Low-dose cryo-electron ptychography of proteins at sub-nanometer resolution.

Cryo-transmission electron microscopy (cryo-EM) of frozen hydrated specimens is an efficient method for the structural analysis of purified biological molecules. However, cryo-EM and cryo-electron tomography are limited by the low signal-to-noise ratio (SNR) of recorded images, making detection of smaller particles challenging. For dose-resilient samples often studied in the physical sciences, electron ptychography - a coherent diffractive imaging technique using 4D scanning transmission electron microscopy (4D-STEM) - has recently demonstrated excellent SNR and resolution down to tens of picometers for thin specimens imaged at room temperature. Here we apply 4D-STEM and ptychographic data analysis to frozen hydrated proteins, reaching sub-nanometer resolution 3D reconstructions. We employ low-dose cryo-EM with an aberration-corrected, convergent electron beam to collect 4D-STEM data for our reconstructions. The high frame rate of the electron detector allows us to record large datasets of electron diffraction patterns with substantial overlaps between the interaction volumes of adjacent scan positions, from which the scattering potentials of the samples are iteratively reconstructed. The reconstructed micrographs show strong SNR enabling the reconstruction of the structure of apoferritin protein at up to 5.8 Å resolution. We also show structural analysis of the Phi92 capsid and sheath, tobacco mosaic virus, and bacteriorhodopsin at slightly lower resolutions.

miRNA and mRNA Signatures in Human Acute Kidney Injury Tissue.

Acute kidney injury (AKI) is an important contributor to the development of chronic kidney disease (CKD). There is a need to understand molecular mediators that drive recovery and progression to CKD. In particular, the regulatory role of miRNAs in AKI is poorly understood. miRNA and mRNA sequencing were performed on biobanked human kidney tissues obtained in the routine care of subjects with a diagnosis of AKI, minimal change disease, or without known kidney disease in nephrectomy tissue. mRNA analysis revealed that nephrectomy tissues exhibited an injury signature similar to that of AKI and not identified in minimal change disease samples. The transcriptomic signature of human AKI was enriched in pathways involved in cell adhesion, epithelial-to-mesenchymal transition, and cell cycle arrest (eg, CDH6, ITGB6, CDKN1A). In AKI, up-regulation of miR-146a, miR-155, miR-142, and miR-122 was associated with pathways involved in immune cell recruitment, inflammation, and epithelial-to-mesenchymal transition. miR-122 and miR-146 were associated with down-regulation of DDR2 and IGFBP6, which are genes involved in the recovery and progression of kidney disease. These data provide integrated miRNA signatures that complement mRNA and other epigenetic data available in kidney atlases.

Machine Learning Approach to Support Taxonomic Discrimination of Mayflies Species Based on Morphologic Data.

Artificial intelligence (AI) and machine learning (ML) offer objective solutions in the elaboration of taxonomic keys, such as the processing of large numbers of samples, aiding in the species identification, and optimizing the time required for this process. We utilized ML to study the morphological data of eight species of Americabaetis Kluge 1992, a diverse genus in South American freshwater environments. Decision trees were employed, examining specimens from the Museu de Entomologia da Universidade Federal de Viçosa (UFVB/Brazil) and literature data. Eleven morphological traits of taxonomic importance from the literature, including frontal keel, shape of the mouthparts, and abdominal color pattern, were analyzed. The decision tree obtained with the Gini algorithm effectively differentiates eight species (40% of the known species), using only eight morphological characters. Our analysis revealed distinct groups within Americabaetis alphus Lugo-Ortiz and McCafferty 1996a, based on variations in abdominal tracheae pigmentation. This study introduces a novel approach, integrating AI techniques, biological collections, and literature data for aid in the Americabaetis species identification. It provides a valuable tool for taxonomic research on contemporary and extinct mayflies.

Personalized Biomodel of the Cervical Spine for Laboratory Laminoplasty Training.

