p &lt; 0.05; Rho= -0,21). The age and LoS were associated to M, SC and UA (p &lt; 0,03 Rho&lt;0,25). The gender appeared related to the M (p &lt; 0,02) with a worse perception in the female.

Conclusions

Our sample perceived a low quality of life that appeared to be related to the length of stay. Among the 5 dimensions mobility, self-care and usual activities were more influenced by our variables. A higher BMI doesn't appear as a limit to the habitual daily activities.

Key messages

Health requires a multi-dimensional approach and not just a cure for illness beacause it could influence the quality of life. The length of the stay seems to condition the quality of life of patiens and also a higher BMI seems not impacted the habitual daily activities.

Advance Care Planning and Care Coordination for People With Parkinson's Disease and Their Family Caregivers-Study Protocol for a Multicentre, Randomized Controlled Trial

Background: Parkinson's disease (PD) is a progressive neurodegenerative disease with motor- and non-motor symptoms. When the disease progresses, symptom burden increases. Consequently, additional care demands develop, the complexity of treatment increases, and the patient's quality of life is progressively threatened. To address these challenges, there is growing awareness of the potential benefits of palliative care for people with PD. This includes communication about end-of-life issues, such as Advance Care Planning (ACP), which helps to elicit patient's needs and preferences on issues related to future treatment and care. In this study, we will assess the impact and feasibility of a nurse-led palliative care intervention for people with PD across diverse European care settings.

Methods: The intervention will be evaluated in a multicentre, open-label randomized controlled trial, with a parallel group design in seven European countries (Austria, Estonia, Germany, Greece, Italy, Sweden and United Kingdom). The “PD_Pal intervention” comprises (1) several consultations with a trained nurse who will perform ACP conversations and support care coordination and (2) use of a patient-directed “Parkinson Support Plan-workbook”. The primary endpoint is defined as the percentage of participants with documented ACP-decisions assessed at 6 months after baseline (t1). Secondary endpoints include patients' and family caregivers' quality of life, perceived care coordination, patients' symptom burden, and cost-effectiveness. In parallel, we will perform a process evaluation, to understand the feasibility of the intervention. Assessments are scheduled at baseline (t0), 6 months (t1), and 12 months (t2). Statistical analysis will be performed by means of Mantel–Haenszel methods and multilevel logistic regression models, correcting for multiple testing.

Discussion: This study will contribute to the current knowledge gap on the application of palliative care interventions for people with Parkinson's disease aimed at ameliorating quality of life and managing end-of-life perspectives. Studying the impact and feasibility of the intervention in seven European countries, each with their own cultural and organisational characteristics, will allow us to create a broad perspective on palliative care interventions for people with Parkinson's disease across settings.

Clinical Trial Registration:www.trialregister.nl, NL8180.

Imaging of calcified hepatic lesions: spectrum of diseases

Hepatic calcifications have been increasingly identified over the past decade due to the widespread use of high-resolution Computed Tomography (CT) imaging. Calcifications can be seen in a vast spectrum of common and uncommon diseases, from benign to malignant, including cystic lesions, solid neoplastic masses, and inflammatory focal lesions. The purpose of this paper is to present an updated review of CT imaging findings of a wide range of calcified hepatic focal lesions, which can help radiologists to narrow the differential diagnosis.

Adult-type Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery

Online supplemental material is available for this article.

Coronary CT angiography: a guide to examination, interpretation, and clinical indications

INTRODUCTION

The introduction of Cardiac Computed Tomography (CCT) has changed the paradigm in the field of diagnostic cardiovascular medicine. CCT is the primary tool in the assessment of suspected Coronary Artery Disease (CAD) and should be followed by functional assessment when needed to stratify disease and to plan potential interventional or surgical therapy.

AREAS COVERED

We provided the current state of the knowledge on the main aspects of technique of examination, image interpretation and clinical indications. We have focused our attention on the basic routine applications and activities.

