Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk.

BACKGROUND: While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. METHODS: In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). RESULTS: We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. CONCLUSIONS: Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.

The Role of Multimodality Imaging in Pediatric Cardiomyopathies.

Cardiomyopathies are a heterogeneous group of myocardial diseases representing the first cause of heart transplantation in children. Diagnosing and classifying the different phenotypes can be challenging, particularly in this age group, where cardiomyopathies are often overlooked until the onset of severe symptoms. Cardiovascular imaging is crucial in the diagnostic pathway, from screening to classification and follow-up assessment. Several imaging modalities have been proven to be helpful in this field, with echocardiography undoubtedly representing the first imaging approach due to its low cost, lack of radiation, and wide availability. However, particularly in this clinical context, echocardiography may not be able to differentiate from cardiomyopathies with similar phenotypes and is often complemented with cardiovascular magnetic resonance. The latter allows a radiation-free differentiation between different phenotypes with unique myocardial tissue characterization, thus identifying the presence and extent of myocardial fibrosis. Nuclear imaging and computed tomography have a complementary role, although they are less used in daily clinical practice due to the concern related to the use of radiation in pediatric patients. However, these modalities may have some advantages in evaluating children with cardiomyopathies. This paper aims to review the strengths and limitations of each imaging modality in evaluating pediatric patients with suspected or known cardiomyopathies.

Do not disturb: Visitors' effect on the behavior and welfare of female and male big cats in zoos.

The effect of visitor presence on animal behavior needs to be evaluated to ensure the welfare and improve the husbandry of the individuals in zoos. This study aims to assess the effect of visitor presence on the behavior and welfare of pairs of Amur tiger, snow leopard, and Eurasian lynx at Parco Natura Viva, Italy. The study was made of two periods: the baseline, in which the zoo was closed, and the visitor presence period, in which the zoo was opened. Per period and per subject 12 30-min observations were done. Continuous focal animal sampling method was used to collect behavior duration of the big cats. The main results of the study highlighted that, when visitors were present, all felids except for the female lynx were significantly more inactive than in the baseline. Moreover, despite interindividual and inter-species variability in the significance level of findings, natural behaviors such as attentive behavior, exploration/marking, locomotion, and positive social interactions were performed more in the baseline than in the visitor presence period. Finally, when visitors were present, as the studied subjects experienced daily longer exposure to visitors, inactivity increased whereas individual species-typical behaviors (e.g., locomotion) and positive social interactions decreased. Thus, visitors seem to partially alter the behavioral time-budgets of the study big cats, increasing inactivity and decreasing the performance of species-specific behavior, at least in some individuals.

Exploration of Social Proximity and Behavior in Captive Malayan Tigers and Their Cubs.

The survival of endangered felids is becoming increasingly dependent on the successful management and breeding of reserve populations in captivity. While most felid species are reported to be solitary in the wild, increasing evidence suggests that some big cats have greater social plasticity than is currently acknowledged. This social plasticity allows felids to be sometimes socially housed in environments such as zoos and rescue centers. While the effects of such shared enclosures remain in question, many reports provide evidence of several welfare benefits of maintaining these large carnivores in pairs or even groups. Since 2019, Le Parc des Félins has housed a breeding pair of Malaysian tigers (Panthera tigris jacksoni) alongside their offspring. The purpose of this study was to quantify the social affiliation between the male tiger and his cubs and to investigate the female's tolerance toward him. The data were collected using video recordings in the outdoor enclosure when social interactions were observed. The data were coded and categorized in the open-source software BORIS, from which behavioral activity budgets were calculated. Data were analyzed using the chi-squared test for association to determine differences in affiliative frequency, with directed and undirected sociograms created to visualize individual relationships. Overall, the male regularly engaged in affiliative behaviors with the cubs, with no significant difference found in the frequency of interactions with them compared to the female. No physical aggression was directed by the male toward the cubs. Although the female maintained a stronger bond with the cubs compared to the male, he displayed a greater range of affiliative behaviors toward them than male tigers are thought to exhibit. Both adults showed a high degree of tolerance toward their conspecifics, suggesting that maintaining breeding pairs with their offspring is a viable management strategy in zoological collections. This study could therefore improve husbandry and conservation practices by developing our understanding of felid sociality and the potential welfare benefits of social housing, allowing for evidence-based captive management decisions.

Development and Multicenter Validation of a Novel Immune-Inflammation-Based Nomogram to Predict Survival in Western Resectable Gastric and Gastroesophageal Junction Adenocarcinoma (GEA): The NOMOGAST.

