Hypoxia Promotes the Stemness of Mesangiogenic Progenitor Cells and Prevents Osteogenic but not Angiogenic Differentiation.

The stem cell niche in the bone marrow is a hypoxic environment, where the low oxygen tension preserves the pluripotency of stem cells. We have identified mesangiogenic progenitor cells (MPC) exhibiting angiogenic and mesenchymal differentiation capabilities in vitro. The effect of hypoxia on MPC has not been previously explored. In this study, MPCs were isolated from volunteers' bone marrow and cultured under both normoxic and hypoxic conditions (3% O2). MPCs maintained their characteristic morphology and surface marker expression (CD18 + CD31 + CD90-CD73-) under hypoxia. However, hypoxic conditions led to reduced MPC proliferation in primary cultures and hindered their differentiation into mesenchymal stem cells (MSCs) upon exposure to differentiative medium. First passage MSCs derived from MPC appeared unaffected by hypoxia, exhibiting no discernible differences in proliferative potential or cell cycle. However, hypoxia impeded the subsequent osteogenic differentiation of MSCs, as evidenced by decreased hydroxyapatite deposition. Conversely, hypoxia did not impact the angiogenic differentiation potential of MPCs, as demonstrated by spheroid-based assays revealing comparable angiogenic sprouting and tube-like formation capabilities under both hypoxic and normoxic conditions. These findings indicate that hypoxia preserves the stemness phenotype of MPCs, inhibits their differentiation into MSCs, and hampers their osteogenic maturation while leaving their angiogenic potential unaffected. Our study sheds light on the intricate effects of hypoxia on bone marrow-derived MPCs and their differentiation pathways.

Exploring Negated Entites for Named Entity Recognition in Italian Lung Cancer Clinical Reports.

This paper explores the potential of leveraging electronic health records (EHRs) for personalized health research through the application of artificial intelligence (AI) techniques, specifically Named Entity Recognition (NER). By extracting crucial patient information from clinical texts, including diagnoses, medications, symptoms, and lab tests, AI facilitates the rapid identification of relevant data, paving the way for future care paradigms. The study focuses on Non-small cell lung cancer (NSCLC) in Italian clinical notes, introducing a novel set of 29 clinical entities that include both presence or absence (negation) of relevant information associated with NSCLC. Using a state-of-the-art model pretrained on Italian biomedical texts, we achieve promising results (average F1-score of 80.8%), demonstrating the feasibility of employing AI for extracting biomedical information in the Italian language.

All-Inside Arthroscopic Meniscus Repair for Patients Over 40 Years of Age: Is Forty the New Twenty?

INTRODUCTION: Meniscal injuries are a common challenge in orthopedic surgery. For decades, partial or total meniscectomy has been the primary surgical treatment for meniscal tears. In recent years, the increased recognition of menisci's biomechanical importance has progressively shifted the paradigm towards meniscus repair. However, meniscus-sparing surgery remains the treatment of choice for selected lesions in young and active patients, especially for young and active patients. In this study, we evaluated the effectiveness of all-inside sutures in treating meniscus tears in patients over 40. METHODS: In our retrospective evaluation, we evaluated the clinical and functional outcomes of cases over 40 years of age with post-traumatic acute meniscus tears that received meniscus repairs using the all-inside technique. The pre-operative and post-operative functionality of treated patients were assessed using the knee injury and osteoarthritis outcome score (KOOS) score. Major complications were recorded. RESULTS: Twenty-three cases met our inclusion criteria. Eight females and fifteen males with a mean age of 44.9 were included in our study. Their mean follow-up was 35.1 months. Before surgery, our patients' mean KOOS score was 55.4 (18-80). At the patients' latest follow-up, the value had risen to 87.4 (63-100). There was no statistical correlation between patients' age and their functional recovery. No surgical failure was recorded at the latest follow-up. CONCLUSION: The all-inside suture technique can represent a suitable and reliable solution for suturable meniscal tears, even for patients over 40. Preserving the meniscus and restoring patients' functionality allows patients to return to their daily activities and promote their quality of life.

Design, Fabrication, and Preliminary Validation of Patient-Specific Spine Section Phantoms for Use in Training Spine Surgeons Outside the Operating Room/Theatre.

