Beyond Immunity: Challenges in Kidney Retransplantation Among Persons Living With HIV.

INTRODUCTION: While superb outcomes have been observed in the HIV-positive (HIV+) population, graft failure and subsequent need for kidney retransplantation (re-KT) remain a concern. This study aims to investigate the difference in success rates of re-KT allograft survival in the HIV+ versus HIV-negative (HIV-) population in the current era of transplantation (2014-2022). METHODS: Data was collected from the Organ Procurement and Transplantation Network on all kidney transplant donors and recipients who had their first re-KT between 2014 and 2022. Allograft survival was assessed using Kaplan-Meier analysis with a log-rank test, while risk factors for graft loss were assessed using Cox proportional hazards with statistical significance set to P = 0.05. RESULTS: HIV+ recipients were significantly more likely to be Black (P < 0.001), have an HLA mismatch >3 (P = 0.018), delayed graft function (P = 0.023), and graft loss from primary nonfunction (P < 0.001). Their HIV- counterparts were more likely to be White (P < 0.001) and Hispanic (<0.001), lose their graft from acute rejection (P = 0.044), and have a living donor (P = 0.001). Being HIV+ was associated with a 1.68-fold increased risk of graft loss, an HLA mismatch >3 held a 1.18-fold increase, experiencing delayed graft function held a 1.89-fold increase, and having diabetes was associated with a 1.16-fold increased risk. Living donor kidneys were associated with a 15.8% decrease in risk for graft failure. Kaplan-Meier curves showed a significantly lower duration of kidney allograft survival in the HIV+ community (P = 0.02). CONCLUSIONS: Disproportional graft failure and inadequate HLA mismatching persist within the HIV+ Re-KT community. Stronger organ matching and new approaches for desensitizing retransplant candidates are vital.

Modified laparoscopic transthoracic hepatectomy for upper liver segments: Technique, indications, and early outcomes.

Transthoracic access emerges as an innovative approach to reach lesions in the upper hepatic segments, especially in patients with prior surgeries. This study evaluates transthoracic access for these resections through a retrospective single-center analysis of demographic data, surgical techniques, and postoperative outcomes of 353 liver surgeries, revealing promising results with minimal complications. Transthoracic access and pneumoperitoneum establishment via the transthoracic route, combined with intercostal trocar insertion, offer a viable alternative for minimally invasive liver surgeries.

Influence of biliary and vascular resection types on morbidity in hepatectomies with vascular involvement.

INTRODUCTION: Hepatectomies associated with vascular resections pose a technical challenge for surgeons, involving multiple reconstruction techniques. Moreover, adding clinical and surgical risks in the postoperative setting of these complex procedures are mainly due to prolonged surgical periods and potential complications inherent to vascular manipulation. Leveraging the expertise of a Cancer Center, we propose an institutional assessment utilizing the case series from A. C. Camargo Cancer Center in hepatectomies associated with vascular resection, evaluating postoperative complications and outcomes while highlighting clinical, laboratory, pathological, and surgical factors that may influence results. OBJECTIVE: To assess mortality and morbidity associated with hepatectomies involving vascular resection. MATERIALS AND METHODS: From a prospective database, a study was performed evaluating postoperative survival and morbidity using scoring systems such as Clavien-Dindo through a cohort analysis. RESULTS: From a total of 1021 liver resections for a period of 10 years, 31 cases were evaluated from a unique cancer center in Brazil! Factors such as the performance of major hepatectomies, the need for blood transfusion, and the administration of neoadjuvant or adjuvant systemic therapy did not appear to influence the outcome of morbidity or mortality. However, the resection of the associated bile duct and the type of vascular resection seemed to influence morbidity outcomes with statistical significance (p = 0.006+ …). CONCLUSION: Hepatectomies associated with vascular resections are safe in selected cases and when performed in referral centers. Factors such as associated bile duct resection and type of vascular resection should be considered for procedure indication.

Integration of music-based game approaches with wearable devices for hand neurorehabilitation: a narrative review.

