Management of Coronary Disease in Patients with Advanced Kidney Disease.

BACKGROUND: Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS: We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS: At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS: Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).

THE FRAMEWORK OF THE PILOT PROJECT FOR TESTING A TELEMEDICINE MODEL IN THE FIELD OF GERIATRICS - HEALTH CHALLENGES AND JUSTIFICATION OF THE PROJECT IMPLEMENTATION.

OBJECTIVE: Aim: To present the essentials of the pilot project for testing a telemedicine model in the field of geriatrics, along with a snapshot of the health challenges. PATIENTS AND METHODS: Materials and Methods: This review paper use the synthetic method summarizing the main objectives of the telemedicine project in the field of geriatrics. The described project involving telemedical care of patients with geriatric complexes in the area of frailty syndrome, sarcopenia and malnutrition, according to the proposed model addresses the aforementioned problems. The project provides a holistic model of home and outpatient care, which will allow concerting on 3 groups of the above-mentioned geriatric syndromes. The project will have a pilot character and is aimed at clinical verification through the introduction (implementation) of the new method and accompanying organizational and technological solutions (platform, equipment) in an area where current models and schemes of therapeutic and diagnostic support were insufficient. CONCLUSION: Conclusions: The implementation of telemedicine solutions creates an opportunity for geriatric patients and their families by improving access to specialized medical care. This project will support patients, but also caregivers, who (through training and telemedicine) will be better able to provide care services with the ability to reconcile them with their own work.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials.

BACKGROUND: Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS: Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS: Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Video-Based Microsurgical Education versus Stationary Basic Microsurgical Course: A Noninferiority Randomized Controlled Study.

BACKGROUND: Repetitive training is essential for microsurgical performance. This study aimed to compare the improvement in basic microsurgical skills using two learning methods: stationary microsurgical course with tutor supervision and self-learning based on digital instructional materials. We hypothesized that video-based training provides noninferior improvement in basic microsurgical skills. METHODS: In this prospective study, 80 participants with no prior microsurgical experience were randomly divided into two groups: the control group, trained under the supervision of a microsurgical tutor, and the intervention group, where knowledge was based on commonly available online instructional videos without tutor supervision. Three blinded expert microsurgeons evaluated the improvement in basic microsurgical skills in both groups. The evaluation included an end-to-end anastomosis test using the Ten-Point Microsurgical Anastomosis Rating Scale (MARS10) and a six-stitch test on a latex glove. Statistically significant differences between groups were identified using standard noninferiority analysis, chi-square, and t-tests. RESULTS: Seventy-seven participants completed the course. Baseline test scores did not differ significantly between groups. After the 4-day microsurgical course, both groups showed statistically significant improvement in microsurgical skills measured using the MARS10. The performed tests showed that data for self-learning using digital resources provides noninferior data for course with surpervision on the initial stage of microsurgical training (7.84; standard deviation [SD], 1.92; 95% confidence interval [CI], 7.25-8.44) to (7.72; SD, 2.09; 95% CI, 7.07-8.36). CONCLUSION: Video-based microsurgical training on its initial step provides noninferior improvement in microsurgical skills to training with a dedicated instructor.

Role of P2Y Receptors in Platelet Extracellular Vesicle Release.

Platelet extracellular vesicles (PEVs) are potential new biomarkers of platelet activation which may allow us to predict and/or diagnose developing coronary thrombosis before myocardial necrosis occurs. The P2Y1 and P2Y12 receptors play a key role in platelet activation and aggregation. Whereas the P2Y1 antagonists are at the preclinical stage, at present, the P2Y12 antagonists are the most effective treatment strategy to prevent stent thrombosis after percutaneous coronary intervention. Despite an increasing number of publications on PEVs, the mechanisms underlying their formation, including the role of purinergic receptors in this process, remain an active research field. Here, we outline the clinical relevance of PEVs in cardiovascular disease, summarize the role and downstream signalling of P2Y receptors in platelet activation, and discuss the available evidence regarding their role in PEV formation.

