Low-tube-voltage whole-body CT angiography with extremely low iodine dose: a comparison between hybrid-iterative reconstruction and deep-learning image-reconstruction algorithms

AIM

To evaluate arterial enhancement, its depiction, and image quality in low-tube potential whole-body computed tomography (CT) angiography (CTA) with extremely low iodine dose and compare the results with those obtained by hybrid-iterative reconstruction (IR) and deep-learning image-reconstruction (DLIR) methods.

MATERIALS AND METHODS

This prospective study included 34 consecutive participants (27 men; mean age, 74.2 years) who underwent whole-body CTA at 80 kVp for evaluating aortic diseases between January and July 2020. Contrast material (240 mg iodine/ml) with simultaneous administration of its quarter volume of saline, which corresponded to 192 mg iodine/ml, was administered. CT raw data were reconstructed using adaptive statistical IR-Veo of 40% (hybrid-IR), DLIR with medium- (DLIR-M), and high-strength level (DLIR-H). A radiologist measured CT attenuation of the arteries and background noise, and the signal-to-noise ratio (SNR) was then calculated. Two reviewers qualitatively evaluated the arterial depictions and diagnostic acceptability on axial, multiplanar-reformatted (MPR), and volume-rendered (VR) images.

RESULTS

Mean contrast material volume and iodine weight administered were 64.1 ml and 15.4 g, respectively. The SNRs of the arteries were significantly higher in the following order of the DLIR-H, DLIR-M, and hybrid-IR (p<0.001). Depictions of six arteries on axial, three arteries on MPR, and four arteries on VR images were significantly superior in the DLIR-M or hybrid-IR than in the DLIR-H (p≤0.009 for each). Diagnostic acceptability was significantly better in the DLIR-M and DLIR-H than in the hybrid-IR (p<0.001-0.005).

CONCLUSION

DLIR-M showed well-balanced arterial depictions and image quality compared with the hybrid-IR and DLIR-H.

Robotic-Assisted Anastomosis in Orthoplastic Surgery: Preliminary Data

BACKGROUND

The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction.

METHODS

We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023.

RESULTS

Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

A chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to reconstruct partial necrosis of talar body: A case report

Total talar extrusion is a rare complication of high-energy traumas. A consequence of this injury can be avascular necrosis (AVN) of the talus. Patients are confronted with pain, limited range of motion and post-traumatic arthritis. As AVN progresses the talus is gradually destroyed. This report presents the use of a chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to increase vascular supply to the traumatized area, accelerate bone formation, flap integration, and restore articular surfaces in a patient with partial necrosis of talar body. The patient was a 26-year-old female with open left lateral talar extrusion after a motor-vehicle accident that developed a partial avascular necrosis, at the level of the subtalar and ankle joint with altered talar dome surface with partial depression of 2 cm. The patient was in pain and not able to walk. The medial femoral condyle chondro-osseus portion was placed in the talar dome depression to restore the subtalar joint, the periosteal flaps were placed on top to reconstruct the ankle joint restoring the articular surfaces and the correct weight-bearing distribution. No complications or morbidity of donor site were observed. One year after the operation, the patient walks free, without pain. Post-operatory x-ray performed, evidenced progressive bone healing and reduction of the AVN. In the intent of performing a joint-saving procedure, the presented chimeric flap might be effective in the short-term with excellent clinical and radiographic outcomes.

Nonlinear-cost random walk: Exact statistics of the distance covered for fixed budget

We consider the nonlinear-cost random-walk model in discrete time introduced in Phys. Rev. Lett. 130, 237102 (2023)10.1103/PhysRevLett.130.237102, where a fee is charged for each jump of the walker. The nonlinear cost function is such that slow or short jumps incur a flat fee, while for fast or long jumps the cost is proportional to the distance covered. In this paper we compute analytically the average and variance of the distance covered in n steps when the total budget C is fixed, as well as the statistics of the number of long or short jumps in a trajectory of length n, for the exponential jump distribution. These observables exhibit a very rich and nonmonotonic scaling behavior as a function of the variable C/n, which is traced back to the makeup of a typical trajectory in terms of long or short jumps, and the resulting entropy thereof. As a by-product, we compute the asymptotic behavior of ratios of Kummer hypergeometric functions when both the first and last arguments are large. All our analytical results are corroborated by numerical simulations.

Viscoelastic confinement induces periodic flow reversals in active nematics

We use linear stability analysis and hybrid lattice Boltzmann simulations to study the dynamical behavior of an active nematic confined in a channel made of viscoelastic material. We find that the quiescent, ordered active nematic is unstable above a critical activity. The transition is to a steady flow state for high elasticity of the channel surroundings. However, below a threshold elastic modulus, the system produces spontaneous oscillations with periodic flow reversals. We provide a phase diagram that highlights the region where time-periodic oscillations are observed and explain how they are produced by the interplay of activity and viscoelasticity. Our results suggest experiments to study the role of viscoelastic confinement in the spatiotemporal organization and control of active matter.

Current fluctuations in stochastically resetting particle systems

We consider a system of noninteracting particles on a line with initial positions distributed uniformly with density ρ on the negative half-line. We consider two different models: (i) Each particle performs independent Brownian motion with stochastic resetting to its initial position with rate r and (ii) each particle performs run-and-tumble motion, and with rate r its position gets reset to its initial value and simultaneously its velocity gets randomized. We study the effects of resetting on the distribution P(Q,t) of the integrated particle current Q up to time t through the origin (from left to right). We study both the annealed and the quenched current distributions and in both cases, we find that resetting induces a stationary limiting distribution of the current at long times. However, we show that the approach to the stationary state of the current distribution in the annealed and the quenched cases are drastically different for both models. In the annealed case, the whole distribution P_{an}(Q,t) approaches its stationary limit uniformly for all Q. In contrast, the quenched distribution P_{qu}(Q,t) attains its stationary form for QQ_{crit}(t). We show that Q_{crit}(t) increases linearly with t for large t. On the scale where Q∼Q_{crit}(t), we show that P_{qu}(Q,t) has an unusual large deviation form with a rate function that has a third-order phase transition at the critical point. We have computed the associated rate functions analytically for both models. Using an importance sampling method that allows to probe probabilities as tiny as 10^{-14000}, we were able to compute numerically this nonanalytic rate function for the resetting Brownian dynamics and found excellent agreement with our analytical prediction.

Cost of Diffusion: Nonlinearity and Giant Fluctuations

We introduce a simple model of diffusive jump process where a fee is charged for each jump. The nonlinear cost function is such that slow jumps incur a flat fee, while for fast jumps the cost is proportional to the velocity of the jump. The model-inspired by the way taxi meters work-exhibits a very rich behavior. The cost for trajectories of equal length and equal duration exhibits giant fluctuations at a critical value of the scaled distance traveled. Furthermore, the full distribution of the cost until the target is reached exhibits an interesting "freezing" transition in the large-deviation regime. All the analytical results are corroborated by numerical simulations. Our results also apply to elastic systems near the depinning transition, when driven by a random force.

CT Perfusion as a Predictor of the Final Infarct Volume in Patients with Tandem Occlusion

BACKGROUND

CT perfusion (CTP) is used in patients with anterior circulation acute ischemic stroke (AIS) for predicting the final infarct volume (FIV). Tandem occlusion (TO), involving both intracranial large vessels and the ipsilateral cervical internal carotid artery could generate hemodynamic changes altering perfusion parameters. Our aim is to evaluate the accuracy of CTP in the prediction of the FIV in TOs.

