bluuebunny/crossref_metadata_2025 huggingface dataset:
Measures of wave intensity as a non-invasive surrogate for cardiac function predicts mortality in haemodialysis patients
Authors: Mayer Christopher C , Sarafidis Pantelis A , Matschkal Julia , Theodorakopoulou Marieta , Lorenz Georg , Karagiannidis Artemios , Angermann Susanne , Iatridi Fotini , Braunisch Matthias C , Karpetas Antonios , Baumann Marcus , Pella Eva , Heemann Uwe , Wassertheurer Siegfried , Schmaderer Christoph
Published: June 2024

Background

Risk prediction in haemodialysis (HD) patients is challenging due to the impact of the dialysis regime on the patient's volume status and the complex interplay with cardiac function, comorbidities and hypertension. Cardiac function as a key predictor of cardiovascular (CV) mortality in HD patients is challenging to assess in daily routine. Thus the aim of this study was to investigate the association of a novel, non-invasive relative index of systolic function with mortality and to assess its interplay with volume removal.

Methods

A total of 558 (373 male/185 female) HD patients with a median age of 66 years were included in this analysis. They underwent 24-hour ambulatory blood pressure monitoring, including wave intensity analysis [i.e. S:D ratio (SDR)]. All-cause and CV mortality served as endpoints and multivariate proportional hazards models were used for risk prediction. Intradialytic changes were analysed in tertiles according to ultrafiltration volume. During a follow-up of 37.8 months, 193 patients died (92 due to CV reasons).

Results

The SDR was significantly associated with all-cause {univariate hazard ratio [HR] 1.36 [95% confidence interval (CI) 1.20–1.54], P < .001} and CV [univariate HR 1.41 (95% CI 1.20–1.67), P < .001] mortality. The associations remained significant in multivariate analysis accounting for possible confounders. Changes in the SDR from pre-/early- to post-dialytic averages were significantly different for the three ultrafiltration volume groups.

Conclusion

This study provides well-powered evidence for the independent association of a novel index of systolic function with mortality. Furthermore, it revealed a significant association between intradialytic changes of the measure and intradialytic volume removal.
High sensitivity of aortic valve calcium score in predicting high gradients in patients with severe aortic stenosis
Authors: Stergianos E , Benetos G , Ktenopoulos N , Drakopoulou M , Synetos A , Tsalamandris S , Aznaouridis K , Tsioufis C , Toutouzas K
Published: June 2024

Introduction

During the last decade, the use of aortic valve calcium (AVC) score as measured by multidetector computed tomography (MDCT) has gained ground as a reliable, supplemental method of detecting patients with severe aortic stenosis (AS). While its validity has been tested using indirect echocardiographic measures of AS, the relationship between AVC score and peak to peak gradient during left heart catheterization is less well studied.

Purpose

We aimed to evaluate the relationship between AVC score and peak to peak gradient, the sensitivity and specificity of the method using strictly hemodynamic criteria for the severity of AS and to determine the factors associated with poor testing efficacy in diagnosing AS with AVC scoring.

Methods

We retrospectively reviewed the medical records of 126 patients with tricuspid, degenerative, native valve severe AS planned for transcatheter aortic valve implantation (TAVI) in our hospital. All patients included had MDCT and Doppler echocardiography performed prior the operation while peak to peak gradient was measured during TAVI.

Results

Mean AVC was higher in men than women (p=0.02) and in patients with increased interventricular septum thickness at end diastole (p=0.01). AVC score was positively correlated with measured peak to peak gradient (r=+0.43, p=0.001). In our study, measured sensitivity was 89,5% and specificity 27%. Patients were classified into two groups based on whether AVC scoring predicted accurately the severity of AS. Group A (N=106) consisted of patients with concordant severity of AS by AVC and peak to peak gradient while Group B (N=20) had patients with disconcordant severity of AS. We found that there was a statistically significant difference between the two groups regarding the presence of left ventricular hypertrophy (p=0.01).

Conclusion

AVC score is strongly correlated with hemodynamic peak to peak gradient in patients with severe AS undergoing TAVI, showing high sensitivity but moderate specificity.
Epicardial adipose tissue predicts adverse outcomes in asymptomatic aortic stenosis
Authors: Geers J , Manral N , Grodecki K , Newby D E , Slomka P J , Dweck M R , Dey D
Published: June 2024

Background

Epicardial adipose tissue (EAT) represents a metabolically active visceral fat depot within the pericardium, associated with cardiovascular risk factors, but little is known about its role in patients with aortic stenosis (AS).

Purpose

This study sought to investigate the association of EAT volume with disease severity, disease progression, and outcome of asymptomatic patients with AS.

Methods

In a post-hoc analysis of 124 patients with asymptomatic mild to severe AS participating in the prospective SALTIRE2 trial, baseline EAT volume was quantified on computed tomography angiography (CTA) using fully automated deep learning-enabled software (Figure 1A & 1B). AS disease severity was calculated at baseline and 1-year. The primary endpoint was defined as all-cause mortality during follow-up.