BACKGROUND: Restoring hand functionality is critical for fostering independence in individuals with neurological disorders. Various therapeutic approaches have emerged to address motor function restoration, with music-based therapies demonstrating notable advantages in enhancing neuroplasticity, an integral component of neurorehabilitation. Despite the positive effects observed, there remains a gap in the literature regarding implementing music treatments in neurorehabilitation, such as Neurologic Music Therapy (NMT), especially in conjunction with emerging fields like wearable devices and game-based therapies. METHODS: A literature search was conducted in various databases, including PubMed, Scopus, IEEE Xplore, and ACM Digital Library. The search was performed using a literature search methodology based on keywords. Information collected from the studies pertained to the approach used in music therapy, the design of the video games, and the types of wearable devices utilized. RESULTS: A total of 158 articles were found, including 39 from PubMed, 34 from IEEE Xplore, 48 from Scopus, 37 from ACM Digital Library, and 35 from other sources. Duplicate entries, of which there were 41, were eliminated. In the first screening phase, 152 papers were screened for title and abstract. Subsequently, 89 articles were removed if they contained at least one exclusion criterion. Sixteen studies were considered after 63 papers had their full texts verified. CONCLUSIONS: The convergence of NMT with emerging fields, such as gamification and wearable devices designed for hand functionality, not only expands therapeutic horizons but also lays the groundwork for innovative, personalized approaches to neurorehabilitation. However, challenges persist in effectively incorporating NMT into rehabilitation programs, potentially hindering its effectiveness.

First Report of Bacterial Blight of Pennycress Caused by Xanthomonas campestris in Wisconsin.

In May 2023, pennycress (Thlaspi arvense, L.) lines undergoing seed production in the Walnut Street Greenhouse at the University of Wisconsin-Madison displayed symptoms of chlorosis and black necrotic leaf spots (Fig. S1-A). Lesions eventually enlarged to 1-2 cm in diameter, became necrotic, and coalesced to cover a substantial portion of leaves. Symptoms were observed in ~30% of the pennycress lines adversely affecting overall growth and reproduction. Symptomatic leaves were surface sterilized for 30 seconds in 0.75% sodium hypochlorite, rinsed in sterile deionized water, and bacteria were isolated using three-phase streaking of symptomatic tissue onto KB medium (King et al., 1954). Single colonies of three isolates (creamy white to yellow) from this initial isolation were streaked onto KB medium to obtain pure cultures. Individual colonies were transferred for growth overnight in nutrient broth (Difco) and an equal amount of the broth was added to 30% glycerol in deionized (di) water and stored at -80 °C. To validate Koch's Postulates, bacteria were grown from these stocks on Yeast Dextrose Calcium Carbonate medium (Wilson et al., 1967) and were used to inoculate 5-week-old pennycress plants in the greenhouse. The bacteria were grown for 48 hours at 26°C, suspended in 300 ml of 0.05 M PBS buffer (pH=7.2) for inoculum preparation. Plants were inoculated with three bacterial isolates (approx. 108 CFU/ml) by piercing the mid veins or hydathodes with a sterilized toothpick dipped in the suspension. Inoculated plants were then enclosed in clear plastic bags for 24-48 hours and maintained in the greenhouse at a constant temperature of 26°C with a 16-hour photoperiod. After seven days, water-soaked lesions appeared on the inoculated leaves, eventually developing into the characteristic black spots (Fig. S1-B). DNA from the original isolates was extracted, and 16S PCR and sequencing of the positive bands was done. The negative control only produced brown spots at the site of inoculation (Fig. S1-C). The primer sequences were as follows: 27F: AGAGTTTGATCMTGGCTCAG; 1492R: GGTTACCTTGTTACGACTT (Eden et al., 1991; Weisburg et al., 1991). A BLAST analysis showed that the isolates had an E value of 0.0 to the genus Xanthomonas as well as 100% identity. Amplification and sequencing of the bacterium using gyrB amplicons revealed a 99-100% pairwise match with Xc. To enhance taxonomy resolution and confirm the identity of these isolates, the complete genomes of three samples were sequenced using NextSeq2000 Illumina platform (NCBI bioproject ID PRJNA1040293). Average Nucleotide Identity (ANI) analysis was conducted with representative strains from the Xc species (Dubrow et al., 2022), using PanExplorer (Dereeper et al., 2020) featuring integrated FastANI module (Jain et al., 2018). The isolates genomes exhibited over 98% identity and clustered with that of Xc pv. incanae and Xc pv. barbarae (Fig S2). Further work will be required to identify the pathovar of Xc identified in this study through phenotypic host range assay. This marks the first documented case of Xc in pennycress in the Midwestern US. Given the potential use of pennycress as a cover crop in the region, further investigations are warranted to assess its economic impact on production and develop management strategies.