EXPERT OPINION

The primary role of CCT in suspected CAD will progressively become the standard approach. In general, any situation in which anatomy of the heart and thoracic vessels/structures is mandatory must be approached using CT first, whenever possible. The quantity and quality of information that can be provided by CCT is big and the operators should learn how to deal with this information. On the other hand, CCT is only apparently a straightforward and simple examination. It is actually the most complex diagnostic procedure that can be performed on CT and requires highly skilled operators and state-of-art-technology.

Prognostic Role of Left Ventricular Intramyocardial Fatty Metaplasia in Patients With Previous Myocarditis (MYOFAT Study)

Left ventricular intramyocardial fat (LV-IMF) is often found in patients with previous irreversible myocardial damage and may be detected by cardiac magnetic resonance (CMR). No data are currently available about the prevalence of LV-IMF in patients with previous myocarditis. Our aim was to assess the prevalence of LV-IMF in patients with previous myocarditis by repeating after >3 years a follow-up CMR examination and to evaluate its clinical and prognostic role. Patients with clinical suspected myocarditis who underwent CMR within the first week from the onset of their symptoms and underwent repeated CMR were enrolled. LV-IMF was detected as areas of left ventricular intramyocardial "India ink" black boundary with or without a hyperintense core. Overall, in 235 patients with a definitive diagnosis of acute myocarditis, CMR was repeated after a median of 4 (3 to 6) years from symptom onset. LV-IMF positive patients (n = 35, 15%) presented greater ventricular volumes and more frequently a mid-wall late gadolinium enhancement than those without LV-IMF (both p < 0.05). Patients presenting major cardiac events (sudden cardiac deaths, resuscitated cardiac arrest, and appropriate implantable cardioverter-defibrillator-firing) at follow-up had a greater prevalence of LV-IMF than those without (55% vs 11%, p < 0.001). Patients with LV-IMF had a higher incidence myocarditis relapse (27% vs 9%, p = 0.003) and a greater risk of major cardiac events (p < 0.0001) than those without. At logistic regression analysis, LV-IMF was an independent predictor of major cardiac events. In conclusion, LV-IMF is not an uncommon finding in patients with previous myocarditis and is associated with worse ventricular remodeling and prognosis.

Longitudinal Course of Depressive, Anxiety, and Posttraumatic Stress Disorder Symptoms After Heart Surgery: A Meta-Analysis of 94 Studies

OBJECTIVE

This study aimed to analyze the longitudinal course of depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms in patients with cardiac disease after heart surgery (HS).

METHODS

We conducted a systematic review and random-effects meta-analysis of cohort studies in patients undergoing HS, measuring anxiety, depressive, and PTSD symptoms before and at least 30 days thereafter. Subgroup and meta-regression analyses, investigation of publication bias, and quality assessment were undertaken.

RESULTS

We included 94 studies relating to 15,561 patients. HS included coronary artery bypass graft surgery, valve replacement, implantable cardioverter-defibrillator placement, left ventricular assist device placement, heart transplantation, and other types of HS. Across studies, symptoms of depression (g = 0.32; 95% confidence interval [CI] = 0.25 to 0.39; p < .001) and anxiety improved after HS (g = 0.52; 95% CI = 0.43 to 0.62; p < .001), whereas PTSD symptoms worsened (g = -0.42; 95% CI = -0.80 to -0.04; p = .032). The reduction of depression and anxiety levels was more pronounced for patients with underlying coronary artery disease and heart failure and persisted for 1 year after HS, whereas the increase in PTSD symptoms returned to baseline after 6 months. Depression improvement was inversely associated with older age, diabetes, hypertension, and dyslipidemia and positively with baseline heart failure. No additional clinical or demographic variables were associated with the course of anxiety symptoms. Quality of included studies was low overall. Publication bias was nonsignificant.

CONCLUSIONS

Depressive and anxiety symptoms improve for 1 year after HS, whereas PTSD symptoms might worsen. Older patients and those with metabolic comorbidities, valve disease, or ventricular arrhythmias are at higher risk for continued depressive and anxiety symptoms and should be monitored closely.

