Mind the gap: quantification of incomplete ablation patterns after pulmonary vein isolation using minimum path search

Pulmonary vein isolation (PVI) is a common procedure for the treatment of atrial fibrillation (AF). A successful isolation produces a continuous lesion (scar) completely encircling the veins that stops activation waves from propagating to the atrial body. Unfortunately, the encircling lesion is often incomplete, becoming a combination of scar and gaps of healthy tissue. These gaps are potential causes of AF recurrence, which requires a redo of the isolation procedure. Late-gadolinium enhanced cardiac magnetic resonance (LGE-CMR) is a non-invasive method that may also be used to detect gaps, but it is currently a time-consuming process, prone to high inter-observer variability. In this paper, we present a method to semi-automatically identify and quantify ablation gaps. Gap quantification is performed through minimum path search in a graph where every node is a scar patch and the edges are the geodesic distances between patches. We propose the Relative Gap Measure (RGM) to estimate the percentage of gap around a vein, which is defined as the ratio of the overall gap length and the total length of the path that encircles the vein. Additionally, an advanced version of the RGM has been developed to integrate gap quantification estimates from different scar segmentation techniques into a single figure-of-merit. Population-based statistical and regional analysis of gap distribution was performed using a standardised parcellation of the left atrium. We have evaluated our method on synthetic and clinical data from 50 AF patients who underwent PVI with radiofrequency ablation. The population-based analysis concluded that the left superior PV is more prone to lesion gaps while the left inferior PV tends to have less gaps (p<0.05 in both cases), in the processed data. This type of information can be very useful for the optimization and objective assessment of PVI interventions

Scar-Related Ventricular Arrhythmia Prediction from Imaging Using Explainable Deep Learning

International audienceThe aim of this study is to create an automatic frameworkfor sustained ventricular arrhythmia (VA) prediction using cardiac com-puted tomography (CT) images. We built an image processing pipelineand a deep learning network to explore the relation between post-infarctleft ventricular myocardium thickness and previous occurrence of VA.Our pipeline generated a 2D myocardium thickness map (TM) from the3D imaging input. Our network consisted of a conditional variationalautoencoder (CVAE) and a classifier model. The CVAE was used tocompress the TM into a low dimensional latent space, then the classifierutilised the latent variables to predict between healthy and VA patient.We studied the network on a large clinical database of 504 healthy and182 VA patients. Using our method, we achieved a mean classificationaccuracy of 75%±4 on the testing dataset, compared to 71%±4 from theclassification using the classical left ventricular ejection fraction (LVEF)

Case report: Alternative approach for management of refractory volume overload in heart failure: usefulness of venous leg compression

BackgroundManagement of patients with refractory congestion, is one of the most important challenges in the field of heart failure (HF). Diuretic therapy remains the most widely used therapy to achieve euvolemia. However, some patients experience fluid overload despite the use of high-dose diuretics and new strategies to overcome diuretic resistance are needed.Case SummaryWe report an 85 years-old male patient admitted for decompensated HF with persistent tissue fluid overload (peripheral edema) for more than two weeks despite high dose of intravenous furosemide with the combination of other diuretics. At this point, we performed leg venous compression using elastic bandages for three days. After 72 h, edema disappeared, and additional weight loss was achieved (1 kg/day). No side effects were observed and the patient was discharged home euvolemic.ConclusionVenous leg compression may be an alternative therapy in patients with persistent tissue fluid overload resistant to diuretics

Interpretable Prediction of Post-Infarct Ventricular Arrhythmia using Graph Convolutional Network

International audienceHeterogeneity of left ventricular (LV) myocardium infarction scar plays an important role as anatomical substrate in ventricular arrhythmia (VA) mechanism. LV myocardium thinning, as observed on cardiac computed tomography (CT), has been shown to correlate with LV myocardial scar and with abnormal electrical activity. In this project, we propose an automatic pipeline for VA prediction, based on CT images, using a Graph Convolutional Network (GCN). The pipeline includes the segmentation of LV masks from the input CT image, the short-axis orientation reformatting, LV myocardium thickness computation and mid-wall surface mesh generation. An average LV mesh was computed and fitted to every patient in order to use the same number of vertices with point-to-point correspondence. The GCN model was trained using the thickness value as the node feature and the atlas edges as the adjacency matrix. This allows the model to process the data on the 3D patient anatomy and bypass the “grid” structure limitation of the traditional convolutional neural network. The model was trained and evaluated on a dataset of 600 patients (27% VA), using 451 (3/4) and 149 (1/4) patients as training and testing data, respectively. The evaluation results showed that the graph model (81% accuracy) outperformed the clinical baseline (67%), the left ventricular ejection fraction, and the scar size (73%). We further studied the interpretability of the trained model using LIME and integrated gradients and found promising results on the personalised discovering of the specific regions within the infarct area related to the arrhythmogenesis

Antimicrobial activity of ceftolozane-tazobactam against multidrug-resistant and extensively drug-resistant Pseudomonas aeruginosa clinical isolates from a Spanish hospital

