Evaluation of foot hypoperfusion and estimation of percutaneous transluminal angioplasty outcome in patients with critical limb ischemia using intravoxel incoherent motion microperfusion MRI

Objectives:To emerge hypoperfusion of lower limbs in patients with critical limb ischemia (CLI) using Intravoxel Incoherent Motion microperfusion magnetic resonance imaging (IVIM-MRI). Moreover to examine the ability of IVIM-MRI to differentiate patients with severe peripheral arterial disease (PAD) from normal subjects and evaluate the percutaneous transluminal angioplasty (PTA) results in patients with CLI.Methods:Eight patients who presented with CLI and six healthy volunteers were examined. The patients underwent IVIM-MRI of lower extremity before and following PTA. The imaging protocol included sagittal diffusion-weighted (DW) sequences. DW images were analyzed and color parametric maps of the micro-circulation of blood inside the capillary network (D*) were constructed. The studies were evaluated by two observers to define interobserver reproducibility.Results:Technical success was achieved in all patients (8/8). The mean ankle-brachial index increased from 0.35 ± 0.2 to 0.76 ± 0.25 (p < 0.05). Successful revascularization improved IVIM microperfusion. Mean D* increased from 279.88 ± 13.47 10⁻⁵ mm²/s to 331.51 ± 31 10⁻⁵ mm²/s, following PTA, p < 0.05. Moreover, PAD patients presented lower D* values as compared to healthy individuals (279.88 ± 13.47 10⁻⁵ mm²/s vs 332.47 ± 22.95 10⁻⁵ mm²/s, p < 0.05, respectively). Good interobserver agreement was obtained with an ICC = 0.84 (95% CI 0.64–0.93).Conclusions:IVIM-MRI can detect differences in microperfusion between patients with PAD and healthy individuals. Moreover, significant restitution of IVIM microperfusion is found following successful PTA.Advances in knowledge:IVIM-MRI is a safe, reproducible and effective modality for evaluation of lower limb hypoperfusion in patients with PAD. It seems also to be a helpful tool to detect changes of tissue perfusion in patients with CLI following revascularization.     

The current status of risk-stratified breast screening

Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.Subject terms: Breast cancer, Cancer epidemiology     

Clinical contraindications to allergen immunotherapy: an EAACI position paper

Clinical indications for allergen immunotherapy (AIT) in respiratory and Hymenoptera venom allergy are well established; however, clinical contraindications to AIT are not always well documented. There are some discrepancies when classifying clinical contraindications for different forms of AIT as ‘absolute’ or ‘relative’. EAACI Task Force on ‘Contraindications to AIT’ was created to evaluate and review current literature on clinical contraindications, and to update recommendations for both sublingual and subcutaneous AIT for respiratory and venom immunotherapy. An extensive review of the literature was performed on the use of AIT in asthma, autoimmune disorders, malignant neoplasias, cardiovascular diseases, acquired immunodeficiencies and other chronic diseases (including mental disorders), in patients treated with β‐blockers, ACE inhibitors or monoamine oxidase inhibitors, in children under 5 years of age, during pregnancy and in patients with poor compliance. Each topic was addressed by the following three questions: (1) Are there any negative effects of AIT on this concomitant condition/disease? (2) Are more frequent or more severe AIT‐related side‐effects expected? and (3) Is AIT expected to be less efficacious? The evidence, for the evaluation of these clinical conditions as contraindications, was limited, and most of the conclusions were based on case reports. Based on an extended literature research, recommendations for each medical condition assessed are provided. The final decision on the administration of AIT should be based on individual evaluation of any medical condition and a risk/benefit assessment for each patient.     

Trends and Risk Factors of In-Hospital Mortality of Patients with COVID-19 in Germany: Results of a Large Nationwide Inpatient Sample

Unselected data of nationwide studies of hospitalized patients with COVID-19 are still sparse, but these data are of outstanding interest to avoid exceeding hospital capacities and overloading national healthcare systems. Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality, and mechanical ventilation (MV) in patients with COVID-19 in Germany. We used the German nationwide inpatient samples to analyze all hospitalized patients with a confirmed COVID-19 diagnosis in Germany between 1 January and 31 December in 2020. We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Overall, age ≥ 70 years (OR 5.91, 95%CI 5.70–6.13, p < 0.001), pneumonia (OR 4.58, 95%CI 4.42–4.74, p < 0.001) and acute respiratory distress syndrome (OR 8.51, 95%CI 8.12–8.92, p < 0.001) were strong predictors of in-hospital death. Most COVID-19 patients were treated in hospitals in urban areas (n = 92,971) associated with the lowest case-fatality (17.5%), as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between the 6th and 8th age decade. In the first age decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV, and five of them died (0.3%). The results of our study indicate seasonal and regional variations concerning the number of COVID-19 patients, necessity of MV, and case fatality in Germany. These findings may help to ensure the flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional healthcare systems.     