Effect of blood glucose level on standardized uptake value (SUV) in 18F- FDG PET-scan: a systematic review and meta-analysis of 20,807 individual SUV measurements.

OBJECTIVES: To evaluate the effect of pre-scan blood glucose levels (BGL) on standardized uptake value (SUV) in 18F-FDG-PET scan. METHODS: A literature review was performed in the MEDLINE, Embase, and Cochrane library databases. Multivariate regression analysis was performed on individual datum to investigate the correlation of BGL with SUVmax and SUVmean adjusting for sex, age, body mass index (BMI), diabetes mellitus diagnosis, 18F-FDG injected dose, and time interval. The ANOVA test was done to evaluate differences in SUVmax or SUVmean among five different BGL groups (< 110, 110-125, 125-150, 150-200, and > 200 mg/dl). RESULTS: Individual data for a total of 20,807 SUVmax and SUVmean measurements from 29 studies with 8380 patients was included in the analysis. Increased BGL is significantly correlated with decreased SUVmax and SUVmean in brain (p < 0.001, p < 0.001,) and muscle (p < 0.001, p < 0.001) and increased SUVmax and SUVmean in liver (p = 0.001, p = 0004) and blood pool (p = 0.008, p < 0.001). No significant correlation was found between BGL and SUVmax or SUVmean in tumors. In the ANOVA test, all hyperglycemic groups had significantly lower SUVs compared with the euglycemic group in brain and muscle, and significantly higher SUVs in liver and blood pool. However, in tumors only the hyperglycemic group with BGL of > 200 mg/dl had significantly lower SUVmax. CONCLUSION: If BGL is lower than 200 mg/dl no interventions are needed for lowering BGL, unless the liver is the organ of interest. Future studies are needed to evaluate sensitivity and specificity of FDG-PET scan in diagnosis of malignant lesions in hyperglycemia.

The position and morphometry of the fovea capitis femoris in computed tomography of the hip.

PURPOSE: The position of the fovea of the femoral head is usually considered to be inferior or inferoposterior, despite the fact that few detailed anatomical studies have been performed. This study was performed to assess the position of the fovea in computed tomography and its correlation with standard radiographic measures of the proximal femur. METHODS: Computed tomography scans of the hip of 107 patients (54 women and 53 men) were evaluated. The semi-coronal and transverse views were used to assess the femoral neck-shaft angle and the neck version, as well as the size and position of the fovea in relation with the femoral neck axis and the size of the head. RESULTS: The fovea was always located inferior to the neck axis in the semi-coronal plane. In the transverse plane, the fovea was always slightly posterior to the femoral neck axis, as approximately ¾ of its diameter was posterior to the axis. The position was unrelated to the neck-shaft axis and the neck-trochanter minor angle. There were no differences in the position between men and women; however, in women, the fovea is slightly larger than in men when related to the femoral head size. CONCLUSION: The femoral neck axis in the transverse plane always crosses the anterior aspect of the fovea. Its position is unrelated to the angular geometry of the proximal femur, but related to the femoral head size. It is found to be relatively larger in women.

Determination of left ventricular ejection fraction by gated 99mTc-MIBI G-SPECT in patients with takotsubo syndrome - comparison with echocardiography.

BACKGROUND: Echocardiography is the first exam to establish the myocardial function in patients with takotsubo syndrome (TTS). However, ECG-Gated Myocardial Single-Photon Emission Tomography (G-SPECT) also allows to calculate left ventricular ejection fraction (LVEF) and can be useful in early stadium of TTS. AIM: To compare LVEF obtained from 99mTc-MIBI G-SPECT and echocardiography in patients with TTS. MATERIAL AND METHODS: Study population:20 patients in medium age 77(62-89) with TTS were included. In all patients 99mTc-MIBI G-SPECT and echocardiography was performed on the same day. RESULTS: LVEF measured by G-SPECT and echocardiography ranged from 34 to 83% and 38 to 69%, respectively. The LVEF values for ECHO were significantly lower than for SPECT. The correlation between the LVEF was r = 0.76. The calculated correlation coefficient (r) for linear regression analysis was 0.64. The following equation shows the approximate interdependence of both LVEF calculations: LVEF GSPECT = 10.35 + 0.93 * LVEF Echo. CONCLUSIONS: G-SPECT tends to overerestimate LVEF compared to echocardiography so these imaging techniques should not be used interchangeably. Calculated equation should be used for comparison of LVEF.