Results

Median EAT volume was 100 [74-139]mL, and was higher in men compared to women (109 [78-148]mL vs 79 [62-106]mL; p=0.004). There was a significant correlation between EAT volume and baseline troponin level (r=0.23, p=0.009), left ventricular (LV) mass (r=0.46, p<0.001), and LV ejection fraction (LVEF, r=-0.28, p=0.002). EAT volume did not correlate with AS severity as assessed by echocardiography (aortic valve peak velocity (Vmax): r=0.02, p=0.83) or CT calcium score (r=0.04, p=0.66). Equally, no correlation was observed between baseline EAT volume and subsequent disease progression (1-year change in Vmax: r=0.02, p=0.86). During the median follow-up of 48 [26-73] months, a total of 23 (18%) patients reached the primary endpoint. Both EAT volume (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.05-2.35; p=0.029) and troponin level (HR 1.43, 95%CI 1.13-1.82; p=0.003) were significant predictors of all-cause mortality in multivariable cox regression. Patients with EAT volume >90mL had worse survival compared to patients with EAT volume ≤90mL (p = 0.026, Figure 1C).

Conclusions

In a prospective trial of patients with asymptomatic AS, EAT volume showed marked prognostic importance and predicted all-cause mortality during follow-up. Higher EAT volume was associated with increased troponin value, increased LV mass, and reduced LVEF, and could therefore be a marker of impaired myocardial health, but further studies are warranted to elucidate the exact underlying mechanisms.
Evaluating cardiac dynamic CZT-SPECT for the measurement of the coronary flow reserve and the determination of the normal values in patients with suspected cardiac micro vascular disease
Authors: Goldstein M , Declerck P , Denizli Y , Venet C , Rezai Monfared M , Elst J , Soens J , Foading Deffo B , Malanca M
Published: June 2024

Reduced coronary flow reserve (CFR) is a strong indicator of major adverse cardiovascular events. It is observed in INOCA and MINOCA. Measuring the CFR is now more recommended in clinical practice, particularly in patients with multiple cardiovascular risk factors.

Different modalities for CFR measurement exist, each with their pros and cons. PET is the most validated modality for measuring CFR, followed by cardiac MR. Both modalities are expensive and not widely available. Cardiac dynamic CZT-SPECT (CD-SPECT) will become more available and less expensive in the future.

The current challenges are how to perform reproducible measurements of the CFR and determining the limit values for normal and decreased CFR. There is a heterogeneity of methods to acquire, to process and to calculate the CFR and not so many studies are done. A well founded and standardized study protocol is needed. An in-house study has been designed including, at the time of writing, 82 patients with multiple cardiac risk factors, all genders and ages. Among those patients 27 had no significant coronary stenosis. The goal is to determine the correct way of performing the CFR measurement and to determine the normal values of CFR.

The CFR cut-off value for CD-SPECT seems to be around 1.5 lower than PET where normal is > 2.0. All patients underwent a one day CD-SPECT rest study followed by a stress study for CFR measurement. Done with Technetium 99m Tc-tetrofosmin through a pump injection (LT Opticvantage®, 30ml/sec, 15 sec). The stress phase was induced with Regadenoson (400mcg) protocol using MyoSpect® GE-Healthcare and calculated with the AlgotMCS6=530C Ottawa Heart Inst. program.

26 patients had no significant coronary stenosis on coronary CT-scan by a Siemens Somaton® force 2x192 following the Cury RC Card Comp Tomography 2016 protocol). A patient had a normal invasive coronarography. In the subgroup with normal coronary arteries, all had a normal myocardial perfusion scintigraphy. 41% had a CFR > 1.5 and 59% a CFR > 1.5. In the group of diabetic patients 19% had a CFR > 1.5. Among those with lowered CFR, 54% were female, age did not demonstrate a significant impact. The preliminary results from this pilot study encourage us to extend our observation to a broader sample.
Myocardial ischemia: beyond the normal perfusion images
Authors: Gobbo M , Meretta A H , Carvelli M V , Rosa D , Corneli M , Perez Balino N A , Masoli O H
Published: June 2024

Background

Historically, a positive exercise stress test (EST) with a normal myocardial perfusion imaging (MPI) in patients without obstructive coronary artery disease (CAD) was considered a false positive of the EST and associated with a good prognosis.

However, it is crucial to acknowledge that myocardial ischemia may present itself due to coronary microvascular dysfunction (MVD) even in the absence of obstructive CAD.

The assessment of MVD can be conducted both invasively and non-invasively, with the latter involving the determination of myocardial flow reserve (MFR). Various stimuli can be employed to assess MFR, each potentially characterizing distinct pathophysiological mechanisms.

The cold pressor test (CPT) is recognized as an endothelium-dependent stimulus, while dipyridamole (DIP) and exercise are considered non-endothelium-dependent stimuli. The utilization of CZT gamma cameras facilitates the comprehensive evaluation of these diverse tests.

Objectives

The aim of this study was to non-invasively evaluate MFR during exercise (EXE), vasodilation with DIP, and CPT in patients with positive EST, normal MPI, and without CAD.

Methods

We studied 10 patients with a history of positive EST in previous studies, without CAD. MPI and dynamic imaging with CZT-SPECT using Tc 99m-MIBI were performed on three consecutive days at rest, during EXE, after DIP administration, and during CPT.

On the first day, rest was followed by EST using a modified Astrand protocol. It was considered positive when changes in the ST segment were equal to or greater than 0.1 mV measured at 80 msec from the J point, descending or horizontal morphology during exertion or immediate recovery.

On the second day, 0.56 mg/kg of DIP was administered intravenously over 4 minutes, and on the third day, CPT was performed was performed immersing their left hand in the ice water bath (4°C) for 2 minutes.

Normal MPI was defined as homogeneous tracer uptake with a summed scale equal to zero.