METHODS

consecutive patients with AIS due to middle cerebral artery occlusion, referred to a tertiary stroke center between March 2019 and January 2021, with an automated CTP and successful recanalization (mTICI = 2b - 3) after endovascular treatment were retrospectively included in the tandem group (TG) or in the control group (CG). Patients with parenchymal hematoma type 2, according to ECASS II classification of hemorrhagic transformations, were excluded in a secondary analysis. Demographic, clinical, radiological, time intervals, safety, and outcome measures were collected.

RESULTS

among 319 patients analyzed, a comparison between the TG (N = 22) and CG (n = 37) revealed similar cerebral blood flow (CBF) > 30% (29.50 ± 32.33 vs. 15.76 ± 20.93 p = 0.18) and FIV (54.67 ± 65.73 vs. 55.14 ± 64.64 p = 0.875). Predicted ischemic core (PIC) and FIV correlated in both TG (tau = 0.761, p < 0.001) and CG (tau = 0.315, p = 0.029). The Bland-Altmann plot showed agreement between PIC and FIV for both groups, mainly in the secondary analysis.

CONCLUSION

automated CTP could represent a good predictor of FIV in patients with AIS due to TO.

Soft Tissue Reconstruction of the Posterior Trunk after Tumor Excision: A Surgical Algorithm

BACKGROUND

The posterior trunk has been considered a challenging area to reconstruct following soft tissue tumor excision because of the shortage of local donor sites. The advent of innovative procedures such as perforator flaps has radically changed this perspective and offered a new approach to the problem.

METHODS

Upon a review of the literature and the personal experiences of the senior author, an algorithm is developed according to the most updated procedure, combined with more conventional options that maintain a role in decision-making.

RESULTS

The upper back latissimus dorsi and trapezium flap are still the most reliable approaches, while perforator flaps based either on the circumflex scapular arteries or the transverse cervical artery represent a more refined option. In the middle third, few indications remain for the reverse latissimus dorsi, while the gold standard is represented by local perforator flaps based on the posterior intercostal system. In the lower back, conventional VY advancement flaps are still a safe and effective option in the sacral area, and perforator flaps based on posterior intercostal arteries, lumbar arteries and superior gluteal arteries are the first choice in most cases.

CONCLUSIONS

Using perforator flaps significantly improved soft tissue reconstruction in the posterior trunk.

Time to reach the maximum for a stationary stochastic process

We consider a one-dimensional stationary time series of fixed duration T. We investigate the time t_{m} at which the process reaches the global maximum within the time interval [0,T]. By using a path-decomposition technique, we compute the probability density function P(t_{m}|T) of t_{m} for several processes, that are either at equilibrium (such as the Ornstein-Uhlenbeck process) or out of equilibrium (such as Brownian motion with stochastic resetting). We show that for equilibrium processes the distribution of P(t_{m}|T) is always symmetric around the midpoint t_{m}=T/2, as a consequence of the time-reversal symmetry. This property can be used to detect nonequilibrium fluctuations in stationary time series. Moreover, for a diffusive particle in a confining potential, we show that the scaled distribution P(t_{m}|T) becomes universal, i.e., independent of the details of the potential, at late times. This distribution P(t_{m}|T) becomes uniform in the "bulk" 1≪t_{m}≪T and has a nontrivial universal shape in the "edge regimes" t_{m}→0 and t_{m}→T. Some of these results have been announced in a recent letter [Europhys. Lett. 135, 30003 (2021)0295-507510.1209/0295-5075/ac19ee].

Heterogeneous mechanisms of pulmonary congestion in hypertrophic cardiomyopathy unmasked by comprehensive exercise stress echocardiography

Background

B-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, are present in 1 out of 3 patients with hypertrophic cardiomyopathy (HCM).

Aim

To assess the functional and anatomical correlates of exercise B-lines in HCM.

Methods

We enrolled 191 HCM patients (age 53±15 years, 123 males) consecutively referred for ESE (treadmill in 74, bicycle in 117 patients) in 11 quality-controlled centers from 8 countries. ESE assessment at rest and peak stress included: left ventricular (LV) outflow tract gradient, left atrial (LAVi) and LV end-diastolic volume index (EDVi), mitral regurgitation (MR, score from 0 to 3); E/e'; systolic pulmonary arterial pressure (SPAP) and LV force (LV outflow tract gradient+systolic blood pressure/LV end-systolic volume). B-lines at rest and at peak exercise were assessed by LUS with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥2.

Results

LUS was feasible in all subjects. B-lines were present in 55 (29%) patients during stress. When compared to patients without stress B-lines (n=136), patients with B-lines (n=55) at peak exercise had lower peak EDVi (43±17 vs 52±18 ml/m2, p=0.003) higher peak E/e' (16±6 vs 12±5, p&lt;0.001), increase in MR (34 vs 12%, p=0.001), greater stress LAVi (43±14 vs 37±14 ml/m2, p=0.003) and stress SPAP (56±18 vs 40±12 mm Hg p&lt;0.0001): see Figure. Among baseline parameters, the number of B-lines (OR: 7.53, 95% CI 1.21–46.72 p=0.03), LAVi (OR: 1.05, 95% CI 1.00–1.09 p=0.04), and LV force (OR: 1.36, 95% CI 1.04–1.79 p=0.03) were the independent predictors of exercise pulmonary congestion.

Conclusion

HCM patients with pulmonary congestion on exercise show different, and not mutually exclusive mechanisms of diastolic dysfunction and worsening mitral regurgitation. These different hemodynamic mechanisms may require personalized therapeutic actions beyond a pulmonary decongestion therapy with diuretics.

Funding Acknowledgement

Type of funding sources: None.

Clinical, functional and prognostic correlates of excess left ventricular force in hypertrophic cardiomyopathy

Background

Excess force generation during myocardial contraction represents a cardinal feature of hypertrophic cardiomyopathy (HCM).

Purpose

To evaluate the anatomical, functional and prognostic correlates of left ventricular (LV) force in HCM.

Methods

We prospectively recruited a consecutive sample of 408 HCM patients with LV ejection fraction (EF) &gt;50%, referred for baseline transthoracic echocardiography in 2 primary HCM centers in Hungary and Italy between 1999 and 2021. LV force was calculated as LV outflow tract gradient+systolic blood pressure/LV end-systolic volume. Patients were followed for a median of 107 months (IQ range, 58–158 months), the study endpoint was all-cause mortality.

Results

Mean LV force was 6.0±4.6 mm Hg/ml. Receiver-operating characteristic analysis identified 7.5 mm Hg/ml the best cut-off value to predict mortality. LV force &gt;7.5 mm Hg/ml was present in 86 patients (21%), more frequently in women (58 vs 27%, p&lt;0.0001), more often in patients with diabetes (16 vs 6%, p=0.003), beta-blocker (81 vs 58%, p&lt;0.0001), calcium channel-blocker (19 vs 9%, p=0.012) and diuretic therapy (19 vs 8%, p=0.004), compared to patients with LV force ≤7.5 mm Hg/ml. Patients with excess LV force had more advanced NYHA class (1.8±0.7 vs 1.4±0.7, p=0.0001), greater left atrial diameter [(LAd), 46.7±6.6 vs 43.0±7.2 mm, &lt;0.0001], LV maximal wall thickness (23.2±5.5 vs 21.6±5.5 mm p=0.01), LV EF (74.6±6.4 vs 67.0±6.8%, &lt;0.0001), mitral regurgitation grade (1.2±0.7 vs 0.7±0.7, p&lt;0.0001) and E/e' (10.3±5.0 vs 7.8±5.0, p=0.005). During follow-up 43 deaths occurred. All-cause death was more frequent in patients with excess LV force (21 vs 8%, p&lt;0.0001). At multivariable Cox regression analysis, excess LV force was an independent predictor of mortality (HR 2.9, 95% CI 1.14–7.26, p=0.025) independent of age (HR 1.03, 95% CI 1.00–1.05, p=0.022) and LAd (HR 1.07, 95% CI 1.02–1.14, p=0.005).