Pedicle screw fixation (PSF) demands rigorous training to mitigate the risk of severe neurovascular complications arising from screw misplacement. This paper introduces a patient-specific phantom designed for PSF training, extending a portion of the learning process beyond the confines of the surgical room. Six phantoms of the thoracolumbar region were fabricated from radiological datasets, combining 3D printing and casting techniques. The phantoms were employed in three training sessions by a fifth-year resident who performed full training on all six phantoms; he/she placed a total of 57 pedicle screws. Analysis of the learning curve, focusing on time per screw and positioning accuracy, revealed attainment of an asymptotic performance level (around 3 min per screw) after 40 screws. The phantom's efficacy was evaluated by three experts and six residents, each inserting a minimum of four screws. Initial assessments confirmed face, content, and construct validity, affirming the patient-specific phantoms as a valuable training resource. These proposed phantoms exhibit great promise as an essential tool in surgical training as they exhibited a demonstrable learning effect on the PSF technique. This study lays the foundation for further exploration and underscores the potential impact of these patient-specific phantoms on the future of spinal surgical education.

Distal Femur Megaprostheses in Orthopedic Oncology: Evaluation of a Standardized Post-Operative Rehabilitation Protocol.

BACKGROUND AND OBJECTIVES: Megaprostheses are the most used reconstructive approach for patients who have undergone massive resection of their distal femurs due to bone tumors. Although the literature about their outcomes has flourished in recent decades, to date, a consensus on rehabilitative treatment is yet to be established. In this study, we report on our experience with our latest standardized rehabilitation program, evaluating our results in a mid-to-long-term scenario. MATERIALS AND METHODS: We evaluated the functional results of all our oncologic patients treated between 2016 and 2022 who could follow our standardized post-operative rehabilitative approach, consisting of progressive knee mobilization and early weight-bearing. RESULTS: Sixteen cases were included in our study. The average duration of the patients' hospitalization was 12.2 days. A standing position was reached on average 4.1 days after surgery, while assisted walking was started 4.5 days after surgery. After a mean post-operative follow-up of 46.7 months, our patients' mean MSTS score was 23.2 (10-30). Our data suggest that the sooner patients could achieve a standing position (R = -0.609; p = 0.012) and start walking (R = -0.623; p = 0.010), the better their final functional outcomes regarding their MSTS scores. CONCLUSIONS: Rehabilitation should be considered a pivotal factor in decreeing the success of distal femur megaprosthetic implants in long-surviving oncologic patients. Correct rehabilitation, focused on early mobilization and progressive weight-bearing, is crucial to maximizing the post-operative functional outcomes of these patients.

Preliminary Results of Preoperative Planning Using 3D Printing and Augmented Reality in Cryotherapy Treatment of Giant Cell Tumor of Bone-CRIO2AR Project.

Giant Cell Tumor of Bone is a benign tumor with high local aggressive expansion, which, in rare cases, spreads metastasis. Surgical treatment, which often consists of wide curettage to reduce recurrence risk, can lower the quality of life for those affected. Along with aggressive surgery, adjuvant intraoperative techniques have been implemented such as PMMA and cryotherapy. One of the most widely used cryotherapy techniques involves the use of probes to generate ice balls, which have been scientifically shown to have various impacts on the tumor. Although this has been acknowledged, no one has yet tested a way to accurately plan the positioning of cryotherapy probes before surgery, according to the research conducted by the authors. CRIO2AR is a randomized clinical prospective ongoing study by which it will be experimented via preoperative planning of ice probes placement using AR and 3D printing technologies. By studying a single clinical case with these technologies, the surgeon gains better awareness of patient's anatomy and tumor localization. Preliminary results are shown in the article. The first results are confirming that these technologies are applicable in clinical practice. Secondly, preoperative planning is proving to be reliable, easily replicable, and useful for the surgeon.

Aneurysmal Bone Cyst of the Pelvis in Children and Adolescents: Effectiveness of Surgical Treatment with Curettage, Cryotherapy and Bone Grafting.

