The Influence of the Learning Curve on Clinical Outcomes in Balloon-Expandable versus Self-Expandable Transfemoral Transcatheter Aortic Valve Implantation

INTRODUCTION

Balloon-expandable (BE) and self-expandable (SE) prostheses are the main types of devices currently used in transcatheter aortic valve implantation (TAVI). Despite the different designs, clinical practice guidelines do not make any specific recommendation on the selection of one device over the other. Most operators are trained in using both BE and SE prostheses, but operator experience with each of the two designs might influence patient outcomes. The aim of this study was to compare the immediate and mid-term clinical outcomes during the learning curve in BE versus SE TAVI.

METHODS

The transfemoral TAVI procedures performed in a single center between July 2017 and March 2021 were grouped according to the type of implanted prosthesis. The procedures in each group were ordered according to the case sequence number. For each patient, a minimum follow-up time of 12 months was required for inclusion in the analysis. The outcomes of the BE TAVI procedures were compared with the outcomes of the SE TAVI procedures. Clinical endpoints were defined according to the Valve Academic Research Consortium 3 (VARC-3).

RESULTS

The median follow-up time was 28 months. Each device group included 128 patients. In the BE group, case sequence number predicted mid-term all-cause mortality at an optimal cutoff value ≤58 procedures (AUC 0.730; 95% CI: 0.644-0.805; p < 0.001), while in the SE group, the cutoff value was ≤85 procedures (AUC 0.625; 95% CI: 0.535-0.710; p = 0.04). A direct comparison of the AUC showed that case sequence number was equally adequate in predicting mid-term mortality, irrespective of prosthesis type (p = 0.11). A low case sequence number was associated with an increased rate of VARC-3 major cardiac and vascular complications (OR 0.98 95% CI: 0.96-0.99; p = 0.03) in the BE device group, and with an increased rate of post-TAVI aortic regurgitation ≥ grade II (OR 0.98; 95% CI: 0.97-0.99; p = 0.03) in the SE device group.

CONCLUSIONS

In transfemoral TAVI, case sequence number influenced mid-term mortality irrespective of prosthesis type, but the learning curve was longer in the case of SE devices.

Contrast enhanced endoscopic ultrasound in the diagnosis of pancreatic metastases

AIM

Less than 5% of pancreatic masses represent metastases and differentiation from primitive tumors using endo-scopic ultrasound (EUS) is difficult. The aim of our work was to assess the diagnostic value of contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) for pancreatic metastases.

MATERIAL AND METHODS

We retrospectively analyzed patients with pancreatic metastasis identified during a 8 year period in a tertiary medical center.

RESULTS

We included in the study 20 patients evaluated with EUS and CH-EUS. The primary tumor was localized in the kidney (6 cases), lung (5 cases), colon (3 cases), skin (2 patients) and stomach, breast, ovary and liver (1 patient each). Only 11 patients (55%) (kidney, lung, liver, ovary or skin metastases), presented hypervascularity at EUS and arterial hyperenhancement on CH-EUS, with similar diag-nostic value. All renal metastases were hyperenhanced (the negative predictive value 100%) and the stomach, colon and ovary metastases were hypoenhanced. The fast wash-out of contrast substance was encountered in all cases or renal, pulmonary and digestive metastases, but with 53.3-64.3% specificity for the different origin of pancreatic metastases.

CONCLUSIONS

The vascularity assessments on conventional EUS or CH-EUS are similar for pancreatic metastases of different origin. EUS tissue acquisition remains mandatory for the diagnosis.

Biomarkers of pediatric obstructive sleep apnea syndrome and the assessment of quality of life before and after adenotonsillectomy

The study aims to explore the inflammatory cytokines and oxidative stress in children with obstructive sleep apnea syndrome (OSAS) triggered by adenoids and/or tonsillar hypertrophy and their changes after adenotonsillectomy (AT) and to investigate the associated behavioral disorders in OSAS, before and after AT. Thirty patients with OSAS and 20 healthy children, aged 3 - 13 years were included in the study. According to apnea-hypopnea index (AHI), OSAS children were classified into 3 groups: mild (n = 19), moderate (n = 5), and severe OSAS (n = 6). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, malondialdehyde (MDA) and antioxidant enzymes activities were assessed in serum, preoperative and 6 weeks after AT. TNF-α, IL-6 and malondialdehyde levels were also estimated in adenoid and tonsils tissues. A Pediatric Sleep Questionnaire was completed by the parents before and after AT. As a result of the study, we obtained the following results: TNF-α, IL-6 and malondialdehyde evaluated preoperative increased in serum and tissues in OSAS, especially in severe disease compared to mild and moderate forms. Six weeks after AT, AHI diminished significantly in OSAS, as well as the inflammatory markers and malondialdehyde, in parallel with significant improvement of antioxidant enzymes activities. Daytime sleepiness, hyperactivity and attention deficit in OSAS, even in mild disease were present, with significant improvements of obstructive symptoms after AT. We conclude that OSAS caused by adenoids and/or tonsillar hypertrophy led to changes in the blood parameters, with significant improvement after AT. Postoperatively, a significant improvement in sleep quality and behavior in OSAS patients was also observed.