Takotsubo cardiomyopathy: FDG myocardial uptake pattern in fasting patients. Comparison of PET/CT, SPECT, and ECHO results.

BACKGROUND: The aim of this study was to assess the accumulation pattern of 18F-FDG in fasting patients with takotsubo cardiomyopathy (TTC) and to correlate the results with perfusion scintigraphy and echocardiography. METHODS: 18 consecutive patients with TTC were identified by clinical symptoms, cardiac catheterization, and echocardiography. Coronary angiography (CA) and transthoracic echocardiography (TTE) were performed on the day of the onset of symptoms. An assessment of myocardial perfusion (99mTc-MIBI) and glucose metabolism (18F-FDG) was performed within 18 days. RESULTS: SPECT showed no regional perfusion abnormalities in 10/18 patients, and a mild perfusion defect was found in 8/18 patients. Perfusion abnormalities were limited to apical and para-apical regions. In 8/18 cases, there was an increased selective apical 18F-FDG accumulation. In 10/18 cases, in spite of the fastened 18F-FDG protocol, slightly inhomogeneous 18F-FDG uptake was present in the entire myocardium: with relatively reduced uptake of 18F-FDG in the apical region and LV mid-segments. CONCLUSION: This study demonstrated the heterogeneous nature of myocardial 18F-FDG accumulation in patients with TTC. Selective, preferential apical 18F-FDG uptake in almost half of the patients confirms an existing disorder of glucose metabolism, similar to that observed in stunned or hibernated myocardium.

The prevalence and ossification pattern of the biphalangeal and triphalangeal lateral toes.

PURPOSE: Biphalangealism of the toes is an exclusively human phenomenon. The aim of this study was to evaluate the development of the lateral toes in childhood by following the ossification pattern of the phalanges. METHODS: Foot radiographs of 913 adults have been evaluated for biphalangealism of 3rd to 5th toe. The pediatric group, aged 6-15 years of age, was assessed for the number of ossification centers in the foot. RESULTS: In adults, the mean prevalence of biphalangealism in the 5th toe was 41.39%, in the 4th toe was 2.15%, and in the 3rd toe was 0.48%. In children, 45% feet had four ossification centers in the 5th toe. The epiphysis center of the middle and distal phalanx was missing. In the 4th toe, four centers were present in of 2.47% of cases. Those values are similar to the prevalence of the biphalangeal toes in adult population. The remaining toes had 5 or 6 ossification centers. In the 5-center toe, the epiphysis of the middle phalanx was missing. CONCLUSION: A missing distal phalanx epiphyseal ossification center is considered indicative of a biphalangeal toe, and the toes with 5 or 6 ossification centers are indicative of triphalangeal toes. The reason for such evolution of the lateral toes is still debated, but the differences in anatomy most likely have no impact on foot function.

PET/CT evaluation of 18F-FDG uptake in pericoronary adipose tissue in patients with stable coronary artery disease: Independent predictor of atherosclerotic lesions' formation?

