Quantification of periaortic fat tissue in contrast-enhanced computed tomography

Objective. Periaortic fat tissue (PaFT) has been implicated in the progression of abdominal aortic aneurysms (AAAs). Therefore, its quantification as a prognostic marker for aneurysm expansion has attracted clinical interest. Most existing research on PaFT, however, is based on unenhanced aortic CT scans, whereas the CT diagnosis of aortic aneurysms is usually performed with enhanced CT angiographies. The objective of this study is to examine the feasibility of measuring abdominal periaortic fat tissue in enhanced aortic CT-scans using a new method based on the OsirixMD post-processing software and evaluate any methodological issues/considerations arising from it, in order to reliably quantify periaortic fat tissue from enhanced and unenhanced CT-scans. Methods. In a derivation cohort (n= 101), PaFT Volume and PaFT mean HU value were measured within a 5 mm-wide periaortic ring in arterial phases and compared to the same values from native scans. Fat tissue was defined within the range of -45 to -195 Hounsfield Units (HU). After testing their correlation, fat tissue values from both CT phases underwent linear regression through the origin to define a correction factor (slope of the line of best fit), allowing the conversion of arterial back to native scores. This conversion factor was then applied to fat tissue values in a different validation cohort (n=47) and the agreement of the corrected fat tissue values and values in the native scans was examined using Bland-Altman plots and Passing-Bablok regression. In a secondary study the pooled date sets from both studies (n=148) were stratified in an AAA and non-AAA group and the average fat tissue values for both groups (with PaFT volumes adjusted for aortic size) were calculated using both native and corrected arterial values. Results. In the derivation cohort, periaortic fat tissue Volume and mean HU value showed very high correlations between arterial and native scans (r> .99 and r= .95 respectively, p< .0001 both). Linear regression defined a conversion factor of 1.1057 for arterial periaortic fat tissue Volume and 1.0011 for arterial periaortic fat tissue mean HU. Potential confounding factors (mean intraluminal contrast density, aortic wall calcification, longitudinal contrast dispersion, aortic diameter, CT-tube voltage, slice thickness, image noise) showed no significant impact in multivariate regression. Application of the conversion factors in arterial scans of the validation study resulted in corrected arterial fat tissue values that showed very good agreement with PaFT values in native scans. Bland Altman analysis showed the following mean differences [95% confidence interval]: 0.36 [-0.01 to 0.73] for periaortic fat tissue Volume and 0.83 [-1.08 to 0.1] for periaortic fat tissue mean HU. Passing-Bablok regression confirmed minimal/no residual bias. Median periaortic fat tissue size-adjusted PaFT Volumes and Mean HU values from the Mann-Whitney test showed no significant difference between the AAA and non-AAA groups. Conclusion. Periaortic fat tissue Volume and mean HU values demonstrate only minimal variation between arterial and native scans and can be measured in enhanced aortic CT scans with very high reliability. Periaortic fat tissue Mean HU value, unlike Volume, is independent from the presence of paraaortic organs. Certain issues, like non-circular aortic discs, histological boundaries of periortic fat tissue and dependence from Body Mass Index and other fat tissue depots need to be explored further.1. ZUSAMMENFASSUNG Ziel. Das periaortale Fettgewebe spielt bei der Progression von Aortenaneurysmen eine Rolle, so dass seine Quantifizierung als prognostischer Marker für die Aneurysmaprogression von besonderem klinischem Interesse ist. Die aktuelle Forschung ist basiert jedoch fast ausschließlich auf nativen CTs, während Aortenaneurysmen üblicherweise nur mittels kontrastmittelverstärkten CT angiographien dargestellt werden. Das Ziel dieser Studie ist die methodische Überprüfung der Bestimmung vom abdominalen periaortalen Fettgewebe in kontrastmittelverstärkten CTs mit der frei verfügbaren OsirixMD Softwareanwendung und die Evaluation von potenziellen Faktoren, die eine zuverlässige periaortale Fettgewebsquantifikation in nativen und kontrastverstärkten CTs ermöglichen. Methodik. In einer Derivationsgruppe (n=101), wurde das Fettgewebsvolumen und die HU Mittelwerte innerhalb von einem 5 mm breiten periaortalen Ring in arteriellen CTs bestimmt und die Werte wurden mit entsprechenden Werten aus nativen CTs verglichen. Das Fettgewebe wurde als HU Werte -45 bis -195 HU definiert. Die Fettgewebswerte von beiden CT-Phasen wurden auf Korrelation überprüft und anschließend einer linearen Regressionsanalyse unterzogen, wobei ein Konversionsfaktor bestimmt wurde, um arterielle in nativen Fettgewebswerten zu konvertieren. Der Konversionsfaktor wurde danach in einer zweiten Validierungsgruppe (n=47) angewendet. Sodann wurde die Übereinstimmung von korrigierten arteriellen und nativen Fettgewebswerten mittels Bland-Altmann Plots und Passing-Bablok Regressionsanalyse überprüft. In einer Sekundärstudie, wurden die gepoolten Datasets beider Studien (n=148) in einer Bauchaortenaneurysma- und einer Nichtbauchaortenanerysmagruppe stratifiziert, um die Mittelwerte von Fettgewebsvolumen (adjustiert für Aortengröße) und HU Mittelwert in beiden Gruppen zu bestimmen. Ergebnisse. In der Derivationsgruppe, zeigte das Fettgewebsvolumen und der HU Mittelwert eine sehr hohe Korrelation zwischen kontrastverstärkten und nativen CTs (r > 0,99 und r= 0,95 entsprechend, p< 0,0001 für beide). Die lineare Regressionsanalyse ergab einen Konversionsfaktor von 1,1057 für das Fettgewebsvolumen und 1,0011 für den Fettgewebs-HU Mittelwert. Potenzielle Störfaktoren (intraluminale Kontrastmitteldichte, Aortenwandkalzifikation, longitudinale Kontrastmittelverteilung, Aortendiameter, CT-Röhrenspannung, Slicestärke, Größe der intraluminalen Kontrast-ROI, Bildrauschen) zeigten keinen signifikanten Einfluss in der multiplen Regressionsanalyse. In der Validierungsgruppe, zeigten die mittels Konversionsfaktor korrigierten Fettgewebswerte der arteriellen Phase eine sehr hohe Übereinstimmung mit den Fettgewebswerten der nativen CT-Phase. Die Bland-Altman Analyse ergab folgende mittlere Differenzen [95% Konfidenzintervall]: 0,36 [- 0,01 bis 0,73] fürs Volumen und 0,83 [-1,08 bis 0,1] für den HU Mittelwert. Die Passing-Bablok Regressionsanalyse bestätigte ein minimales bzw. kein residuales Bias. In der Sekundärstudie, zeigten die Mediane der Fettgewebswerte aus dem Mann-Whitney Test keinen signifikanten Unterschied zwischen der BAA und nicht-BAA Gruppe. Schlussfolgerung. Periaortales Fettgewebsvolumen und HU-Mittelwert zeigen eine minimale Variation zwischen arteriellen und nativen CTs und lassen sich in kontrastverstärkten Aorten-CTs sehr zuverlässig bestimmen. Der Fettgewebsmittelwert ist von der Präsenz anderer paraaortale Organe unabhängig. Gewisse Faktoren, z.B. nicht-zirkuläre aortalen Scheiben, histologische Grenzen des periaortalen Fettgewebes und seine Abhängigkeit vom Body Mass Index und anderen Fettgewebskompartimenten benötigen eine weitere Analyse