OBJECTIVE: The use of biomodels in the laboratory for studying and training cervical laminoplasty has not yet been reported. We propose the use of a cervical spine biomodel for surgical laminoplasty training. METHODS: This is an experimental study. Ten 3D identical cervical spine biomodels were printed based on computed tomography (CT) and magnetic resonance imaging scans of a patient diagnosed with spondylotic cervical myelopathy. The additive manufacturing method used fused deposition modeling and polylactic acid (PLA) was selected as the raw material. The sample was divided into 2 groups: control (n = 5; the biomodels were submitted to CT scanning) and open-door (n = 5; the biomodels were submitted to open-door laminoplasty and postoperative CT). The area and anteroposterior diameter of the vertebral canal were measured on CT scans. RESULTS: Printing each piece took 12 hours. During the surgical procedure, there was sufficient support from the biomodels to keep them immobilized. Using the drill was feasible; however continuous irrigation was mandatory to prevent plastic material overheating. The raw material made the biomodel CT study possible. The vertebral canal dimensions increased 24.80% (0.62 cm2) in area and 24.88% (3.12 mm) in anteroposterior diameter CONCLUSIONS: The cervical spine biomodels can be used for laminoplasty training, even by using thermosensitive material such as PLA. The use of continuous irrigation is essential while drilling.

On the pH-dependence of α-synuclein amyloid polymorphism and the role of secondary nucleation in seed-based amyloid propagation.

The aggregation of the protein α-synuclein is closely associated with several neurodegenerative disorders and as such the structures of the amyloid fibril aggregates have high scientific and medical significance. However, there are dozens of unique atomic-resolution structures of these aggregates, and such a highly polymorphic nature of the α-synuclein fibrils hampers efforts in disease-relevant in vitro studies on α-synuclein amyloid aggregation. In order to better understand the factors that affect polymorph selection, we studied the structures of α-synuclein fibrils in vitro as a function of pH and buffer using cryo-EM helical reconstruction. We find that in the physiological range of pH 5.8-7.4, a pH-dependent selection between Type 1, 2, and 3 polymorphs occurs. Our results indicate that even in the presence of seeds, the polymorph selection during aggregation is highly dependent on the buffer conditions, attributed to the non-polymorph-specific nature of secondary nucleation. We also uncovered two new polymorphs that occur at pH 7.0 in phosphate-buffered saline. The first is a monofilament Type 1 fibril that highly resembles the structure of the juvenile-onset synucleinopathy polymorph found in patient-derived material. The second is a new Type 5 polymorph that resembles a polymorph that has been recently reported in a study that used diseased tissues to seed aggregation. Taken together, our results highlight the shallow amyloid energy hypersurface that can be altered by subtle changes in the environment, including the pH which is shown to play a major role in polymorph selection and in many cases appears to be the determining factor in seeded aggregation. The results also suggest the possibility of producing disease-relevant structure in vitro.

Purinergic exposure induces epigenomic and transcriptomic-mediated preconditioning resembling epilepsy-associated microglial states.

Microglia play a crucial role in a range of neuropathologies through exacerbated activation. Microglial inflammatory responses can be influenced by prior exposures to noxious stimuli, like increased levels of extracellular adenosine and ATP. These are characteristic of brain insults like epileptic seizures and could potentially shape subsequent responses through epigenetic regulation. We investigated DNA methylation and expression changes in human microglia-like cells differentiated from monocytes following ATP-mediated preconditioning. We demonstrate that microglia-like cells display homeostatic microglial features, shown by surface markers, transcriptome, and DNA methylome. After exposure to ATP, TLR-mediated activation leads to an exacerbated pro-inflammatory response. These changes are accompanied by methylation and transcriptional reprogramming associated with enhanced immune-related functions. The reprogramming associated with ATP-mediated preconditioning leads to profiles found in microglial subsets linked to epilepsy. Purine-driven microglia immune preconditioning drives epigenetic and transcriptional changes that could contribute to altered functions of microglia during seizure development and progression.

The Effects of Nordic Hamstring Exercise on Performance and Injury in the Lower Extremities: An Umbrella Review.

Due to their potential positive outcomes, hamstring eccentric exercises are becoming increasingly popular in training regimens. Among the various exercises, the Nordic Hamstring Exercise (NHE) is the most common. Despite its popularity, there are still some doubts about its benefits and risks. So, the aim of this umbrella review was to summarize the effects of NHE on performance and injury prevention. Following the PRISMA guidelines, a comprehensive literature search was conducted across multiple e-databases, according to the P (injured and non-injured athletes or recreationally active or healthy individuals) I (NHE) C (no intervention, placebo, or other interventions) O (performance or injury) S (systematic reviews) model. The quality of the studies was accessed with the AMSTAR-2. From the 916 systematic reviews found, only 10 could be included. They encompassed 125 studies, enrolling 17,260 subjects. The results from the studies indicate that NHE interventions demonstrated positive effects on sprint performance, muscle activation, eccentric strength, and muscle architecture (fascicle length, muscle thickness, and pennation angle). Furthermore, NHE is effective in preventing hamstring injuries (up to 51%). In conclusion, NHE should be integrated in training (especially, in the warm-up phase) for both enhancing athletic performance and preventing hamstring injuries. For achieving more positive results, it is recommended that high-volume is followed by low-volume maintenance, targeting 48 reps/week.