Identification of the Biomechanical Response of the Muscles That Contract the Most during Disfluencies in Stuttered Speech.

Stuttering, affecting approximately 1% of the global population, is a complex speech disorder significantly impacting individuals' quality of life. Prior studies using electromyography (EMG) to examine orofacial muscle activity in stuttering have presented mixed results, highlighting the variability in neuromuscular responses during stuttering episodes. Fifty-five participants with stuttering and 30 individuals without stuttering, aged between 18 and 40, participated in the study. EMG signals from five facial and cervical muscles were recorded during speech tasks and analyzed for mean amplitude and frequency activity in the 5-15 Hz range to identify significant differences. Upon analysis of the 5-15 Hz frequency range, a higher average amplitude was observed in the zygomaticus major muscle for participants while stuttering (p < 0.05). Additionally, when assessing the overall EMG signal amplitude, a higher average amplitude was observed in samples obtained from disfluencies in participants who did not stutter, particularly in the depressor anguli oris muscle (p < 0.05). Significant differences in muscle activity were observed between the two groups, particularly in the depressor anguli oris and zygomaticus major muscles. These results suggest that the underlying neuromuscular mechanisms of stuttering might involve subtle aspects of timing and coordination in muscle activation. Therefore, these findings may contribute to the field of biosensors by providing valuable perspectives on neuromuscular mechanisms and the relevance of electromyography in stuttering research. Further research in this area has the potential to advance the development of biosensor technology for language-related applications and therapeutic interventions in stuttering.

Structural and Biochemical Characterization of MppQ, an L-Enduracididine Biosynthetic Enzyme from Streptomyces hygroscopicus.

MppQ is an enzyme of unknown function from Streptomyces hygroscopicus (ShMppQ) that operates in the biosynthesis of the nonproteinogenic amino acid L-enduracididine (L-End). Since L-End is a component of several peptides showing activity against antibiotic-resistant pathogens, understanding its biosynthetic pathway could facilitate the development of chemoenzymatic routes to novel antibiotics. Herein, we report on the crystal structures of ShMppQ complexed with pyridoxal-5'-phosphate (PLP) and pyridoxamine-5'-phosphate (PMP). ShMppQ is similar to fold-type I PLP-dependent aminotransferases like aspartate aminotransferase. The tertiary structure of ShMppQ is composed of an N-terminal extension, a large domain, and a small domain. The active site is placed at the junction of the large and small domains and includes residues from both protomers of the homodimer. We also report the first functional characterization of MppQ, which we incubated with the enzymatically produced 2-ketoenduracidine and observed the conversion to L-End, establishing ShMppQ as the final enzyme in L-End biosynthesis. Additionally, we have observed that MppQ has a relatively high affinity for 2-keto-5-guanidinovaleric acid (i.e., 2-ketoarginine), a shunt product of MppP, indicating the potential role of MppQ in increasing the efficiency of L-End biosynthesis by converting 2-ketoarginine back to the starting material, l-arginine. A panel of potential amino-donor substrates was tested for the transamination activity against a saturating concentration of 2-ketoarginine in end-point assays. Most l-Arg was produced with l-ornithine as the donor substrate. Steady-state kinetic analysis of the transamination reaction with l-Orn and 2-ketoarginine shows that the kinetic constants are in line with those for the amino donor substrate of other fold-type I aminotransferases.

Recurrence Patterns and Clinical Management after a Positive Sentinel Node Biopsy in Melanoma Patients.

Introduction melanoma patients who become stage III after a positive sentinel node biopsy (SNB) may have several patterns of recurrence patients and methods retrospective analysis of melanoma patients who have undergone SNB in a single institution from 2000 to 2015. Results There were 111 recurrences (45.1%) among 246 (20.3%) SNB positive patients and median DRFS was 77.7 months. After initial treatment, further recurrences occurred in 68 (77.3%) patients, regardless the site of initial recurrence conclusions multimodal strategies are recommended to achieve better results when managing stage III melanoma patients after a positive SNB.