BACKGROUND: Inflammatory infiltrations in EAT which releases inflammatory cytokines correspond anatomically to the atheromatous plaques in underlying coronary vessels. However, it is unknown whether inflammatory activity of pericoronary adipose tissue (PCAT) promotes coronary atherosclerosis. METHODS AND RESULTS: 35 non-diabetic patients with confirmed CAD and 35 non-CAD controls matched for age and BMI underwent 18F-FDG-PET/CT. Maximal SUV normalized by LA blood activity was measured on the sections corresponding to the respective coronaries (RCA, LCX, LAD), as well, as in subcutaneous fat, visceral fat, and epicardial fat. Extent of CAD was determined by % stenosis in segments corresponding to 18F-FDG-PET/CT sections in coronarography using quantitative coronary analysis. PCAT SUV was significantly greater than SUV in other fat locations, as well as PCAT SUV in the controls. In CAD patients with BMI >25, PCAT SUV was positively related to % stenosis of a respective coronary artery (RCA: 0.43; P < .05; LCX 0.58; P < .05; LAD 0.65; P < .05). PCAT SUV was the only independent predictor of coronary stenosis of LAD and RCA. CONCLUSIONS: Inflammatory activity of PCAT is greater than in other fat locations, in CAD is greater than in non-CAD controls, and is independently associated with coronary stenosis. In overweight patients, PCAT SUV correlates with the extent of CAD.

The sensory function of the uninjured nerve in patients after median and ulnar nerve injury.

STUDY DESIGN: A retrospective cohort study. INTRODUCTION: Some patients after median or ulnar nerve injury report a diminished sensibility in the fingers that are supplied by the uninjured nerve. PURPOSE OF THE STUDY: The purpose of this study was to evaluate the function of the uninjured nerve in patients after peripheral nerve injury to assess the presence and degree of its functional impairment. METHODS: There were 28 patients with median and 29 patients with ulnar nerve injury examined for sensory disturbances in the injured and uninjured nerves, using several tests assessing touch, temperature, and vibration sensibility. RESULTS: In 16 patients after ulnar and 13 patients after median nerve injury, some disturbances in the uninjured nerve were found, mostly in individual tests. Only 8 patients had 3 or more different tests abnormal. DISCUSSION: The injured nerve function in patients with functional disturbances in the uninjured nerve was worse than in patients with normal test results. CONCLUSION: Posttraumatic changes in central nervous system are the possible reasons. LEVEL OF EVIDENCE: Level III study.

Pericoronary adipose tissue: a novel therapeutic target in obesity-related coronary atherosclerosis.

Inflammation plays a crucial role in the development and destabilization of atherosclerotic plaques in coronary vessels. Adipose tissue is considered to act in paracrine manner, which modulates a number of physiological and pathophysiological processes. Perivascular adipose tissue has developed specific properties that distinguish it from the fat in other locations. Interestingly, its activity depends on several metabolic conditions associated with insulin resistance and weight gain. Particularly in obesity perivascular fat seems to change its character from a protective to a detrimental one. The present review analyzes literature in terms of the pathophysiology of atherosclerosis, with particular emphasis on inflammatory processes. Additionally, the authors summarize data about confirmed paracrine activity of visceral adipose tissue and especially about pericoronary fat influence on the vascular wall. The contribution of adiponectin, leptin and resistin is addressed. Experimental and clinical data supporting the thesis of outside-to-inside signaling in the pericoronary milieu are further outlined. Clinical implications of epicardial and pericoronary adipose tissue activity are also evaluated. The role of pericoronary adipose tissue in obesity-related atherosclerosis is highlighted. In conclusion, the authors discuss potential therapeutical implications of these novel phenomena, including adipokine imbalance in pericoronary adipose tissue in the setting of obesity, the influence of lifestyle and diet modification, pharmaceutical interventions and the growing role of microRNAs in adipogenesis, insulin resistance and obesity. Key teaching points: • adipose tissue as a source of inflammatory mediators • changes in the vascular wall as a result of outside-to-inside signaling • anatomy, physiology, and clinical implications of epicardial and pericoronary adipose tissue activity • adipokines and their role in obesity-related atherosclerosis • therapeutic perspectives and future directions.