Role of myocardial microRNAs in the long-term ventricular remodelling of patients with aortic stenosis.

Aims: We hypothesize that miRs are key players in the dynamics of the hypertrophy phenotype in aortic stenosis (AS) patients. In our study, we aimed to identify the transcriptional patterns (protein-coding transcripts and miRs) from myocardial sample biopsies that could be associated with the absence of left ventricular (LV) mass regression after aortic valve replacement (AVR) in patients with severe AS and LV hypertrophy. Methods and results: We prospectively included 40 patients with severe AS, LV hypertrophy, and preserved ejection fraction undergoing AVR. Myocardial biopsies obtained during surgery were analysed for transcriptomic analysis performed by next-generation sequencing. At a 1-year follow-up, no hypertrophy reversal was observed in about half of the patients in the absence of patient-prosthesis mismatch and prosthesis dysfunction of uncontrolled hypertension. Predictors of mass regression were assessed from clinical, echocardiographic, and biochemical variables as well as from 300 miRs obtained from myocardial specimens, allowing the identification 29 differentially expressed. miR-4709-3p was found as a positive independent predictor of hypertrophy regression together with high-sensitivity troponin T (cTNT-hs) as a negative predictor. Gene transcripts RFX1, SIX5, MAPK8IF3, and PKD1 were predicted as simultaneous targets of five upregulated miRs suggesting its importance in LV hypertrophy. Conclusion: In our cohort, tissue miR-4709-3p and cTNT-hs were independent predictors of hypertrophy regression. The hypertrophy reversal process will likely depend from a complex network where miRNAs may have an important role, allowing a potential opportunity for therapy.

Phenolic Compounds Characterization of Caryocar brasiliense Peel with Potential Antioxidant Activity.

The pequi (Caryocar brasiliense) fruit peel, despite being frequently discarded, has a high content of bioactive compounds, and therefore has a high nutritional value. The present study aimed to explore the bioactivities in the pequi peel, particularly their potential health benefits at the level of antioxidant activity. The exploitation of this fruit could also present significant economic benefits and applications of pequi by-products would represent a reduction in waste, having a positive impact on the environment. Phenolic compounds present in the pequi exocarp and external mesocarp were identified by paper spray mass spectrometry (PS-MS) and quantified by HPLC. The total phenolic content (TPC) along with the amount of 2,2-diphenyl-1-picrylhydrazyl (DPPH), Ferric Reducing Antioxidant Power (FRAP), and the amount of 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid (ABTS) were also determined in peel extracts. Epicatechin was the most abundant phenolic compound found, followed by the caffeic, salicylic, and gallic acids. In addition, fingerprinting revealed compounds related to several beneficial health effects. In short, the results obtained were encouraging for potential applications of pequi peel in the field of functional foods.

Nephroblastoma in Older Adult: Case Report and Review of Literature.

Introduction: Nephroblastoma, or Wilms' tumor, is a malignant renal neoplasm commonly found in children, is extremely rare in adults representing only 0.5% of all renal neoplasms. Adult Wilms tumor is rare, to our knowledge fewer than 300 cases have been reported in the English literature to date. However, in older adults after 60 years of age, only less than 45 cases have been reported. For this reason, treatment guidelines in adults still are lacking. Prognosis in nephroblastoma for adult patients is found to be worse than in children. Case Presentation: We report the case of a 65-year-old female with lumbar fossa mass, flank pain and hematuria, and pathologic diagnosis of Wilms tumor. We performed nephrectomy. No adjuvant treatment was given. Our patient remains asymptomatic and without evidence of recurrence 12 months after the surgery. Conclusion: Nephroblastoma in the elderly presents different clinical behavior and prognosis compared to nephroblastoma in children.