EPCephalic duodenopancreatectomy for neurofibromatosis associated with gastrointestinal stromal tumor. A case report

BACKGROUND

Neurofibromatosis is a genetic autosomal dominant disease characterized by multiple skin nodules and hyperpigmentation. This condition is frequently associated with a large variety of neoplasia, including gastrointestinal stromal tumors (GIST) in about 6% of cases. We present a case of neurofibromatosis associated GIST.

CASE REPORT

A 57 year-old male patient with Von Recklinghausen disease was referred into our service after he was discovered with a 7 mm nodular formation in contact with the pancreatic head, during a routine abdominal ultrasonography. Ultrasound examination performed into our service reveals a nodular formation with hypoechoic circumference, central translucency, with central necrosis, contrast medium uptake and dimensions at about 78/49/77 mm, without peritoneal fluid content. Trans-gastric biopsy specimen shows mesenchymal proliferation with spindle cells and elongated nuclei and c-kit intensely positive. The diagnosis was gastrointestinal stromal tumor. Delimitation towards pancreatic head was unclear. A cephalic duodenopacreatectomy was performed. Morphopathology confirmed a multifocal GIST of low grade G1, in the second stage.

CONCLUSION

A rare case of neurofibromatosis associated GIST with multifocal localization was successfully treated by cephalic duodenopancreatectomy.

KEY WORDS

Neurofibromatosis type 1 (NF1), Retroperitoneal Gastrointestinal Stromal Tumor (GIST).

Musculoskeletal ultrasound versus MRI of the hands in healthy subjects - a pilot study

AIM

High resolution imaging methods detect a spectrum of inflammatory-like and structural modifications at joint and tendon level in healthy subjects. The knowledge of their extent and degree is important when subclinical disease activity (implying therapy reassessment) must be differentiated from normality. Musculoskeletal ultrasound (MSUS) evaluation may be challenging even for experts when borderline or low grade lesions are present. Our objective was to analyse the frequency of inflammatory-like lesions in hand joint and tendons in healthy young subjects and to evaluate the concordance between MSUSand magnetic resonance imaging (MRI) findings.

MATERIAL AND METHODS

Ten healthy young women (age range 24-32 years) clinically asymptomatic (joints and tendons) were selected to have bilateral hand MSUS and MRI evaluation. Based on current definitions, synovitis/tenosynovitis-like lesions, erosions, osteophytes and bone edema were quantified and concordance between the two imaging methods was calculated.

RESULTS

Overall, both imaging evaluation methods showed a low frequency of inflammatory-like and structural lesions. No joint presented power Doppler signal or erosions. No abnormalities suggestive for inflammatory or structural pathology were detected at the tendon compartments level. No erosions and no signs of osteitis were detected. The concordance between MSUS and MRI findings was high except for the wrist area.

CONCLUSION

MSUS was demonstrated to be a very accurate imaging method, mostly for hand tendon evaluation. This would allow a better discrimination between normality and pathologic findings, adding supplementary information.

Understanding the Chromatographic Properties and Cytotoxicity of Hidrazinoselenazole Compounds by Computational Study

Selenium compounds have been proven to possess anti-inflammatory, anti-cancer, anti-bacterial and anti-viral activities. A series of fifteen synthesized hidrazinoselenazole was investigated to assess the chromatographic properties as function of structural features and the cytotoxicity as function of chromatographic properties and/or structural descriptors. The investigated chromatographic properties were retention factor, specific surface area of the solvent and chromatographic hydrophobicity index. The 3D model of the compounds was optimized using Hartree-Fock DFT/B3LYP method, 6-31+G* basis set both in vacuum and water with Spartan software (v.8). Furthermore, several quantitative structure-activity relationship (QSAR) descriptors were calculated with Spartan and Dragon (v. 5.5) software. Full search approach was used to construct simple and multiple linear regression models. No reliable model was identified for specific surface area of the solvent. The models with higher performances in estimation and prediction for retention factor and chromatographic hydrophobicity index proved the ones with Dragon descriptors and molecules optimized in water (retention factor: rloo2 (loo = leave-one-out analysis) = 0.9244; rtr2 (tr = training set) = 0.9652; rts2 (ts = test set) = 0.9606; chromatographic hydrophobicity index: rloo2 = 0.9489; rtr2 = 0.9592; rts2 = 0.9669). The cytotoxicity proved related neither to chromatographic properties nor with compounds� structural characteristics.

