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Abstract Aim This study aimed to identify what young adults with type 1 diabetes (T1D) do to make diabetes care fit in their lives and the impact of diabetes and diabetes care on living. Methods Dutch young adults with T1D (18–30 years old) submitted photographed real‐life situations of efforts to make care fit and of the impact of care on their lives. Participants organised their photos in themes, which guided the focus group discussions. We added a reflective questionnaire, semi‐structured interview and iterative validation to identify participant‐defined themes and summarise the data. Results Participants ( N = 18) submitted 240 photographs in total, showing a broad range of situations and emotions. Participants identified 16 themes, grouped into four overarching categories describing their experiences with diabetes: (1) My diabetes: glucose levels, workload, 24/7 present; (2) My life: flow of (daily) life, special and irregular circumstances, life changes, body and health; (3) Support: devices and technology, social network, clinical (diabetes) care; (4) Mental aspects: emotional processes, perspective, being a patient. In the overlap of My diabetes and My life, they identified eating and counting carbohydrates, activity and exercise, recreational substances. Conclusion Young adults with T1D face the complex challenge of fitting their care into their ever‐changing lives. While support systems, such as devices, healthcare professionals and social networks can help, they can also create burdens. Participants emphasised the importance of mental health in their lives with T1D. This study highlights the need for diabetes care that acknowledges the emotional, social and practical realities of young adults' lives.

BACKGROUND AND OBJECTIVES: Myelomeningocele is defined by the presence of a fluid-filled sac that contains the neural placode and cerebrospinal fluid (CSF) at the level of the spinal defect. Alternatively, the term myeloschisis is used when the neural placode is not contained within a CSF-filled sac. While both are eligible for prenatal closure, few studies have characterized the impact of the type of lesion on postnatal outcomes. This study compares the outcomes of these 2 types of open spinal dysraphism using data from the Fetal Myelomeningocele Consortium registry sponsored by the North American Fetal Therapy Network. METHODS: The prospective observational Fetal Myelomeningocele Consortium registry was used to extract deidentified data corresponding to patients who underwent fetal closure of myelomeningocele vs myeloschisis. Demographics, operative characteristics, perioperative complications, and postnatal outcomes were collected. RESULTS: A total of 1327 patients were identified, including 991 (74.7%) with myelomeningocele and 336 (25.3%) with myeloschisis. Compared with myelomeningocele, myeloschisis was associated with lower rates of prenatal talipes (11% vs 24%, P < .001) and higher rates of favorable prenatal movement (94% vs 86%, P < .001). Postnatally, myeloschisis conferred higher rates of leg movement (97% vs 90%, P = .002) and an increased likelihood of ambulation in the household (10.4% vs 4.1%, P = .009) and outside (7.2% vs 1.9%, P = .004) at 1 year. However, myeloschisis was also linked to greater use of skin patches during closure (49% vs 27%, P < .001), higher CSF leak rates among those with wound dehiscence (26% vs 8%, P = .014), and more frequent CSF diversion and tethered cord surgeries at follow-up. CONCLUSION: Myeloschisis and myelomeningocele demonstrate distinct clinical profiles. Although patients with myeloschisis may have favorable motor outcomes, they are also characterized by higher rates of CSF leakage, CSF diversion, and tethered cord surgery. These findings highlight the need for lesion-specific prognostication and may inform surgical planning and parental counseling in the context of prenatal spina bifida closure.