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign but locally aggressive cystic lesions of the bone. Pelvic ABCs are extremely rare and hard to treat due to their high risk of local recurrence and the tough access to pelvic bones. METHODS: In this retrospective study, we evaluated pediatric cases with pelvic ABC treated with curettage, cryotherapy and bone grafting treated in our institution between 2016 and 2022. Complications were recorded, as well as local recurrences. Patients' post-operative functionality was assessed with the MSTS score. RESULTS: Fourteen consecutive cases were included in our study. Their mean age at surgery was 13.5 years. The mean lesion size was 55 mm. The mean follow-up was 38 months. Two cases (11.8%) had local recurrences, which were successfully treated with further curettage. At their latest FU, 13 cases were continuously disease free (CDF), and one had no evidence of disease (NED). Only one case had a post-operative compilation (wound dehiscence). Patients' mean post-operative MSTS score was 29.6. CONCLUSIONS: Pelvic ABCs are a challenge, even for the most experienced orthopedic surgeon. Our study suggests that the association of an accurate curettage, intraoperative cryotherapy and bone grafting can be a reliable and effective therapeutic option for large-sized ABCs of the pelvis.

Is the Combination of Platelet-Rich Plasma and Hyaluronic Acid the Best Injective Treatment for Grade II-III Knee Osteoarthritis? A Prospective Study.

Background: Knee osteoarthritis is a common disease with increasing incidence and prevalence in western countries. It can cause severe pain and functional limitations, thereby representing a threat for patients' quality of life and a burden for national health systems. Intra-articular injections with hyaluronic acid (HA) and platelet-rich plasma (PRP) have been used for decades in order to reduce the symptoms caused by osteoarthritis. In recent years, a combination of HA and PRP has been introduced in clinical practice with the aim to minimize the clinical presentation of osteoarthritis and potentially delay articular degeneration. Materials and Methods: Sixty cases with grade II-III knee osteoarthritis according to the Kellgren-Lawrence classification were included in a prospective study, focused on the evaluation of clinical and functional outcomes after intra-articular knee injections. Cases were randomly divided into three groups. Twenty cases (Group A) were injected with HA, 20 (Group B) had PRP, and the remaining 20 (Group C) received a combination of HA and PRP. Basal WOMAC score and VAS score were recorded before the treatment and repeated within 3 and 6 months after the treatment. Results: At 6-month follow-up, Group C (PRP + HA) was the one with the lowest WOMAC and VAS mean values. It was also the only group that reported a reduction in the two values both in the first three months and in the following three months. No major complication was recorded. Conclusion: The combination of platelet-rich plasma and hyaluronic acid can be effective in the treatment of grade II-III knee osteoarthritis in a short-to-mid-term scenario. It represents an innovative and valuable alternative to the administration of its two components alone.

Femoral neck fractures treated with cannulated screws: can surgeons predict functional outcomes and minimize the risk of necrosis?

BACKGROUND AND AIM: Femoral neck fractures are among the most frequent in mankind. Screw fixation is considered a suitable approach specially for undisplaced or slightly displaced fractures that occur to young patients. We conducted our study in order to evaluate both functional outcomes and complication rates of patients who received this treatment in our institution. A particular focus was given to the aseptic necrosis of the head, trying to identify if anamnestic, clinical or radiological data could play a significant role as prognostic factors. METHODS: For each case who was treated with screw fixation due to a femoral neck fracture, we recorded data regarding, among the others, BMI and whether they used tobacco products or corticosteroids on a regular basis. Necrosis of the femoral head and mechanical complications were recorded. Functional outcome was evaluated using the Harris Hip Score.      Results: 74 cases were included in our study. The mean Harris Hip score was 89.5. Aseptic necrosis of the femoral head occurred in 9 cases (12.2%). Regular use of tobacco was associated with a higher risk to develop necrosis (p=0.007). The Body Mass Index was significantly higher in cases who had necrosis compared to the rest of our population (p=0.043) and was inversely proportional to the post-operative Harris hip score (p=0.001). CONCLUSIONS: While considering screw fixation to treat cases with femoral neck fractures, patient's weight and use of tobacco should be considered as prognostic factors.  (www.actabiomedica.it).

Prognostic impact of late gadolinium enhancement at the right ventricular insertion points in non-ischaemic dilated cardiomyopathy.