Assessment of rehabilitation nurses' knowledge and results of nurse educational programme (C2F) regarding osteoporosis and fragility fractures.

BACKGROUND: Providing adequate care for the person with a fragility fracture is essential to prevent recurrences. A key strategy involves training by improving nursing care in the fields of osteoporosis and fragility fractures. However, in Portugal, there is no report on the level of knowledge of nurses, nor experimental studies on how to improve it. OBJECTIVE: The study aimed to assess the knowledge of Rehabilitation Nurses in Portugal on osteoporosis and fragility fractures. Additionally, it sought to evaluate the impact of a specific educational programme on nurses' knowledge. METHODS: In Phase I, a cross-sectional study involved 452 participants, utilizing a 26-question knowledge test. In Phase II, a quasi-experimental study included 42 nurses from 28 hospitals, subjected to a 30-h hybrid educational programme. The program comprised 9 online (2 h 30 min each) and 2 live sessions, covering assessment, pharmacological and non-pharmacological treatment, monitoring, project planning, consultations, and outcome indicators measurement. A before-and-after programme knowledge test was administered. RESULTS: Phase I revealed an average knowledge score of 69.6%. In Phase II, there was a significant improvement with programme (70.4% vs. 85.8%, p < 0.01). Specialized nurses performed better than non-specialized nurses (80% vs. 75%, p = 0.011), and those from orthopaedic services showed the greatest improvement (92% vs. 83%, p = 0.014). CONCLUSIONS: Rehabilitation Nurses in Portugal have room to improve their knowledge of osteoporosis and fragility fractures. The hybrid educational programme proved effective in improving nurses' knowledge, especially among specialist and orthopaedic service nurses. We hope that this knowledge can be translated into continuous improvement in healthcare provision.

FUSION: A web-based application for in-depth exploration of multi-omics data with brightfield histology.

Spatial -OMICS technologies facilitate the interrogation of molecular profiles in the context of the underlying histopathology and tissue microenvironment. Paired analysis of histopathology and molecular data can provide pathologists with otherwise unobtainable insights into biological mechanisms. To connect the disparate molecular and histopathologic features into a single workspace, we developed FUSION (Functional Unit State IdentificatiON in WSIs [Whole Slide Images]), a web-based tool that provides users with a broad array of visualization and analytical tools including deep learning-based algorithms for in-depth interrogation of spatial -OMICS datasets and their associated high-resolution histology images. FUSION enables end-to-end analysis of functional tissue units (FTUs), automatically aggregating underlying molecular data to provide a histopathology-based medium for analyzing healthy and altered cell states and driving new discoveries using "pathomic" features. We demonstrate FUSION using 10x Visium spatial transcriptomics (ST) data from both formalin-fixed paraffin embedded (FFPE) and frozen prepared datasets consisting of healthy and diseased tissue. Through several use-cases, we demonstrate how users can identify spatial linkages between quantitative pathomics, qualitative image characteristics, and spatial --omics.

[Prehospital Care Times and Interventions for Victims of Major Trauma in the Central Region of Portugal: A Retrospective Study]. / Tempos de Resposta e Intervenções Extra-Hospitalar à Vítima de Trauma Major na Região Centro de Portugal: Um Estudo Retrospetivo.

INTRODUCTION: The quality and promptness of prehospital care for major trauma patients are vital in order to lower their high mortality rate. However, the effectiveness of this response in Portugal is unknown. The objective of this study was to analyze response times and interventions for major trauma patients in the central region of Portugal. METHODS: This was a retrospective, descriptive study, using the 2022 clinical records of the National Institute of Medical Emergency's differentiated resources. Cases of death prior to arrival at the hospital and other non-transport situations were excluded. Five-time intervals were determined, among which are the response time (T1, between activation and arrival at the scene), on-scene time (T2), and transportation time (T5; between the decision to transport and arrival at the emergency service). For each ambulance type, averages and dispersion times were calculated, as well as the proportion of cases in which the nationally and internationally recommended times were met. The frequency of recording six key interventions was also assessed. RESULTS: Of the 3366 records, 602 were eliminated (384 due to death), resulting in 2764 cases: nurse-technician ambulance (SIV) = 36.0%, physician- nurse ambulance (VMER) = 62.2% and physician-nurse helicopter = 1.8%. In a very large number of records, it was not possible to determine prehospital care times: for example, transport time (T5) could be determined in only 29%, 13% and 8% of cases, respectively for SIV, VMER and helicopter. The recommended time for stabilization (T2 ≤ 20 min) was met in 19.8% (SIV), 36.5% (VMER) and 18.2% (helicopter). Time to hospital (T5 ≤ 45 min) was achieved in 80.0% (SIV), 93.1% (VMER) and 75.0% (helicopter) of the records. The administration of analgesia (42% in SIV) and measures to prevent hypothermia (23.5% in SIV) were the most recorded interventions. CONCLUSION: There was substantial missing data on statuses and a lack of information in the records, especially in the VMER and helicopter. According to the records, the time taken to stabilize the victim on-scene often exceeded the recommendations, while the time taken to transport them to the hospital tended to be within the recommendations.