Foot Pressure Wearable Sensors for Freezing of Gait Detection in Parkinson's Disease

Freezing of Gait (FoG) is a common symptom in Parkinson's Disease (PD) occurring with significant variability and severity and is associated with increased risk of falls. FoG detection in everyday life is not trivial, particularly in patients manifesting the symptom only in specific conditions. Various wearable devices have been proposed to detect PD symptoms, primarily based on inertial sensors. We here report the results of the validation of a novel system based on a pair of pressure insoles equipped with a 3D accelerometer to detect FoG episodes. Twenty PD patients attended a motor assessment protocol organized into eight multiple video recorded sessions, both in clinical and ecological settings and both in the ON and OFF state. We compared the FoG episodes detected using the processed data gathered from the insoles with those tagged by a clinician on video recordings. The algorithm correctly detected 90% of the episodes. The false positive rate was 6% and the false negative rate 4%. The algorithm reliably detects freezing of gait in clinical settings while performing ecological tasks. This result is promising for freezing of gait detection in everyday life via wearable instrumented insoles that can be integrated into a more complex system for comprehensive motor symptom monitoring in PD.

Cardiac CT angiography: normal and pathological anatomical features-a narrative review

The normal and pathological anatomy of the heart and coronary arteries are nowadays widely developed topics and constitute a fundamental part of the cultural background of the radiologist. The introduction of cardiac ECG-gated synchronized CT scanners with an ever-increasing number of detectors and with increasingly high structural characteristics (increase in temporal resolution, increase in contrast resolution with dual-source, dual energy scanners) allows the virtual measurement of anatomical in vivo structures complying with heart rate with submillimetric precision permitting to clearly depict the normal anatomy and follow the pathologic temporal evolution. Accordingly to these considerations, cardiac computed tomography angiography (CCTA) asserts itself as a gold standard method for the anatomical evaluation of the heart and permits to evaluate, verify, measure and characterize structural pathological alterations of both congenital and acquired degenerative diseases. Accordingly, CCTA is increasingly used as a prognostic model capable of modifying the outcome of diseased patients in planning interventions and in the post-surgical/interventional follow-up. The profound knowledge of cardiac anatomy and function through highly detailed CCTA analysis is required to perform an efficient and optimal use in real-world clinical practice.

Deep learning approach for the segmentation of aneurysmal ascending aorta

Diagnosis of ascending thoracic aortic aneurysm (ATAA) is based on the measurement of the maximum aortic diameter, but size is not a good predictor of the risk of adverse events. There is growing interest in the development of novel image-derived risk strategies to improve patient risk management towards a highly individualized level. In this study, the feasibility and efficacy of deep learning for the automatic segmentation of ATAAs was investigated using UNet, ENet, and ERFNet techniques. Specifically, CT angiography done on 72 patients with ATAAs and different valve morphology (i.e., tricuspid aortic valve, TAV, and bicuspid aortic valve, BAV) were semi-automatically segmented with Mimics software (Materialize NV, Leuven, Belgium), and then used for training of the tested deep learning models. The segmentation performance in terms of accuracy and time inference were compared using several parameters. All deep learning models reported a dice score higher than 88%, suggesting a good agreement between predicted and manual ATAA segmentation. We found that the ENet and UNet are more accurate than ERFNet, with the ENet much faster than UNet. This study demonstrated that deep learning models can rapidly segment and quantify the 3D geometry of ATAAs with high accuracy, thereby facilitating the expansion into clinical workflow of personalized approach to the management of patients with ATAAs.