Multimodal endocavitary ultrasound versus MRI and clinical findings in pre- and post-treatment advanced cervical cancer. Preliminary report

AIMS

The aim of this study was to evaluate the use of pre and post-therapy transrectal and transvaginal ultrasonography (TRUS, TVUS) with contrast enhancement and strain elastography compared with clinical examination and magnetic resonance imaging (MRI) in the assessment of advanced stage cervical cancer.

MATERIAL AND METHODS

This was a prospective study, carried out over a period of nine months on subjects with advanced-stage cervical cancer (stage >/= IIB). All included patients were examined clinically and underwent abdomino-pelvic contrast enhanced MRI and multimodal US examinations (TRUS with strain elastography and contrast enhanced TVUS) at the time of diagnosis and after radiochemotherapy. Tumor size and staging at TRUS and TVUS was compared with the same data obtained by clinical examination and MRI. Pathology was the golden standard.

RESULTS

Eight patients accomplished the inclusion criteria. In five cases the tumor stage was identical on clinical and MRI examinations. In all cases parametrial infiltration was diagnosed by all pre-treatment examinations. No significant differences were observed in tumor size between clinical, US and MRI exams either at baseline or post-therapy, in native or post-contrast examinations. The size of the tumor evaluated pre-treatment proved to be significantly smaller post-contrast in both US and MRI examinations compared with the native images. Post-therapy, no significant differences were observed on US measured tumor dimensions when comparing native with post-contrast images. Oppositely, significant smaller dimensions were observed on post-contrast MRI compared with native scans.

CONCLUSIONS

TRUS is accurate in the estimation of pre-therapy cervical cancer dimension. The post therapy tumor evaluation is better performed with MRI. The use of intravenous contrast agents on both examinations did not improved the accuracy of tumor evaluation pre or post-therapy.

Neonatal short-term outcomes in infants with intrauterine growth restriction

OBJECTIVES

To assess the neonatal outcomes in newborns with intrauterine growth restriction (IUGR) in a Romanian population in a 3 level maternity unit.

METHODS

A matched case-control design, with one control for each patient was used. The case group comprised neonates with birth weight and birth length below the 10th percentile for the gestational age. Individual matching by gender and age of gestation was used to identify the control group. Both cases and controls were selected from the infants admitted to and discharged from the Neonatal Ward, at the First Gynecology Clinic, of the County Emergency Hospital Cluj-Napoca, Cluj-Napoca, Romania, between January 2012 and June 2014.

RESULTS

One hundred and forty-two subjects were included in each group. The cesarean delivery was significantly more frequent in the IUGR group (66.9%) compared with controls (46.5%; p=0.0006). The Apgar score at one minute was ≥ 7 for most infants in both groups (77.9% IUGR group versus 77.5% control group), with no significant differences between the groups. A significantly higher percentage of infants in the IUGR group had hypoglycemia or intraventricular hemorrhage compared with the controls (p < 0.05). Hypoglycemia proved a significant factor for IUGR (odds ratio = 4.763, 95% confidence interval: 1.711-13.255).

CONCLUSION

Hypoglycemia and intraventricular hemorrhage characterized the IUGR newborns.

Comparative study of three sonoelastographic scores for differentiation between benign and malignant cervical lymph nodes

PURPOSE

The aim of the study was to explore the diagnostic value of three different sonoelastographic scoring systems (labeled S1-S3) for the differentiation between benign and malignant cervical lymph nodes.

MATERIALS AND METHOD

The authors propose a six pattern scoring system of the elastographic images with pattern 1 - representing purely soft nodes, pattern 2 - predominantly soft nodes, pattern 3 - predominantly soft nodes with focal had area, pattern 4 - predominantly hard node, pattern 5 - entirely hard node and pattern 6 - node with necrosis. The sonoelastographic images of 50 benign and 70 malignant lymph nodes were assessed. The area under the ROC curve (AUROC) for the differentiation between benign vs. malignant and benign vs. metastatic nodes were analyzed for the three scoring systems.