Conclusion

LV force with a threshold of 7.5 mm Hg/ml, independently predicts adverse outcome in patients with HCM and preserved systolic function. Excess LV force generation is associated with female sex, diabetes, NYHA class, medications, LAd, LV wall thickness, EF, mitral regurgitation grade and E/e'.

Funding Acknowledgement

Type of funding sources: None.

Adverse prognostic value of supernormal left ventricular force noninvasively assessed by resting transthoracic echocardiography in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Stress Echo 2030 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI).

Background The excessive cross-bridging of cardiac myosin and actin, resulting in increased left ventricular (LV) force development, is one of the biomechanical abormalities inhypertrophic cardiomyopathy (HCM).

Purpose

To assess the prognostic value of increased LV force development at rest in patients with HCM

Methods

We enrolled 918 HCM patients (age 48 ± 16 years, 502 males, New York Heart Association I or II, Class III in 48 patients, 6% and with LVOTG &gt;30 mmHg in 211patients, 23%) with ejection fraction (EF) ≥50%, referred for rest transthoracic echocardiography (TTE) in 10 quality-controlled labs from 7 countries (Belgium, Hungary, Italy, Portugal, Serbia, Spain, Brazil). The maximal wall thickness was 21 ± 5 mm. TTE assessment included left ventricular outflow tract gradient (LVOTG, mmHg), EF (%), and LV force (systolic arterial pressure + LVOTG/LV endsystolic volume assessed with 2-D, mmHg/mL). All patients were followed-up. An age- and gender matched control group of 95 healthy subjects was also evaluated.

Results.  Compared to normals, HCM showed higher values of EF (68 ± 8 vs 65 ± 5%, p &lt; 0.001) and force (7.2 ± 5.5 vs 4.0 ± 1.8 mmHg/mL, p &lt; 0.001). At a median follow-up of 94 months [interquartile range 40-140 months], 95 all-cause deaths occurred. Mortality was significantly increased in the force highest quartile compared to other quartiles (see figure). At multivariable Cox analysis, increased Force (highest quartile &gt;8.5 mmHg/mL hazard ratio= 2.189 95% CI = 1.095-4.377, p = 0.027 and the intermediate quartile: Force 5.7-8.5 mmHg/mL hazard ratio= 2.525 95% CI = 1.2205.228, p = 0.013) were independent predictors of mortality with age (hazard ratio= 1.065 95% CI = 1.047-1.084, p &lt; 0.001) and maximal wall thickness (hazard ratio= 1.094, 95% CI = 1.055-1.135, p &lt; 0.001). At univariate analysis neither LVOTG (hazard ratio= 1.430, 95% CI = 0.920-2.222, p = 0.112) nor quartiles of EF (hazard ratio= 1.497, 95% CI = 0.868-2.582, p = 0.147) were significant.

Conclusion

HCM patients with preserved baseline LV function and higher values of resting LV force ("too good to be normal") show a worse survival, highlighting the dark prognostic side of an excess of force. The hypercontractile phenotype possibly indicates an increased activity of myosin resulting in increased force production at the sarcomere and cellular levels that propagates at the whole-organ level with unfavorable long-term effects on outcome.

Figure

Mortality rate based on quartiles of resting LV Force in HCM. Abstract Figure. Mortality rate

Comprehensive stress echocardiography in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging

Background

Stress echocardiography (SE) in hypertrophic cardiomyopathy (HCM) has more to offer beyond dynamic left ventricular outflow obstruction (LVOTO) to capture the functional heterogeneity of the disease.

Objectives

To determine the feasibility of comprehensive SE in HCM.

Methods

We prospectively enrolled 235 HCM patients (age = 48 ± 15 years, 113 men) assessed with exercise stress echocardiography (ESE) in 4 centers. ESE modality was semi-supine bicycle in 29 patients in one center, and treadmill in 206 (followed by same-day, same session, adenosine for step D) in another centers. During SE, we assessed stress-induced new regional wall motion abnormalities (RWMA, step A), coronary flow velocity reserve (CFVR) in left anterior descending coronary artery with Doppler (step D) by semi-supine exercise or adenosine, heart rate reserve (peak/rest heart rate) for EKG-based step E, mitral regurgitation (MR) flow for step F, and LVOTO (step G for gradient). A comprehensive SE score was generated from 0 (all parameters normal) to 5 (all abnormal).

Results

 Technical success rate was 100% for all steps, except step D (80% with semi-supine, 100% with adenosine after treadmill) and F (232/235, 99%).  Extra-analysis time was &lt; 3 minutes for steps A + D + E + F + G. Rate of abnormal results ranged from 73% for step E (peak/rest heart rate reserve &lt; 1.80) to 1% for step A (inducible RWMA), with intermediate values for step D (CFVR &lt; 2.0, 44%), step F (at least moderate MR, 32%) and step G (LVOTG &gt; 50 mm Hg, 26%): see figure. SE score was 0 in 14 pts (6%), 1 or 2 in 202 patients (86%) and ≥ 3 in 19 patients (8%).

Conclusions

 Comprehensive SE is feasible in HCM with single stress (semi-supine exercise) or hybrid treadmill exercise followed by adenosine for step D. Phenotyping of the multiform manifestations of HCM with a personalized functional blueprint is now possible. Abstract Figure.

Clinical course and outcome of pregnancy in patients with hypertrophic cardiomyopathy

Background

Hypertrophic Cardiomyopathy (HCM) is the most common genetic cardiomyopathy. However, few studies have systematically investigated the clinical course of pregnancy in HCM.

Purpose

To determine whether pregnancy is well tolerated in HCM.

Methods

Women consecutively referred to our Tertiary Clinic for Cardiomyopathies from 1969 to

2019 were retrospectively reviewed. Only women with complete data regarding pregnancy and with a follow up (FU)&gt;1 year were included in the study. Overall, of the 647 women followed at our center, 378 (58%) fulfilled our inclusion criteria. Demographic, clinical and instrumental records were retrieved. The peripartum period was defined as the timeframe from −1 to 6 months after delivery.

Results

There were 433 pregnancies in 239 (63%) women with 132 (62%) having &gt;1 pregnancy. By contrast, 139 (37%) reported no pregnancy or miscarriages: in 6 cases pregnancy was discouraged due to advanced disease stage. Twenty-eight (12%) women had 39 pregnancies after HCM diagnosis and were followed by the obstetrics department: this subset was significantly younger at diagnosis (age at diagnosis: 21 [13–29] vs 56 [47–66] vs 45 [24–62] years, p&lt;0.001, in women with a pregnancy after diagnosis vs women diagnosed after the pregnancy vs women with no pregnancy, respectively). Instrumental characteristics were comparable among women. Thirty percent presented with obstructive physiology at baseline. Among the 39 pregnancies in women who had a pregnancy after the diagnosis, there were 3 reported episodes of paroxysmal atrial fibrillation, one sustained ventricular tachycardia with pulse and three episodes of non-sustained ventricular tachycardia in the peripartum period. In this cohort, prevalence of intra-uterine growth delay and miscarriage was 8%. Only 3 women experienced a worsening clinical profile requiring hospitalization during the peripartum period: 2 were hospitalized for acute heart failure (AHF) and 1 was experienced a resuscitated cardiac arrest. Of note, 2/3 of patients were carriers of a (likely)pathogenic troponin mutation.