AIMS: To evaluate the baseline characteristics and the prognostic implications associated with late gadolinium enhancement limited to the right ventricular insertion points (IP-LGE) or present at both the right ventricular insertion points and the left ventricle (IP&LV-LGE) in non-ischaemic dilated cardiomyopathy (DCM). METHODS AND RESULTS: This is a retrospective observational multicentre cohort study including 1165 consecutive patients with DCM evaluated by cardiac magnetic resonance. The primary endpoint included appropriate defibrillator therapies, sustained ventricular tachycardia, resuscitated cardiac arrest, or sudden death. The secondary outcome encompassed heart failure hospitalizations, heart transplant, left ventricular assist device implantation, and end-stage heart failure death. IP-LGE was found in 72 patients (6%), who had clinical characteristics closer to LGE- than to LGE+ patients. During follow-up (median 36 months), none of the IP-LGE patients experienced the primary endpoint. The cumulative incidence of the primary endpoint was similar between IP-LGE and LGE- patients (P = 1), while IP-LGE had significantly lower cumulative incidence when compared with LGE+ patients (P < 0.001). When compared with IP-LGE patients, the cumulative incidence of the secondary endpoint was similar in LGE- cases (P = 0.86) but tended to be higher in LGE+ patients (P = 0.06). Both clinical characteristics and outcomes were similar between IP&LV-LGE patients and the rest of LGE+ cases. CONCLUSIONS: In a large cohort of DCM patients, IP-LGE was associated with similar outcome when compared with LGE- patients and with significant lower risk of ventricular arrhythmias and sudden death when compared with LGE+ cases. Patients with IP&LV-LGE had clinical characteristics and outcomes similar to the rest of LGE+ cases.

A real-time integrated framework to support clinical decision making for covid-19 patients.

BACKGROUND: The COVID-19 pandemic affected healthcare systems worldwide. Predictive models developed by Artificial Intelligence (AI) and based on timely, centralized and standardized real world patient data could improve management of COVID-19 to achieve better clinical outcomes. The objectives of this manuscript are to describe the structure and technologies used to construct a COVID-19 Data Mart architecture and to present how a large hospital has tackled the challenge of supporting daily management of COVID-19 pandemic emergency, by creating a strong retrospective knowledge base, a real time environment and integrated information dashboard for daily practice and early identification of critical condition at patient level. This framework is also used as an informative, continuously enriched data lake, which is a base for several on-going predictive studies. METHODS: The information technology framework for clinical practice and research was described. It was developed using SAS Institute software analytics tool and SAS® Vyia® environment and Open-Source environment R ® and Python ® for fast prototyping and modeling. The included variables and the source extraction procedures were presented. RESULTS: The Data Mart covers a retrospective cohort of 5528 patients with SARS-CoV-2 infection. People who died were older, had more comorbidities, reported more frequently dyspnea at onset, had higher d-dimer, C-reactive protein and urea nitrogen. The dashboard was developed to support the management of COVID-19 patients at three levels: hospital, single ward and individual care level. INTERPRETATION: The COVID-19 Data Mart based on integration of a large collection of clinical data and an AI-based integrated framework has been developed, based on a set of automated procedures for data mining and retrieval, transformation and integration, and has been embedded in the clinical practice to help managing daily care. Benefits from the availability of a Data Mart include the opportunity to build predictive models with a machine learning approach to identify undescribed clinical phenotypes and to foster hospital networks. A real-time updated dashboard built from the Data Mart may represent a valid tool for a better knowledge of epidemiological and clinical features of COVID-19, especially when multiple waves are observed, as well as for epidemic and pandemic events of the same nature (e. g. with critical clinical conditions leading to severe pulmonary inflammation). Therefore, we believe the approach presented in this paper may find several applications in comparable situations even at region or state levels. Finally, models predicting the course of future waves or new pandemics could largely benefit from network of DataMarts.

Ventricular Arrhythmias and Sudden Death in Nonischemic Dilated Cardiomyopathy: Matter of Sex or Scar?

BACKGROUND: To evaluate the association between sex and ventricular arrhythmias (VA) or sudden death (SD) in nonischemic dilated cardiomyopathy, including analysis of potential confounders. METHODS AND RESULTS: Retrospective cohort study of consecutive patients with DCM referred for cardiac magnetic resonance at 2 tertiary hospitals. The primary combined end point encompassed sustained VA, appropriate implantable cardioverter defibrillator therapies, resuscitated cardiac arrest, and SD. We included 1165 patients with median follow-up of 36 months (interquartile range 20-58 months). The majority of patients (66%) were males. Males and females had similar left ventricular ejection fraction, but the prevalence of late gadolinium enhancement (LGE) at cardiac magnetic resonance was significantly higher among males (48% vs 30%, P < .001). Males had higher cumulative incidence of the primary end point (8% vs 4%, P = .02), and male sex was a significant predictor of the primary end point at univariate analysis (hazard ratio 1.93, P = .02). However, LGE had a major confounding effect in the association between sex and the primary outcome: the hazard ratio of male sex adjusted for LGE was 1.29 (P = .37). LGE+ females had significantly higher cumulative incidence of the primary end point than LGE- males (13% vs 1.8%, P < .001). CONCLUSIONS: In patients with DCM, the prevalence of LGE is significantly higher among males, implying a major confounding effect in the association between male sex and VA or SD. LGE+ females have significantly higher risk than LGE- males. These data do not support the inclusion of sex into risk stratification algorithms for VA or SD in DCM.