Myocardial blood flow was determined at rest and after each stress. MFR was defined as the ratio of hyperemic flow during each stress to resting flow. Normal values were set as EXE and DIP ³2; CPT ³1.5. MVD was defined as the presence of one or more abnormal MFR values.

Results

All patients had positive EST with normal MPI at rest and after different stresses. Of the total patients, only 4 (40%) showed abnormal MFR with DIP, while 7 (70%) had altered MFR during EXE, and 8 (80%) had abnormal MFR with CPT (Table 1) (Figure 1).

Conclusions

MVD was present in almost all patients with positive EST, normal MPI without CAD. The presence of positive EST could be a predictor of myocardial ischemia caused by MVD.

The use of different stressors allowed the evaluation of various pathophysiological mechanisms of MVD, which could be underdiagnosed if only assessed with DIP.
Assessing myocardial flow reserve using CZT SPECT perfusion imaging: a step towards clinical application
Authors: Mesquita C , Palazzo I , Pacheco J , Ker W , Sabra M M M , Chambi A , Correa N L
Published: June 2024

Background

Maximal hyperemia capacity and myocardial flow reserve (MFR) have emerged as critical indicators of cardiovascular prognosis, with reduced vascular functionality associated with adverse outcomes (1). PET-CT serves as the gold standard for MFR assessment in clinical practice. In recent years, SPECT equipment with high-performance CZT detectors has been utilized for quantitative assessment of coronary flow at rest and under maximal hyperemia. The potential of MFR in guiding clinical decision-making for coronary artery disease (CAD) management is increasingly recognized. However, the clinical feasibility and utility of CZT-derived MFR data remains under active investigation.

Objective

This study aims to describe the feasibility of quantitatively measuring myocardial flow reserve obtained using SPECT equipment with CZT detectors in patients undergoing scintigraphy to assess coronary disease.

Methodology

One hundred patients with suspected or known CAD underwent pharmacological stress myocardial perfusion scintigraphy (adenosine) and rest imaging using a D-SPECT device (Spectrum Dynamics) between October 7th, 2021, and December 30th, 2022. Dynamic tomographic images were acquired with the administration of 99mTc-sestamibi via an injection pump (Bracco) at a flow rate of 1 ml/second. Cedars Sinai's QPS kinetic software was used to calculate MFR, with values < 2 considered abnormal. Statistical analysis was performed using a significance level of 5% and the Student's T-type comparison test.

Results

Twenty patients (71 men), with a mean age of 69.4 years, were evaluated. Thirteen exams presented global MFR < 2, with an additional 11 patients showing global MFR > 2 and regional MFR in any of the three coronary territories below 2. Notably, six patients with MFR < 2 did not demonstrate abnormal myocardial perfusion imaging in SPECT. Patients with MFR values < 2 had a lower mean left ventricular ejection fraction compared to those with MFR > 2 (52% vs. 62%; p = 0.02). All exams were of good quality and interpretable. Motion correction was required in most exams (>90%). In two patients, the radiotracer and adenosine were administered through external jugular venous access due to unavailability of venous access in the cubital fossa.

Conclusion

Myocardial flow reserve (MFR) assessment can be effectively conducted using SPECT equipment equipped with CZT detectors, enabling the identification of patients with diminished MFR both globally and within specific coronary territories. These findings provide valuable insights into the management of patients with suspected or confirmed coronary artery disease (CAD). However, further investigation is warranted to elucidate the precise clinical implications of MFR assessment with CZT SPECT in guiding management strategies for patients with CAD.
Low sensitivity of 99mTc-DPD bone scan in early onset Val50Met cardiac amyloidosis
Authors: Jimenez-Heffernan A , Manovel-Sanchez A , Fernandez-Romero P , Brero-Sanchez L , Sanchez-Mora E , Rebollo-Aguirre A , Gonzalez-Macia A , Moreno-Ballesteros A , Gragera-Martinez A , Salgado-Garcia C , Borrachero-Garro C
Published: June 2024

Introduction

Low sensitivity of 99mTc-DPD has been reported in early-onset Val50Met amyloidosis by Azevedo and by Rodrigues.

Purpose

We aim to assess the frequency of negative 99mTc-DPD scans in our patient cohort of hereditary ATTR in an endemic area.

Methods

Since 2012 all patients under evaluation by our hospital’s Multidisciplinary Amyloidosis Team for cardiac amyloidosis have undergone 99mTc-DPD scintigraphy. Up to January 2024 55 patients with biopsy-proven and genetic testing for ATTR Val50Met mutation have been studied.

Cardiac evaluation is noninvasive including: clinical functional capacity, ECG, Holter, echocardiography and cardiac biomarkers. The subsets of early onset (age <50 y) and late onset (age ≥50 y) comprised 22 and 33 patients respectively. Mean age was 41.7±6.1 y and 65.3±9.2 y for the early-onset and late-onset subsets respectively. Wholebody planar images were acquired 3h post-injection and visually assessed for cardiac uptake. Patients with Perugini grade uptake >0 underwent SPECT/CT.

Results

Cardiac involvement was considered to be present in 12 of 22 (54.5%) patients with early onset and in 16 of 33 (48.5%) patients with late onset of disease. Cardiac scans were negative (Perugini =0 or 1) in 11 of the 12 (91%) early-onset patients and in 2 of the 16 (12.5%) late-onset patients. Of note the only positive patient (Perugini 3) in the early-onset group was 49 years old and the two patients with negative scans (Perugini 0) in the late-onset group were both 56 years old. These ages are quite near the 50 y age cut-off value for classification of disease onset as early or late, suggesting the idea that probably the real limit is a range around 50 y and not a sharp line. The poor diagnostic performance of 99mTc-DPD in early-onset Val50Met ATTR is a worrisome situation and is related to the full-length TTR fiber composition (type B) in contrast to the mixture of full-length and truncated TTR (type A) present in Val50Met late-onset disease.