Long-term (FU: 5±3 years), nulligravida women were more symptomatic at last evaluation (NYHA III/IV: 25 vs 17, p&lt;0.05), reported a higher incidence of ICD appropriate shocks (26 vs 12%p=0.02) but had similar rates of heart transplant (2.1 vs 0.5%, p=0.143) and episodes of AHF (12 vs 14%, p=0.193). Eighteen patients (8.2%) died: incidence of cardiovascular mortality was 4.8%, with a lower rate in patients who reported a pregnancy (0.8%/year vs 2.8%/year, p=0.01).

Conclusions

Women with HCM tolerate pregnancy well. Rare complications occurred in the peripartum period which were manageable. In the long-term, pregnancy, even when multiple, did not influence the long-term course of the disease nor its outcome. Strategies to support appropriate counselling and antenatal care should be implemented to identify those at greater risk of disease progression.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary congestion during exercise stress echocardiography in hypertrophic cardiomyopathy

Background

B-lines detected by lung ultrasound (LUS) indicate pulmonary congestion during exercise stress echo (ESE).

Aim

To assess B-lines during ESE in hypertrophic cardiomyopathy (HCM).

Methods

We enrolled 110 HCM patients (age 52±16 years, 74 males) referred for ESE (treadmill in 39, semi-supine bicycle in 71 patients) in 10 quality-controlled centers from 8 countries (Belgium, Brazil, Bulgaria, Hungary, Italy, Portugal, Serbia, Spain). ESE assessment included: left ventricular outflow tract gradient (LVOTG); mitral regurgitation (MR, score from 0 to 3); E/e'; systolic pulmonary arterial pressure (SPAP, from tricuspid regurgitant jet velocity); end-diastolic volume (EDV); left atrial volume (LAV). B-lines were assessed by LUS with the 4-site simplified scan, each site scored from 0 (normal A-lines) to 10 (coalescing B-lines). The positivity criterion was a B-line score stress ≥2 points.

Results

LUS was feasible in all subjects, with additional scanning and analysis time &lt;1 minute for each stage (rest and peak stress). B-lines were present in 13 patients at rest and in 33 during stress (12 vs 30%, p&lt;0.001). When compared to patients without stress B-lines (Group 2, n=77), patients with B-lines (Group 1) showed higher values of change from rest to stress (Δ) in LVOTG (Group 1= 39±54 vs Group 2= 21±24 mm Hg, p=0.015) and ΔMR grade (Group 1= 0.7±0.8 vs Group 2= 0.1±0.5, p&lt;0.001), more frequent peak stress E/e' ≥15 (Group 1=61% vs Group 2=27%, p=0.007), lower peak EDV (Group 1= 86±35 vs Group 2= 102±33 ml, p=0.039) and higher peak SPAP (Group 1= 60±21 vs Group 2= 39±12 mm Hg, p&lt;0.001): see figure. At multivariable logistic regression analysis, presence of stress B-lines was predicted by ΔMR grade (odds ratio: 3.96, 95% CI 1.46–10.71) and stress E/e' ≥15 (odds ratio: 4.95, 95% CI 1.24–19.70).

Conclusion

B-lines are found in about 1 of 10 HCM patients at rest and in 1 of 3 during ESE. Acute backward heart failure during exercise can recognize multiple mechanisms in HCM, and ESE can help to capture this heterogeneity.

Funding Acknowledgement

Type of funding sources: None. Functional correlates of stress B-lines

Condensation transition in the late-time position of a run-and-tumble particle

We study the position distribution P(R[over ⃗],N) of a run-and-tumble particle (RTP) in arbitrary dimension d, after N runs. We assume that the constant speed v>0 of the particle during each running phase is independently drawn from a probability distribution W(v) and that the direction of the particle is chosen isotropically after each tumbling. The position distribution is clearly isotropic, P(R[over ⃗],N)→P(R,N) where R=|R[over ⃗]|. We show that, under certain conditions on d and W(v) and for large N, a condensation transition occurs at some critical value of R=R_{c}∼O(N) located in the large-deviation regime of P(R,N). For R<R_{c} (subcritical fluid phase), all runs are roughly of the same size in a typical trajectory. In contrast, an RTP trajectory with R>R_{c} is typically dominated by a "condensate," i.e., a large single run that subsumes a finite fraction of the total displacement (supercritical condensed phase). Focusing on the family of speed distributions W(v)=α(1-v/v_{0})^{α-1}/v_{0}, parametrized by α>0, we show that, for large N, P(R,N)∼exp[-Nψ_{d,α}(R/N)], and we compute exactly the rate function ψ_{d,α}(z) for any d and α. We show that the transition manifests itself as a singularity of this rate function at R=R_{c} and that its order depends continuously on d and α. We also compute the distribution of the condensate size for R>R_{c}. Finally, we study the model when the total duration T of the RTP, instead of the total number of runs, is fixed. Our analytical predictions are confirmed by numerical simulations, performed using a constrained Markov chain Monte Carlo technique, with precision ∼10^{-100}.

Mean perimeter and area of the convex hull of a planar Brownian motion in the presence of resetting

We compute exactly the mean perimeter and the mean area of the convex hull of a two-dimensional isotropic Brownian motion of duration t and diffusion constant D, in the presence of resetting to the origin at a constant rate r. We show that for any t, the mean perimeter is given by 〈L(t)〉=2πsqrt[D/r]f_{1}(rt) and the mean area is given by 〈A(t)〉=2πD/rf_{2}(rt) where the scaling functions f_{1}(z) and f_{2}(z) are computed explicitly. For large t≫1/r, the mean perimeter grows extremely slowly as 〈L(t)〉∝ln(rt) with time. Likewise, the mean area also grows slowly as 〈A(t)〉∝ln^{2}(rt) for t≫1/r. Our exact results indicate that the convex hull, in the presence of resetting, approaches a circular shape at late times due to the isotropy of the Brownian motion. Numerical simulations are in perfect agreement with our analytical predictions.

Hymenoptera venom allergy among children in Italy: time for pediatricians to take action

Hymenoptera venom allergy (HVA) is one of the most frequent causes of anaphylaxis following a bee, vespid or ant sting. Real-life data regarding the management of HVA in children are lacking. To address this unmet need, we carried out a survey defining the current management of HVA in children among pediatric allergists in Italy. Educational investments on the improvement of the management of pediatric patients with HVA are urgently needed, and our analysis represents a relevant instrument in targeting a roadmap with this aim. The time for pediatric allergists to take action has come, and a task force from the Rare Allergic Diseases Commission of the Italian Society of Pediatric Allergy and Immunology is working on the topic to improve pediatricians' knowledge and optimize the care of these patients.

Suppression of gastric acid secretion decreased cardiovascular events independent of severe bleeding events in patients after percutaneous coronary intervention – sub-analysis from multicenter registry

Background

Suppression of gastric acid secretion by proton-pump inhibitor (PPI) or potassium-competitive acid blocker (P-CAB) has recently been developed as a standard strategy for preventing gastrointestinal bleeding for patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI). However, there has been limited evidences on the association between PPI/P-CAB administration and adverse cardiovascular events in patients undergoing PCI.

Purpose

We aimed to evaluate the prognostic impact of the prescription of PPI/P-CAB on clinical outcomes in patients after PCI.

