Undiagnosed Chronic Obstructive Pulmonary Disease is Highly Prevalent in Patients Referred for Dobutamine Stress Echocardiography with Shortness of Breath.

PURPOSE: Shortness of breath (SOB) is a common symptom referral for dobutamine stress echocardiography (DSE). Patients with SOB and a normal DSE have worse long-term outcome than the general population. This suggests multiple aetiologies are involved. The purpose of this study was to assess the prevalence and clinical significance of undiagnosed COPD amongst patients referred for a DSE with SOB. METHODS: We prospectively studied 114 patients referred for DSE with SOB without prior evidence of lung disease (mean age 64.9 ± 18.5 years, 60 male). Respiratory function testing using spirometry was performed on all patients on the day of their DSE. The study end-points were cardiac events and total mortality. RESULTS: Respiratory function testing and DSE was performed in all patients and COPD was highly prevalent (n = 93). Multivariate Cox regression analysis was used to estimate the effect of dyspnoea on non-fatal cardiac events (NFCE) and all-cause mortality. Over a mean follow-up of 4.5 ± 2.6 years, the composite end-point of NFCE and all-cause mortality occurred in 62.7% and 16.7% patients, respectively. COPD (HR 1.27; 95% CI 1.17-1.93), previous myocardial infarction (HR 1.84; 95% CI 1.06-3.2), myocardial ischaemia (HR 2.56; 95% CI 1.48-4.43), peak wall motion score index (HR 4.66; 95% CI 2.26-9.6), and mitral E/E' (HR 1.21; 95% CI 1.1-1.33) were significantly associated with a NFCE. Myocardial ischaemia (HR 4.43; 95% CI 1.24-15.81) was the only independent predictor of all-cause mortality. CONCLUSION: Undiagnosed COPD is highly prevalent and independently associated with worse outcome amongst patients with SOB referred for DSE. Symptom presentation is therefore an important consideration when interpreting DSE results.

A Novel Method of Vein Detection with the Use of Digital Image Correlation.

Digital image correlation may be useful in many different fields of science, one of which is medicine. In this paper, the authors present the results of research aimed at detecting skin micro-shifts caused by pulsation of the veins. A novel technique using digital image correlation (DIC) and filtering the resulting shifts map to detect pulsating veins was proposed. After applying the proposed method, the veins in the forearm were visualized. The proposed technique may be used in the diagnosis of venous stenosis and may also contribute to reducing the number of adverse events during blood collection. The great advantage of the proposed method is the lack of the need to have specialized equipment, only a typical mobile phone camera is needed to perform the test.

Quality of Life in Patients over Age 65 after Intestinal Ostomy Creation as Treatment of Large Intestine Disease.

INTRODUCTION: For patients with severe intestinal diseases, ostomy surgery can be health-preserving and even lifesaving. Unfortunately, stoma creation also results in a morbidity that patients must manage. Utilization of the correct ostomy appliances is essential for the patient to regain full daily fitness. Patients also now have access to stoma clinics and fistula support groups where they can receive education and emotional support. AIM: The aim of the study was to assess the quality of life of patients over 65 years of age with an intestinal stoma, created for treatment of severe colorectal disease. MATERIAL AND METHODS: The study involved 100 patients (52 women, 48 men) over the age of 65 with an intestinal stoma. Demographic and medical information was collected. The patients completed diagnostic surveys using the SF-36v2 questionnaire and the author's questionnaire. RESULTS: Analysis demonstrated statistically significant relationships between the quality of life of the patient population and stressors of everyday life. Furthermore, there are statistically significant relationships between quality of life and demographic factors including age, marital status, place of residence, and education. Only gender was not a statistically significant factor. CONCLUSIONS: A lengthened time interval to intestinal stoma creation is associated with an improved quality of life as well as psychological and emotional acceptance of the intestinal stoma. Support relationships with loved ones is associated with the acceptance of an intestinal stoma. There is a relationship between acceptance of an intestinal stoma and demographic factors such as marital status, place of residence, and education. Gender did not show any significant relationship. Stoma complications are not related to the acceptance of an intestinal stoma.