Conclusion

A negative 99mTc-DPD scan should not exclude the diagnosis of Val50Met ATTR cardiomyopathy in patients with early onset of disease or in patients classified as late onset but in the younger range of the age spectrum.
Molecular imaging of valvular fibroblast activation and established fibrosis in aortic stenosis: analysis from the SALTIRE programme
Authors: Craig N , Geers J , Loganath K , Clark L , White A , Whittington B , Barton A , Balmforth C , Dey D , Slomka P , Newby D , Dweck M
Published: June 2024

Introduction

Progressive leaflet thickening in aortic stenosis is driven by fibrosis and calcification. Recent studies have quantified valvular fibrosis using contrast enhanced computed tomography (CT) techniques, with the combined fibro-calcific score correlating better with disease severity than CT-calcium scoring alone. However, understanding fibrosis activity within the aortic valve may allow detection of disease prior to extracellular matrix remodelling and progressive valve thickening. Gallium68 Fibroblast Activation Protein Inhibitor (68Ga-FAPI) binds to activated fibroblasts, the key effector cell of fibrosis formation, and provides a readout of fibroblast activation and fibrosis activity. We aimed to identify the relationship between 68Ga-FAPI intensity, CT calcium score, and quantified fibrocalcific volume.

Methods

In a prospective cohort, patients across the spectrum of aortic stenosis severity and a control population with normal aortic valves underwent combined 68Ga-FAPI Positron Emission Tomography (PET), non-contrast CT and contrast-enhanced CT. Valvular 68Ga-FAPI uptake was quantitatively assessed in a standardised fashion, with the maximal standardised uptake value (SUVmax) recorded within the defined region of interest, and divided by right atrial bloodpool uptake to provide a tissue-to-background ratio (TBRmax). CT-Calcium Scores were quantified in Agatston Units. The fibrocalcific volume was quantified by the sum of non-calcific and calcific tissue volume using bespoke software (Autoplaque, Cedars-Sinai).

Results

29 patients with aortic valve disease (mean age 71 ± 8 years; 76% male; peak velocity 3.4 ± 0.7 m/s) and 4 control participants (mean age 66 ± 7 years; 50% male) were included. 5 patients had aortic sclerosis or mild stenosis, 15 had moderate stenosis and 8 had severe aortic stenosis. Increased 68Ga-FAPI activity was observed in the aortic valves of all patients with aortic stenosis (mean SUVmax 2.1 ± 0.3; TBRmax 1.5 ± 0.1), of higher intensity than that of controls (mean TBRmax 1.3 ± 0.0, p<0.05; Figure 2). There was a moderate relationship between 68Ga-FAPI uptake and the CT-Calcium Score (r = 0.371, p<0.05), but a stronger correlation between the combined fibrocalcific volume and 68Ga-FAPI TBRmax (r = 0.562, p = 0.002).

Conclusion

In patients with aortic stenosis, valvular fibrosis activity can be measured using 68Ga-FAPI PET. Increased 68Ga-FAPI uptake correlates better with complete anatomical quantification combining calcific and non-calcific leaflet thickening than with CT-Calcium Score alone. 68Ga-FAPI PET is a promising technique to assess fibroblast activation and fibrosis activity in aortic stenosis.Figure 1  Figure 2
Safety, tolerability and diagnostic ability of a novel 18F-labelled tracer, [18F]SYN2, for PET myocardial perfusion imaging (SAFER) in patients with suspected coronary artery disease - phase II trial
Authors: Dziuk M , Knuuti J , Krajewski S , Gerszewska M , Steczek L , Gotowicz K , Wlostowska J , Towpik J , Kozanecki P , Kozanecki C
Published: June 2024

Aim

To assess safety and tolerability of [18F]SYN2 in phase 2 trial in patients with suspected CAD and referred to invasive coronary angiography (ICA). To test diagnostic ability of [18F]SYN2 PET perfusion in the detection of CAD using ICA or ICA with fractional flow reserve (FFR)in patients with coronary stenoses as the reference standard.

Method

The study was performed in 7 centers, and 40 subjects were enrolled. Patients were screened within 28 days prior to first dosing day. The patients were asked to admit to investigational site 2-3 hours before the first dosing and PET scan (resting baseline). The second dosing and stress PET scan (during regadenosone vasodilation) was performed 1 day – 7 days after the first. All patients returned to the investigational site 5 ± 2 days after the last dosing for a follow-up safety visit. During the follow-up period the ICA was performed for all patients at dedicated sites. All subjects also received an additional folow-up telephone call 30 ± 7 days after the last PET examination.