Abstract Background Computed tomography coronary angiography (CCTA) has emerged as a powerful non-invasive imaging modality for the evaluation of coronary artery disease (CAD), with a global trend towards a "CT-first" strategy in stable patients with suspected CAD. While overall beneficial, this approach requires a shift in resources, straining specific parts of healthcare systems. Pre-test probability (PTP) models stratify risks of obstructive CAD and are intended to result in better utilization of CCTA. However, these models show variability across subpopulations and have modest discriminatory power with low positive predictive values (PPV). Purpose This study aims to leverage explainable artificial intelligence (XAI) for optimization of PTP models. Methods Patients that underwent a CCTA for suspected CAD with a CAD-Reporting and Data System (CAD-RADS) classification and Coronary Artery Calcium Score (CACS) were included. Obstructive CAD was defined as stenosis &gt;50% (CAD-RADS 3 or higher). Missing data was imputed. The Risk Factor Weighted Clinical Likelihood (RF-CL) model based on clinical risk factors (age, sex, type of symptoms, smoking, hypertension, dyslipidemia, diabetes and familial predisposition) was calculated. Two gradient descent-based decision tree models, "AI-ECG" and "AI-CAC" were developed. AI-ECG is built using clinical risk factors and electrocardiogram (ECG) classification. AI-CAC is built using the aforementioned features with addition of CACS. Sensitivity analysis was performed using a 15% threshold, aligning with the threshold for CCTA acquisition. Comparative analysis was performed using Python 3.10.2, with area under the curve (AUC) analysis using the DeLong test and feature importance calculation using shapely values. Preliminary results: We identified 6178 patients with a CCTA between 2022 and 2024 in the Cardiology Centers Netherlands (CCN) and included 2083 patients (mean age 57.4 ± 10.2; 48.1% male). Obstructive CAD was present in 413 (19.8%) patients. The RF-CL model was outperformed by the AI-ECG model (AUC: 0.69 vs 0.80, p&lt;0.001) and the AI-CACS model (AUC: 0.69 vs 0.90, p&lt;0.001). Although sensitivity increased in both the AI-ECG and AI-CACS models from 0.46 to 0.87 and 0.83 respectively, PPV increased only in the AI-CACS model (0.37 to 0.61). Most important features were CACS, age, sex, ECG classification and familial predisposition. Conclusion and Discussion Our study demonstrates that the incorporation of XAI with clinical risk factors, ECG classification and CACS improves the pre-test probability estimation of obstructive CAD. ECG classification appears to be a robust feature. Adopting these models can stratify patients at risk for obstructive CAD, enabling targeted use of CCTA, reducing unnecessary testing, and thus alleviate the burden on healthcare systems. However, further external validation is necessary to assess the model’s performance in prospective real-world settings.Sensitivity analysis feature importance

Abstract Background Increased QRS voltages in athletes’ ECGs are attributed to electrophysiological cellular adaptations, complicating the detection of left ventricular hypertrophy (LVH). Conversely, higher extracellular volume (ECV), indicative of diffuse fibrosis, reduces QRS voltages – so-called ‘relative voltage deficiency’– and can mask true LVH on ECG. Purpose To investigate sex-specific associations between QRS voltages and myocardial ECV and assess the impact of ECV on false-positive and negative ECG-LVH detection in elite athletes. Methods We conducted a cross-sectional, sex-specific, contrast-enhanced CMR study in healthy, elite athletes with normal ECGs and no complete right bundle branch blocks. Myocardial ECV (%) was measured from pre- and post-contrast T1 mapping. LVH on CMR was defined as an indexed LVM &gt;75 g/m² (men) or &gt;59 g/m² (women). Primary analyses evaluated correlations between ECV, LVM, and summed 12-lead ECG voltages (including voltage/LVM to assess independence), as well as Sokolow-Lyon and Cornell voltages. Secondary multivariable logistic regression examined the association of ECV on false-positive and false-negative ECG-LVH rates using Sokolow-Lyon (≥3.5 mV) and sex-specific Cornell (≥2.8 mV in men; ≥2.3 mV in women) criteria for CMR-LVH. Results In 162 elite athletes (median age 25 years, 44% female, 45% endurance, 96% Caucasian), 23% met Sokolow-Lyon criteria, 6% met Cornell criteria, and 17% had LVH on CMR. The median myocardial ECV was 23% (range 19–31%), which was lower in male compared to female athletes (22% [Q1-Q3: 21–23%] vs 25% [23–26%]; p&lt;0.001). In both sexes, summed 12-lead voltages were inversely correlated with ECV (ρ=–0.36 to –0.37; p=0.001), independent of LVM (voltage/LVM: ρ=–0.33; p=0.004). Only in female athletes did 12-lead voltages correlate with LVM (ρ=0.37; p=0.001). Logistic regression confirmed that lower ECV was associated with an increased likelihood of false-positive Sokolow-Lyon (OR: 0.64 per 1% ECV increment; p=0.011), independent of body mass index (OR: 0.77 per kg/m²; p=0.039) male sex (OR: 2.7; p=0.123) and age (OR: 0.93 per year; p=0.075; AUROC 0.82). Higher ECV conferred greater odds of a false-negative (OR 3.98 per %; p=0.041), though this was limited by small LVH-positive sample size. In Cornell-based models, lower ECV was not statistically significantly associated with increased false-positive rate (OR 0.59; p=0.059). Conclusion In elite athletes, lower ECV ("denser" myocardium) is associated with increased QRS voltages and higher false-positive ECG-LVH rate, particularly for Sokolow-Lyon, while higher ECV may dampen voltages and can mask true LVH on the ECG. Although sex-specific criteria partly mitigate ECV-related effects, these findings demonstrate inherent limitations of voltage-based LVH criteria in athletes. Unexpectedly low QRS voltages in athletes with otherwise high LVM may imply increased ECV, though further research is warranted.Figure:Likelihood of False Pos SL rate Table:Population characteristics