Assessing the quality of studies in meta-research: Review/guidelines on the most important quality assessment tools

Systematic reviews and meta-analyses pool data from individual studies to generate a higher level of evidence to be evaluated by guidelines. These reviews ultimately guide clinicians and stakeholders in health-related decisions. However, the informativeness and quality of evidence synthesis inherently depend on the quality of what has been pooled into meta-research projects. Moreover, beyond the quality of included individual studies, only a methodologically correct process, in relation to systematic reviews and meta-analyses themselves, can produce a reliable and valid evidence synthesis. Hence, quality of meta-research projects also affects evidence synthesis reliability. In this overview, the authors provide a synthesis of advantages and disadvantages and main characteristics of some of the most frequently used tools to assess quality of individual studies, systematic reviews, and meta-analyses. Specifically, the tools considered in this work are the Newcastle-Ottawa scale (NOS) and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) for observational studies, the Consolidated Standards of Reporting Trials (CONSORT), the Jadad scale, the Cochrane risk of bias tool 2 (RoB2) for randomized controlled trials, the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and the Assessment of Multiple Systematic Reviews 2 (AMSTAR2), and AMSTAR-PLUS for meta-analyses. WHAT IS ALREADY KNOWN?: The informativeness and quality of evidence synthesis inherently depend on the quality of what has been pooled into meta-research projects. Beyond the quality of included individual studies, only a methodologically correct process, in relation to systematic reviews and meta-analyses themselves, can produce a reliable and valid evidence synthesis. WHAT IS NEW?: In this overview, the authors provide a synthesis of advantages and disadvantages and main characteristics of some of the most frequently used tools to assess quality of individual studies, systematic reviews, and meta-analyses. POTENTIAL IMPACT: This overview serves as a starting point and a brief guide to identify and understand the main and most frequently used tools for assessing the quality of studies included in meta-research. The authors here share their experience in publishing several meta-research-related articles covering different areas of medical sciences.

Feasibility of combined ECG-Gated and Helical acquisition mode in a pre-TAVI computed tomography angiography protocol using a fixed low-volume contrast medium injection

BACKGROUND

To investigate the feasibility, image quality, and clinical implications of a combined ECG-gated and helical acquisition mode in a computed tomography angiography (CTA) protocol in patients scheduled for transcatheter aortic valve implantation (TAVI) using a fixed, low-volume, contrast medium injection.

METHODS

Between July and October 2019, 43 TAVI candidates underwent investigation with CTA using a 64-slice CT scanner. Images obtained were prospectively evaluated. 65 mL of low iodine dose contrast medium (CM), followed by 25 mL of saline, were administered using a fixed multiphasic injection protocol in all patients. Patients were divided into three groups based on BMI: Group 1 (n = 9) with BMI < 22 kg/m²; Group 2 (n = 22) with BMI 22-29 kg/m²; Group 3 (n = 12) with BMI > 29 kg/m². Images were evaluated for image quality, vessel attenuation (HU), Signal-to-Noise Ratio (SNR), Contrast-to-Noise Ratio (CNR) and estimated radiation dose. Image quality of the aortic root and iliac-femoral vessels was diagnostic in all patients.

RESULTS

Vascular attenuation was > 200 HU and CNR > 3 at all vessel levels.

CONCLUSION

Data from our study suggest that it is possible to image the aortic annulus and aorto-iliac anatomy and obtain high image quality in all patients by using a combined ECG-gated and helical acquisition mode in a computed tomography angiography (CTA) protocol with a fixed low-volume contrast medium injection (65 mL). This allows for accurate CT measurements of the aortic annulus, recruitment of patients for TAVI and facilitates pre-procedural planning in these high surgical risk patients.

Feasibility and Utility of mHealth for the Remote Monitoring of Parkinson Disease: Ancillary Study of the PD_manager Randomized Controlled Trial

Background

Mobile health, predominantly wearable technology and mobile apps, have been considered in Parkinson disease to provide valuable ecological data between face-to-face visits and improve monitoring of motor symptoms remotely.

Objective

We explored the feasibility of using a technology-based mHealth platform comprising a smartphone in combination with a smartwatch and a pair of smart insoles, described in this study as the PD_manager system, to collect clinically meaningful data. We also explored outcomes and disease-related factors that are important determinants to establish feasibility. Finally, we further validated a tremor evaluation method with data collected while patients performed their daily activities.