Results

Out of 34 reported adverse events (AE), 27 (79%) were not related to [18F]SYN2, 3 (9%) (chest pain, peripheral edema, musculoskeletal pain) were unlikely related and 4 (12%) were possibly related (diarrhea, musculoskeletal pain, palpitations). AEs of the highest incidence were general disorders and administration site conditions (5 cases in 5 (12.5%) patients), cardiac disorders (6 cases in 4 (10.0%) patients), and nervous system disorders (6 cases in 4 (10.0%) patients). The most common AE was headache (n = 4, 12%). The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of SYN2 PET/CT MPI (results provided by independent panel of cardiologists) in comparison to ICA or ICA/FFR in diagnosis of CAD were 80% , 75%, 77%, 62% and 88%, respectively. The inter-rater agreement (results provided by the each of the experts included in the independent panel of cardiologists and by local laboratory were taken in the analysis) for [18F]SYN2 PET/CT MPI was almost perfect in terms of inter-rater agreement in diagnosis of CAD and diagnosis of fixed defect (Fleiss' kappas = 1.000), and moderate in terms of agreement in diagnosis on reversible defect (Fleiss' kappa = 0.593), which corresponds to the almost perfect agreement in SSS and SDS (ICC of 0.900 and 0.903 respectively), and good agreement in SRS (ICC of 0.784).

Conclusion

[18F]SYN2 tracer administration for PET/CT myocardial perfusion imaging in subjects with suspected coronary artery disease was feasible and safe and shows reproducible diagnostic results to be confirmed in larger population.
Prognostic value of myocardial flow reserve for all-cause mortality, cardiovascular mortality, and non-cardiovascular mortality in hemodialysis patients
Authors: Ohshima S
Published: June 2024

Background

We have reported the prognostic value of myocardial flow reserve (MFR) in hemodialysis (HD) patients. Some prior studies showed that low MFR would predict poor prognosis for not only cardiovascular event but also all-cause mortality, however it is limited about that. In this study, we investigated the prognostic value of MFR in all-cause mortality, cardiovascular (CV) mortality and non- CV mortality.

Methods

1020 HD patients who underwent N13-NH3-PET myocardial perfusion imaging (MPI) suspected for ischemic heart disease were included. They are divided into two groups according to median value of MFR (2.0). We collected all-cause mortality, CV mortality and non- CV mortality. We have followed them for 1282 days.

Results

Kaplan-Meier curve analysis and Cox regression model showed the low MFR groups had poor prognosis for all-cause mortality, CV mortality and non-CV mortality. Furthermore, multivariate cox regression model showed the continuous value of MFR was an independent predictor for both all-cause mortality and non-CV mortality.

Conclusion

In HD patients, low MFR would be an important predictor for all-cause mortality, CV mortality and non-CV mortality.
Deceived by the Fick principle: blood flow distribution in heart failure
Authors: Agostoni Piergiuseppe , Cattadori Gaia , Vignati Carlo , Apostolo Anna , Farina Stefania , Salvioni Elisabetta , Di Marco Silvia , Sonaglioni Andrea , Nodari Savina , Marenzi Giancarlo , Schmidt-Trucksäss Arno , Myers Jonathan
Published: June 2024

Aims

The Fick principle states that oxygen uptake (V̇O2) is cardiac output (Qc) * arterial-venous O2 content difference [ΔC(a-v)O2]. Blood flow distribution is hidden in Fick principle, and its relevance during exercise in heart failure (HF) is undefined. To highlight the role of blood flow distribution, we evaluated peak exercise V̇O2, Qc, and ΔC(a-v)O2, before and after HF therapeutic interventions.

Methods and results

Symptom-limited cardiopulmonary exercise tests with Qc measurement (inert gas rebreathing) was performed in 234 HF patients before and 6 months after successful exercise training, cardiac resynchronization therapy, or percutaneous edge-to-edge mitral valve repair. Considering all tests (n = 468), a direct correlation between peakV̇O2 and peakQc (R2 = 0.47) and workload (R2 = 0.70) was observed. Patients were grouped according to treatment efficacy in Group 1 (peakV̇O2 increase >10%, n = 93), Group 2 (peakV̇O2 change between 0 and 10%, n = 60), and Group 3 (reduction in peakV̇O2, n = 81). Post-treatment peakV̇O2 changes poorly correlated with peakQc and peakΔC(a-v)O2 changes. Differently, post-procedure peakQc vs. peakΔC(a-v)O2 changes showed a close negative correlation (R2 = 0.46), becoming stronger grouping patients according to peakV̇O2 improvement (R2 = 0.64, 0.79, and 0.58 in Groups 1, 2, and 3, respectively). In 76% of patients, peakQc and ΔC(a-v)O2 changes diverged regardless of treatment.

Conclusion

The bulk of these data suggests that blood flow distribution plays a pivotal role on peakV̇O2 determination regardless of HF treatment strategies. Accordingly, for assessing HF treatment efficacy on exercise performance, the sole peakV̇O2 may be deceptive and the combination of V̇O2, Qc and ΔC(a-v)O2, must be considered.
Clinical outcomes of catheter ablation for atrial fibrillation, atrial flutter, and atrial tachycardia in wild-type transthyretin amyloid cardiomyopathy: a proposed treatment strategy for catheter ablation in each arrhythmia
Authors: Kanazawa Hisanori , Takashio Seiji , Hoshiyama Tadashi , Ito Miwa , Kaneko Shozo , Kiyama Takuya , Kawahara Yusei , Sumi Hitoshi , Tsuruta Yuichiro , Kuyama Naoto , Hirakawa Kyoko , Ishii Masanobu , Tabata Noriaki , Yamanaga Kenshi , Fujisue Koichiro , Hanatani Shinsuke , Sueta Daisuke , Arima Yuichiro , Araki Satoshi , Matsuzawa Yasushi , Usuku Hiroki , Nakamura Taishi , Yamamoto Eiichiro , Soejima Hirofumi , Matsushita Kenichi , Tsujita Kenichi
Published: June 2024

Aims

Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is often accompanied by atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT), which are difficult to control because beta-blockers and antiarrhythmic drugs can worsen heart failure (HF). This study aimed to investigate the outcomes of catheter ablation (CA) for AF/AFL/AT in patients with ATTRwt-CM and propose a treatment strategy for CA.