Methods

This study is a subanalysis from the TWINCRE registry that is a multicentral prospective cohort including patients who underwent PCI at 12 hospitals in Japan between 2017 and 2019. Among registered patients, we ultimately evaluated 1,428 patients who were followed-up. They were divided into two groups by the prescriptions of PPI or P-CAB at discharge for the index PCI; the PPI/P-CAB group (n=1,023), and the Non-PPI/P-CAB group (n=407). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, acute coronary syndrome, stent thrombosis, hospitalization due to heart failure and ischemic stroke. Secondary endpoints was major bleeding events defined BARC3, 4 and 5.

Results

The average age of the study population was 70.3 years and 80.3% were male. Baseline clinical profiles were comparable between the groups, except that the PPI/P-CAB group included significantly higher rate of patients who had history of prior PCI (28.4% vs 18.7%, P=0.02). Additionally, there was no significant difference in the duration of dual antiplatelet therapy between the PPI/P-CAB group and Non-PPI/P-CAB group (average duration; 287±8 vs. 285±8 days, P=0.66). Overall, MACCE was developed in 132 patients (9.3%), and bleeding event was observed in 24 patients (1.7%) during 574 days of median follow-up period. Kaplan-Meier analysis showed that patients in the PPI/P-CAB group had a significantly lower rate of MACCE than those in the Non-PPI/P-CAB group (Log-rank test, p=0.0003, Figure 1A). Multivariate Cox regression analysis revealed that the prescription of PPI/P-CAB still was independently associated with the primary endpoint (hazard ratio 0.532, 95% confidence interval 0.369–0.766, p=0.0007), even after the adjustment by diverse covariates. Whereas, there was no significant difference in the bleeding event (p=0.64, Figure 1B).

Conclusion

PPI or P-CAB therapy was associated with better clinical outcomes after PCI, independent of the incidences of severe bleeding events.

Figure 1

Funding Acknowledgement

Type of funding source: None

Universal properties of a run-and-tumble particle in arbitrary dimension

We consider an active run-and-tumble particle (RTP) in d dimensions, starting from the origin and evolving over a time interval [0,t]. We examine three different models for the dynamics of the RTP: the standard RTP model with instantaneous tumblings, a variant with instantaneous runs and a general model in which both the tumblings and the runs are noninstantaneous. For each of these models, we use the Sparre Andersen theorem for discrete-time random walks to compute exactly the probability that the x component does not change sign up to time t, showing that it does not depend on d. As a consequence of this result, we compute exactly other x-component properties, namely, the distribution of the time of the maximum and the record statistics, showing that they are universal, i.e., they do not depend on d. Moreover, we show that these universal results hold also if the speed v of the particle after each tumbling is random, drawn from a generic probability distribution. Our findings are confirmed by numerical simulations. Some of these results have been announced in a recent Letter [Phys. Rev. Lett. 124, 090603 (2020)10.1103/PhysRevLett.124.090603].

Distribution of the time between maximum and minimum of random walks

We consider a one-dimensional Brownian motion of fixed duration T. Using a path-integral technique, we compute exactly the probability distribution of the difference τ=t_{min}-t_{max} between the time t_{min} of the global minimum and the time t_{max} of the global maximum. We extend this result to a Brownian bridge, i.e., a periodic Brownian motion of period T. In both cases, we compute analytically the first few moments of τ, as well as the covariance of t_{max} and t_{min}, showing that these times are anticorrelated. We demonstrate that the distribution of τ for Brownian motion is valid for discrete-time random walks with n steps and with a finite jump variance, in the limit n→∞. In the case of Lévy flights, which have a divergent jump variance, we numerically verify that the distribution of τ differs from the Brownian case. For random walks with continuous and symmetric jumps we numerically verify that the probability of the event "τ=n" is exactly 1/(2n) for any finite n, independently of the jump distribution. Our results can be also applied to describe the distance between the maximal and minimal height of (1+1)-dimensional stationary-state Kardar-Parisi-Zhang interfaces growing over a substrate of finite size L. Our findings are confirmed by numerical simulations. Some of these results have been announced in a recent Letter [Phys. Rev. Lett. 123, 200201 (2019)PRLTAO0031-900710.1103/PhysRevLett.123.200201].

Universal Survival Probability for a d-Dimensional Run-and-Tumble Particle

We consider an active run-and-tumble particle (RTP) in d dimensions and compute exactly the probability S(t) that the x component of the position of the RTP does not change sign up to time t. When the tumblings occur at a constant rate, we show that S(t) is independent of d for any finite time t (and not just for large t), as a consequence of the celebrated Sparre Andersen theorem for discrete-time random walks in one dimension. Moreover, we show that this universal result holds for a much wider class of RTP models in which the speed v of the particle after each tumbling is random, drawn from an arbitrary probability distribution. We further demonstrate, as a consequence, the universality of the record statistics in the RTP problem.

Epidemiology and drug allergy results in children investigated in allergy unit of a tertiary-care paediatric hospital setting

Background and objective

Drug Hypersensitivity Reactions (DHRs) are considered adverse effects of medications that resemble allergy symptoms. The reported positive clinical history of pediatric drug reactions is about 10%, however, after allergy investigations, only a small percent is confirmed as hypersensitivity.

The aim of this study was to analyze the clinical history, allergy work-up results and sensitization profile of children and adolescents referred to our Allergy Unit for suspected DHRs.

Methods

The study evaluated data related to a group of children with a positive history of drug reactions during a two-year period. The allergy work-up consisted of in vivo and in vitro tests, in accordance with the recommendations of the ENDA/EAACI guidelines.

Results

Data from a group of 637 patients [348 M (54.6%); 289 F (45.4%)] were retrospectively analyzed. Beta lactams (BLs) were the most common drugs involved in the reported clinical history, followed by non-steroidal anti-inflammatory drugs (NSAIDs). Severe cutaneous adverse reactions (SCARs) were most frequently observed during BL treatment. The confirmation of BL hypersensitivity was higher for immediate reactions (IRs) [9.4%; 5.1% through positive skin tests (STs) and 5.5% through drug provocation test (DPT)] compared to non-immediate reactions (non-IRs) (8.1%; 2.2% through STs and 6.2% through DPT). A higher number of positive results was obtained for BLs and macrolides when the tests were performed within 12 months after the index reaction (p < 0.05). During DPTs with amoxicillin-clavulanic acid, four hypersensitivity reactions (including one anaphylaxis) occurred despite negative STs.

Conclusion

Our data demonstrated that only 9.1% of patients resulted in being positive to allergy tests which is in line with the data in literature. An allergy work-up is mandatory for excluding suspected hypersensitivity.

Time Between the Maximum and the Minimum of a Stochastic Process

We present an exact solution for the probability density function P(τ=t_{min}-t_{max}|T) of the time difference between the minimum and the maximum of a one-dimensional Brownian motion of duration T. We then generalize our results to a Brownian bridge, i.e., a periodic Brownian motion of period T. We demonstrate that these results can be directly applied to study the position difference between the minimal and the maximal heights of a fluctuating (1+1)-dimensional Kardar-Parisi-Zhang interface on a substrate of size L, in its stationary state. We show that the Brownian motion result is universal and, asymptotically, holds for any discrete-time random walk with a finite jump variance. We also compute this distribution numerically for Lévy flights and find that it differs from the Brownian motion result.