Methods

PD_manager trial was an open-label parallel group randomized study.The mHealth platform consists of a wristband, a pair of sensor insoles, a smartphone (with dedicated mobile Android apps) and a knowledge platform serving as the cloud backend. Compliance was assessed with statistical analysis and the factors affecting it using appropriate regression analysis. The correlation of the scores of our previous algorithm for tremor evaluation and the respective Unified Parkinson’s Disease Rating Scale estimations by clinicians were explored.

Results

Of the 75 study participants, 65 (87%) completed the protocol. They used the PD_manager system for a median 11.57 (SD 3.15) days. Regression analysis suggests that the main factor associated with high use was caregivers’ burden. Motor Aspects of Experiences of Daily Living and patients’ self-rated health status also influence the system’s use. Our algorithm provided clinically meaningful data for the detection and evaluation of tremor.

Conclusions

We found that PD patients, regardless of their demographics and disease characteristics, used the system for 11 to 14 days. The study further supports that mHealth can be an effective tool for the ecologically valid, passive, unobtrusive monitoring and evaluation of symptoms. Future studies will be required to demonstrate that an mHealth platform can improve disease management and care.

Trial Registration

ISRCTN Registry ISRCTN17396879; http://www.isrctn.com/ISRCTN17396879

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-018-2767-4

Shear Stress and Aortic Strain Associations With Biomarkers of Ascending Thoracic Aortic Aneurysm

BACKGROUND

This study aims to investigate the association of wall shear stress (WSS) and aortic strain with circulating biomarkers including matrix metalloproteinases (MMP), tissue inhibitors of metalloproteinase (TIMP), and exosomal level of microRNA (miRNA) in ascending aortic aneurysms of patients with bicuspid or tricuspid aortic valve.

METHODS

A total of 76 variables from 125 patients with ascending aortic aneurysms were collected from (1) blood plasma to measure plasma levels of miRNAs and protein activity; (2) computational flow analysis to estimate peak systolic WSS and time-average WSS (TAWSS); and (3) imaging analysis of computed tomography angiography to determine aortic wall strain. Principal component analysis followed by logistic regression allowed the development of a predictive model of aortic surgery by combining biomechanical descriptors and biomarkers.

RESULTS

The protein activity of MMP-1, TIMP-1, and MMP-2 was positively correlated to the systolic WSS and TAWSS observed in the proximal ascending aorta (eg, R = 0.52, P < .001, for MMP-1 with TAWSS) where local maxima of WSS were found. For bicuspid patients, aortic wall strain was associated with miR-26a (R = 0.55, P = .041) and miR-320a (R = 0.69, P < .001), which shows a significant difference between bicuspid and tricuspid patients. Receiver-operating characteristics curves revealed that the combination of WSS, MMP-1, TIMP-1, and MMP-12 is predictive of aortic surgery (area under the curve 0.898).

CONCLUSIONS

Increased flow-based and structural descriptors of ascending aortic aneurysms are associated with high levels of circulating biomarkers, implicating adverse vascular remodeling in the dilated aorta by mechanotransduction. A combination of shear stress and circulating biomarkers has the potential to improve the decision-making process for ascending aortic aneurysms to a highly individualized level.

Designing a mHealth clinical decision support system for Parkinson's disease: a theoretically grounded user needs approach

Background

Despite the established evidence and theoretical advances explaining human judgments under uncertainty, developments of mobile health (mHealth) Clinical Decision Support Systems (CDSS) have not explicitly applied the psychology of decision making to the study of user needs. We report on a user needs approach to develop a prototype of a mHealth CDSS for Parkinson’s disease (PD), which is theoretically grounded in the psychological literature about expert decision making and judgement under uncertainty.

Methods

A suite of user needs studies was conducted in 4 European countries (Greece, Italy, Slovenia, the UK) prior to the development of PD_Manager, a mHealth-based CDSS designed for Parkinson’s disease, using wireless technology. Study 1 undertook Hierarchical Task Analysis (HTA) including elicitation of user needs, cognitive demands and perceived risks/benefits (ethical considerations) associated with the proposed CDSS, through structured interviews of prescribing clinicians (N = 47). Study 2 carried out computational modelling of prescribing clinicians’ (N = 12) decision strategies based on social judgment theory. Study 3 was a vignette study of prescribing clinicians’ (N = 18) willingness to change treatment based on either self-reported symptoms data, devices-generated symptoms data or combinations of both.