Quantification of periaortic adipose tissue in contrast-enhanced CT angiography: technical feasibility and methodological considerations

To examine the feasibility of the quantifcation of abdominal periaortic fat tissue (PaFT) (tissue within − 45 to − 195 HU) in enhanced CT-angiographies compared to unenhanced CT-scans and identify methodological issues afecting its clinical implementation. Using OsirixMD, PaFT volume and mean HU value were retrospectively measured within a 5 mm periaortic ring in paired unenhanced and enhanced abdominal aortic CT-scans. The correlation between PaFT values was examined in a derivation cohort (n=101) and linear regression analysis produced correction factors to convert values from enhanced into values from unenhanced CTs. The conversion factors were then applied to enhanced CTs in a diferent validation cohort (n=47) and agreement of corrected enhanced values with values from unenhanced scans was evaluated. Correlation between PaFT Volume und Mean HU from enhanced and unenhanced scans was very high (r >0.99 and r=0.95, respectively, p<0.0001 for both). The correction factors for PaFT Volume and Mean HU were 1.1057 and 1.0011. Potential confounding factors (CT-kilovoltage, slice thickness, mean intraluminal contrast density, aortic wall calcifcation, longitudinal variation of intraluminal contrast density, aortic diameter) showed no signifcant efect in a multivariate regression analysis (p>0.05). Bland-Altman analysis of corrected enhanced and unenhanced values showed excellent agreement and Passing–Bablok regression confrmed minimal/no residual bias. PaFT can be quantifed in enhanced CT-angiographies very reliably. PaFT Volume scores are very consistently slightly underestimated in enhanced scans by about 10%, while the PaFT Mean HU value remains practically constant and ofers distinct methodological advantages. However, a number of methodological issues remain to be addressed

