An externally validated guide to anatomical interpretation using a direct-vision ('IRIS') feeding tube.

BACKGROUND & AIMS: Most of the 11.5 million feeding tubes placed annually in Europe and the USA are placed 'blind'. This carries a 1.6% risk that these tubes will enter the lung and 0.5% cause pneumothorax or pneumonia regardless of whether misplacement is identified prior to feeding. Tube placement by direct vision may reduce the risk of respiratory or oesophageal misplacement. This study externally validated whether an 'operator guide' would enable novice operators to differentiate the respiratory and alimentary tracts. METHODS: One IRIS tube was placed in each of 40 patients. Novice operators interpreted anatomical position using the built-in tube camera. Interpretation was checked from recorded images by consultant gastroenterologists and end-of-procedure checks using pH or X-ray checked by Radiologists and a consultant intensivist. RESULTS: The 40 patients were a median of 68y (IQR: 56-75), 70% male, mostly medical (65%), conscious (67.5%) and 70% had no artificial airway. Three tubes were removed due to failed placement. In the remaining 37 placements, novice operators identified the airway in 17 (45.9%) and airway + respiratory tract in 19 (51.4%), but redirected all these tubes into the oesophagus. By using direct vision to reduce the proportion of tubes near the airway or in respiratory tract from 0.514 to 0, operator discrimination between the respiratory and alimentary tracts was highly significant (0.514 vs 0: p < 0.0001, power >99.9% when significance = 0.05). In addition, organ boundaries (respiratory tract vs oesophagus, oesophagus vs stomach, stomach vs intestine) were identified in 100%. CONCLUSIONS: Novice operators, trained using the guide, identified all respiratory misplacements and accurately interpreted IRIS tube position. Guide-based training could enable widespread use of direct vision as a means to prevent tube-related complications.

Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association.

Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.

Europe PMC in 2023.

Europe PMC (https://europepmc.org/) is an open access database of life science journal articles and preprints, which contains over 42 million abstracts and over 9 million full text articles accessible via the website, APIs and bulk download. This publication outlines new developments to the Europe PMC platform since the last database update in 2020 (1) and focuses on five main areas. (i) Improving discoverability, reproducibility and trust in preprints by indexing new preprint content, enriching preprint metadata and identifying withdrawn and removed preprints. (ii) Enhancing support for text and data mining by expanding the types of annotations provided and developing the Europe PMC Annotations Corpus, which can be used to train machine learning models to increase their accuracy and precision. (iii) Developing the Article Status Monitor tool and email alerts, to notify users about new articles and updates to existing records. (iv) Positioning Europe PMC as an open scholarly infrastructure through increasing the portion of open source core software, improving sustainability and accessibility of the service.

Validation of image interpretation for direct vision-guided feeding tube placement.

BACKGROUND: Unguided (blind) tube placement commonly results in lung (1.6%) and oesophageal (5%) misplacement, which can lead to pneumothorax, aspiration pneumonia, death, feeding delays, and increased cost. Use of real-time direct vision may reduce risk. We validated the accuracy of a guide to train new operators in the use of direct vision-guided tube placement. METHODS: Using direct vision, operators matched anatomy viewed to anatomical markers in a preliminary operator guide. We examined how accurately the guide predicted tube position, specifically whether respiratory and gastrointestinal placement could be differentiated. RESULTS: A total of 100 patients each had one tube placement. Placement was aborted in 6% because of inability to enter or move beyond the oesophagus. In 15 of 20 placements in which the glottic opening was identified, the tube was maneuvered to avoid entry into the respiratory tract. Of 96 tubes that reached the oesophagus, 17 had entered the trachea; all were withdrawn pre-carina. One or more specific characteristics identified each organ, differentiating the trachea-oesophagus (P < 0.0001), oesophagus-stomach, and stomach-intestine in 100%. End-of-procedure tube position was ascertained by pH ≤4.0 (gastric) of aspirated fluid and/or x-ray (gastric or intestinal). In patients with a trauma risk (13%), it was avoided by identification that the tube remained within the nasal, oesophageal, or gastric lumen. CONCLUSION: Operators successfully matched anatomy seen by direct vision to images and descriptions of anatomy in the "operator guide." This validated that the operator guide accurately facilitates interpretation of tube position and enabled avoidance of lung trauma and oesophageal misplacement.