Methods and results

A cohort study was conducted on 233 patients diagnosed with ATTRwt-CM, including 54 who underwent CA for AF/AFL/AT. The background of each arrhythmia and the details of the CA and its outcomes were investigated. The recurrence-free rate of AF/AFL/AT overall in ATTRwt-CM patients with multiple CA was 70.1% at 1-year, 57.6% at 2-year, and 44.0% at 5-year follow-up, but CA significantly reduced all-cause mortality [hazard ratio (HR): 0.342, 95% confidence interval (CI): 0.133–0.876, P = 0.025], cardiovascular mortality (HR: 0.378, 95% CI: 0.146–0.981, P = 0.045), and HF hospitalization (HR: 0.488, 95% CI: 0.269–0.889, P = 0.019) compared with those without CA. There was no recurrence of the cavotricuspid isthmus (CTI)–dependent AFL, non-CTI–dependent simple AFL terminated by one linear ablation, and focal AT originating from the atrioventricular (AV) annulus or crista terminalis eventually. Twelve of 13 patients with paroxysmal AF and 27 of 29 patients with persistent AF did not have recurrence as AF. However, all three patients with non-CTI–dependent complex AFL not terminated by a single linear ablation and 10 of 13 cases with focal AT or multiple focal ATs originating beyond the AV annulus or crista terminalis recurred even after multiple CA.

Conclusion

The outcomes of CA for ATTRwt-CM were acceptable, except for multiple focal AT and complex AFL. Catheter ablation may be aggressively considered as a treatment strategy with the expectation of improving mortality and hospitalization for HF.
‘Disturbing the Work of the Office’: The Limits of Refugee Collective Action on ‘UNHCR Territory’ in Beirut
Authors: Janmyr Maja
Published: June 2024

There is a tension in the policy and practice of refugee presence in and around the offices of the United Nations High Commissioner for Refugees (UNHCR). The core principle of direct accessibility to UNHCR is continuously balanced against other competing concerns. But what, in policy and practice, are these competing concerns? And at what point does the presence of refugees and other protection seekers become illegitimate from the perspective of UNHCR? Building on original empirical research, this article explores collective action by Sudanese protection seekers at UNHCR’s office in Beirut, Lebanon. It shows how the spatial practices of UNHCR influence its relationship with protection seekers, and how these relations intersect with broader dynamics of securitization. In Beirut, once a presence was considered to ‘disturb the work of the Office’, a more restrictive policy involving host state security was triggered. The article interrogates what it means to ‘disturb the work of the Office’ in the context of a heavily securitized city and spotlights the blocking of UNHCR entrance doors in Beirut as a pivotal example of when collective action is considered by UNHCR to be so disturbing that protection seekers are to be forcibly removed from UNHCR ‘territory’.
Carbapenemase gene blaOXA-48 detected at six freshwater sites in Northern Ireland discharging onto identified bathing locations
Authors: Brooks Catherine , Mitchell Elaine , Brown James , O'Donovan Sinéad , Carnaghan Kelly-Anne , Bleakney Eoin , Arnscheidt Joerg
Published: June 2024

Faecal contamination of surface waters has the potential to spread not only pathogenic organisms but also antimicrobial resistant organisms. During the bathing season of 2021, weekly water samples, from six selected coastal bathing locations (n = 93) and their freshwater tributaries (n = 93), in Northern Ireland (UK), were examined for concentrations of faecal indicator bacteria Escherichia coli and intestinal enterococci. Microbial source tracking involved detection of genetic markers from the genus Bacteroides using PCR assays for the general AllBac marker, the human HF8 marker and the ruminant BacR marker for the detection of human, and ruminant sources of faecal contamination. The presence of beta-lactamase genes blaOXA-48, blaKPC, and blaNDM-1 was determined using PCR assays for the investigation of antimicrobial resistance genes that are responsible for lack of efficacy in major broad-spectrum antibiotics. The beta-lactamase gene blaOXA-48 was found in freshwater tributary samples at all six locations. blaOXA-48 was detected in 83% of samples that tested positive for the human marker and 69% of samples that tested positive for the ruminant marker over all six locations. This study suggests a risk of human exposure to antimicrobial resistant bacteria where bathing waters receive at least episodically substantial transfers from such tributaries.
50 Studies Every Orthopaedic Surgeon Should Know
Authors: Doudoulakis Konstantinos
Published: June 2024

50 Studies Every Orthopaedic Surgeon Should Know is a compilation of landmark studies from all subspecialties within emergency and elective trauma and orthopaedic practice. It is written in an accessible way, appropriate for an array of practicing experts, allied healthcare professionals, and students with the goal of disseminating findings from high-quality studies that have led to standardized clinical guidelines for front-line clinicians and real-world gains for patients. Chapters focus on key findings, implications for practice, study funding sources and conflicts of interest, criticisms and limitations, and results from associated studies. Each chapter also concludes with a case study, offering readers the opportunity to conceptualize the key findings in practice. Like other books in the 50 Studies series, an objective selection criterion was conducted by an international consensus to identify the most influential landmark publications that took into account the citations per year, high levels of evidence, clinical studies and trials, and available references and guidelines. This book will simplify, consolidate, and reinforce the current literature of the most important research published into digestible, manageable, and reader-friendly content for trauma and orthopaedic surgeons, practicing clinicians, trainees, students, and those led by data-driven evidence-based clinical care. The general public and patients on the receiving end of clinical care may benefit from understanding the surgical decision-making backed by international evidence and professional guidelines.
Treatment for Acute Anterior Cruciate Ligament Tears
Authors: Blucher Nicola , Bhattee Ghias
Published: June 2024