A qualitative analysis describing attrition from bariatric surgery to identify strategies for improving retention in patients who desire treatment.

BACKGROUND: Among patients who express interest in bariatric surgery, dropout rates from bariatric surgery programs are reported as high as 60%. There is a lack of understanding how we can better support patients to obtain treatment of this serious chronic disease. METHODS: Semi-structured interviews with individuals who dropped out of bariatric surgery programs from three clinical sites were conducted. Transcripts were iteratively analyzed to understand patterns clustering around codes. We mapped these codes to domains of the Theoretical Domains Framework (TDF) which will serve as the basis of future theory-based interventions. RESULTS: Twenty patients who self-identified as 60% female and 85% as non-Hispanic White were included. The results clustered around codes of "perceptions of bariatric surgery," "reasons for not undergoing surgery," and "factors for re-considering surgery." Major drivers of attrition were burden of pre-operative workup requirements, stigma against bariatric surgery, fear of surgery, and anticipated regret. The number and time for requirements led patients to lose their initial optimism about improving health. Perceptions regarding being seen as weak for choosing bariatric surgery, fear of surgery itself, and possible regret over surgery grew as time passed. These drivers mapped to four TDF domains: environmental context and resources, social role and identity, emotion, and beliefs about consequences, respectively. CONCLUSIONS: This study uses the TDF to identify areas of greatest concern for patients to be used for intervention design. This is the first step in understanding how we best support patients who express interest in bariatric surgery achieve their goals and live healthier lives.

Fatal leukodystrophy in Costello syndrome: a case report.

BACKGROUND: Costello syndrome (CS) is a rare genetic condition characterized by dysregulation of the signaling pathway, phenotypic alteration due to fetal macrosomia or growth retardation, facial abnormalities, loose skin, cardiovascular abnormalities, and a variable degree of intellectual disability. CASE PRESENTATION: We describe the case of a 20-month-old male patient with fetal macrosomia and polyhydramnios, presenting psychomotor development delay and growth limitation during the first months of life. CS was diagnosed at four months of age after detecting a variant of the HRAS gene c.35G > C (p.G12A). A clinical description of his condition was recorded throughout his life, including cardiovascular diseases, endocrine disorders, and recurrent infections. At 20 months of age, after presenting events of marked hypotonia and generalized seizures, brain magnetic resonance revealed symmetrical lesions of the infra- and supratentorial white matter in both cerebral hemispheres, which resulted in the diagnosis of cerebral leukodystrophy. The patient had a rapid and progressive deterioration that eventually led to death. CONCLUSIONS: This is the first report of a case of CS in Peru. In addition, this is a case that presented with multisystemic conditions culminating in leukodystrophy, which is a rare event according to the literature.

The LIBRA NeuroLimb: Hybrid Real-Time Control and Mechatronic Design for Affordable Prosthetics in Developing Regions.

Globally, 2.5% of upper limb amputations are transhumeral, and both mechanical and electronic prosthetics are being developed for individuals with this condition. Mechanics often require compensatory movements that can lead to awkward gestures. Electronic types are mainly controlled by superficial electromyography (sEMG). However, in proximal amputations, the residual limb is utilized less frequently in daily activities. Muscle shortening increases with time and results in weakened sEMG readings. Therefore, sEMG-controlled models exhibit a low success rate in executing gestures. The LIBRA NeuroLimb prosthesis is introduced to address this problem. It features three active and four passive degrees of freedom (DOF), offers up to 8 h of operation, and employs a hybrid control system that combines sEMG and electroencephalography (EEG) signal classification. The sEMG and EEG classification models achieve up to 99% and 76% accuracy, respectively, enabling precise real-time control. The prosthesis can perform a grip within as little as 0.3 s, exerting up to 21.26 N of pinch force. Training and validation sessions were conducted with two volunteers. Assessed with the "AM-ULA" test, scores of 222 and 144 demonstrated the prosthesis's potential to improve the user's ability to perform daily activities. Future work will prioritize enhancing the mechanical strength, increasing active DOF, and refining real-world usability.