RESULTS

When all the malignant lymph nodes were considered, the S1 score showed an AUROC=0.873 (95%CI [0.805-0.918], where CI=confidence interval; p<0.001), sensibility (Se)=58.57%, and specificity (Sp)=96%. For S2 score the AUROC was 0.890 (95%CI [0.824-0.933], p<0.001), Se=92.86%, and Sp=72%. For S3 score, the AUROC was 0.852 (95%CI [0.778-0.902], p<0.001), Se=64.29%, and Sp=94%). When lymphomatous nodes were excluded, for S1 the AUROC was 0.884 (95%CI [0.809-0.932], p<0.001), Se=64%, and Sp=96%. For S2 the AUROC was 0.894 (95%CI [0.818-0.939], p<0.001), Se=92%, and Sp=72%. For S3, the AUROC was 0.856 (95%CI [0.771-0.911], p<0.001), Se=66%, and Sp=94%. In the S3 scoring system, setting the benign vs. malignant cut off at pattern 3 increases the sensibility (41-65%) with minimal loss of specificity (96-94%). From the gray-scale and Doppler criteria, changes of the nodular margins and the presence of the vessels in the cortical part of the lymph node showed both very high sensibility and specificity, the others criteria taken into account had either very good sensibility with low specificity or high specificity and low sensibility.

CONCLUSIONS

Our study suggests that there are no significant differences between the three scoring systems in terms of overall diagnostic value.

Study of preoperative predictive signs in management of facial nerve in parotid tumors

OBJECTIVES

To find preoperative predictive signs for better surgical planning of the facial nerve in parotid tumors.

METHODS

Prospective study in patients with primary parotid malignancies. Patients with primary parotid malignant tumor were investigated for preoperative clinical signs in correlation with histological findings and surgical management of the facial nerve.

OUTCOMES

The study included 47 patients. Several clinical findings as facial pain, paresthesia, and rapid growth of tumor might suggest the risk of malignancy. Paresis/palsy of the facial nerve was correlates with direct neural involvement.

CONCLUSION

There are several predictive clinical signs that might suggest malignancy of a parotid tumor.

Efficiency of oxygen therapy by head box for acute respiratory failure in infants

Oxygen therapy is the main treatment method for acute respiratory failure in children. The method consisting in the administration of oxygen therapy by head box to infants is frequently used in pediatric practice. Objectives. To evaluate the efficiency of oxygen therapy administered by head box to infants suffering from pneumonic acute respiratory failure by comparing two methods for measuring hemoglobin oxygen saturation: in arterialized capillary blood and by pulse oximetry. Material and method. 30 infants suffering from pneumonic acute respiratory failure were studied. We used a clinical appraisal score for acute respiratory failure, which appraises respiratory rate, nasal flaring, recession, cyanosis, sensorial, before and after oxygen therapy. In arterialized capillary blood we measured partial pressure of oxygen and hemoglobin oxygen saturation, and we used an Automatic Blood Gas System analyzer. We also measured hemoglobin oxygen saturation using a pulse oximeter. Determinations were made before the initiation of oxygen therapy, and 30 minutes and 60 minutes after the initiation of oxygen therapy. Results. As compared to the baseline values, determined before the initiation of oxygen therapy, we recorded a statistically significant improvement in the clinical score both after 30 minutes and 60 minutes from the initiation of oxygen therapy (p<0.001). The improvement was greater after 60 minutes. The increase in the partial pressure of oxygen was statistically significant both at the 30 minute and 60 minute determination (p<0.001). Both methods of SaO2 measurement recorded statistically significant increases (p<0.001) in this variable after 30 and 60 minutes, respectively. Conclusions. Oxygen therapy administered by head box improves acute respiratory failure appraised by clinical score. The administration of oxygen therapy by head box to infants significantly increases the values of partial pressure of oxygen and hemoglobin oxygen saturation measured in capillary blood, as well as the values of hemoglobin oxygen saturation determined by pulse oximeter both after 30 minutes and after 60 minutes. The increases in the three parameters are larger after 60 minutes. There is statistically significant concordance between the values of hemoglobin oxygen saturation determined in capillary blood and by pulse oximetry at all determinations.

The value of a new score for sonoelastographic differentiation between benign and malignant cervical lymph nodes

OBJECTIVE

The aim of this study is to explore the diagnostic value of sonoelastography for the differentiation between benign and malignant superficial lymph nodes of the neck. In this respect the utility of an original scoring system was explored.

MATERIAL AND METHOD

Over a period of 30 months the patients examined routinely for the assessment of superficial lymph nodes of the neck were recorded in a data base containing grey-scale, Doppler and sonoelastographic information and images. The sonoelastographic images of 30 benign and 39 malignant lymph nodes were assessed. The images were scored according to a new, eight pattern scoring system proposed by our group. Interobserver agreement and area under the ROC curve (AUROC) for the differentiation between benign vs. malignant and benign vs. metastatic nodes were analyzed.