Risk Factors for CIED Infection After Secondary Procedures: Insights From the WRAP-IT Trial.

OBJECTIVES: This study aimed to identify risk factors for infection after secondary cardiac implantable electronic device (CIED) procedures. BACKGROUND: Risk factors for CIED infection are not well defined and techniques to minimize infection lack supportive evidence. WRAP-IT (World-wide Randomized Antibiotic Envelope Infection Prevention trial), a large study that assessed the safety and efficacy of an antibacterial envelope for CIED infection reduction, offers insight into procedural details and infection prevention strategies. METHODS: This analysis included 2,803 control patients from the WRAP-IT trial who received standard preoperative antibiotics but not the envelope (44 patients with major infections through all follow-up). A multivariate least absolute shrinkage and selection operator machine learning model, controlling for patient characteristics and procedural variables, was used for risk factor selection and identification. Risk factors consistently retaining predictive value in the model (appeared >10 times) across 100 iterations of imputed data were deemed significant. RESULTS: Of the 81 variables screened, 17 were identified as risk factors with 6 being patient/device-related (nonmodifiable) and 11 begin procedure-related (potentially modifiable). Patient/device-related factors included higher number of previous CIED procedures, history of atrial arrhythmia, geography (outside North America and Europe), device type, and lower body mass index. Procedural factors associated with increased risk included longer procedure time, implant location (non-left pectoral subcutaneous), perioperative glycopeptide antibiotic versus nonglycopeptide, anticoagulant, and/or antiplatelet use, and capsulectomy. Factors associated with decreased risk of infection included chlorhexidine skin preparation and antibiotic pocket wash. CONCLUSIONS: In WRAP-IT patients, we observed that several procedural risk factors correlated with infection risk. These results can help guide infection prevention strategies to minimize infections associated with secondary CIED procedures.

A machine-learning parsimonious multivariable predictive model of mortality risk in patients with Covid-19.

The COVID-19 pandemic is impressively challenging the healthcare system. Several prognostic models have been validated but few of them are implemented in daily practice. The objective of the study was to validate a machine-learning risk prediction model using easy-to-obtain parameters to help to identify patients with COVID-19 who are at higher risk of death. The training cohort included all patients admitted to Fondazione Policlinico Gemelli with COVID-19 from March 5, 2020, to November 5, 2020. Afterward, the model was tested on all patients admitted to the same hospital with COVID-19 from November 6, 2020, to February 5, 2021. The primary outcome was in-hospital case-fatality risk. The out-of-sample performance of the model was estimated from the training set in terms of Area under the Receiving Operator Curve (AUROC) and classification matrix statistics by averaging the results of fivefold cross validation repeated 3-times and comparing the results with those obtained on the test set. An explanation analysis of the model, based on the SHapley Additive exPlanations (SHAP), is also presented. To assess the subsequent time evolution, the change in paO2/FiO2 (P/F) at 48 h after the baseline measurement was plotted against its baseline value. Among the 921 patients included in the training cohort, 120 died (13%). Variables selected for the model were age, platelet count, SpO2, blood urea nitrogen (BUN), hemoglobin, C-reactive protein, neutrophil count, and sodium. The results of the fivefold cross-validation repeated 3-times gave AUROC of 0.87, and statistics of the classification matrix to the Youden index as follows: sensitivity 0.840, specificity 0.774, negative predictive value 0.971. Then, the model was tested on a new population (n = 1463) in which the case-fatality rate was 22.6%. The test model showed AUROC 0.818, sensitivity 0.813, specificity 0.650, negative predictive value 0.922. Considering the first quartile of the predicted risk score (low-risk score group), the case-fatality rate was 1.6%, 17.8% in the second and third quartile (high-risk score group) and 53.5% in the fourth quartile (very high-risk score group). The three risk score groups showed good discrimination for the P/F value at admission, and a positive correlation was found for the low-risk class to P/F at 48 h after admission (adjusted R-squared = 0.48). We developed a predictive model of death for people with SARS-CoV-2 infection by including only easy-to-obtain variables (abnormal blood count, BUN, C-reactive protein, sodium and lower SpO2). It demonstrated good accuracy and high power of discrimination. The simplicity of the model makes the risk prediction applicable for patients in the Emergency Department, or during hospitalization. Although it is reasonable to assume that the model is also applicable in not-hospitalized persons, only appropriate studies can assess the accuracy of the model also for persons at home.