Norepinephrine activates ß1 -adrenergic receptors at the inner nuclear membrane in astrocytes.

Norepinephrine exerts powerful influences on the metabolic, neuroprotective and immunoregulatory functions of astrocytes. Until recently, all effects of norepinephrine were believed to be mediated by receptors localized exclusively to the plasma membrane. However, recent studies in cardiomyocytes have identified adrenergic receptors localized to intracellular membranes, including Golgi and inner nuclear membranes, and have shown that norepinephrine can access these receptors via transporter-mediated uptake. We recently identified a high-capacity norepinephrine transporter, organic cation transporter 3 (OCT3), densely localized to outer nuclear membranes in astrocytes, suggesting that adrenergic signaling may also occur at the inner nuclear membrane in these cells. Here, we used immunofluorescence and western blot to show that ß1 -adrenergic receptors are localized to astrocyte inner nuclear membranes; that key adrenergic signaling partners are present in astrocyte nuclei; and that OCT3 and other catecholamine transporters are localized to astrocyte plasma and nuclear membranes. To test the functionality of nuclear membrane ß1 -adrenergic receptors, we monitored real-time protein kinase A (PKA) activity in astrocyte nuclei using a fluorescent biosensor. Treatment of astrocytes with norepinephrine induced rapid increases in PKA activity in the nuclear compartment. Pretreatment of astrocytes with inhibitors of catecholamine uptake blocked rapid norepinephrine-induced increases in nuclear PKA activity. These studies, the first to document functional adrenergic receptors at the nuclear membrane in any central nervous system cell, reveal a novel mechanism by which norepinephrine may directly influence nuclear processes. This mechanism may contribute to previously described neuroprotective, metabolic and immunoregulatory actions of norepinephrine.

Surgery or active surveillance for pNETs < 2 cm: Preliminary results from a single center Brazilian cohort.

BACKGROUND AND OBJECTIVES: Incidence of pancreatic neuroendocrine tumors (pNETS) seems to be rising over the years, with many cases incidentally diagnosed. Surgery and active surveillance are current treatment modalities for small pNETS. We review our institutional series and compare outcomes for small asymptomatic and nonfunctioning tumors. METHODS: This retrospective cohort study included patients with 2 cm or less and well differentiated pNETS at a single Brazilian Cancer Center. From 2002 to 2020, patients received active surveillance or surgery as a treatment strategy. Short and long-term results were compared. RESULTS: Sixty-four patients were included, 41 in surgical strategy and 23 in the active surveillance approach. Baseline group characteristics were comparable. More patients on active surveillance underwent abdominal magnetic resonance imaging (MRI) and had tumors located in the pancreatic head (41% vs. 17%, p = 0.038). Minimally invasive procedure was chosen in 80.1% of the surgical patients. No patient died after surgery. Median follow-up period was 38.6 and 46.4 months for active surveillance and surgery cohorts, respectively. No difference in disease progression rate was observed. CONCLUSION: Both approaches seem to be safe for small pNETs. Long-term outcome and quality of life should be considered when discussing such options with patients.

A 3D-Printed Knee Wearable Goniometer with a Mobile-App Interface for Measuring Range of Motion and Monitoring Activities.

Wearable technology has been developed in recent years to monitor biomechanical variables in less restricted environments and in a more affordable way than optical motion capture systems. This paper proposes the development of a 3D printed knee wearable goniometer that uses a Hall-effect sensor to measure the knee flexion angle, which works with a mobile app that shows the angle in real-time as well as the activity the user is performing (standing, sitting, or walking). Detection of the activity is done through an algorithm that uses the knee angle and angular speeds as inputs. The measurements of the wearable are compared with a commercial goniometer, and, with the Aktos-t system, a commercial motion capture system based on inertial sensors, at three speeds of gait (4.0 km/h, 4.5 km/h, and 5.0 km/h) in nine participants. Specifically, the four differences between maximum and minimum peaks in the gait cycle, starting with heel-strike, were compared by using the mean absolute error, which was between 2.46 and 12.49 on average. In addition, the algorithm was able to predict the three activities during online testing in one participant and detected on average 94.66% of the gait cycles performed by the participants during offline testing.

Survival probability during one-year follow-up after index hospitalization for heart failure: an Italian retrospective study.