RESULTS

The analysis of the interobserver agreement for the investigated score provided a weighted Kappa = 0.687, 95%CI [0.572 to 0.802] and standard error = 0.059. In the differentiation benign - malignant, the AUROC was 0.846, with sensitivity of 66.67% and specificity of 96.67% for score &gt; 3. In the differentiation between benign and metastasis, the same criterion provided an AUROC of 0.855, with sensitivity of 71.43 and specificity of 96.67%.

CONCLUSIONS

Our study suggests that applying the proposed score provides good interobserver agreement. The score also provided very good specificity and reasonable sensitivity in the differentiation between malignant and benign lymph nodes in the neck.

[Lymphatic and vascular invasion in laryngeal and pyriform sinus carcinomas]

BACKGROUND

To investigate prognostic significance of the lymphatic and vascular invasion in patients with squamous cell carcinoma of the larynx and pyriform sinus.

MATERIAL AND METHODS

Patients with squamous cell carcinoma of the larynx and pyriform sinus who underwent laryngectomies between 2002 and 2006 in the ENT Clinic of Cluj-Napoca were investigated for lymphatic and vascular invasion and their effect on disease-free survival and recurrence rates.

RESULTS

The present study included 396 patients. The mean disease-free survival of patients with or without lymphatic invasion was statistically significant (p=0.000000). The mean disease-free survival of patients with or without vascular invasion was statistically significant (p=0.000021). In multivariant analysis, the lymphatic invasion was significantly correlated only with surgical resection borders (p=0.0004), while vascular invasion was significantly correlated with surgical resection borders (p=0.0000), nodes diameter (p=0.0075) and postoperative radiotherapy and/or chemotherapy (p=0.0002).

CONCLUSION

Lymphatic and vascular invasion have a significant prognostic value and influence the disease-free survival, regional and distant metastasis rates significantly.

The influence of technical factors on sonoelastographic assessment of solid breast nodules

PURPOSE

The aim of the study was to assess the influence of technical factors and/or lesion characteristics on the final elastographic score in solid breast nodules.

MATERIALS AND METHODS

Patients with solid breast masses examined between May 2007 and May 2008 in the Radiology Department of Cluj District University Hospital were included in the study. All lesions were examined with conventional ultrasound, Doppler ultrasound and sonoelastography, according to a preset protocol. The influence of the following factors on the elastographic score was evaluated: type of section (sagittal versus transverse); size of region of interest (small versus large); amplitude and frequency of movement; initial compression (light versus strong); angulation (perpendicular versus angulated transducer); characteristics of the lesion (size and location). The reference diagnosis was the histopathology diagnosis and, in twenty cases, short-term follow-up.

RESULTS

Ninety-two patients with a mean age of 48.11 years and 101 breast nodules were included in the study. The overall sensitivity and specificity for elastography were 79 % [68-88 %] and 79 % [65 - 89 %], respectively, with a negative predictive value of 74 % [60-85 %] and a positive predictive value of 84 % [72-91 %]. The following factors did not influence the elastographic score: type of section (scores on transverse and longitudinal section, Z = -0.641, p = 0.552); the amplitude and frequency of movements during the elastographic examination (Cochran's Q concordance = 0.706, p = 0.872); strong initial compression in the case of benign nodules (Z = 0.000, p = 1.000); size of the lesions. Of the elastographically benign nodules, 9 were false negative and of the 46 elastographically malignant nodules, 12 were false positive. The following factors influenced the elastographic scores: size of the region of interest (the scores were significantly different when small or large region of interest was used, Z = -0.671, p < 0.0001); transducer angulation (Z = -5.42, p < 0.0001); strong initial compression in the case of malignant nodules (Z = -6.044, p < 0.0001) and the location of the mass in the vicinity of the chest wall.

CONCLUSION

The most important factors that influence the final elastographic score, leading to false negative results, are the size of the region of interest, the initial compression and angulation of the transducer, while the frequency and amplitude of movement during the examination proved to be of no importance as long as the images were obtained within a range of assessment usefulness. Changing the scanning parameters never led to false positive results in the case of malignant breast masses.

A structural informatics study on collagen

The study integrates knowledge resulting from structure-activity relationships analysis of amino acids with respect to the characterization of alpha1 and alpha2 type I collagen chains. Specifically, 15 amino acids and 14 properties were investigated and their structure-activity relationship models were obtained. The models were integrated into a web application and were used to predict the properties of a set of six amino acids. The similarities in alpha1 and alpha2 type I collagen chains has been investigated starting from the observed and predicted properties of amino acids by using two-step cluster analysis.