Clinical application of risk assessment in PAH: Expert center APRN recommendations.

Performing longitudinal and consistent risk assessments for patients with pulmonary arterial hypertension (PAH) is important to help guide treatment decisions to achieve early on and maintain a low-risk status and improve patient morbidity and mortality. Clinical gestalt or expert perception alone may over or underestimate a patient's risk status. Indeed, regular and continued use of validated risk assessment tools more accurately predict patients' survival. Effective PAH risk assessments are often underutilized even though many seasoned clinicians will attest to using these tools routinely. We present recommendations based on real-world experience in varied clinical practice settings around the United States for overcoming barriers to facilitate regular, serial formal risk assessment. Expert advanced practice provider clinicians from mid to large-size medical centers collaborated to formulate recommendations based on multiple discourses and discussions. Enlisting the help of support staff, such as medical assistants and nurses, to fill in available risk parameters in risk assessment tools can save time for providers and increase efficiency, as can technology-based solutions such as integrating risk assessments into electronic medical records. Modified, abbreviated risk assessment tools can be applied to a patient's clinical scenario when all of a patient's data are not available to complete a more comprehensive assessment. Initial discussions regarding the overall meaning and prognostic importance of risk scores may assist patients to take on a more active role in terms of informed decision-making regarding their care. A collaborative approach can help clinics establish consistent use of risk assessment.

Europe PMC in 2020.

Europe PMC (https://europepmc.org) is a database of research articles, including peer reviewed full text articles and abstracts, and preprints - all freely available for use via website, APIs and bulk download. This article outlines new developments since 2017 where work has focussed on three key areas: (i) Europe PMC has added to its core content to include life science preprint abstracts and a special collection of full text of COVID-19-related preprints. Europe PMC is unique as an aggregator of biomedical preprints alongside peer-reviewed articles, with over 180 000 preprints available to search. (ii) Europe PMC has significantly expanded its links to content related to the publications, such as links to Unpaywall, providing wider access to full text, preprint peer-review platforms, all major curated data resources in the life sciences, and experimental protocols. The redesigned Europe PMC website features the PubMed abstract and corresponding PMC full text merged into one article page; there is more evident and user-friendly navigation within articles and to related content, plus a figure browse feature. (iii) The expanded annotations platform offers ∼1.3 billion text mined biological terms and concepts sourced from 10 providers and over 40 global data resources.

Initial clinical and hemodynamic results of a regional pulmonary thromboendarterectomy program.

BACKGROUND: Pulmonary thromboendarterectomy (PTE) is the treatment of choice for eligible patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, access to CTEPH and PTE care is limited. There is a paucity of published data on PTE efficacy and outcomes from alternative, regional centers of excellence in CTEPH and PTE care in the USA, outside a single national and international referral center. METHODS: We performed a retrospective review of patients undergoing PTE at our institution from June 2013 to December 2016 (42 months), and collected clinical, echocardiographic and hemodynamic data on our patients pre- and post-PTE (N.=71). RESULTS: Patients age ranged between 20-83 years (mean±SD: 56±16), with 54% of patients female and 61% Caucasians. The predominant symptom was shortness of breath with a median duration of symptoms of 17 months. Following PTE, clinical improvements included a reduction in NYHA class from 3.1±1.1 to 2.2±1.2. There were major improvements in hemodynamics and echocardiographic parameters pre- versus post-PTE: mean pulmonary artery pressure (mmHg) 45±11 to 24±8, cardiac index (L/min/m2) 2.1±0.5 to 2.8±0.5, pulmonary vascular resistance (mmHg/L/min) 8.9±4.5 to 2.8±1.8, ratio of right ventricle (RV): left ventricle (LV) 1.2±0.3 to 0.9±0.2, RV fractional area change (%) 23±14 to 44±13, reduction in the incidence of RV outflow tract Doppler notching and improved pulmonary artery acceleration time (96% to 30%, and 74±19 to 111±21). In-hospital mortality was 4.2% (3 patients). CONCLUSIONS: Herein, we report for the first time, the improvements in patient functionality, hemodynamics, right heart function and outcomes at a major regional PTE program.