Background: Heart failure affects about 64 million people worldwide, and despite the economic resources employed to improve its prognosis, mortality is still alarming. The aim of this study was to investigate the impact of patients' characteristics on survival probability during one-year follow-up after an index hospitalization for heart failure. Study design: A three-year retrospective study was conducted on the records of the Hospitals belonging the Local Health Unit of L'Aquila, a Healthcare Facility located in the centre of Italy. Methods: Patients admitted to hospital with a heart failure event as main diagnosis were selected and followed up for one year after their discharge to obtain data for survival analysis. Results: During the observational period for 1,929 patients hospitalized with a Heart failure index event, 1,655 (85.8%) of them were discharged alive and followed up for one year after the discharge. Fourteen percent of patients (n = 232) died for reasons related to Heart failure during the follow-up period. Fifty percent of them (n = 116), died within three months from the index hospitalization discharge. Age ≥75 years (HR 3.192, 95% CI 1.964-5.188), discharging to home (HR 0.399, 95% CI 0.297-0.536), length of stay ≥8 days during the index hospitalization (HR 1.533, 95% CI 1.163-2.019), and high education level (HR 0.517, 95% CI 0.273-0.977), were found to be associated with the survival probability. Conclusion: Study results indicate that older patients, especially those with a low educational level, those with longer index hospitalization, and those not sent directly to home, deserve more care and attention after discharge.

Syntheses, Structures, Reactivities, and Basicities of Quinolinyl and Isoquinolinyl Complexes of an Electron Rich Chiral Rhenium Fragment and Their Electrophilic Addition Products.

Reactions of Li+ [(η5 -C5 H5 )Re(NO)(PPh3 )]- with 2- and 4-chloroquinoline or 1-chloroisoquinoline give the corresponding σ quinolinyl and isoquinolinyl complexes 3, 6, and 8. With 3 and 8 there is further protonation to yield HCl adducts, but additions of KH give the free bases. Treatment of 3 with HBF4 ⋅OEt2 or H(OEt2 )2 + BArf - gives the quinolinium salts [(η5 -C5 H5 )Re(NO)(PPh3 )(C(NH)C(CH)4 C(CH)(CH))]+ X- (3-H+ X- ; X- =BF4 - /BArf - , 94-98 %). Addition of CF3 SO3 CH3 to 3, 6, or 8 affords the corresponding N-methyl quinolinium salts. In the case of [(η5 -C5 H5 )Re(NO)(PPh3 )(C(NCH3 )C(CH)4 C(CH)(CH))]+ CF3 SO3 - (3-CH3 + CF3 SO3 - ), addition of CH3 Li gives the dihydroquinolinium complex (SRe RC ,RRe SC )-[(η5 -C5 H5 )Re(NO)(PPh3 )(C(NCH3 )C(CH)4 C(CHCH3 )(CH2 ))]+ CF3 SO3 - ((SRe RC ,RRe SC )-5+ CF3 SO3 - , 76 %) in diastereomerically pure form. Crystal structures of 3-H+ BArf - , 3-CH3 + CF3 SO3 - , (SRe RC , RRe SC )-5+ Cl- , and 6-CH3 + CF3 SO3 - show that the quinolinium ligands adopt Re⋅⋅⋅C conformations that maximize overlap of their acceptor orbitals with the rhenium fragment HOMO, minimize steric interactions with the bulky PPh3 ligand, and promote various π interactions. NMR experiments establish the Brønsted basicity order 3>8>6, with Ka (BH+ ) values >10 orders of magnitude greater than the parent heterocycles, although they remain less active nucleophilic catalysts in the reactions tested. DFT calculations provide additional insights regarding Re⋅⋅⋅C bonding and conformations, basicities, and the stereochemistry of CH3 Li addition.

A Rationale for Use of High Flow Nasal Cannula for Select Patients With Suspected or Confirmed Severe Acute Respiratory Syndrome Coronavirus-2 Infection.

Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.

Impact of machine learning-based coronary computed tomography angiography fractional flow reserve on treatment decisions and clinical outcomes in patients with suspected coronary artery disease.

