Citations

Abstract Aims While intentional weight loss achieved through cardiometabolic medications has been associated with robust salutary effects in heart failure (HF) with preserved ejection fraction (HFpEF), the clinical significance of unintentional weight loss in this setting remains unclear. Methods and results This retrospective cohort study included 434 overweight or obese patients with invasively proven HFpEF (67 ± 11 years, 236 female), without weight-reducing therapies or known malignancy, who underwent invasive hemodynamic cardiopulmonary testing and long-term clinical follow-up. The annualized weight change from index to final evaluation for the tertiles was: −21.1 to −1.8 kg/year (tertile 1); −1.8 to 0 kg/year (tertile 2); and 0 to +17.0 kg/year (tertile 3). Patients in tertile 1 had subtle abnormalities in ventilatory control at baseline, but there were no other significant differences between groups across a vast array of haemodynamic and metabolic parameters, both at rest and during exercise. Baseline weight was directly correlated with right and left heart filling pressures (r = 0.23–0.34, p < 0.001), but annualized weight change showed no correlation with any baseline haemodynamic measurements (all p > 0.05). Over a median follow-up of 4.7 years (interquartile range 2.3–6.5), patients in tertile 1 had higher risk of all-cause death (hazard ratio [HR] 3.36, 95% confidence interval [CI] 1.77–6.39, p < 0.001), all-cause death or HF hospitalization (HR 2.49, 95% CI 1.53–4.04, p < 0.001) and cardiac death or HF hospitalization (HR 2.28, 95% CI 1.28–4.07, p = 0.005) compared with those in tertile 2 or 3. These findings were consistent after multivariable adjustment. Conclusions Unintentional weight loss is associated with worse prognosis in patients with HFpEF and overweight or obesity, even as haemodynamics, exercise capacity, and gas exchange are not different from patients with stable or increasing weight. These data underline important and fundamental differences between therapeutic and unintended weight loss in HFpEF.

Segmental bone loss reconstruction using frozen bone allografts has a great advantage over amputation. Unfortunately, frozen allografts are avascular, and their use often results in infection, non-union, or fracture. We have attempted to overcome these complications by revascularizing the bone using gene therapy. Segmental tibial bone transplants were performed in 16 Yucatan minipigs. An arteriovenous (AV) bundle was placed intramedullary inside the allografts, which were transfected with growth factors vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) in 8 out of the 16 pigs. Survival time was set at 20 weeks. Bone remodeling and biomechanical properties were tested using histology, compression testing, bone mineralization, and gait analysis. In the growth factor group, five out of eight pigs developed cutaneous vascular tumors, causing excessive bleeding, which led to the exclusion of one pig. Bone remodeling was significantly more present in the VEGF group compared to the control group. This correlated with the amount of pressure the pig allowed on the operated leg for 10 weeks, which was also significantly more (p = 0.029) than the control. Both bone mineralization (p = 0.156) of the area inside the cortex and the amount of stress the allograft could endure before breaking (p = 0.078) seemed to be no different for the VEGF group compared to its healthy contralateral side, which was the control group. We have shown that growth factor-induced frozen allograft bone revascularization using an intramedullary AV bundle results in significantly more bone remodeling and better biomechanical bone properties. However, we encountered benign vascular cutaneous tumors in five out of eight pigs, making the clinical application of this technique impossible at this time.

Photon-counting computed tomography (PCCT) is a new imaging technology that has advanced diagnostic imaging by offering improved spatial and contrast resolution as well as novel spectral imaging capabilities. Unlike conventional CT, which uses energy-integrating detectors, PCCT employs photon-counting detectors that directly measure individual photon energies, enabling applications such as virtual monochromatic imaging (VMI) and material decomposition. These innovations allow for artifact reduction, better visualization of fine anatomic structures, and improved diagnostic accuracy, all while reducing radiation dose. This review explores select applications of PCCT in neuroimaging, focusing on the brain, temporal bone, and spine. In the brain, we discuss how PCCT demonstrates superior performance for evaluating aneurysms, metallic prostheses, and vessel stenosis, offering enhanced visualization of vascular structures and minimizing artifacts. For temporal bone imaging, we review assessment of both complex anatomy and potentially subtle pathologies such as otosclerosis, as well as visualization of implants like cochlear devices and their intricate components. In spinal imaging, we explore how PCCT improves precise detection of causes of cerebrospinal fluid leaks, improves localization of tiny vessels such as the artery of Adamkiewicz and spinal dural arteriovenous fistulas, and reduces metal artifacts associated with postoperative hardware. PCCT addresses limitations of conventional CT while unlocking new diagnostic possibilities across neuroimaging applications. As clinical adoption of PCCT grows, ongoing research and development will refine imaging protocols and expand its utility. The accumulating evidence underscores PCCT’s transformative potential to improve diagnostic confidence in neuroimaging and beyond.