Europe PMC in 2017.

Europe PMC (https://europepmc.org) is a comprehensive resource of biomedical research publications that offers advanced tools for search, retrieval, and interaction with the scientific literature. This article outlines new developments since 2014. In addition to delivering the core database and services, Europe PMC focuses on three areas of development: individual user services, data integration, and infrastructure to support text and data mining. Europe PMC now provides user accounts to save search queries and claim publications to ORCIDs, as well as open access profiles for authors based on public ORCID records. We continue to foster connections between scientific data and literature in a number of ways. All the data behind the paper - whether in structured archives, generic archives or as supplemental files - are now available via links to the BioStudies database. Text-mined biological concepts, including database accession numbers and data DOIs, are highlighted in the text and linked to the appropriate data resources. The SciLite community annotation platform accepts text-mining results from various contributors and overlays them on research articles as licence allows. In addition, text miners and developers can access all open content via APIs or via the FTP site.

Case series of 5 patients with end-stage renal disease with reversible dyspnea, heart failure, and pulmonary hypertension related to arteriovenous dialysis access.

Patients with end-stage renal disease (ESRD) with arteriovenous dialysis access (AVDA) can develop symptoms of heart failure and pulmonary hypertension (PH). We report on 5 patients with ESRD and AVDA who presented with shortness of breath, heart failure, and PH. All patients had partial or complete closure of AVDA and were reevaluated after AVDA revision. All 5 subjects had clinical and echocardiographic evidence of heart failure, hypertensive heart disease, left ventricular diastolic dysfunction, and PH at baseline. After complete closure ([Formula: see text]) or partial banding ([Formula: see text]) of AVDA, mean New York Heart Association class improved from [Formula: see text] to [Formula: see text] ([Formula: see text]). Mean 6-minute walk distance improved from [Formula: see text] to [Formula: see text] m ([Formula: see text]). Serial echocardiography revealed a decrease in the right ventricle∶left ventricle ratio from [Formula: see text] to [Formula: see text] ([Formula: see text]) and improved diastolic dysfunction parameters. On right heart catheterization before definitive AVDA revision, acute manual fistula or graft occlusion led to an average decrease in cardiac output of 1.1 L/min with no other changes in hemodynamics: [Formula: see text] to [Formula: see text] L/min ([Formula: see text]). However, the average decrease in cardiac output after definitive revision of the AVDA (mean, 90 days) was 4.0 L/min with marked improvements in biventricular filling pressures and pulmonary artery pressure. In patients with ESRD and AVDA presenting with heart failure and PH, revision or closure of AVDA can markedly improve dyspnea as well as the clinical, echocardiographic, and hemodynamic manifestations of heart failure and PH.