Results

Study 1 indicated that system development should move away from the traditional silos of ‘motor’ and ‘non-motor’ symptom evaluations and suggest that presenting data on symptoms according to goal-based domains would be the most beneficial approach, the most important being patients’ overall Quality of Life (QoL). The computational modelling in Study 2 extrapolated different factor combinations when making judgements about different questions. Study 3 indicated that the clinicians were equally likely to change the care plan based on information about the change in the patient’s condition from the patient’s self-report and the wearable devices.

Conclusions

Based on our approach, we could formulate the following principles of mHealth design: 1) enabling shared decision making between the clinician, patient and the carer; 2) flexibility that accounts for diagnostic and treatment variation among clinicians; 3) monitoring of information integration from multiple sources. Our approach highlighted the central importance of the patient-clinician relationship in clinical decision making and the relevance of theoretical as opposed to algorithm (technology)-based modelling of human judgment.

Tuning of polyurethane foam mechanical and thermal properties using ball-milled cellulose

Cystalline-Cc and ultra-milled Amorphous-Ca cellulose were used as reactive filler to tune the performances of composite polyurethane-cellulose-foams, PUC. The effect of Cc and Ca on chemo-physical and mechanical properties of PUC was analysed through FTIR, morphological analysis, thermal conductivity and compression measurements. FTIR results show that, both Cc and Ca react with isocyanate through the OH functional groups contributing to the formation of a tough cellulose-polyurethane network. Morphological observations show that the addition of both Cc and Ca induces a decrease of average cell-size compared to the pristine-PU, thus confirming that they act as nucleating agent. In addition, the better dispersion of the Ca in the polyol, with respect to Cc induces, a finer cell leading to a reduction of the thermal conductivity around 33 % (for the composite loaded with 20 %wt-Ca) with respect to pristine-PU. Finally, the addition of Ca highly reactive modifies the mechanical behaviour from rigid-brittle to semi-rigid.

Endomyocardial fibrosis of the right ventricle: A case report of successful surgery

AIMS

The case we report, shows a successful treatment of right ventricle endomyocardial fibrosis.

MATERIALS AND METHODS

Surgical therapy by endocardial decortication seems to be beneficial for many patients with advanced disease who are in functional-therapeutic class III or IV. The operative mortality rate is high, but successful surgery has a clear benefit on symptoms and seems to favourably affect survival as well.

Incidence of acute respiratory tract infections (2006-2015) and influenza (2006-2013) among French armed forces

OBJECTIVES

We aimed to assess the incidence of respiratory tract infections in military settings between 2006 and 2015.

PATIENTS AND METHODS

We performed a retrospective epidemiological study of the entire military population from 2006 to 2015. Comprehensive data was collected from all medical centers, operational medical units, naval services, and army training hospitals and provided by the epidemiological surveillance of the armies.

RESULTS

The annual average population of the study was 331,394 soldiers. For acute respiratory tract infections (2006-2015), 22,818 cases were reported in metropolitan France, 3,211 cases in French overseas territories, 1,595 cases in the French Navy, and 1,318 cases in external military operations for a total of 28,942 cases. For influenza (2006-2013), 934 cases were reported in metropolitan France, 101 cases in French overseas territories, and 23 cases in external operations, for a total of 1,058 cases. The mean incidence rate of acute respiratory tract infections expressed as case number per 1,000 person-years (PY) was 8.7 PY (95% CI [8.6-8.8]) with an exceptional increased incidence rate in 2009 (25.9 PY, 95% CI [25.4-26.4]). The mean incidence rate of influenza was 0.35 PY (95% CI [0.33-0.37]) with a peak incidence rate of 1.9 PY in 2009.

CONCLUSION

Acute respiratory tract infections are at the forefront of infectious episodes in the French armies. Although not necessarily severe, current prevention measures are not enough to reduce the incidence threshold of these infections and need to be improved.