[Impact of military service in Afghanistan on mental health of Polish soldiers]. / Wplyw sluzby wojskowej w Afganistanie na zdrowie psychiczne zolnierzy.

UNLABELLED: Many of the challenges they have to face the soldiers in Afghanistan acts as a specific stressors. They have been identified and defined during the past armed conflict. THE AIM OF THE STUDY: A preliminary analysis of the factors affecting the mental health of soldiers during their service in Afghanistan and determining ways to cope with stress by them, including the motivation to take medication. MATERIAL AND METHODS: The study was conducted under the conditions of the mission in Afghanistan and involved a group of 100 men aged 21-54 years (Wed 37.7 years). Analyses were based on questionnaires completed by soldiers twice in the conditions of the mission. RESULTS: Studies show that 73.3% of men in the study group were directly exposed to the loss of life, 40% knew someone who was injured or killed, 60% were direct witnesses of the death or life-threatening injury. 25% of soldiers deployed in Afghanistan led fire on the enemy, 3.3% were perpetrators of the death of enemy combatants. Furthermore, only 2% of the soldiers who have experienced health problems and seemed aware of them, were interested in receiving help. It seems that this was due to fear of soldiers before them as the perception of the mentally ill, which might be considered prejudicial to their career. CONCLUSIONS: The soldiers undergoing military service in Afghanistan are subject to the influence of multiple stressors of combat and operational, with a significant proportion of stressors carrying a direct threat to health and life. Stressors of the battlefield have modulatory effects on the process of adaptation by increasing the use of such coping styles that lead to developing a sense of security. Wrong attitudes and beliefs about the stress soldiers translate negatively to search for assistance and additional help in overcoming the effects of stress. Recognizing the impact of stressors and injuries resulting from the new course of the service can help to raise awareness of soldiers returning home, as well as families prepare for their return.

Percutaneous left atrial appendage closure with the Watchman device: a systematic review.

Atrial fibrillation (AF) is the most commonly observed arrhythmia in the world and its prevalence increases with age. The main and most severe complication of AF is ischemic stroke. Oral anticoagulation (OAC) therapy is the standard of care for stroke prevention in the high risk population. Initiation of this treatment is associated with a substantial risk of bleeding complications. Moreover, there is a group of patients who cannot tolerate OAC. In patients with AF the left atrial appendage (LAA) is the main source of thrombus formation. Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular AF. The procedure aims to reduce the risk of thromboembolism without increasing the risk of bleeding. Over the last few years, the safety and long-term efficacy of the procedure in specific populations have increased and more patients are being treated. The Watchman device is the most studied device in this field. Randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using the WATCHMAN 2.5 device to OAC (Boston Scientific, Marlborough, MA, USA). The new generation device, WATCHMAN FLX, was introduced and its use was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved problems remain, including device-related thrombosis, the post-LAAC antithrombotic regimen, and peri-device leakage. This review will focus on LAAC with the Watchman device for stroke prevention in AF patients. Current status, available literature, clinical safety and efficacy will be summarized.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention.

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)-356 patients or percutaneous coronary intervention (PCI)-679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Systematic screening by a heart team and a machine learning approach contribute to unraveling novel risk factors in revascularization candidates with complex coronary artery disease.