Objectives. Our objective was to evaluate the in vitro activity of ceftolozane-tazobactam against multidrug resistant (MDR) and extensively drug-resistant (XDR) non metallo-ß-lactamase producing Pseudomonas aeruginosa clinical isolates at Hospital Universitario Miguel Servet (Zaragoza, Spain) from February 2016 to October 2017. Material and methods. We evaluated the in vitro activity of ceftolozane-tazobactam and other antipseudomonal antibiotics against 12 MDR and 117 XDR non metallo-ß-lactamase producing P. aeruginosa isolates. Ceftolozane-tazobactam minimal inhibitory concentrations (MICs) were determined by MIC gradient diffusion test strip. Results. Among the 129 MDR/XDR isolates included, 119 (92.2%) were susceptible to ceftolozane-tazobactam, and ten (7.8%) were resistant. MIC50 was 2 mg/L, and MIC90 4 mg/L. Ceftolozane-tazobactam was the second most active antibiotic after colistin, overtaking amikacin. Conclusions. Ceftolozane-tazobactam is a valuable treatment option for MDR and XDR P. aeruginosa infections in our setting. Objectives. Our objective was to evaluate the in vitro activity of ceftolozane-tazobactam against multidrug resistant (MDR) and extensively drug-resistant (XDR) non metallo-beta-lactamase producing Pseudomonas aeruginosa clinical isolates at Hospital Universitario Miguel Servet (Zaragoza, Spain) from February 2016 to October 2017. Material and methods. We evaluated the in vitro activity of ceftolozane-tazobactam and other antipseudomonal antibiotics against 12 MDR and 117 XDR non metallo-beta-lactamase producing P. aeruginosa isolates. Ceftolozane-tazobactam minimal inhibitory concentrations (MICs) were determined by MIC gradient diffusion test strip. Results. Among the 129 MDR/XDR isolates included, 119 (92.2%) were susceptible to ceftolozane-tazobactam, and ten (7.8%) were resistant. MIC50 was 2 mg/L, and MIC90 4 mg/L. Ceftolozane-tazobactam was the second most active antibiotic after colistin, overtaking amikacin. Conclusions. Ceftolozane-tazobactam is a valuable treatment option for MDR and XDR P. aeruginosa infections in our setting

Progressive and Simultaneous Right and Left Atrial Remodeling Uncovered by a Comprehensive Magnetic Resonance Assessment in Atrial Fibrillation

Background Left atrial structural remodeling contributes to the arrhythmogenic substrate of atrial fibrillation (AF), but the role of the right atrium (RA) remains unknown. Our aims were to comprehensively characterize right atrial structural remodeling in AF and identify right atrial parameters predicting recurrences after ablation. Methods and Results A 3.0 T late gadolinium enhanced-cardiac magnetic resonance was obtained in 109 individuals (9 healthy volunteers, 100 patients with AF undergoing ablation). Right and left atrial volume, surface, and sphericity were quantified. Right atrial global and regional fibrosis burden was assessed with validated thresholds. Patients with AF were systematically followed after ablation for recurrences. Progressive right atrial dilation and an increase in sphericity were observed from healthy volunteers to patients with paroxysmal and persistent AF; fibrosis was similar among the groups. The correlation between parameters recapitulating right atrial remodeling was mild. Subsequently, remodeling in both atria was compared. The RA was larger than the left atrium (LA) in all groups. Fibrosis burden was higher in the LA than in the RA of patients with AF, whereas sphericity was higher in the LA of patients with persistent AF only. Fibrosis, volume, and surface of the RA and LA, but not sphericity, were strongly correlated. Tricuspid regurgitation predicted right atrial volume and shape, whereas diabetes was associated with right atrial fibrosis burden; sex and persistent AF also predicted right atrial volume. Fibrosis in the RA was mostly located in the inferior vena cava-RA junction. Only right atrial sphericity is significantly associated with AF recurrences after ablation (hazard ratio, 1.12 [95% CI, 1.01-1.25]). Conclusions AF progression associates with right atrial remodeling in parallel with the LA. Right atrial sphericity yields prognostic significance after ablation

Evaluating radiological response in pancreatic neuroendocrine tumours treated with sunitinib : comparison of Choi versus RECIST criteria (CRIPNET_ GETNE1504 study)

The purpose of our study was to analyse the usefulness of Choi criteria versus RECIST in patients with pancreatic neuroendocrine tumours (PanNETs) treated with sunitinib. A multicentre, prospective study was conducted in 10 Spanish centres. Computed tomographies, at least every 6 months, were centrally evaluated until tumour progression. One hundred and seven patients were included. Median progression-free survival (PFS) by RECIST and Choi were 11.42 (95% confidence interval [CI], 9.7-15.9) and 15.8 months (95% CI, 13.9-25.7). PFS by Choi (Kendall's τ = 0.72) exhibited greater correlation with overall survival (OS) than PFS by RECIST (Kendall's τ = 0.43). RECIST incorrectly estimated prognosis in 49.6%. Partial response rate increased from 12.8% to 47.4% with Choi criteria. Twenty-four percent of patients with progressive disease according to Choi had stable disease as per RECIST, overestimating treatment effect. Choi criteria predicted PFS/OS. Changes in attenuation occurred early and accounted for 21% of the variations in tumour volume. Attenuation and tumour growth rate (TGR) were associated with improved survival. Choi criteria were able to capture sunitinib's activity in a clinically significant manner better than RECIST; their implementation in standard clinical practice shall be strongly considered in PanNET patients treated with this drug