Multidisciplinary case conferences have been shown to improve patient outcomes. However, such case conferences may be unavailable in some settings. This multidisciplinary discussion of 4 challenging hepatobiliary cases was presented at the 2023 Society of Advanced Body Imaging Annual Meeting in Dallas, TX. The cases include an “imaging occult” pancreatic tumor, a large pancreatic mass, an intraductal biliary mass, and a polypoid intraluminal gallbladder mass.

ABSTRACT Background This medical center migrated from alcohol to sotradecol foam sclerotherapy (SFS) because of perceived improved efficacy in managing symptomatic kidney and liver cysts. We report technical aspects, change in short- and long-term cyst volumes, patient-reported outcomes, safety and applications of the technique. Methods In this retrospective observational study, cases from January 2017 to December 2021 had TKCV/TLCV (per Targeted Kidney or Liver or Cyst analysis) segmented using a deep-learning algorithm and cyst segmentation software (pre-, post-procedure and longitudinally). TKCV/TLCV % change were evaluated using the one-sample Wilcoxon signed rank test. For analyses involving changes in cyst volumes, the median % change in cyst volume per patient was assessed. Longitudinal changes in cyst volumes were assessed using linear mixed models. Changes in quality of life (QOL) [Linear Analog Self-Assessment (LASA), Polycystic Liver Disease Quality of life Questionnaire (PLD-Q) and 12-item short-form (SF12)] were also assessed. Results There were 102 SFS sessions (38 kidney, 58 liver, 6 combined liver/kidney cysts) performed on 77 unique individuals included for analysis. Median [interquartile range (IQR)] % reductions in TKCV were –92.0% (IQR –98.2%, –82.7%, P < .001) and for TLCV were –83.1% (IQR –93.5%, –52.9%, P < .001). Among patients with multiple kidney procedures (n = 7), median % reduction in TKCV was –94.3% (IQR –96.6%, –92.4%, P = .023). For patients with multiple liver procedures (n = 11), median % reduction in TLCV was –63.3% (IQR –85.2%, –28.3%, P = .004). Results were similar among the four patients undergoing multi-stage procedures (n = 1 kidney, n = 3 liver). When measured longitudinally, both liver and kidney cyst volumes declined to levels near 0 mL by 1 year follow-up and remained stable several years later. LASA physical domain and PLD-Q QOL scores improved post-SFS procedure. Conclusion SFS led to substantial long-term reductions in TKCV/TLCV and improved QOL. SFS can augment cyst volume reduction in addition to tolvaptan (kidney cysts) and octreotide (liver cysts). In some individuals with large symptomatic cysts, multiple SFS procedures were safe and effective in reducing TLCV/TKCV and improving symptoms.

Abstract More than half of randomized phase 3 oncology trials fail to meet their primary endpoints, often despite favorable results from phase 1 and phase 2 trials. One potential reason for this high failure rate is effect size selection practices for powering these trials. In a systematic review of phase 3 oncology trials published in 10 top medical journals in 2023, we identified a pattern of effect size overestimation for survival endpoints, where the expected hazard ratios (average HR = 0.66) were stronger than those observed in the primary analyses (average HR = 0.72; 2-sided signed-rank test P = .0035). Across 111 trials, 82 of 143 (57.3%) observed hazard ratios for primary survival endpoints were weaker than expected; among 5 journals with 2023 impact factors between 9.9 and 56.7 (vs 58.7-98.4 for the top 5 journals), this ratio was 70.2% (59/84). These results suggest that phase 3 oncology trials are likely underpowered, contributing to the high failure rates in oncology research.

Pediatric central nervous system tumors are the leading cause of cancer-related deaths in children. The five-year survival rate for high-grade glioma in children is less than 20%. The development of new treatments is dependent upon multi-institutional collaborative clinical trials requiring reproducible and accurate centralized response assessment. We present the results of the BraTS-PEDs 2023 challenge, the first Brain Tumor Segmentation (BraTS) challenge focused on pediatric brain tumors. This challenge utilized data acquired from multiple international consortia dedicated to pediatric neuro-oncology and clinical trials. BraTS-PEDs 2023 aimed to evaluate volumetric segmentation algorithms for pediatric brain gliomas from magnetic resonance imaging using standardized quantitative performance evaluation metrics employed across the BraTS 2023 challenges. The top-performing AI approaches for pediatric tumor analysis included ensembles of nnU-Net and Swin UNETR, Auto3DSeg, or nnU-Net with a self-supervised framework. The BraTS-PEDs 2023 challenge fostered collaboration between clinicians (neuro-oncologists, neuroradiologists) and AI/imaging scientists, promoting faster data sharing and the development of automated volumetric analysis techniques. These advancements could significantly benefit clinical trials and improve the care of children with brain tumors.