Exercise Mode in Heart Failure: A Systematic Review and Meta-Analysis.

BACKGROUND: Optimising exercise prescription in heart failure (HF) with a preserved (HFpEF) or reduced (HFrEF) ejection fraction is clinically important. As such, the aim of this meta-analysis was to compare traditional moderate intensity training (MIT) against combined aerobic and resistance training (CT) and high-intensity interval training (HIIT) for improving aerobic capacity (VO2), as well as other clinically relevant parameters. METHODS: A comprehensive systematic search was performed to identify randomised controlled trials published between 1990 and May 2021. Research trials reporting the effects of MIT against CT or HIIT on peak VO2 in HFpEF or HFrEF were considered. Left-ventricular ejection fraction (LVEF) and various markers of diastolic function were also analysed. RESULTS: Seventeen studies were included in the final analysis, 4 of which compared MIT against CT and 13 compared MIT against HIIT. There were no significant differences between MIT and CT for peak VO2 (weighted mean difference [WMD]: 0.521 ml min-1 kg-1, [95% CI] = - 0.7 to 1.8, Pfixed = 0.412) or LVEF (WMD: - 1.129%, [95% CI] = - 3.8 to 1.5, Pfixed = 0.408). However, HIIT was significantly more effective than MIT at improving peak VO2 (WMD: 1.62 ml min-1 kg-1, [95% CI] = 0.6-2.6, Prandom = 0.002) and LVEF (WMD: 3.24%, [95% CI] = 1.7-4.8, Prandom < 0.001) in HF patients. When dichotomized by HF phenotype, HIIT remained significantly more effective than MIT in all analyses except for peak VO2 in HFpEF. CONCLUSIONS: HIIT is significantly more effective than MIT for improving peak VO2 and LVEF in HF patients. With the exception of peak VO2 in HFpEF, these findings remain consistent in both phenotypes. Separately, there is no difference in peak VO2 and LVEF change following MIT or CT, suggesting that the addition of resistance exercise does not inhibit aerobic adaptations in HF.

Pre-processing methods in chest X-ray image classification.

BACKGROUND: The SARS-CoV-2 pandemic began in early 2020, paralyzing human life all over the world and threatening our security. Thus, the need for an effective, novel approach to diagnosing, preventing, and treating COVID-19 infections became paramount. METHODS: This article proposes a machine learning-based method for the classification of chest X-ray images. We also examined some of the pre-processing methods such as thresholding, blurring, and histogram equalization. RESULTS: We found the F1-score results rose to 97%, 96%, and 99% for the three analyzed classes: healthy, COVID-19, and pneumonia, respectively. CONCLUSION: Our research provides proof that machine learning can be used to support medics in chest X-ray classification and improving pre-processing leads to improvements in accuracy, precision, recall, and F1-scores.

Mending the broken valentine heart: a case report.

Background: Mortality from myocardial infarction (MI) has been decreasing since the introduction of primary percutaneous intervention. Late complications still pose a dilemma, such as deterioration of left ventricle (LV) function, LV aneurysms, and LV thrombus formation. If not adequately managed in a timely manner, this can result in life-threatening consequences. Restoration of LV function by surgical resection of the infarcted LV wall is an option for a few complicated cases, with variable outcomes. Case summary: A 66-year-old man presented with dyspnoea 2 years after his initial MI, which was treated with a drug-eluting stent to his left circumflex artery. His Warfarin had been stopped after 6 months of treatment of a small LV thrombus, which was noted at the time of his initial infarction. His echocardiogram on admission demonstrated severe LV systolic impairment of 23% (which had deteriorated from 40%) with a giant true aneurysm of the basal to mid-lateral wall, which resembled a Valentine heart. The presence of a large, organized thrombus filling the aneurysm complicated the case further. The patient underwent a resection of the LV aneurysm and thrombus. He remained asymptomatic and maintained a significant improvement of his LV function to 47% at his 5 months scan. Discussion: The importance of imaging post-large MI and follow-up imaging once thrombus resolution has occurred is crucial. Patients with large LV aneurysm associated with severe refractory LV impairment and LV thrombus should be considered for LV aneurysmectomy for prognostic benefit and symptom relief.