INTRODUCTION: The baseline characteristics affecting mortality following percutaneous or surgical revascularization in patients with left main and / or 3­vessel coronary artery disease (CAD) observed in real­world practice differ from those established in randomized controlled trials (RCTs) due to the constraints of inclusion / exclusion criteria. OBJECTIVES: This study aimed to assess whether systematic screening enables identification of novel and registry­specific baseline patient characteristics influencing long­term mortality. PATIENT AND METHODS: Least absolute shrinkage and selection operator (LASSO) regression was used to screen 42 baseline patient characteristics shared by the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial and a single­center Polish registry of 1035 consecutive patients with complex CAD who received revascularization and were followed-up for 5 years. After screening, a classic Cox regression analysis was performed to examine the suitability of a linear model for predicting 5­year mortality, which was then compared with the mortality predicted in the same cohort using the SYNTAX score II 2020 (SS2020). RESULTS: The 5­year mortality rate in the registry was 12.3%, and the strongest predictors were pulmonary hypertension, chronic obstructive pulmonary disease, and insulin­dependent diabetes. In an internal validation, the linear model constructed after LASSO screening and combined with a classic Cox regression analysis improved the prediction of 5­year mortality, as compared with the SS2020 (concordance index of 0.92 and 0.75, respectively). CONCLUSIONS: A machine learning approach improved the detection of registry­specific risk factors in all­comer patients amenable to surgical or percutaneous revascularization who were evaluated by a heart team. The risk factors identified in RCTs are not necessarily the same as those detected in real clinical practice when systematic screening is applied.

Osteoid Osteoma, a Diagnostic Problem: A Series of Atypical and Mimicking Presentations and Review of the Recent Literature.

Osteoid osteoma (OO) is a common benign bone tumour, usually affecting young people. Typically, it is localised to the diaphyses or metaphyses of long bones. The classical manifestation includes distinctive night pain, almost always present, responding well to non-steroidal anti-inflammatory drugs, sometimes accompanied by complaints due to physical activity, and a typical picture on additional tests. A characteristic of osteoid osteoma is the presence of a nidus, usually visible on imaging tests. The nidus generally presents as a single, round lytic lesion up to 1 cm in diameter, surrounded by an area of reactive ossification. However, OO is a multifaceted neoplasm, and its diagnosis can cause numerous difficulties. OO can mimic multiple diseases and vice versa, which often leads to a prolonged diagnostic and therapeutic path and associated complications. There are few literature reviews about the differentiation and diagnostic difficulties of osteoid osteoma. Very effective therapies for this tumour are known, such as ablation and resection. Enhanced detection of osteoid osteoma could result in faster diagnosis and less suffering for the patient, avoidance of complications, and reduced costs of incorrect and prolonged treatment.

Safety and efficacy of percutaneous atrial appendage closure followed by antiplatelet therapy in a high-risk population: single-center experience with a WATCHMAN device.

Introduction: In our everyday practice we encounter many patients with non-valvular atrial fibrillation with either a contraindication to oral anticoagulation or with its inefficiency. Aim: To investigate whether left atrial appendage closure (LAAC) followed by post-procedure antiplatelet therapy is safe and efficient in a high-risk population. Material and methods: Ninety-one (48 males) consecutive patients with non-valvular atrial fibrillation (NVAF) underwent an LAAC procedure using a first-generation WATCHMAN 2.5 device followed by antiplatelet therapy. Clinical and transesophageal echocardiography data were collected at baseline and at the follow-up visit. Results: The median (IQR) CHA2DS2-VASc score was 5 (4.0-6.0) and the HAS-BLED score was 3 (3.0-4.0); the mean (SD) age was 74.4 (8.4). A bleeding history was observed in 89% of patients and 24.2% of patients had a history of stroke or transient ischemic attack (TIA). The procedure was successful in 98.9%. Post-procedure therapy was dual antiplatelet therapy in 85 patients; 3 patients received single antiplatelet therapy and the therapy was maintained until the follow-up visit. Peri-procedural complications were tamponade (3.3%), pericardial effusion (2.2%) and two deaths (2.2%) with no bleeding or vascular complications. The median follow-up was 67 (52.75-84.75) days. Primary safety endpoint (bleeding BARC type 3 or more, tamponade, pericardial effusion, and device embolization) and primary efficacy endpoint (stroke or TIA, hemorrhagic stroke, peripheral embolism, cardiovascular (CV) and non-CV death) were observed in 2 and 4 patients, respectively. Conclusions: The LAAC procedure followed by antiplatelet therapy seems to be safe and efficient in the high-risk population. Further studies in this field are required.