OBJECTIVES: This study investigated the impact of machine learning (ML)-based fractional flow reserve derived from computed tomography (FFRCT) compared to invasive coronary angiography (ICA) for therapeutic decision-making and patient outcome in patients with suspected coronary artery disease (CAD). METHODS: One thousand one hundred twenty-one consecutive patients with stable chest pain who underwent coronary computed tomography angiography (CCTA) followed ICA within 90 days between January 2007 and December 2016 were included in this retrospective study. Medical records were reviewed for the endpoint of major adverse cardiac events (MACEs). FFRCT values were calculated using an artificial intelligence (AI) ML platform. Disagreements between hemodynamic significant stenosis via FFRCT and severe stenosis on qualitative CCTA and ICA were also evaluated. RESULTS: After FFRCT results were revealed, a change in the proposed treatment regimen chosen based on ICA results was seen in 167 patients (14.9%). Over a median follow-up time of 26 months (4-48 months), FFRCT ≤ 0.80 was associated with MACE (HR, 6.84 (95% CI, 3.57 to 13.11); p < 0.001), with superior prognostic value compared to severe stenosis on ICA (HR, 1.84 (95% CI, 1.24 to 2.73), p = 0.002) and CCTA (HR, 1.47 (95% CI, 1.01 to 2.14, p = 0.045). Reserving ICA and revascularization for vessels with positive FFRCT could have reduced the rate of ICA by 54.5% and lead to 4.4% fewer percutaneous interventions. CONCLUSIONS: This study indicated ML-based FFRCT had superior prognostic value when compared to severe anatomic stenosis on CCTA and adding FFRCT may direct therapeutic decision-making with the potential to improve efficiency of ICA. KEY POINTS: • ML-based FFRCT shows superior outcome prediction value when compared to severe anatomic stenosis on CCTA. • FFRCT noninvasively informs therapeutic decision-making with potential to change diagnostic workflows and enhance efficiencies in patients with suspected CAD. • Reserving ICA and revascularization for vessels with positive FFRCT may reduce the normalcy rate of ICA and improve its efficiency.

Individualized coronary calcium scoring at any tube voltage using a kV-independent reconstruction algorithm.

PURPOSE: We prospectively investigate the feasibility of a patient specific automated tube voltage selection (ATVS)-based coronary artery calcium scoring (CACS) protocol, using a kV-independent reconstruction algorithm, to achieve significant dose reductions while maintaining the overall cardiac risk classification. METHODS: Forty-three patients (mean age, 61.8 ± 9.0 years; 40% male) underwent a clinically indicated CACS scan at 120kVp, as well as an additional CACS acquisition using an individualized tube voltage between 70 and 130kVp based on the ATVS selection (CARE-kV). Datasets of the additional CACS scans were reconstructed using a kV-independent algorithm that allows for calcium scoring without changing the weighting threshold of 130HU, regardless of the tube voltage chosen for image acquisition. Agatston scores and radiation dose derived from the different ATVS-based CACS studies were compared to the standard acquisition at 120kVp. RESULTS: Thirteen patients displayed a score of 0 and were correctly identified with the ATVS protocol. Agatston scores derived from the standard 120kVp (median, 33.4; IQR, 0-289.7) and the patient-tailored kV-independent protocol (median, 47.5; IQR, 0-287.5) showed no significant differences (p = 0.094). The intra-class correlation for Agatston scores derived from the two different protocols was excellent (ICC = 0.99). The mean dose-length-product was 29.8 ± 11.9 mGy × cm using the ATVS protocol and 31.7 ± 11.4 mGy × cm using the standard 120kVp protocol (p < 0.001). Additionally, 95% of patients were classified into the same risk category (0, 1-10, 11-100, 101-400, or > 400) using the patient-tailored protocol. CONCLUSIONS: ATVS-based CACS, using a kV-independent algorithm, allows for high accuracy compared to the standard 120kVp scanning, while significantly reducing radiation dose parameters. KEY POINTS: • ATVS allows for CT scanning with reduced radiation dose values. • KV-independent CACS is feasible at any tube voltage between 70 and 130 kVp. • ATVS applied to kV-independent CACS can significantly reduce the radiation dose.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort.

BACKGROUND: Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments. METHODS: We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012. RESULTS: To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive. CONCLUSIONS: Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.