Predictions of cervical cancer identification by photonic method combined with machine learning.

Cervical cancer is one of the most commonly appearing cancers, which early diagnosis is of greatest importance. Unfortunately, many diagnoses are based on subjective opinions of doctors-to date, there is no general measurement method with a calibrated standard. The problem can be solved with the measurement system being a fusion of an optoelectronic sensor and machine learning algorithm to provide reliable assistance for doctors in the early diagnosis stage of cervical cancer. We demonstrate the preliminary research on cervical cancer assessment utilizing an optical sensor and a prediction algorithm. Since each matter is characterized by refractive index, measuring its value and detecting changes give information about the state of the tissue. The optical measurements provided datasets for training and validating the analyzing software. We present data preprocessing, machine learning results utilizing four algorithms (Random Forest, eXtreme Gradient Boosting, Naïve Bayes, Convolutional Neural Networks) and assessment of their performance for classification of tissue as healthy or sick. Our solution allows for rapid sample measurement and automatic classification of the results constituting a potential support tool for doctors.

A Novel Lightweight Approach to COVID-19 Diagnostics Based on Chest X-ray Images.

BACKGROUND: This paper presents a novel lightweight approach based on machine learning methods supporting COVID-19 diagnostics based on X-ray images. The presented schema offers effective and quick diagnosis of COVID-19. METHODS: Real data (X-ray images) from hospital patients were used in this study. All labels, namely those that were COVID-19 positive and negative, were confirmed by a PCR test. Feature extraction was performed using a convolutional neural network, and the subsequent classification of samples used Random Forest, XGBoost, LightGBM and CatBoost. RESULTS: The LightGBM model was the most effective in classifying patients on the basis of features extracted from X-ray images, with an accuracy of 1.00, a precision of 1.00, a recall of 1.00 and an F1-score of 1.00. CONCLUSION: The proposed schema can potentially be used as a support for radiologists to improve the diagnostic process. The presented approach is efficient and fast. Moreover, it is not excessively complex computationally.

Longitudinal survey of antibiotic stewardship practices in Wisconsin nursing homes, before and after a policy change.

The Centers for Medicare and Medicaid mandated that nursing homes implement antibiotic stewardship programs (ASPs) by November 2017. We conducted surveys of Wisconsin nursing-home stewardship practices before and after this mandate. Our comparison of these surveys shows an overall increase in ASP implementation efforts, but it also highlights areas for further improvement.

Left ventricular assessment with artificial intelligence increases the diagnostic accuracy of stress echocardiography.

Aims: To evaluate whether left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), automatically calculated by artificial intelligence (AI), increases the diagnostic performance of stress echocardiography (SE) for coronary artery disease (CAD) detection. Methods and results: SEs from 512 participants who underwent a clinically indicated SE (with or without contrast) for the evaluation of CAD from seven hospitals in the UK and US were studied. Visual wall motion scoring (WMS) was performed to identify inducible ischaemia. In addition, SE images at rest and stress underwent AI contouring for automated calculation of AI-LVEF and AI-GLS (apical two and four chamber images only) with Ultromics EchoGo Core 1.0. Receiver operator characteristic curves and multivariable risk models were used to assess accuracy for identification of participants subsequently found to have CAD on angiography. Participants with significant CAD were more likely to have abnormal WMS, AI-LVEF, and AI-GLS values at rest and stress (all P < 0.001). The areas under the receiver operating characteristics for WMS index, AI-LVEF, and AI-GLS at peak stress were 0.92, 0.86, and 0.82, respectively, with cut-offs of 1.12, 64%, and -17.2%, respectively. Multivariable analysis demonstrated that addition of peak AI-LVEF or peak AI-GLS to WMS significantly improved model discrimination of CAD [C-statistic (bootstrapping 2.5th, 97.5th percentile)] from 0.78 (0.69-0.87) to 0.83 (0.74-0.91) or 0.84 (0.75-0.92), respectively. Conclusion: AI calculation of LVEF and GLS by contouring of contrast-enhanced and unenhanced SEs at rest and stress is feasible and independently improves the identification of obstructive CAD beyond conventional WMSI.