Aplikasi Herbisida 2,4-d Dan Penoxsulam Pada Pertumbuhan Dan Hasil Tanaman Padi Sawah (Oryza Sativa L.)

Salah satu teknik budidaya untuk meningkatkan produksi tanaman padi sawah yaitu dengan mengurangi persaingan antara tanaman dengan gulma. Pengendalian dengan kimiawi merupakan salah satu cara mengurangi pertumbuhan gulma di pertanaman padi. Cara kimiawi merupakan cara yang praktis, efektif dan efisien untuk mengendalikan gulma. Penelitian ini bertujuan untuk mempelajari pengaruh dari aplikasi herbisida 2,4-D dan penoxsulam dalam meningkatkan pertumbuhan dan hasil padi sawah serta menentukan dosis aplikasi herbisida 2,4-D dan penoxsulam baik secara tunggal maupun campuran dalam mengendalikan gulma pada tanaman padi sawah. Penelitian telah dilaksanakan pada bulan Maret-Juli 2014 di Desa Campurasri, Ngawi. Penelitian menggunakan Rancangan Acak Kelompok sederhana, dengan menempatkan 11 perlakuan yaitu H1 : kontrol herbisida 2,4-D; H2 : 2,4-D 11,25 kg ha-1; H3 : 2,4-D 22,5 kg ha-1; H4 : 2,4-D 33,75 kg ha-1; H5 : kontrol herbisida penoxsulam; H6 : penoxsulam 200 ml ha-1; H7 : penoxsulam 400 ml ha-1; H8 : penoxsulam 600 ml ha-1; H9 : 2,4-D 11,25 kg ha-1 dan penoxsulam 200 ml ha-1; H10 : 2,4-D 22,5 kg ha-1 dan penoxsulam 400 ml ha-1; H11 : 2,4-D 33,75 kg ha-1 dan penoxsulam 600 ml ha-1. Hasil penelitian menunjukkan bahwa perlakuan herbisida 2,4-D 11,25 kg ha-1 dan penoxsulam 200 ml menghasilkan bobot kering total tanaman dengan peningkatan sebesar 34,62 % dibandingkan dengan kontrol. Pada produksi tanaman padi peningkatan terjadi sebesar 29,77 % pada perlakuan herbisida 2,4-D 33,75 kg ha-1 dan penoxsulam 600 ml dibandingkan dengan kontrol

Current clinical spectrum of common variable immunodeficiency in Spain: The multicentric nationwide GTEM-SEMI-CVID registry

Common variable immunodeficiency (CVID) constitutes a heterogenic group of primary immunodeficiency disorders with a wide-ranging clinical spectrum. CVID-associated non-infectious morbidity constitutes a major challenge requiring a full understanding of its pathophysiology and its clinical importance and global variability, especially considering the broad clinical, genetic, and regional heterogeneity of CVID disorders. This work aimed to develop a nationwide, multicenter, retrospective study over a 3-year period describing epidemiological, clinical, laboratory, therapeutic, and prognostic features of 250 CVID patients in Spain. The mean diagnostic delay was around 10 years and most patients initially presented with infectious complications followed by non-infectious immune disorders. However, infectious diseases were not the main cause of morbimortality. Non-infectious lung disease was extraordinarily frequent in our registry affecting approximately 60% of the patients. More than one-third of the patients in our cohort showed lymphadenopathies and splenomegaly in their follow-up, and more than 33% presented immune cytopenias, especially Evans' syndrome. Gastrointestinal disease was observed in more than 40% of the patients. Among biopsied organs in our cohort, benign lymphoproliferation was the principal histopathological alteration. Reaching 15.26%, the global prevalence of cancer in our registry was one of the highest reported to date, with non-Hodgkin B lymphoma being the most frequent. These data emphasize the importance of basic and translational research delving into the pathophysiological pathways involved in immune dysregulation and diffuse lymphocytic infiltration. This would reveal new tailored strategies to reduce immune complications, and the associated healthcare burden, and ensure a better quality of life for CVID patients

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: A nationwide study in Spain

Objective To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. Settings The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. Participants This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. Interventions An exploratory factorial analysis was performed to select the most relevant variables of the sample. Primary and secondary outcome measures Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. Results Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10 5 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade =3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10 5 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. Conclusions Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10 5 people/week) was a statistically independent predictor of mortality. Trial registration number CEIM 20/217