P6478Resting and exercise pulmonary artery systolic pressure to rule out later development of pulmonary arterial hypertension in systemic sclerosis

Background

Patients with systemic sclerosis (SSc) are at risk of developing pulmonary arterial hypertension (PAH), which is often diagnosed late when the benefits of vasoactive therapies are limited. The concept of exercise pulmonary hypertension as a possible transitional phase anticipating resting PAH has been assessed in several pathologies, but has not been endorsed by the latest European Guidelines, because not supported by sufficient data.

Purpose

To evaluate whether PASP values at rest and at peak exercise, estimated at echocardiography, could be predictors of further development of PAH.

Methods

Four hundred and twenty-nine SSc patients without a previous diagnosis of PAH, enrolled at 4 referral Centres, underwent standard exercise Doppler echocardiography with PASP estimation at rest and at peak stress. Patients were then followed-up to assess the development of PAH, as diagnosed by a complete diagnostic work-up including right heart catheterization. PAH was defined by pre-capillary pulmonary hypertension (mean pulmonary artery pressure ≥25 mmHg with pulmonary arterial wedge pressure ≤15 mmHg), without significant interstitial lung disease and/or left heart disease.

Results

During the median follow-up of 75 months (IQR 29–114), 16 patients developed PAH. A combined cut-off of ≥24 mmHg as resting PASP and ≥40 as peak PASP was identified as the best predictor of further development of PAH (see Figure). Both resting PASP and peak PASP were predictors of PAH at univariate analysis (resting PASP OR 1.13, 95% C.I. 1.07–1.19, p<0.0001; peak PASP OR 1.13, 95% C.I. 1.07–1.18, p<0.0001). At multivariate analysis, only peak PASP was independently associated to PAH development (OR 1.13, 95% C.I. 1.04–1.18, p<0.001). Only one patient among those with resting PASP <24 mmHg and peak PASP <40 mmHg (34.7% of the total population) developed PAH during the follow-up (after 10 years from normal exercise Doppler echocardiography).

Kaplan-Meier curves

Conclusions

Exercise increase in PASP is an independent predictor of later development of PAH in SSc. An increase in exercise PASP is frequent and is not necessarily associated with a later development of PAH, whereas the very high negative predictive value of a normal PASP both at rest and at peak exercise can be used in the clinical practice to confidently rule out about one third of patients.

Acknowledgement/Funding

Italian Ministry of Health (Ricerca Finalizzata 2011-2012)

Interleukin-6 Disrupts Synaptic Plasticity and Impairs Tissue Damage Compensation in Multiple Sclerosis

Background: Synaptic plasticity helps in reducing the clinical expression of brain damage and represents a useful mechanism to compensate the negative impact of new brain lesions in multiple sclerosis (MS). Inflammation, altering synaptic plasticity, could negatively influence the disease course in relapsing-remitting MS (RR-MS). Objective: In the present study, we explored whether interleukin (IL)-6, a major proinflammatory cytokine involved in MS pathogenesis, alters synaptic plasticity and affects the ability to compensate for ongoing brain damage. Methods: The effect of IL-6 incubation on long-term potentiation (LTP) induction was explored in vitro, in mice hippocampal slices. We also explored the correlation between the cerebrospinal fluid (CSF) levels of this cytokine and the LTP-like effect induced by the paired associative stimulation (PAS) in a group of RR-MS patients. Finally, we examined the correlation between the CSF levels of IL-6 at the time of diagnosis and the prospective disease activity in a cohort of 150 RR-MS patients. Results: In vitro LTP induction was abolished by IL-6. Consistently, in patients with MS, a negative correlation emerged between IL-6 CSF concentrations and the effect of PAS. In MS patients, longer disease duration before diagnosis was associated with higher IL-6 CSF concentrations. In addition, elevated CSF levels of IL-6 were associated with greater clinical expression of new inflammatory brain lesions, unlike in patients with low or absent IL-6 concentrations, who had a better disease course. Conclusions: IL-6 interfering with synaptic plasticity mechanisms may impair the ability to compensate the clinical manifestation of new brain lesions in RR-MS patients.

Heparin during endovascular stroke treatment seems safe

BACKGROUND AND PURPOSE

the effect of intravenous heparin during mechanical thrombectomy for acute ischemic stroke is not clear. We aimed to study efficacy and safety of heparin use during endovascular stroke treatment in a real-world setting.

MATERIALS AND METHODS

patients with anterior circulation stroke were divided, based on the use of intraprocedural heparin, in those treated and those untreated. Main outcomes were successful reperfusion defined as a TICI Score ≥ 2b, 3-month functional independence defined as a modified Rankin Scale ≤ 2, symptomatic intracranial hemorrhage (sICH) and mortality.

RESULTS

361 patients were eligible for analysis; 200 were (H+) and 161 (H-). The (H-) group showed higher age and ASPECTS (74 ± 14 vs. 68.9 ± 12.2; P = 0.001; 8 ± 1.6 vs. 7.4 ± 2.1; P = 0.009) without differences in vascular risk factors. Heparin untreated patients showed a shorter onset-to-reperfusion time (271 ± 57.6 min vs. 309 ± 102.2 min; P < 0.001). No differences were found in 3-month functional independence, sICH and mortality whereas the rate of successful reperfusion was higher in the (H-) group. After logistic regression analysis successful reperfusion was independently associated with CT ASPECTS (OR: 1.16; 95%CI 1.01-1.35; P = 0.040) but inversely associated with the use of heparin (OR: 0.48; 95% CI 0.24-0.98; P = 0.045).

CONCLUSIONS

Heparin use during mechanical thrombectomy for anterior circulation acute ischemic stroke in a real world setting is safe.

Oral D-Aspartate enhances synaptic plasticity reserve in progressive multiple sclerosis

Background:

Synaptic plasticity reserve correlates with clinical recovery after a relapse in relapsing–remitting forms of multiple sclerosis (MS) and is significantly compromised in patients with progressive forms of MS. These findings suggest that progression of disability in MS is linked to reduced synaptic plasticity reserve. D-Aspartate, an endogenous aminoacid approved for the use in humans as a dietary supplement, enhances synaptic plasticity in mice.

Objective:

To test whether D-Aspartate oral intake increases synaptic plasticity reserve in progressive MS patients.

Methods:

A total of 31 patients affected by a progressive form of MS received either single oral daily doses of D-Aspartate 2660 mg or placebo for 4 weeks. Synaptic plasticity reserve and trans-synaptic cortical excitability were measured through transcranial magnetic stimulation (TMS) protocols before and after D-Aspartate.

Results:

Both TMS-induced long-term potentiation (LTP), intracortical facilitation (ICF) and short-interval ICF increased after 2 and 4 weeks of D-Aspartate but not after placebo, suggesting an enhancement of synaptic plasticity reserve and increased trans-synaptic glutamatergic transmission.

Conclusion:

Daily oral D-Aspartate 2660 mg for 4 weeks enhances synaptic plasticity reserve in patients with progressive MS, opening the path to further studies assessing its clinical effects on disability progression.

Increase of natural killer cells in children with liver transplantation-acquired food allergy

BACKGROUND

Transplantation-acquired food allergies (TAFA) are frequently reported and considered to be caused by immunosuppressive therapy. The aim of this study was to investigate the allergic and immunologic responses in children who had liver or kidney transplantations.

METHODS

Twelve children receiving liver transplantations and 10 children receiving kidney transplantations were investigated. All children underwent the allergy work-up and in most of them, lymphocyte screening and serum cytokine measurements were also performed.