Abstract Background Coronary Computed Tomography Angiography (CCTA) is the first-line diagnostic tool for suspected stable Coronary Artery Disease (CAD) to rule out obstructive CAD and is recommended for risk stratification. Both obstructive CAD and total plaque burden on CCTA predict cardiovascular (CV) risk. Prior studies demonstrated that type 2 diabetes (T2D) patients exhibit greater plaque burden and higher CV event risk. Purpose This study evaluates whether T2D patients undergoing CCTA for stable CAD symptoms, when matched for traditional cardiovascular risk factors, have a higher prevalence of CAD and greater atherosclerotic plaque burden. Methods A total of 568 patients were included: 284 T2D patients were 1:1 propensity-matched to 284 non-T2D patients based on age, sex, and CV risk factors. All underwent diagnostic CCTA between January 2022 and November 2023. CCTA parameters included CAD-Reporting and Data System (RADS) classification, segment involvement score (SIS), coronary artery calcium (CAC) score, and plaque composition. SIS was defined as the number of segments with at least mild plaque. Coronary segmentation followed the 16-segment model (SCCT). Plaque burden was classified as P1 (mild), P2 (moderate), P3 (severe), and P4 (extensive) per CAD-RADS 2.0, based on SIS, CAC score, and the number and severity of affected vessels. Results The mean age was 60.8 ± 9.97 years (T2D) vs. 61.2 ± 9.80 years (non-T2D), with similar gender distribution (48.6% vs. 48.9% female). BMI was significantly higher in T2D patients (29.2 vs. 26.5, p &lt; 0.05). Smoking was less frequent in T2D patients (56.0% vs. 60.9%, p = 0.03). Other CV risk factors were similar. T2D patients were more likely to use antiplatelet and lipid-lowering agents. CAD prevalence was higher in T2D patients (83.1% vs. 76.4%, p &lt; 0.05), while obstructive CAD was not significantly higher in T2D (33.5% vs. 27.5%, p = 0.13). No significant differences were observed in 1-, 2-, or 3-vessel disease. The SIS was significantly higher in T2D patients (3.85 vs. 3.37, p = 0.03). CAC scores were higher in T2D patients (median 60 [6–369] vs. 31 [0–224]), though not statistically significant. For plaque burden classification, P2 (moderate plaque burden) was more common in non-T2D patients (23.6% vs. 15.5%, p = 0.02), while P4 (extensive plaque burden) was significantly higher in T2D patients (21.1% vs. 14.1%, p = 0.03). Conclusion When matched for cardiovascular risk factors, T2D patients more frequently exhibited CAD on CCTA, with higher SIS scores and a greater prevalence of extensive plaque burden (P4 classification). Despite greater use of preventive medication and a lower smoking prevalence in the T2D group, plaque burden remained higher in these patients. These findings emphasize the need for improved risk stratification and preventive strategies in individuals with T2D.

Abstract Background Coronary computed tomography angiography (CCTA) and myocardial perfusion imaging (MPI) are guideline-recommended to assist in clinical decision-making in patients with prior coronary artery bypass grafting (CABG). However, the value of combining CCTA and MPI for guiding revascularization decision-making in post-CABG patients with recurrent ischemic symptoms remains unexplored. In this study, we compared Heart Team strategies for revascularization based on CCTA and MPI as standalone and hybrid CCTA/MPI imaging, to strategies guided by invasive coronary angiography (ICA). Methods We included symptomatic patients with prior CABG who underwent CCTA and MPI (single-photon emission computed tomography, positron emission tomography or stress perfusion cardiac magnetic resonance imaging) preceding ICA. Simulated Heart Teams, blinded to other Heart teams and outcomes, performed revascularization decision-making based on conventional CCTA, MPI and a hybrid CCTA/MPI strategy (non-invasive Heart Team) or based on ICA (invasive Heart Team). The primary outcome was the Cohen’s kappa agreement (κ) between non-invasive and invasive Heart Teams. Results A total of 115 patients (mean age 73±7 years; 99 [86%] male) were included. Revascularization was recommended in 96 patients (83.5%) by CCTA, 92 patients (80.0%) by MPI, 80 patients (69.6%) by hybrid CCTA/MPI and 76 patients (66.1%) by ICA. The agreements were significant but low for CCTA (κ: 0.25 [95% confidence interval (CI): 0.07-0.42], P=0.003) and MPI (κ: 0.27 [95% CI: 0.09-0.48], P=0.002) compared to ICA, with only a modest increase when using the hybrid non-invasive imaging strategy (κ: 0.32 [95% CI: 0.14-0.51], P&lt;0.001). Conclusions In patients with recurrent ischemic symptoms after CABG, Heart Team assessment of conventional CCTA and MPI yielded similarly poor agreements with revascularization strategies based on ICA, with only a modest improvement observed when using a hybrid CCTA/MPI approach. Overall, non-invasive imaging alone appears insufficient to accurately guide treatment strategies in patients with prior CABG, and their use as gatekeeping for ICA in these patients should be questioned.