Use of a Plasma-Sprayed Titanium-Hydroxyapatite Femoral Stem in Hip Arthroplasty in Patients Older than 70 Years. Is Cementless Fixation a Reliable Option in the Elderly?

BACKGROUND: Although cementless implants are increasing in popularity, the use of cementless femoral stems for total hip arthroplasty (THA) and hip hemiarthroplasty (HH) in elderly patients remains controversial. The aim of this study was to report the outcomes of a cementless stem used in a large multicentric cohort of elderly patients receiving elective THA and HH for displaced femoral neck fracture. METHODS: A total of 293 patients (301 hips) aged 70 years or older (mean age, 78 years; range, 70-93) who received the same cementless plasma-sprayed porous titanium-hydroxyapatite stem were retrospectively evaluated after primary THA and HH to investigate stem survival, complications, and clinical and radiographic results. RESULTS: Cumulative stem survival was 98.5% (95% CI, 96.4-99.4%; 91 hips at risks) with revision due to any reason as the end-point at 10-year follow-up (mean 8.6 years, range 4-12). No stem was revised due to aseptic loosening. The mean Forgotten Joint Score was 98.7. Radiographically, the implants showed complete osseointegration, with slight stress-shieling signs in less than 10% of the hips. CONCLUSION: The use of cementless stems was proven to be a reliable and versatile option even in elderly patients for elective THA and HH for femoral neck fracture.

Can Liquid Lenses Increase Depth of Field in Head Mounted Video See-Through Devices?

Wearable Video See-Through (VST) devices for Augmented Reality (AR) and for obtaining a Magnified View are taking hold in the medical and surgical fields. However, these devices are not yet usable in daily clinical practice, due to focusing problems and a limited depth of field. This study investigates the use of liquid-lens optics to create an autofocus system for wearable VST visors. The autofocus system is based on a Time of Flight (TOF) distance sensor and an active autofocus control system. The integrated autofocus system in the wearable VST viewers showed good potential in terms of providing rapid focus at various distances and a magnified view.

Hybrid Simulation and Planning Platform for Cryosurgery with Microsoft HoloLens.

Cryosurgery is a technique of growing popularity involving tissue ablation under controlled freezing. Technological advancement of devices along with surgical technique improvements have turned cryosurgery from an experimental to an established option for treating several diseases. However, cryosurgery is still limited by inaccurate planning based primarily on 2D visualization of the patient's preoperative images. Several works have been aimed at modelling cryoablation through heat transfer simulations; however, most software applications do not meet some key requirements for clinical routine use, such as high computational speed and user-friendliness. This work aims to develop an intuitive platform for anatomical understanding and pre-operative planning by integrating the information content of radiological images and cryoprobe specifications either in a 3D virtual environment (desktop application) or in a hybrid simulator, which exploits the potential of the 3D printing and augmented reality functionalities of Microsoft HoloLens. The proposed platform was preliminarily validated for the retrospective planning/simulation of two surgical cases. Results suggest that the platform is easy and quick to learn and could be used in clinical practice to improve anatomical understanding, to make surgical planning easier than the traditional method, and to strengthen the memorization of surgical planning.

Bibliometric trend analysis in a decade of European Orthopaedic literature.