RESULTS

TAFA were found in 7/12 (58%) children with liver transplantations and in none of the 10 children with kidney transplantations. The mean age at transplantation was significantly lower in children who underwent liver transplantations (p<0.001). The immunosuppressive therapy administered to children with liver transplantation was tacrolimus in 11 patients and cyclosporine in one patient, while all 10 children with kidney transplantation received tacrolimus plus mycophenolate. The most common antigenic food was egg. The natural killer (NK) cell numbers were significantly higher in liver-transplant children than in kidney-transplant children. No significant differences were found in the serum cytokine levels.

CONCLUSIONS

This study confirms that liver-transplant children treated with tacrolimus alone have a higher risk of developing TAFA than kidney-transplant children treated with tacrolimus plus mycophenolate. NK cells might be involved in this difference.

P210Long- term outcome of primary mitral valve prolapse: results from a population of 250 patients referred to a tertiary cardiovascular center

Background

Outcome of Mitral Valve Prolapse (MVP) was controversial for long time. Many studies reported great differences in the incidence of cardiovascular events due, above all, to heterogeneous and small studied populations. Most of theme were also published to late '80 of the last century till early '00.

Purpose

To make a contemporary survey on the incidence of cardiovascular events in a selected population of patients affected by primary MVP referred to a tertiary cardiovascular center for the medical and surgical care of valvular heart disease.

Methods

We reviewed our MVP database; patients with at least 2 cardiologic evaluations inclusive of echocardiographic examination and at least 6 months follow up were enrolled. A total of 250 patients (126 F) were selected. Their mean age was 52.1 years (ranging from 13 to 88 yo). The average follow-up time was 100 months (8,33 yrs).

Results

At the first medical and echocardiographic examination 8 patients (3,2%) had no mitral regurgitation (MR), 104 (41.6%) have a trace/mild MR, 93 (37,2%) a moderate MR and 46 (18,4%) a severe MR. They were widely asymptomatic (NYHA I 205-82%, NYHA II 44-17.60%, NYHA III 1- 0.40%). Most of theme presented a bileaflet (140-55.8%) or a posterior MVP (94 - 37.6%); an isolated anterior MVP was rare (16 - 6,4%). Flail leaflet was present in 8 (3,2%) and 25 (10%) had a chordal rupture. Respectively 165 (65,6%) and 115 (46,1%) patients had thick and redundant leaflets. Mean antero-posterior mitral annulus diameter was 37 mm. During the follow up 7 patients died of non-cardiac cause and 5 (2%) of suspected cardiac cause (2 because of acute coronary syndrome and 3 died suddenly). MR progresses in 43 (17,2%) patients and finally we observed 81 (32,4%) moderate/severe and severe MR. 12 new chordal rupture occurred during the follow up in most cases concerning mitral chordae linked to posterior mitral leaflet (10 cases-83,3%). The worsening of MR provoked an evolution of the clinical condition of 48 patients (19.2%) which developed Dyspnea On Excertion (DOE) with 42 new NYHA II and 6 new NYHA III. At the end of the follow up the amount of patients symptomatic for DOE was 93 (37.2% vs 18% at the initial evaluation). A total of 45 patients (18%) underwent mitral valve surgery. 40 needed in-hospital treatment in most cases due to the development of atrial fibrillation (19 -7.6%) or heart failure ( 8- 3,2%). Endocarditis occurred in 4 patients (1.6%) and cerebrovascular accidents/cardioembolic event in 6 (2.4%). The overall cardiovascular event rate was 4,33/100 patients-year, significantly higher than reported in community based studies.

Conclusions

The prognosis of a MVP population referred to a tertiary cardiovascular center is not benign. The most frequent complications are progression of MR and MV surgery. Sudden death is also more frequent than in general population. More studies are needed to identify what patients with MVP are at risk for it.

Mechanical thrombectomy of acute ischemic stroke with a new intermediate aspiration catheter: preliminary results

Background and purpose

To report clinical and procedural outcomes of acute ischemic stroke patients after endovascular treatment with the new thromboaspiration catheter AXS Catalyst 6.

Methods

Patients with anterior and posterior circulation stroke were selected. Successful reperfusion defined as a Thrombolysis in Cerebral Infarction (TICI) score ≥2 b and 3-month functional independence defined as a modified Rankin Scale (mRS) ≤2 were the main efficacy outcomes. Symptomatic intracranial hemorrhage and mortality were the main safety outcomes.

Results

107 patients were suitable for analysis. Mean age was 73.18±12.62 year and median baseline NIHSS was 17 (range: 3–32). The most frequent site of occlusion was the middle cerebral artery (MCA) (60.7%). 76.6% of patients were treated with AXS Catalyst 6 alone without the need for rescue devices or thromboaspiration catheters. Successful reperfusion was achieved in 84.1%, functional independence in 47.6%, symptomatic intracranial hemorrhage occurred in 3.7%, and mortality in 21.4%.

Conclusions

Endovascular treatment with AXS Catalyst 6 proved to be safe, technically feasible, and effective. Comparison analyses with other devices for mechanical thrombectomy are needed.

PDGF Modulates Synaptic Excitability and Short-Latency Afferent Inhibition in Multiple Sclerosis

Maintenance of synaptic plasticity reserve is crucial to contrast clinical deterioration in MS and PDGF plays a key role in this phenomenon. Indeed, higher cerebrospinal fluid PDGF concentration correlates with improved clinical recovery after a relapse, and the amplitude of LTP-like cortical plasticity in relapsing-remitting MS patients. However, LTP-like cortical plasticity varies depending on the individual level of inhibitory cortical circuits. Aim of this study was to explore whether PDGF-CSF concentration correlates with inhibitory cortical circuits explored by means of transcranial magnetic stimulation in patients affected by relapsing-remitting MS. We further performed electrophysiological experiments evaluating GABAergic transmission in the experimental autoimmune encephalomyelitis (EAE) hippocampus. Our results reveal that increased CSF PDGF concentration correlates with decreased short afferent inhibition in the motor cortex in MS patients and decreased GABAergic activity in EAE. These findings show that PDGF affects GABAergic activity both in MS patients and in EAE hippocampus.

Amyloid-β Homeostasis Bridges Inflammation, Synaptic Plasticity Deficits and Cognitive Dysfunction in Multiple Sclerosis

Cognitive deficits are frequently observed in multiple sclerosis (MS), mainly involving processing speed and episodic memory. Both demyelination and gray matter atrophy can contribute to cognitive deficits in MS. In recent years, neuroinflammation is emerging as a new factor influencing clinical course in MS. Inflammatory cytokines induce synaptic dysfunction in MS. Synaptic plasticity occurring within hippocampal structures is considered as one of the basic physiological mechanisms of learning and memory. In experimental models of MS, hippocampal plasticity is profoundly altered by proinflammatory cytokines. Although mechanisms of inflammation-induced hippocampal pathology in MS are not completely understood, alteration of Amyloid-β (Aβ) metabolism is emerging as a key factor linking together inflammation, synaptic plasticity and neurodegeneration in different neurological diseases. We explored the correlation between concentrations of Aβ_1–42 and the levels of some proinflammatory and anti-inflammatory cytokines (interleukin-1β (IL-1β), IL1-ra, IL-8, IL-10, IL-12, tumor necrosis factor α (TNFα), interferon γ (IFNγ)) in the cerebrospinal fluid (CSF) of 103 remitting MS patients. CSF levels of Aβ_1–42 were negatively correlated with the proinflammatory cytokine IL-8 and positively correlated with the anti-inflammatory molecules IL-10 and interleukin-1 receptor antagonist (IL-1ra). Other correlations, although noticeable, were either borderline or not significant. Our data show that an imbalance between proinflammatory and anti-inflammatory cytokines may lead to altered Aβ homeostasis, representing a key factor linking together inflammation, synaptic plasticity and cognitive dysfunction in MS. This could be relevant to identify novel therapeutic approaches to hinder the progression of cognitive dysfunction in MS.