Endometrial scratching during hysteroscopy in women undergoing in vitro fertilization: a systematic review and meta-analysis

ObjectiveEndometrial scratching (ES) during hysteroscopy before embryotransfer (ET) remains doubtable on whether it benefits the reproductive outcomes. The optimal technique is not clear and repeated implantation failure as a challenging field in in vitro fertilization (IVF) seems to be the springboard for clinicians to test its effectiveness.MethodsMedline, PMC, ScienceDirect, Scopus, CENTRAL, Google Scholar were searched from their inception up to April 2023 for studies to evaluate the effectiveness of adding endometrial scratching during hysteroscopy before ET.ResultsThe initial search yielded 959 references, while 12 eligible studies were included in the analyses, involving 2,213 patients. We found that hysteroscopy and concurrent ES before ET resulted in a statistically significant improvement in clinical pregnancy rate (CPR) [RR = 1.50, (95% CI 1.30–1.74), p &lt; 0.0001] and live birth rate (LBR) [RR = 1.67, (95% CI 1.30–2.15), p &lt; 0.0001] with no statistically significant difference on miscarriage rate [RR = 0.80 (95% CI 0.52–1.22), p = 0.30]ConclusionOur meta-analysis suggests that hysteroscopy with concurrent ES may be offered in IVF before ET as a potentially improving manipulation. Future randomized trials comparing different patient groups would also provide more precise data on that issue, to clarify specific criteria in the selection of patients.Systematic Review RegistrationPROSPERO (CRD42023414117

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Serologic and immunologic factors of the servicovaginal secretions, indicative of preterm labor