Does the Aortic Annulus Dilate After Aortic Root Remodeling?

BACKGROUND: The 2 main techniques of valve-sparing aortic root replacement (VSRR) are remodeling and reimplantation. There is concern that the aortic annulus, which is not stabilized in remodeling technique, may dilate over time and cause aortic regurgitation. Our aim was to assess whether the aortic annulus dilates after VSRR with remodeling technique without aortic annuloplasty. METHODS: Data on patients undergoing elective or urgent VSRR remodeling technique between 2005 and 2018 were collected. Patients undergoing arch and emergency surgery for acute type A aortic dissection were excluded. Preoperative aortic annulus diameter was measured by transthoracic echocardiography, and this was compared with the annulus diameter measured from the most recently available transthoracic echocardiography. The requirement for reintervention during follow-up was recorded. RESULTS: Between 2005 and 2018, 98 patients underwent VSRR. Sixty-six (67.3%) had Marfan syndrome or Loeys-Dietz syndrome. Median age was 60 (interquartile range, 18-68) years and 71 (72.4%) were men. Median cross-clamp and cardiopulmonary bypass times were 122 (interquartile range, 104-164) minutes and 138 (interquartile range, 121-198) minutes, respectively. Median intensive care unit and hospital stay were 1 day and 6 days, respectively. No patients suffered perioperative stroke. There was no in-hospital mortality. At median follow-up of 7.1 years (interquartile range, 5-129 months), mean postoperative annular diameter was 25.7 mm, from 24.2 mm preoperatively (P = .403). One patient required aortic valve replacement during follow-up. Freedom from moderate or severe aortic regurgitation was 97%. CONCLUSIONS: There was no significant aortic annular dilatation in selected patients undergoing remodeling VSRR. Our data do not support routine use of annuloplasty in patients with annular diameter less than or equal to 25 mm.

Myocardial deformation abnormalities in patients with aortic regurgitation: a strain rate imaging study.

AIMS: Early left ventricular (LV) dysfunction in asymptomatic patients with severe aortic regurgitation (AR) may go undetected due to the lack of a sufficiently sensitive diagnostic tool. Ultrasonic strain/strain rate (S/SR) imaging should now provide such sensitivity in detecting early dysfunction in regional LV systolic deformation. The aim of this study was to understand and define the changes in LV regional systolic deformation based on S/SR imaging in patients with asymptomatic or minimally symptomatic AR. METHODS AND RESULTS: Eighty-one individuals were studied: 59 asymptomatic patients with isolated non-ischaemic AR who were divided into three sub-groups such as mild, moderate, and severe AR and 22 age-matched healthy subjects. All patients underwent standard echocardiographic examinations including a tissue Doppler imaging study. For LV radial deformation, the posterior wall (LVPW) was examined. To assess LV longitudinal deformation, S and SR data were acquired from the LV lateral wall and septum. Radial as well as longitudinal peak systolic SRs were significantly decreased in patients with both moderate AR (LVPW, P=0.0009; septum, P=0.03; LV lateral wall, P=0.0009) and severe AR (P<0.0001) compared with healthy subjects. Changes in regional LV deformation correlated inversely both with LV end-diastolic volume and with end-systolic volume. CONCLUSIONS: Strain rate imaging is a sensitive tool in detecting the spectrum of changes in radial and longitudinal deformation in asymptomatic or minimally symptomatic patients with AR. The index where volume was corrected by deformation should form the basis for predicting subclinical LV dysfunction in patients with increasing LV dilatation.

Münchausen Syndrome as an Unusual Cause of Pseudo-resistant Hypertension: A Case Report.