Nerve growth factor is elevated in the CSF of patients with multiple sclerosis and central neuropathic pain

Central neuropathic pain (CNP) is common and disabling among patients with multiple sclerosis (MS). The pathological mechanisms underlying CNP in MS are not well understood. We explored whether NGF is implicated in the pathogenesis of CNP in MS. We measured NGF concentration in the CSF of 73 patients affected by MS, 15 with and 58 without CNP and 14 controls. We found increased levels of NGF in the CSF of patients with CNP compared to patients without and to controls. This finding supports the hypothesis that NGF plays a role in MS related CNP.

Evaluation of Long-term Outcomes of Correction of Severe Blepharoptosis with Advancement of External Levator Muscle Complex: Descriptive Statistical Analysis of the Results

AIM

Evaluation of long-term results after aponeurotic blepharoptosis correction with external levator muscle complex advancement.

PATIENTS AND METHODS

We carried out a retrospective study with medical record review of 20 patients (40 eyes) affected by bilateral aponeurotic moderate and severe ptosis who underwent primary surgery between January 2010 and December 2013. Criteria for outcome evaluations included 3-year postoperative follow-up of upper margin reflex index (uMRD) and symmetry.

RESULTS

3-Year postoperative follow-up showed 17 (85%) cases of successful correction of ptosis and three cases (15%) showed partial success. Two eyes showed hypocorrection, while one eye was overcorrected. The symmetry was maintained in all patients except for the oldest.

CONCLUSION

External superior levator advancement is an effective procedure for moderate and severe aponeurotic blepharoptosis correction, and establishes good long-term eyelid position and symmetry.

No evidence of beneficial effects of plasmapheresis in natalizumab-associated PML

Objective:

To examine retrospectively the effects of plasmapheresis (PLEX) on the survival and clinical outcomes of patients with multiple sclerosis (MS) and natalizumab (NTZ)–associated progressive multifocal leukoencephalopathy (PML).

Methods:

The medical literature was searched for the terms natalizumab and progressive multifocal leukoencephalopathy. A total of 193 international and 34 Italian NTZ-PML cases were included. Clinical outcome was determined by comparing the patients' clinical status at PML diagnosis with status after PML resolution. The effects on survival and clinical outcome of PLEX, sex, age, country, pre-PML Expanded Disability Status Scale score, NTZ infusion number, prior immunosuppressant exposure, PML symptoms, PML lesion location at diagnosis, CSF JC virus status and copies, additional PML treatments and steroids, and PML immune reconstitution inflammatory syndrome (IRIS) development were investigated with both univariate and multivariate analyses.

Results:

A total of 219 NTZ-PML cases were analyzed, and 184 (84%) underwent PLEX, which did not reduce the mortality risk or the likelihood of poor vs favorable outcomes. Country was predictive of mortality and poor outcome, while PML-IRIS development was predictive of poor outcome.

Conclusions:

PLEX did not improve the survival or clinical outcomes of Italian or international patients with MS and NTZ-PML, suggesting that this treatment should be performed cautiously in the future.

Classification of evidence:

This study provides Class III evidence that for patients with NTZ-PML, PLEX does not improve survival. The study lacks the statistical precision to exclude an important benefit or harm of PLEX.

TRPV1 polymorphisms and risk of interferon β-induced flu-like syndrome in patients with relapsing-remitting multiple sclerosis

Interferon-β (IFN-β) is often discontinued in RRMS patients due to its most common side effect, the flu-like syndrome (FLS). The mechanisms underlying IFN β-induced FLS symptoms are still unclear. The endocannabinoid system (ECS) is a key regulator of pain and inflammation. Thus we tested the hypothesis that the ECS could be involved in FLS severity by exploring the effect of genetic polymorphisms with functional impact on the ECS, on patient-reported FLS symptoms. GG-carriers of the transient-receptor-potential-vanilloid-1 (TRPV1) single nucleotide polymorphism rs222747 reported greater pain and weakness during FLS. This study suggests that the TRPV1 channel is involved in FLS severity.

Comment on: “A case report of a complete degloving injury of the penile skin”

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Genitalia are a key element for male self-esteem, contributing towards mental and physical balance and influencing their social life.

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Scrotal dartos-fascio-mio-cutaneous flap for shaft coverage offers a large amount of tissue with low donor site morbidity, avoiding unsightly scars in more visible parts of the body.

Introduction

We recently published an article in the International Journal of Surgical Case Reports titled: “Scrotal dartos-fascio-myo-cutaneous flap for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap”.

Presentation of case

We propose a comment on a recent article titled “A case report of a complete degloving injury of the penile skin” by Helena Aineskog and Frederik Huss that we read with great interest.

Discussion

Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Various techniques are available for pe-nile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar.

Conclusion

Scrotal flap is a single stage procedure that is easy and safe to perform.

Scrotal dartos-fascio-myo-cutaneous flaps for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap

Introduction

Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Among the surgical procedures requested for aesthetical purposes, circumcision is one of the most popular. Although it can be considered to be a simple surgical practice, it may cause severe complications such as penile skin necrosis.

Presentation of case

We report a case of a catastrophic situation after a circumcision performed on a 27-year-old HIV positive man resulted in a drastic reduction in the length of the penile shaft due to extensive skin loss; this was subsequently restored using dartos-fascio-myo-cutaneous flaps. Primary healing occurred in 10 days. No infection, dehiscence or flap ischemia were reported. Donor site morbidity was minimal. An adequate aesthetical appearance and satisfactory functional results were obtained.

Discussion and conclusion

Various techniques are available for penile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. Dartos-fascio-myo-cutaneous flap is a single stage procedure that is easy and safe to perform. It can provide satisfactory cosmetic and functional results, offering a large amount of tissue, with minimal donor site morbidity.

Eyelash Length in Children with Vernal Keratoconjunctivitis: Effect of Treatment with Cyclosporine Eye Drops

The upper eyelashes in vernal keratoconjunctivitis (VKC) patients have been reported to be longer than in healthy age- and gender-matched subjects. Eyelash length positively correlated to the severity of the disease and negatively to the employment of cyclosporine eye drops, suggesting that specific humoral factors could be involved in both ocular inflammation and elongation of the eyelashes. The aim of the present study is to evaluate a possible relationship between eyelash length and the duration of topical cyclosporine treatment. The length of the upper eyelashes of 34 VKC patients never treated with topical cyclosporine (Cyc-NT) was matched with that of 58 VKC patients treated with cyclosporine (Cyc-T). The latter group was divided into three subgroups, depending on the duration of therapy: 1–6 months (group 1; 21 subjects), 7–12 months (group 2; 19 subjects), >12 months (group 3; 19 subjects). Cyc-NT patients' eyelashes were significantly longer than those of VKC patients treated for 1–6 months (group 1). No significant difference was found between Cyc-NT and Cyc-T patients in group 2 and group 3. The differences between Cyc-T patients and group 1 and 2, group 2 and 3, and group 1 and 3 were not statistically significant. The eyelash shortening observed seems directly related to the rapid improvement of ocular symptoms induced by the treatment. A receptor down-regulation by mediators of ocular inflammation may explain this data, although different cytokines, hormones or other humoral mediators could be expressed on the ocular surface at different stages of the disease, mainly in periods of rapid change of the clinical course.