Abstract Background Left atrial appendage (LAA) closure or amputation is commonly performed in atrial fibrillation (AF) patients undergoing cardiac surgery to reduce stroke risk. It has been shown that LAA closure or amputation results in persistent blood pressure (BP) decrease, which may be due to a surge in atrial natriuretic peptide (ANP) and by suppression of sympathetic activity due to activation of mechanoreceptors by atrial distention. We hypothesize that size of the LAA, a compliant structure, affects atrial distension. Consequently, patients with smaller LAA remnants (i.e. more complete amputation) have more distension of the atrium and a more pronounced BP response upon LAA amputation. Methods We analyzed 33 patients with persistent AF from the MARK AF registry who underwent LAA amputation concomitant to thoracoscopic AF ablation. Systolic BP was measured at baseline, 12 hours (h), 24h, and 48h, 1 month, 1 year, and 2 years postoperatively. Complete amputation was defined as LAA remnant depth &lt;10mm and a remnant LAA was defined as depth ≥ 10 mm on contrast enhanced CT 6 months post surgery. The postoperative LAA remnant/LA volume ratio was calculated by segmenting the atria and quantifying the volume of the contrast pools. T-tests and linear regression analyzed BP changes by remnant size and LAA remnant/LA volume ratio. Results were visualized using a boxplot and scatter plots with regression lines. Results 25/33 Patients had a LAA remnant. Baseline systolic BP was similar with 147 ± 31 mmHg in the complete amputation group vs. 137 ± 23 mmHg in the remnant group, p=0.389. Complete amputation correlated with greater systolic BP reductions in relation to baseline at 12h (-18%, p=0.018), 24h (-14%, p=0.025), 48h (-15%, p=0.028), 1 month (-20%, p=0.024), and 1 year (-16%, p=0.001), Figure 1. BP returned to baseline by 2 years in both groups. Lower LAA remnant/LA volume ratios were significantly associated with greater systolic BP reductions at 12h (β=7.4, p=0.005), 24h (β=9.9, p&lt;0.001), 48h (β=10.1, p=0.002), and 1 month (β=11.1, p=0.01), Figure 2. However, this association was not observed at 1 and 2 years. Conclusion Patients with smaller LAA remnants after LAA amputation experienced a more pronounced transient reduction in blood pressure. Our findings suggest that increased atrial distension—due to the loss of compliant LAA tissue—could play a key role in modulating hemodynamics via sympathoinhibition and suppression of the Renin-Angiotensin-Aldosterone System (RAAS). Further investigation is needed to confirm these results and explore the neurohumoral effects of LAA amputation.Figure 1 Figure 2

Objectives Female sex and anticitrullinated protein antibodies (ACPA) are associated with higher disease activity in rheumatoid arthritis (RA). Since disease-related inflammation is linked to cardiovascular risk, we explored whether sex and ACPA influenced the association between disease activity at study entry and cardiovascular risk in established RA. Methods We evaluated 4008 patients with prevalent RA from an international observational cohort enrolled between 1985 and 2012. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction and stroke) and ischaemic cardiovascular events (iCVE: MACE, angina, revascularisation, transient ischaemic attack and peripheral arterial disease). Follow-up accrued from enrolment until the first event or censoring. Multivariable Cox models stratified by centre risk evaluated disease activity, sex, ACPA and their interactions. Results We documented 193 MACE and 299 iCVE. Disease activity and sex were associated with MACE (all p≤0.017) and iCVE (p≤0.005) but ACPA was only associated with MACE (p=0.043). A three-way interaction on MACE (p=0.034) but not iCVE was noted. Among ACPA-negative patients, disease activity was associated with MACE in males (HR 1.57 (95% CI 1.14 to 2.16)) but not females (p-for-interaction=0.022). Among ACPA-positive patients, neither the disease activity x sex interaction (p=0.929), nor main effect of disease activity on MACE (p=0.124) was significant, but male sex was (HR 1.61 (95% CI 1.15 to 2.27)). Among females, neither disease activity x ACPA interaction (p=0.523) nor disease activity (p=0.319) was significant for MACE, but ACPA was (HR 1.57 (95% CI 1.02 to 2.42)). Conclusions The effect of disease activity at enrolment on cardiovascular risk in prevalent RA varies across patient groups with different sex and ACPA characteristics.