A randomized trial compared the patient-reported outcomes of knee function following acute anterior cruciate ligament (ACL) reconstruction with structured rehabilitation versus potential delayed ACL reconstruction in young, active adults. It randomized patients who had sustained an acute ACL injury into two groups. Twenty-three (38.9%) of the patients in the structured rehabilitation group went on to have ACL reconstruction within the study period. There was no difference in patient-reported outcomes of knee function at two years between patients who had acute surgery and those who had rehabilitation followed by delayed surgery in symptomatic patients.
Open Reduction and Internal Fixation versus Primary Arthrodesis for Primarily Ligamentous Lisfranc Joint Injuries
Authors: Rafferty Michael , Ieong Edmund , Gill Ian
Published: June 2024

Lisfranc injuries can often result in chronic disability. There is still controversy over the optimal treatment for a Lisfranc injury. There is no consensus as to whether outcomes are better with open reduction and internal fixation (ORIF) or with primary arthrodesis for the treatment of Lisfranc injuries. This prospective randomized trial compares the complication rate, patient satisfaction, functional outcomes, American Orthopaedic Foot and Ankle Society score, and visual analog scale scores between primary arthrodesis or ORIF for primarily ligamentous Lisfranc injuries. Advantages of arthrodesis over ORIF are discussed in this level 1 study from the United States.
Surgical versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcome Research Trial
Authors: Nazeer Moideen Abdul , Khurana Ashish
Published: June 2024

The SPORT trial, published in 2010 with a review of 654 patients, analyzed surgical vs. nonsurgical treatment for lumbar spinal stenosis. All patients with neurogenic claudication or radicular symptoms with confirmatory imaging showing lumbar stenosis at one or more levels and symptoms for a minimum of twelve weeks were included. Patients in the surgical group received a standard posterior decompressive laminectomy. Patients in the nonsurgical group received physiotherapy, education/counseling with home exercise, nonsteroidal anti-inflammatories, and spinal injections as appropriate. Patients with spinal stenosis treated surgically showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over four years compared to patients treated nonoperatively.
Vertebroplasty versus Sham Procedure for Management of Painful Osteoporotic Vertebral Fractures
Authors: Ibish Shireen , Brown Chris
Published: June 2024

This randomized controlled trial compares vertebroplasty to a sham procedure. Vertebroplasty has been used for the treatment of painful osteoporotic vertebral fractures, and this chapter analyzes a study comparing the outcomes of seventy-eight patients after randomization to either vertebroplasty or a sham procedure with a six-months posttreatment follow-up period. The authors concluded that no superior benefit was noted in the vertebroplasty cohort compared to the control group. Despite its limitations, the conclusion is backed by more recent studies with a longer follow-up period showing a similar pattern. Guidelines recommend that vertebroplasty should be reserved for patients with pain clearly linked to the site of the vertebral fracture who remain in significant discomfort despite optimal pain management.
Autologous Chondrocyte Implantation Compared with Microfracture in Isolated Symptomatic Chondral Defect of the Knee
Authors: Abukar Amin , Sri-Ram Kesavan
Published: June 2024

This was a randomized trial comparing autologous chondrocyte implantation with microfracture in patients with an isolated symptomatic chondral defect in the knee. This study published the initial short-term results at the two-year follow-up for the treatment groups. Compared with baseline, there were significant clinical improvements in both groups (using Lysholm, visual analog, and SF-36 scores). Between the treatment groups, the clinical results were similar; however, the microfracture group had a significantly better SF-36 physical component score. Additionally, patients within the microfracture group with smaller chondral defects (< 4 cm2) had significantly better clinical results; this association between chondral size defect and clinical outcome was not found in the autologous chondrocyte implantation group. No association was found between the histological quality of the cartilage biopsy and the clinical outcomes in both groups.
A Meta-Analysis of Ankle Arthrodesis versus Replacement
Authors: Milnes Lydia , Sugand Kapil , Ramesh Palanisamy
Published: June 2024

The efficacy of ankle replacement versus arthrodesis remains a contentious issue. Medline was searched for relevant articles reporting outcome of ankle arthroplasty or arthrodesis. This systematic review revealed to date no direct comparisons of the two treatment options. Included were forty-nine primary studies: ten (20%) evaluating arthroplasty and thirty-nine (80%) evaluating arthrodesis. The means and counts of each study were collated for ankle function, pain, revision, and quality of life and weighted according to sample size. Both ankle replacement and arthrodesis have good results; neither one has been shown by this review to be superior to the other.
A Multicenter, Prospective, Randomized, Controlled Trial of Open Reduction—Internal Fixation versus Total Elbow Arthroplasty for Displaced Intra-Articular Distal Humeral Fractures in Elderly Patients
Authors: Khan Yasmeen , Sugand Kapil , Ahearne David
Published: June 2024