Münchausen syndrome can be characterized by simulated illness, pathological lying and wandering from place to place (the patient typically presents to numerous hospitals). Individuals with elevated blood pressure due to non-adherence to medication have the so-called pseudo-resistant hypertension. A 45-year-old woman was admitted to hospital on an emergency basis because of a hypertensive crisis. Despite combination antihypertensive treatment, normalization of blood pressure was not achieved and a device to produce a therapeutic arteriovenous fi stula was implanted. Aft er the procedure, a signifi cant increase in pulmonary artery pressure was observed and closure of the fistula was performed by implantation of the stent graft . The suspicion was raised that the patient had not been taking her prescribed medications. Therefore, blood samples were taken and the serum was analyzed for presence of the prescribed drugs (atorvastatin, bisoprolol, chlorthalidone, clonidine, doxazosin, furosemide, nitrendipine, oxazepam and valsartan). The results confirmed suspected failure of the patient to take the prescribed medications. Münchausen syndrome is usually first suspected when inexplicable laboratory test results are noted. To our knowledge, this is the first reported case of Münchausen syndrome with pseudo-resistant hypertension leading to the implantation of a device to produce a therapeutic arteriovenous fi stula.

Usefulness of changes in left ventricular wall thickness to predict full or partial pressure reperfusion in ST-elevation acute myocardial infarction.

Experimental studies have shown that if an acute transmural myocardial infarction is reperfused at full pressure there is an immediate and persisting increase in end-diastolic wall thickness (EDWT) due to massive intramural edema, with the amount of edema inversely related to the residual stenosis in the infarct-related artery. This study investigated if these findings are paralleled in the clinical setting and whether the resultant myocardial substrate differs after percutaneous coronary intervention (PCI) versus thrombolysis (the latter having a higher incidence of residual flow limiting stenosis in the culprit vessel). Eighty-eight consecutive patients with ST-elevation myocardial infarction were enrolled. Twenty-seven patients underwent primary PCI, 23 had rescue PCI, and 38 had thrombolysis. Standard M-mode and 2-dimensional echocardiographies were performed within 12 hours. Regional EDWT was measured in 904 infarct-related segments after the different reperfusion strategies and compared with 504 remote noninfarcted segments. EDWT of infarct-related segments after primary PCI was significantly increased compared with normal segments. At follow-up, after 6 months, EDWT of these segments was significantly decreased, indicating transmural infarction. EDWT of infarct-related segments after thrombolysis did not differ from that of normal segments. After rescue PCI, EDWT of infarct-related segments was significantly decreased compared with that of normal segments. In conclusion, full-pressure restoration of epicardial blood flow after transmural myocardial infarction causes an immediate increase in EDWT, easily detected by echocardiography. In contrast, pressure-limiting reperfusion (typical for thrombolysis) resultsin normal EDWT. This confirms experimental data that PCI and thrombolysis can differ in their resultant myocardial substrate.

Full or pressure limited reperfusion of an acute myocardial infarct results in a different wall thickness and deformation of the distal myocardium--implications for clinical reperfusion strategies.