Introdução: A qualidade e rapidez do socorro pré-hospitalar à pessoa vítima de trauma major é vital para diminuir a sua elevada mortalidade. Contudo, desconhece-se a efetividade desta resposta em Portugal. O objetivo deste estudo foi analisar os tempos de resposta e as intervenções realizadas às vítimas de trauma major na região centro de Portugal. Métodos: Estudo retrospetivo, descritivo, utilizando os registos clínicos de 2022 dos meios diferenciados do Instituto Nacional de Emergência Médica. Casos de óbito pré-chegada ao hospital e outras situações de não transporte foram excluídos. Determinaram-se cinco tempos, entre os quais o tempo de resposta (T1, decorrente entre acionamento e chegada ao local), o tempo no local (T2) e o tempo de transporte (T5, intervalo entre a decisão de transporte e a chegada ao serviço de urgência). Foram calculadas médias e medidas de dispersão para cada meio, bem como a proporção de casos em que foram cumpridos os tempos recomendados nacional e internacionalmente. Avaliou-se também a frequência de registo de seis intervenções chave. Resultados: Dos 3366 registos, eliminaram-se 602 (384 por óbito), resultando em 2764 casos [suporte imediato de vida (SIV) = 36,0%, viaturas médicas de emergência e reanimação (VMER) = 62,2%, helicóptero de emergência médica (HEM) = 1,8%]. Num elevado número de registos não foi possível determinar tempos de socorro: por exemplo, o tempo de transporte (T5) foi determinável em apenas 29%, 13%, e 8% dos casos, respetivamente para SIV, VMER e HEM. O tempo recomendado para a estabilização (T2 ≤ 20 min), foi cumprido em 19,8% (SIV), 36,5% (VMER), e 18,2% (HEM) dos regis- tos. Já o tempo de transporte (T5 ≤ 45 min) foi cumprido em 80,0% (SIV), 93,1% (VMER) e 75,0% (HEM) dos registos (avaliáveis). A administração de analgesia (42% na SIV) e as medidas de prevenção de hipotermia (23,5% na SIV) foram as intervenções mais registadas. Conclusão: Observaram-se muitos status omissos e falta de informação nos registos, sobretudo na VMER e HEM. De acordo com os registos, o tempo no local superou frequentemente as recomendações, enquanto o tempo de transporte tende a estar dentro das normas.

Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review 5-year update.

Objective: This umbrella review aimed to summarize (and update) the effectiveness of non-pharmacological and non-surgical interventions for patients with knee osteoarthritis. Methods: The study followed the PRISMA guidelines. Manual and electronic databases were searched, to identify systematic reviews, following the P (knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C (pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical conservative treatments) O (pain, function, quality of life, and other knee-specific measures) model. The quality of evidence was assessed using the R-AMSTAR checklist and GRADE principles. Results: The search yielded 4086 records, of which 61 met the eligibility criteria. After evaluation with R-AMSTAR, four systematic reviews were excluded, resulting in 57 included systematic reviews, with an overall score of 29.6. The systematic reviews were published between 2018 and 2022 (29.8% in 2022), conducted in 19 countries (52.6% in China), and explored 24 distinct interventions. The systematic reviews encompassed 714 trials (mean of 13 â€‹± â€‹7.7 studies per systematic review), and 59,343 participants (mean 1041 â€‹± â€‹1002 per systematic review, and 82 â€‹± â€‹59.2 per study). The majority of participants were older obese women (61.6 â€‹± â€‹4.2 years, 30.2 â€‹± â€‹3.6 â€‹kg/m2, 70%, respectively). Conclusions: Based on the systematic reviews findings, Diet Therapy, Patient Education, and Resistance Training are strongly supported as core interventions for managing patients with knee osteoarthritis. Aquatic Therapy, Balance Training, Balneology, Dietary Supplements, Extracorporeal Shockwave Therapy, and Tai Ji show moderate support. For other interventions, the evidence quality was low, results were mixed or inconclusive, or there was not sufficient efficacy to support their use.