This chapter reviews the management of complex intra-articular distal humeral fractures in the elderly population. It is a multicenter prospective randomized controlled trial comparing the treatment options of open reduction and internal fixation (ORIF) against total elbow arthroplasty (TEA). Twenty patients were randomized to each group with clear inclusion and exclusion criteria. The outcome measures included the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Complications, duration of procedure, and reoperations were reported with statistical analysis. Patients treated with TEA had significantly improved MEPSs at all time points in the follow-up period.
Breathlessness
Authors: Lovell Natasha , Bajwah Sabrina
Published: June 2024

Chronic or refractory breathlessness is common and distressing with few effective treatment options. It is experienced by almost all people living with chronic obstructive pulmonary disease (COPD) as well as people living with other chronic lung diseases, chronic heart failure, and advanced cancer. It is distressing for those experiencing it, often resulting in anxiety, physical inactivity, and a poor quality of life. It also impacts significantly on those who are close, including friends and family, with a considerable care burden. The best current evidence is for non-pharmacological interventions, which should take priority initially alongside optimal management of the underlying disease. However, as diseases progress and the severity of breathlessness increases, participation in non-pharmacological interventions such as pulmonary rehabilitation can become more challenging, often limited by physical deconditioning and fatigue. At this stage pharmacological treatments may be indicated, alongside the initiation of prognostic conversations and advance care planning.
Bowel Obstruction
Authors: Webster Sarah , Rea Emily , Husbands Emma
Published: June 2024

This case provides a summary of the presentation, aetiology, diagnosis, and management of palliative bowel obstruction. We focus on malignant bowel obstruction (MBO), which is the most prevalent cause seen in palliative care, describing the different aetiologies, including mechanical and functional obstruction, which may be partial or complete. We cover key aspects of the history, relating symptoms to the level of obstruction. We describe common examination findings and which investigations should be carried out to confirm the diagnosis. We discuss ‘acceleration’ and ‘neutral bowel’ approaches to the management of MBO, as well as ‘putting the brakes on’. Readers should also consider the role of surgery in management. The patient’s goals and priorities should be central to decision-making.
Mouth Care
Authors: Rowley Grace , Lodge Philip
Published: June 2024

This case explores the common oral conditions that may present in palliative care patients and the physical and psychological impacts that oral discomfort may cause. It discusses the presentation of oral mucositis and the challenges that this brings to patients undergoing cancer treatment. It reviews the guidance for the management of oral mucositis, including the use of photobiomodulation therapy. The presentations and pharmacological management of oral candidiasis are discussed. The common symptom of xerostomia is considered, why it can be such a distressing symptom and approaches to reduce its symptom burden. This case also explores the role of dental care, nutrition, and oral hygiene support as part of a multidisciplinary approach to palliative oral care.
Uncertainty and Prognostication
Authors: Etkind Simon Noah , Stone Paddy
Published: June 2024

Uncertainty is an inevitable part of experience in advanced illness; it is experienced by patients, carers, and health professionals. Uncertainty may relate to illness, care, or treatment and is part of the unpredictable illness trajectories of complex illness and multimorbidity. Unpredictable illness trajectories make prognostication difficult, and clinicians may struggle to provide individualized survival predictions. However, people often report that they find it valuable to have prognostic information. Here we consider the uncertainties associated with advanced illness, and approaches to addressing uncertainty. We discuss prognostication in a palliative care context, including the accuracy of clinical estimates of prognosis and tools to support prognostication.
Coordination and Transfer of Care
Authors: Hill Rosanna , Hurlow Adam
Published: June 2024

This case reviews the case of a woman with advanced oesophageal cancer who has an unplanned hospital admission and, despite initial response to treatment, is recognized to be approaching the final weeks of life. It explores how to recognize someone who may be approaching the end of life (EoL), using both patient history and biological markers. It then explores the transfer of care out of hospital informed by the individual’s goals and priorities, including coordinating care between settings and effective documentation and sharing of agreed care preferences and treatment recommendations. It also reviews the anticipation and management of common symptoms, paying attention to anticipatory prescribing and managing bleeding at the EoL.
What to Expect with a Death at Home
Authors: Oxley Tammy , Malia Catherine
Published: June 2024

‘What to Expect with Death at Home’ examines the process of dying at home and key considerations for patients, relatives, and health professionals. It reviews recent trends in the number of patients dying at home, views on home as a preferred place of death and barriers and facilitators to achieving this. It discusses care and support for patients and relatives; both before and after death and from a range of individuals and services, including healthcare professionals and those working in the third sector. The provision of anticipatory medications is discussed, including recent advances in carer administration of subcutaneous medications in the community. The lived experiences of relatives of patients who have died at home are considered.
Delirium
Authors: Jackson Kitty , Wood Felicity
Published: June 2024

This case examines the prevention, recognition, and management of delirium in a palliative care setting. Delirium is common in palliative care patients and is associated with clinical complications and worse patient outcomes. This case reviews common risk factors for delirium. Non-pharmacological interventions that can be enacted to prevent delirium are explored, and the absence of any medication intervention to prevent delirium is discussed. The case examines the diagnosis of delirium, including the importance of screening because delirium is commonly missed or misdiagnosed. It also explains the psychomotor subtypes of delirium and the relationship between delirium and terminal agitation. The management of delirium covers assessment and treatment of reversible causes as well as non-pharmacological and pharmacological management approaches. The importance of communication with patient and family about delirium is emphasised. These approaches are considered in the context of palliative care and the key concerns distinctive to this patient population are examined.