AIM: The study aim was to determine the sequence of changes in both wall thickness and function in 'at risk' myocardium (using M-mode and radial strain/strain-rate imaging) induced by reperfusion of an acute transmural infarction, and to relate these changes to the presence or absence of a pressure-limiting stenosis in the infarct related epicardial vessel. METHODS: Eighteen closed-chest pigs were randomized into two groups (each with nine animals). In Group I, 4 weeks prior to induction of an acute transmural infarct, a copper coated stent was implanted in the proximal circumflex artery (Cx) to create a coronary artery stenosis of between 30 and 95% lumen diameter. At 4 weeks, the stenotic Cx vessel was occluded for 90 min by inflation of a PTCA balloon placed proximal to the stenosis to produce an acute transmural infarction. In Group II (the control group), 90 min Cx occlusion was performed in a normal vessel. In both groups the resulting acute transmural infarction was reperfused after 90 min by removing the PTCA balloon. For both groups, cardiac ultrasound data, including strain/strain-rate imaging, were collected at all stages of the investigation for subsequent offline analysis. RESULTS: In both groups, acute reperfusion (TIMI flow 3 or 2), immediately increased infarct zone end-diastolic wall thickness due to the development of oedema. The acute increase in wall thickness was significantly higher in the non-stenotic animals as compared to the ones with a residual stenosis. Neither of the groups showed any tendency to normalize deformation (strain) during the reperfusion period. CONCLUSION: In this experimental study, the measurement of end-diastolic wall thickness was a simple and non-invasive tool to monitor acute infarct reperfusion. It also provided information on the presence of a flow limiting stenosis in the infarct related artery after restoration of the flow. The deformation of the myocardium remained impaired during early reperfusion, whether reflow was at full pressure or low pressure due to a residual stenosis in the infarct related artery.

Cohort profile: prevalence of valvular heart disease in community patients with suspected heart failure in UK.

PURPOSE: The aim of this study was to evaluate the proportion of suspected heart failure patients with significant valvular heart disease. Early diagnosis of valve disease is essential as delay can limit treatment and negatively affect prognosis for undiagnosed patients. The prevalence of unsuspected valve disease in the community is uncertain. PARTICIPANTS: We prospectively evaluated 79 043 patients, between 2001 and 2011, who were referred to a community open access echocardiography service for suspected heart failure. All patients underwent a standard transthoracic echocardiogram according to British Society of Echocardiography guidelines. FINDINGS TO DATE: Of the total number, 29 682 patients (37.5%) were diagnosed with mild valve disease, 8983 patients (11.3%) had moderate valve disease and 2134 (2.7%) had severe valve disease. Of the total number of patients scanned, the prevalence of aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation was 10%, 8.4%, 1%, and 12.5% respectively. 18% had tricuspid regurgitation. 5% had disease involving one or more valves. CONCLUSIONS: Of patients with suspected heart failure in the primary care setting, a significant proportion have important valvular heart disease. These patients are at high risk of future cardiac events and will require onward referral for further evaluation. We recommend that readily available community echocardiography services should be provided for general practitioners as this will result in early detection of valve disease.

A suicide attempt by intoxication with Taxus baccata leaves and ultra-fast liquid chromatography-electrospray ionization-tandem mass spectrometry, analysis of patient serum and different plant samples: case report.

BACKGROUND: Taxus (yew) is one of the most frequently reported plants causing potentially fatal outcome when taken incidentally or for suicidal reasons. A fast and reliable method of detection of poisonous compounds or their metabolites is critical in life-saving procedures in cases of yew ingestion. Previously, several chromatographic analytical procedures have been described usually taking longer than one hour of total analysis time. CASE PRESENTATION: In this report we describe a suicide case study and an ad hoc developed fast method of detection and quantitation of 3,5-dimethoxyphenol - the main taxane metabolite in the blood plasma from the patient as well as the determination of major taxine components in the plant material (Taxus baccata). At present, there is no reasonable alternative for mass spectrometry that could match its high sensitivity and accuracy, and Multiple Reaction Monitoring could be adequate and useful mass spectrometry technique in analyzing and identification of plants material compounds that cause severe poisoning in humans. In the reported case, intensive cardiac care together with the astuteness of the treating physicians not only saved the patient's life, but also allowed for his complete recovery and return to work. CONCLUSIONS: The development of ultra fast liquid chromatography tandem mass spectrometry UFLC-MS/MS method provides a fast means to confirm yew alkaloids and their metabolite in various material. The applied analytical procedure allows early detection of main metabolite in patient material as well as comparing to those extracted from the plant. In our study, the taxanes remained undetected, probably due to the time elapsing from the patient admittance and collection of plasma. In cases like those reported in this study, retaining the gastric material should be obligatory to confirm the ingestion of yew. The possibility of using this approach in detection of native taxine compounds in human plasma remains to be verified.