Despite the impressive advances that have been noted in Obstetrics over the last decades, the etiology of Preterm Labor still remains obscure. It is probably a multifactorial disease where infection and inflammation of the pregnancy sac plays a crucial role since 40% of the placentas delivered prematurely have histological findings that are consistent with chorioamnionitis. However, only 12.5% of these cases present with clinical signs of an intrauterine infection. For the rest of the cases it is speculated that a subclinical ascending infection is the cause. Activation of the local immune system takes place and triggers a cascade of events that end up in the production mainly of prostaglandins but, also of endothelins, causing, eventually,myometrial contractions. This was a prospective observational study where we compared the concentrations of Interleukins Iβ, 6, 8, TNF-α and Fibronectin in samples of cervical and vaginal secretions that were obtained from 3 groups of pregnant women. They were all singleton pregnancies, above the 26th but below the 34th week and their membranes were intact. The control group consisted of 18 asymptomatic women presenting in the Outpatient department for their routine monthly check-up. The study group consisted of 39 women presenting with premature contractions. This last group was further subdivided into two smaller ones, depending on the gestational week that the delivery took place: the "True" Preterm labor group (17 women) and the "False" Preterm labor group (22 women). Then, we compared the concentrations of the above-mentioned proteins both between the control and the study group but also between the "False" and the "True" preterm labor groups. We also compared those 3 groups as for certain demographic and clinical characteristics. A p<0.05 was considered statistically significant. When compared for the age of pregnancy at delivery, the number of days between sampling and delivery and the Bishop score, the difference proved to be statistically significant between the study and the control group. As for the Apgar score, a statistically significant difference was noted only between the "False" and the "True" Preterm Labor group. Fibronectin was found to be significantly higher both in the study group when compared to the control group but, also in the "True" preterm labor group when compared to the "False" preterm labor group. That difference existed both for the cervical and the vaginal sample. A statistically significant difference was also found when we compared the "False" and the "True" Preterm Labor groups for the TNF-a concentration in the cervical sample. We managed to confirm the crucial role that Fibronectin can play in the clinical management of women presenting with symptoms of threatened Preterm Labor. The significantly higher concentrations of TNF-α that were noted in the cervical secretions of cases that eventually ended up with preterm delivery signifies the potentially vital role that an infection may be playing in the pathophysiology of Preterm Labor. It is known that this cytokine is the first to be produced in cases of microbial infection. The limited number of cases may be the cause that the apparent difference didn't reach statistical significance in the case of the other cytokines. It is obvious that large multicenter studies are needed in order to clarify this difficult problem before the proposal of specific therapeutic measures.Ο Πρόωρος Τοκετός, παρά τις αλματώδεις εξελίξεις στη Μαιευτική-Γυναικολογία, παραμένει μια νόσος άγνωστης αιτιολογίας. Πιθανότατα πρόκειται για μια πολυπαραγοντική ασθένεια, όπου η φλεγμονή των στοιχείων της κύησης παίζει ένα σημαντικό ρόλο, αφού ιστολογικά ευρήματα χοριοαμνιονίτιδας βρίσκονται περίπου στο 40% των πλακούντων εγκύων γυναικών που παρουσιάζονται με πρόωρες συσπάσεις και καταλήγουν σε τοκετό πριν την 37η εβδομάδα της κύησης. Μόνο το 12,5% του συνόλου αυτών των περιστατικών παρουσιάζουν κλινική εικόνα ενδομήτριας λοίμωξης, ενώ για τα υπόλοιπα περιστατικά πιθανολογείται ότι ευθύνεται μια υποκλινική ανιούσα φλεγμονή. Αυτή κινητοποιεί το ανοσοποιητικό σύστημα στον τράχηλο, αλλά και στα υπόλοιπα στοιχεία της κύησης, με αποτέλεσμα την παραγωγή κυρίως προσταγλανδινών αλλά και ενδοθηλινών, που προκαλούν με τη σειρά τους συσπάσεις του μυομητρίου. Στην προοπτική αυτή μελέτη παρατήρησης συμμετείχαν 39 έγκυες γυναίκες που παρουσιάστηκαν με συμπτωματολογία πρόωρου τοκετού (ομάδα ασθενών), που βρισκόταν μεταξύ της 26ης και της 34ης εβδομάδας της κύησης. Από αυτές τις γυναίκες έγινε λήψη κολπικού και τραχηλικού εκκρίματος, στα οποία μετρήθηκαν οι συγκεντρώσεις των Ιντερλευκινών 1β, 6, 8 και του TNF-α καθώς και της Φιμπρονεκτίνης. Η ίδια διαδικασία ακολουθήθηκε και σε 18 ασυμπτωματικές γυναίκες (ομάδα ελέγχου), που βρισκόταν στην ίδια ηλικία κύησης όταν προσήλθαν στα εξωτερικά ιατρεία για τον τακτικό μηνιαίο έλεγχο τους. Σε όλες τις γυναίκες υπήρχε μονήρης ζώσα κύηση με άρρηκτους εμβρυϊκούς υμένες. Το σύνολο των παραπάνω γυναικών χωρίστηκε σε 3 ομάδες ανάλογα με την ηλικία κύησης κατά την οποία συνέβη ο τοκετός, θέτοντας σαν όριο για τη προωρότητα τις 37 εβδομάδες: την ομάδα Ελέγχου, την ομάδα του «Αληθούς» Πρόωρου Τοκετού και την ομάδα του «Ψευδούς» Πρόωρου Τοκετού. Στη συνέχεια συγκρίθηκαν η ομάδα ελέγχου με την ευρύτερη ομάδα των ασθενών, αλλά και οι δυο υποομάδες των ασθενών «Αληθούς» και «Ψευδούς» Πρόωρου Τοκετού) ως προς τις συγκεντρώσεις των πρωτεϊνών που προαναφέρθηκαν και ανιχνεύθηκε η ύπαρξη η μη στατιστικά σημαντικής διαφοράς μεταξύ τους. Επίσης, οι τρεις αυτές ομάδες συγκρίθηκαν και ως προς διάφορα δημογραφικά και κλινικά χαρακτηριστικά. Στατιστικά σημαντική διαφορά παρατηρήθηκε στην ηλικία κύησης (μεταξύ ομάδας ελέγχου και ομάδας ασθενών) και στον αριθμό των ημερών που παρεμβλήθηκαν μεταξύ δειγματοληψίας και τοκετού, καθώς και στο Bishop score (μεταξύ και των τριών ομάδων). Επίσης, στατιστικά σημαντική διαφορά παρατηρήθηκε και στο Apgar score μεταξύ των δύο υποομάδων των ασθενών, αλλά όχι μεταξύ ασθενών και μαρτύρων (ομάδα ελέγχου). Ως προς τις μετρηθείσες ουσίες, στατιστικά σημαντική διαφορά παρατηρήθηκε ως προς τη Φιμπρονεκτίνη τόσο μεταξύ ασθενών και μαρτύρων όσο και μεταξύ των δύο υποομάδων των ασθενών. Όμοια, τέτοιαδιαφορά παρατηρήθηκε μεταξύ των δύο υποομάδων των ασθενών ως προς τον TNF-α του τραχήλου. Επιβεβαιώθηκε η σπουδαιότητα του ρόλου που μπορεί να παίξει η Φιμπρονεκτίνη όσον αφορά την ανίχνευση των περιστατικών που τελικά θα καταλήξουν σε πρόωρο τοκετό. Η παρουσία του TNF-α στον τράχηλο σε σημαντικά υψηλότερα επίπεδα στις περιπτώσεις «Αληθούς» πρόωρου τοκετού αποτελεί μια απόδειξη για τον σημαντικό ρόλο της φλεγμονής στην παθοφυσιολογία του πρόωρου τοκετού, αφού αυτή η κυτταροκίνη είναι η πρώτη που παράγεται σε περίπτωση προσβολής από μικρόβια. Ο περιορισμένος αριθμός των περιστατικών δεν επέτρεψε ίσως να αποκτήσουν στατιστική βαρύτητα οι μικρές διαφορές που παρατηρήθηκαν στις συγκεντρώσεις των άλλων κυτταροκινών. Κατά συνέπεια, χρειάζονται μεγαλύτερες πολυκεντρικές μελέτες που να καθορίσουν κατ' αρχήν τις φυσιολογικές τιμές για κάθε ηλικία κύησης στον Ελληνικό πληθυσμό και στη συνέχεια να ανιχνεύσουν τις τυχόν υπάρχουσες διαφορές στις περιπτώσεις πρόωρου τοκετού