Purpose The purpose of this bibliometric study was to summarize European orthopedic literature produced by EFORT memberships between 2009 and 2019 and to identify the 100 most cited articles, analyzing the characteristics that made them so interesting for the orthopedic scientific world. Method A search of the literature was conducted using Clarivate Analytics Web of Science in the subject category "orthopaedics"; then the results were summarized using Web of Science tools. Results A total of 160.375 articles were found: most of these were produced by England. In particular the most prolific institution was the University of London. Analyzing in detail the 100 most cited publications emerged that most of them were review published in journal with high impact factor (Q1). The University of Oxford was the institution with the greatest number of contributions (13%). The most cited topics were osteoarthritis (24%), followed by orthopedic basic science (22%). Biomaterials was the most common topic by ordering the 100 analyzed articles according to "usage count", a recent indicator of the level of interest in a specific item. Conclusion This bibliometric study can be useful to identify topics of interest for future scientific research and to outline the features that make some publications more interesting than others.

Improved Risk Stratification for Ventricular Arrhythmias and Sudden Death in Patients With Nonischemic Dilated Cardiomyopathy.

BACKGROUND: Risk stratification for ventricular arrhythmias (VA) and sudden death in nonischemic dilated cardiomyopathy (DCM) remains suboptimal. OBJECTIVES: The goal of this study was to provide an improved risk stratification algorithm for VA and sudden death in DCM. METHODS: This was a retrospective cohort study of consecutive patients with DCM who underwent cardiac magnetic resonance with late gadolinium enhancement (LGE) at 2 tertiary referral centers. The combined arrhythmic endpoint included appropriate implantable cardioverter-defibrillator therapies, sustained ventricular tachycardia, resuscitated cardiac arrest, and sudden death. RESULTS: In 1,165 patients with a median follow-up of 36 months, LGE was an independent and strong predictor of the arrhythmic endpoint (hazard ratio: 9.7; p < 0.001). This association was consistent across all strata of left ventricular ejection fraction (LVEF). Epicardial LGE, transmural LGE, and combined septal and free-wall LGE were all associated with heightened risk. A simple algorithm combining LGE and 3 LVEF strata (i.e., ≤20%, 21% to 35%, >35%) was significantly superior to LVEF with the 35% cutoff (Harrell's C statistic: 0.8 vs. 0.69; area under the curve: 0.82 vs. 0.7; p < 0.001) and reclassified the arrhythmic risk of 34% of patients with DCM. LGE-negative patients with LVEF 21% to 35% had low risk (annual event rate 0.7%), whereas those with high-risk LGE distributions and LVEF >35% had significantly higher risk (annual event rate 3%; p = 0.007). CONCLUSIONS: In a large cohort of patients with DCM, LGE was found to be a significant, consistent, and strong predictor of VA or sudden death. Specific high-risk LGE distributions were identified. A new clinical algorithm integrating LGE and LVEF significantly improved the risk stratification for VA and sudden death, with relevant implications for implantable cardioverter-defibrillator allocation.

Reduction in new cardiac electronic device implantations in Catalonia during COVID-19.

AIMS: During the COVID-19 pandemic, concern regarding its effect on the management of non-communicable diseases has been raised. However, there are no data on the impact on cardiac implantable electronic devices (CIED) implantation rates. We aimed to determine the impact of SARS-CoV2 on the monthly incidence rates and type of pacemaker (PM) and implantable cardiac defibrillator (ICD) implantations in Catalonia before and after the declaration of the state of alarm in Spain on 14 March 2020. METHODS AND RESULTS: Data on new CIED implantations for 2017-20 were prospectively collected by nine hospitals in Catalonia. A mixed model with random intercepts corrected for time was used to estimate the change in monthly CIED implantations. Compared to the pre-COVID-19 period, an absolute decrease of 56.5% was observed (54.7% in PM and 63.7% in ICD) in CIED implantation rates. Total CIED implantations for 2017-19 and January and February 2020 was 250/month (>195 PM and >55 ICD), decreasing to 207 (161 PM and 46 ICD) in March and 131 (108 PM and 23 ICD) in April 2020. In April 2020, there was a significant fall of 185.25 CIED implantations compared to 2018 [95% confidence interval (CI) 129.6-240.9; P < 0.001] and of 188 CIED compared to 2019 (95% CI 132.3-243.7; P < 0.001). No significant differences in the type of PM or ICD were observed, nor in the indication for primary or secondary prevention. CONCLUSIONS: During the first wave of the COVID-19 pandemic, a substantial decrease in CIED implantations was observed in Catalonia. Our findings call for measures to avoid long-term social impact.