Background and Objectives: Perineal wound complications and pelvic fluid collections or abscesses following proctectomy for Crohn’s disease are a common cause of morbidity and might be mitigated by filling the pelvis and occluding the pelvic inlet with a flap. Alternative flap options can be considered when inadequate omentum is available and when avoiding myofasciocutaneous flaps. Materials and Methods: A retrospective review of our Crohn’s proctectomy database was conducted to identify patients who underwent a non-omental or non-myofasciocutaneous local pedicle flap to their pelvis or pelvic exclusion using biological material during surgery. The techniques and outcomes of these alternative techniques are described in detail. Results: 228 patients underwent proctectomy for Crohn’s disease during the 10-year study period. However, only six patients had their pelvis filled or pelvic inlet occluded using a non-omental, non-myofasciocutaneous local pedicled flap or biological material. The techniques identified included two sigmoid mesocolic flaps, one peritoneal, preperitoneal fat and falciform ligament flap, one perivesical fat flap, one Gerota’s fat pad flap, and one bovine pericardial patch assisted pelvic exclusion. These flaps’ clinicopathological and operative characteristics, surgical outcomes, and technical aspects are described. Conclusions: When greater omentum is unavailable or inadequate and myofasciocutaneous flaps need to be avoided, local pedicled flaps using a range of intra-abdominal tissues or biological material can be used to fill the pelvis or occlude the pelvic inlet after proctectomy for Crohn’s disease. These techniques may help to prevent short and long-term complications associated with having a pelvic dead space.

Objective: This study evaluated the surgical and long-term patient-reported quality of life outcomes of patients undergoing esophagectomy with gastric advancement. Methods: A retrospective review was performed of all patients undergoing esophagectomy with gastric advancement from 2005 to 2016. Quality of life outcomes were evaluated using the European Organization for research and treatment of cancer quality of life questionnaire - esophageal cancer module (QLQ-OES18), which covered 10 symptom scales: dysphagia, trouble swallowing saliva, choking when swallowing, eating, dry mouth, trouble with taste, trouble with coughing, trouble speaking, reflux, and pain. Results: A total of 129 patients were followed up to 16 years (791.3 patient-years). The median age was 63.5 (IQR 55.9-69.3) years, and 79.9% were male. Eighty-six percentage (111/129) of patients had esophageal malignancy as their operative indication. Median survival was 7.1 years, with patients with benign disease experiencing longer postoperative survival ( P = .006). The response rate to QLQ-OES18 surveys was 53.7% (22/41; median follow-up: 10.4 years). Patients who experienced early postoperative complications were more likely to report trouble with coughing ( P = .032) than those who did not experience early complications. However, postoperative leaks were not associated with worsened QOL. Of note, age ≥ 65 years, obesity status, surgical indication, location of the primary esophageal lesion, tumor stage, and the occurrence of delayed postoperative complications were not associated with long-term QOL (all P > .05). Conclusion: Patients undergoing esophagectomy with gastric advancement generally had good quality of life 10 years postoperatively, though early postoperative complications and gender appeared to influence symptom burden. These findings may improve pre and postoperative patient counseling.

Abstract Donor-derived tuberculosis is a rare complication following solid organ transplantation, and tuberculosis screening is not a current transplant prerequisite for most donors. Donor-derived tuberculosis usually presents sooner than reactivation tuberculosis, and the most common finding is fever. We present 3 cases of donor-derived tuberculosis in the recipients of 2 kidneys and 1 liver from the same donor, who presented with unexplained fevers occurring 4–5 weeks after transplantation. Initial antibacterial therapy failed in all 3 patients, leading to further testing, which identified Mycobacterium tuberculosis by culture and molecular studies. All recipients successfully received tuberculosis therapy but had significant morbidity and prolonged hospital stays. Donor-derived tuberculosis should be among the differential diagnoses of unexplained fever in solid organ transplant recipients in the first few months after transplantation. Screening protocols should be implemented for donors with an epidemiologic risk of tuberculosis, with special emphasis on deceased donors.