Incidental parathyroidectomy during total thyroidectomy

Aim — Background

Total thyroidectomy is the procedure of choice in many diseases of the thyroid gland. This study measures the frequency of incidental parathyroidectomy during thyroidectomy in our department and values the possible correlation between certain clinical parameters, such as inflammation and malignancy, and the frequency of incidental parathyroidectomy.

Patients — Methods

A retrospective study was conducted for the period July 2009–June 2012. The study included 63 patients (51 female, 12 male) with total thyroidectomy. We measured the number of parathyroid glands as recorded in the pathology reports and we compared this with the original disease of the thyroid gland.

Results

Parathyroid tissue was found in 12 cases (19%). One parathyroid gland was found in nine (14%) specimens (group A), and two parathyroid glands were found in three (5%) (group B). The cases in group A comprised: 5/21 (24%) goiter, 3/23 (13%) thyroid cancer, 1/19 (5%) thyroid nodule, and in group B: 1/21 (5%) goiter, 2/23 (9%) thyroid cancer. In 75% of all cases (both groups A & B), there was significant inflammation of the thyroid gland.

Conclusion

Incidental parathyroidectomy during thyroidectomy is usually found in cases of severe inflammation, goiter or thyroid cancer. It is essential that the surgeon recognizes and preserves the parathyroid glands during thyroidectomy.     

Robot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy

Background

Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery.

Objective

We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ–preserving approaches in men and women.

Design, setting, and participants

Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC.

Surgical procedure

We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ–preserving approaches.

Outcome measurements and statistical analysis

Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis.

Results and limitations

RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37–84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0–57). Twenty percent of patients had lymph node–positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3–107). We recorded a total of 70 early complications (0–30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr.

Conclusions

Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.     

Effect of image normalization on carotid plaque classification and the risk of ipsilateral hemispheric ischemic events: results from the asymptomatic carotid stenosis and risk of stroke study

The aim of this study was to determine the effect of image normalization on plaque classification and the risk of ipsilateral ischemic neurologic events in patients with asymptomatic carotid stenosis. The first 1,115 patients recruited to the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study with a follow-up of 6 to 84 months (mean 37.1 months) were included in this study. Duplex ultrasonography was used for grading the degree of internal carotid artery stenosis and for plaque characterization (types 1-5), which was performed before and after image normalization. One hundred sixteen ipsilateral ischemic hemispheric events occurred. Image normalization resulted in 60% of plaques being reclassified. Before image normalization, a high event rate was associated with all types of plaque. After image normalization, 109 (94%) of the events occurred in patients with plaque types 1 to 3. For patients with European Carotid Stenosis Trial (ECST) 70 to 99% diameter stenosis (equivalent to North American Symptomatic Carotid Endarterectomy Trial [NASCET] 50-99%) with plaque types 1 to 3, the cumulative stroke rate was 14% at 7 years (2% per year), and for patients with plaque types 4 and 5, the cumulative stroke rate was 0.9% at 7 years (0.14% per year). The results suggest that asymptomatic patients with plaque types 4 and 5 classified as such after image normalization are at low risk irrespective of the degree of stenosis.     

Using web‐based training to improve accuracy of blood pressure measurement among health care professionals: A randomized trial