A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) has diverse causes with heterogeneous physiology compelling distinct management. Differentiating patients with primarily elevated pulmonary vascular resistance (PVR) from those with PH predominantly because of elevated left-sided filling pressure is critical. METHODS AND RESULTS: We reviewed hemodynamics, echocardiography, and clinical data for 108 patients seen at a referral PH clinic with transthoracic echocardiogram and right heart catheterization within 1 year. We derived a simple echocardiographic prediction rule to allow hemodynamic differentiation of PH attributed to pulmonary vascular disease (PH(PVD), defined as pulmonary artery wedge pressure [PAWP]≤15 mm Hg and PVR>3 WU). Age averaged 61.3±14.8 years, µPAWP and PVR were 16.4±7.1 mm Hg and 6.3±4.0 WU, respectively, and 52 (48.1%) patients fulfilled PH(PVD) hemodynamic criteria. The derived prediction rule ranged from -2 to +2 with higher scores suggesting higher probability of PH(PVD): +1 point for left atrial anterior-posterior dimension <3.2 cm; +1 for presence of a mid systolic notch or acceleration time <80 ms; -1 for lateral mitral E:e'>10; -1 for left atrial anterior-posterior dimension >4.2 cm. PVR increased stepwise with score (for -2, 0, and +2, µPVR were 2.5, 4.5, and 8.1 WU, respectively), whereas the inverse was true for pulmonary artery wedge pressure (corresponding µPAWP were 21.5, 16.5, and 10.4 mm Hg). Among subjects with complete data, the score had an area under the curve (AUC) of 0.921 for PH(PVD). A score ≥0 had 100% sensitivity and 69.3% positive predictive value for PH(PVD), with 62.3% specificity. No patients with a negative score had PH(PVD). Patients with a negative score and acceleration time >100 ms had normal PVR (µPVR=1.8 WU, range=0.7-3.2 WU). CONCLUSIONS: We present a simple echocardiographic prediction rule that accurately defines PH hemodynamics, facilitates improved screening and focused clinical investigation for PH diagnosis and management.

Shape of the right ventricular Doppler envelope predicts hemodynamics and right heart function in pulmonary hypertension.

RATIONALE: Systolic deceleration or "notching" of the right ventricular outflow tract Doppler flow velocity envelope (FVE(RVOT)) relates to pathologic wave reflection in the setting of elevated pulmonary artery impedance. OBJECTIVES: We investigated whether simple visual assessment of FVE(RVOT) morphology aids in hemodynamic differentiation and detection of pulmonary vascular disease among a referral pulmonary hypertension (PH) cohort. METHODS: We reviewed hemodynamics, echocardiography, and clinical data for 88 patients referred for PH and 32 subjects with systolic heart failure and PH. The FVE(RVOT) was categorized as normal (no notch [NN]); late systolic notch (LSN); or midsystolic notch (MSN). MEASUREMENTS AND MAIN RESULTS: The pulmonary vascular resistance (PVR) was highest in the MSN group (9.2 ± 3.5 Wood's units [WU]; P < 0.001) versus the LSN (5.7 ± 3.1 WU) and NN (3.3 ± 2.4 WU) groups. The ratio of stroke volume to pulse pressure (compliance) also differed by FVE(RVOT) morphology (MSN = 1.2 ± 0.5; LSN = 1.7 ± 0.8; NN = 2.6 ± 1.7; P = 0.001 and 0.04, respectively, vs. NN). MSN was 96% specific and 71% sensitive for a PVR >5 WU (positive predictive value, 98%). The MSN group had severe right ventricular dysfunction (tricuspid annular plane systolic excursion 1.6 ± 0.5 cm) relative to the LSN and NN groups (tricuspid annular plane systolic excursion 1.9 ± 0.6 vs. 2.2 ± 0.6 cm; both P < 0.05). In the PH cohort, any FVE(RVOT) notching (MSN or LSN) was highly associated with PVR >3 WU (odds ratio, 22.3; 95% confidence interval, 5.2-96.4), whereas the NN pattern predicted a PVR less than or equal to 3WU and pulmonary artery wedge pressure greater than 15 mm Hg (odds ratio, 30.2; 95% confidence interval, 6.3-144.9). CONCLUSIONS: Visual inspection of the shape of the FVE(RVOT) provides insight into the hemodynamic basis of PH in a referral PH cohort. MSN is associated with the most severe pulmonary vascular disease and right heart dysfunction.