Pregnancy outcomes in Takayasu arteritis patients: a systematic review and meta-analysis

Abstract Takayasu arteritis (TA) is a systemic disease affecting women of reproductive age. Similarly to other systemic autoimmune diseases, pregnancies in patients suffering from TA are at high risk for adverse outcomes; however, the precise incidence of adverse events has not been assessed in a systematic approach. To evaluate the prevalence of adverse pregnancy outcomes in TA. Searches were conducted on PubMed, Cochrane Library, Scopus and Cinahl databases from inception to 25 May 2022. Three independent investigators extracted data and assessed the risk of bias using ROBINS-1 tool. We used a random effects model to calculate the prevalence of the adverse pregnancy outcomes in TA, namely miscarriage, hypertension and pre-eclampsia. We calculated the prevalence of the adverse outcomes in pregnancy for TA. We included 27 studies, with 825 pregnancies. The occurrence of miscarriage, hypertension and pre-eclampsia in patients with TA was 16% (CI 12–21%, p < 0.01), 37% (CI 30–45%, p < 0.01) and 14% (CI 8–23%, p < 0.01), respectively. The results of our meta-analysis indicate that pregnancies in patients with TA are at increased risk for adverse pregnancy outcomes compared to the general population, suggesting that pregnant women with TA should be closely monitored. Trial registration: There was no registration for this systematic review. The aim of this study was to evaluate etc in order to be correct by syntax

Selective feticide reverses intrahepatic cholestasis of pregnancy in twins discordant for growth: A case report

Twin gestations are associated with an increased risk of intrahepatic cholestasis in pregnancy (ICP), probably attributed to the elevated pregnancy hormones. We report a case of a dichorionic diamniotic twin pregnancy, at the third trimester, complicated with ICP and severe, selective fetal growth restriction (sFGR). A 32-year-old primiparous woman with a dichorionic, diamniotic twin gestation conceived via in vitro fertilization (IVF) presented with pruritus at the maternity care unit at 26+4 weeks of pregnancy. Following a detailed assessment, she was diagnosed with severe sFGR and ICP. During her hospitalization, selective feticide of the FGR fetus was decided and a remarkable improvement in the symptoms and the laboratory findings of ICP was noticed. The incidence of ICP is reported to be higher in twin pregnancies, especially those conceived via IVF, compared with singletons. The optimal timing of delivery and management of twin pregnancies complicated with ICP remain unclear. In our case, selective reduction of the FGR fetus led to the resolution of ICP