Presentation of the first international research network to foster high-quality clinical trials testing non-pharmacological interventions (TRACTION network).

Clinical trials are essential for evaluating the efficacy and safety of new treatments and health interventions. However, while pharmacological trials are well-established, non-pharmacological trials face unique challenges related to their complexity and difficulties such as recruitment, retention, intervention standardisation, selection of outcome measures and blinding of clinicians, participants and data collectors. This communication paper describes the objectives, implementation steps and bylaws of the 'Trials foR heAlth Care inTerventIONs' Network (TRACTION), established by an international multiprofessional task force of experts to foster high-quality non-pharmacological research, ultimately improving patient care and healthcare outcomes.The TRACTION research network will provide information and resources through a collaborative hub for researchers, health professionals, patient research partners and stakeholders in diverse biomedical and healthcare areas, connecting people with different levels of expertise but with the same interests (eg, to evaluate the effect of non-pharmacological interventions, recruiting participants). This open network will support researchers in optimising trial design, participant recruitment, data management and analysis, and disseminating and implementing trial results.The network will also facilitate specialisation training and provide educational materials and mentoring.

Investigating the Chemical Profile of Underexplored Parts of Dipteryx alata (Baru) Using the PS-MS Technique.

The baru (Dipteryx alata Vog.), a fruit native to the Cerrado biome, is well-known for its almonds, which are extensively exploited and exported. Unfortunately, the remaining parts of this fruit are often discarded. This study investigates the fixed chemical constituents of the baru, including the bark, pulp, endocarp, and almonds, using the PS-MS technique in positive and negative ionization modes. Notably, this research presents the first chemical profile of baru almonds in both their raw and roasted states. The analysis identified 57 compounds reported for the first time in a baru and 24 common compounds. The majority of these compounds are classified as flavonoids. In both ionization modes, the peel exhibited a higher proportion of phenolic compounds, although the chemical compounds varied among the peel, pulp, almond, and endocarp. These findings highlight the perspective of bioeconomy and biotechnology. By staggering baru fruit production alongside extractivists, we can optimize the utilization of all parts of the fruit. Furthermore, given the knowledge of the biological properties of flavonoids and the baru composition, we recommend additional studies to analyze their potential in preventing chronic non-communicable diseases.

Synthesis of guidance available for assessing methodological quality and grading of evidence from qualitative research to inform clinical recommendations: a systematic literature review.

OBJECTIVE: To understand (1) what guidance exists to assess the methodological quality of qualitative research; (2) what methods exist to grade levels of evidence from qualitative research to inform recommendations within European Alliance of Associations for Rheumatology (EULAR). METHODS: A systematic literature review was performed in multiple databases including PubMed/Medline, EMBASE, Web of Science, COCHRANE and PsycINFO, from inception to 23 October 2020. Eligible studies included primary articles and guideline documents available in English, describing the: (1) development; (2) application of validated tools (eg, checklists); (3) guidance on assessing methodological quality of qualitative research and (4) guidance on grading levels of qualitative evidence. A narrative synthesis was conducted to identify key similarities between included studies. RESULTS: Of 9073 records retrieved, 51 went through to full-manuscript review, with 15 selected for inclusion. Six articles described methodological tools to assess the quality of qualitative research. The tools evaluated research design, recruitment, ethical rigour, data collection and analysis. Seven articles described one approach, focusing on four key components to determine how much confidence to place in findings from systematic reviews of qualitative research. Two articles focused on grading levels of clinical recommendations based on qualitative evidence; one described a qualitative evidence hierarchy, and another a research pyramid. CONCLUSION: There is a lack of consensus on the use of tools, checklists and approaches suitable for appraising the methodological quality of qualitative research and the grading of qualitative evidence to inform clinical practice. This work is expected to facilitate the inclusion of qualitative evidence in the process of developing recommendations at EULAR level.

Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies.

Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.