Accurate blood pressure measurement is crucial for proper screening, diagnosis, and monitoring of high blood pressure. However, providers are not aware of proper blood pressure measurement skills, do not master all the appropriate skills, or miss key steps in the process, leading to inconsistent or inaccurate readings. Training in blood pressure measurement for most providers is usually limited to a one‐time brief demonstration during professional education coursework. The American Medical Association and the American Heart Association developed a 30‐minute e‐Learning module designed to refresh and improve existing blood pressure measurement knowledge and clinical skills among practicing providers. One hundred seventy‐seven practicing providers, which included medical assistants, nurses, advanced practice providers, and physicians, participated in a multi‐site randomized educational study designed to assess the effect of this e‐Learning module on blood pressure measurement knowledge and skills. Participants were randomized 1:1 to either the intervention or control group. The intervention group followed a pre‐post assessment approach, and the control group followed a test‐retest approach. The initial assessment showed that participants in both the intervention and control groups correctly performed less than half of the 14 skills considered necessary to obtain an accurate blood pressure measurement (mean scores 5.5 and 5.9, respectively). Following the e‐Learning module, the intervention group performed on average of 3.4 more skills correctly vs 1.4 in the control group (P < .01). Our findings reinforce existing evidence that errors in provider blood pressure measurements are highly prevalent and provide novel evidence that refresher training improves measurement accuracy.     

Effect of Psychosocial Interventions on Quality of Life in Patients With Chronic Heart Failure: A Meta-analysis of Randomized Controlled Trials

BackgroundPatients with chronic heart failure (CHF) usually experience poor quality of life (QoL). Psychosocial interventions tend to affect QoL in CHF. The aim of this study was to explore: 1) the effectiveness of psychosocial interventions on patients' QoL; 2) the magnitude of this effect; and 3) factors that appear to moderate the reported effect on QoL.Methods and ResultsMeta-analysis of the data of 1,074 intervention patients and 1,106 control patients from 16 randomized controlled trials (RCTs) that reported QoL measures in treatment and control groups before and after a psychosocial intervention. Subgroup analyses were conducted between: 1) face-to-face versus telephone interventions; 2) interventions that included only patients versus those that included patients and their caregivers; and 3) interventions conducted by a physician and a nurse only, versus those conducted by a multidisciplinary team. Psychosocial interventions improved QoL of CHF patients (standardized mean difference 0.46, confidence interval [CI] 0.19–0.72; P < .001). Face-to-face interventions showed greater QoL improvement compared with telephone interventions (χ² = 5.73; df = 1; P < .02). Interventions that included caregivers did not appear to be significantly more effective (χ² = 1.12; df = 1; P > .29). A trend was found for multidisciplinary team approaches being more effective compared with nonmultidisciplinary approaches (χ² = 1.96; df = 1; P = .16).ConclusionsA significant overall QoL improvement emerged after conducting psychosocial interventions with CHF patients. Interventions based on a face-to-face approach showed greater benefit for patients' QoL compared with telephone-based approaches. No significant advantage was found for interventions conducted by a multidisciplinary team compared with a physician and nurse approach, or for psychosocial interventions which included patients' caregivers compared with patient-only approaches.     

Patterns of autophagy in urothelial cell carcinomas—the significance of “stone-like” structures (SLS) in transurethral resection biopsies

ObjectivesTo investigate the microtubule-associated protein LC3A, presumed to reflect autophagic activity, in urothelial cell carcinomas (UCC) for its relevance with muscle invasion in transurethral resection (TUR) biopsies. The LC3A antibody is specific for identifying the autophagy-related protein Atg8 and, hence, autophagy—a self-degradation mechanism by which cells recycle their own cytoplasmic constituents, providing with additional energy the rapidly proliferating cells.MethodsThe study comprised 210 TUR specimens of UCC of the urinary bladder: 70 low-grade non-muscle-invasive (NMI, group A), 70 high-grade NMI (group B), and 70 high-grade muscle invasive tumors (group C). These, together with 40 controls, were stained for Atg8/LC3 using an automated immunohistochemical technique.ResultsThe LC3A was detected as diffuse cytoplasmic staining, and as dense, spheroidal, “stone-like” structures (SLS) of variable size (1.2–12.0 μm in diameter), typically enclosed within cytoplasmic vacuoles. The LC3A reactivity, whether expressed in the form of SLS or as diffuse cytoplasmic staining, was higher in high-grade UCC than in low-grade disease and, more importantly, it was associated with muscle invasion. The median number of SLS per optical field, per section was 17.0, 19.0, and 37.0 for groups A, B, and C, respectively (A, B vs. C P < 178> 0.0001; A vs. B P = 0.27). The median SLS diameter was 4.9, 5.3, and 9.3 μm for groups A, B, and C respectively (A, B, vs. C P < 0.0001; A vs. B P = 0.03).ConclusionIt appears that the LC3A protein is closely connected with muscle invasion, but whether this finding is of clinical value in TUR specimens lacking muscularis propria remains to be proven.