Background. More than 50% of operable GEA relapse after curative-intent resection. We aimed at externally validating a nomogram to enable a more accurate estimate of individualized risk in resected GEA. Methods. Medical records of a training cohort (TC) and a validation cohort (VC) of patients undergoing radical surgery for c/uT2-T4 and/or node-positive GEA were retrieved, and potentially interesting variables were collected. Cox proportional hazards in univariate and multivariate regressions were used to assess the effects of the prognostic factors on OS. A graphical nomogram was constructed using R software's package Regression Modeling Strategies (ver. 5.0-1). The performance of the prognostic model was evaluated and validated. Results. The TC and VC consisted of 185 and 151 patients. ECOG:PS > 0 (p < 0.001), angioinvasion (p < 0.001), log (Neutrophil/Lymphocyte ratio) (p < 0.001), and nodal status (p = 0.016) were independent prognostic values in the TC. They were used for the construction of a nomogram estimating 3- and 5-year OS. The discriminatory ability of the model was evaluated with the c-Harrell index. A 3-tier scoring system was developed through a linear predictor grouped by 25 and 75 percentiles, strengthening the model's good discrimination (p < 0.001). A calibration plot demonstrated a concordance between the predicted and actual survival in the TC and VC. A decision curve analysis was plotted that depicted the nomogram's clinical utility. Conclusions. We externally validated a prognostic nomogram to predict OS in a joint independent cohort of resectable GEA; the NOMOGAST could represent a valuable tool in assisting decision-making. This tool incorporates readily available and inexpensive patient and disease characteristics as well as immune-inflammatory determinants. It is accurate, generalizable, and clinically effectivex.

Examining the generalizability of research findings from archival data.

This initiative examined systematically the extent to which a large set of archival research findings generalizes across contexts. We repeated the key analyses for 29 original strategic management effects in the same context (direct reproduction) as well as in 52 novel time periods and geographies; 45% of the reproductions returned results matching the original reports together with 55% of tests in different spans of years and 40% of tests in novel geographies. Some original findings were associated with multiple new tests. Reproducibility was the best predictor of generalizability-for the findings that proved directly reproducible, 84% emerged in other available time periods and 57% emerged in other geographies. Overall, only limited empirical evidence emerged for context sensitivity. In a forecasting survey, independent scientists were able to anticipate which effects would find support in tests in new samples.

Politicizing mask-wearing: predicting the success of behavioral interventions among republicans and democrats in the U.S.

Scientists and policymakers seek to choose effective interventions that promote preventative health measures. We evaluated whether academics, behavioral science practitioners, and laypeople (N = 1034) were able to forecast the effectiveness of seven different messages compared to a baseline message for Republicans and Democrats separately. These messages were designed to nudge mask-wearing attitudes, intentions, and behaviors. When examining predictions across political parties, forecasters predicted larger effects than those observed for Democrats compared to Republicans and made more accurate predictions for Republicans compared to Democrats. These results are partly driven by a lack of nudge effects on Democrats, as reported in Gelfand et al. (J Exp Soc Psychol, 2021). Academics and practitioners made more accurate predictions compared to laypeople. Although forecasters' predictions were correlated with the nudge interventions, all groups overestimated the observed results. We discuss potential reasons for why the forecasts did not perform better and how more accurate forecasts of behavioral intervention outcomes could potentially provide insight that can help save resources and increase the efficacy of interventions.

Blood flow characteristics after aortic valve neocuspidization in paediatric patients: a comparison with the Ross procedure.

AIMS: The aortic valve (AV) neocuspidization (Ozaki procedure) is a novel surgical technique for AV disease that preserves the natural motion and cardiodynamics of the aortic root. In this study, we sought to evaluate, by 4D-flow magnetic resonance imaging, the aortic blood flow characteristics after AV neocuspidization in paediatric patients. METHODS AND RESULTS: Aortic root and ascending aorta haemodynamics were evaluated in a population of patients treated with the Ozaki procedure; results were compared with those of a group of patients operated with the Ross technique. Cardiovascular magnetic resonance studies were performed at 1.5 T using a 4D flow-sensitive sequence acquired with retrospective electrocardiogram-gating and respiratory navigator. Post-processing of 4D-flow analysis was performed to calculate flow eccentricity and wall shear stress. Twenty children were included in this study, 10 after Ozaki and 10 after Ross procedure. Median age at surgery was 10.7 years (range 3.9-16.5 years). No significant differences were observed in wall shear stress values measured at the level of the proximal ascending aorta between the two groups. The analysis of flow patterns showed no clear association between eccentric flow and the procedure performed. The Ozaki group showed just a slightly increased transvalvular maximum velocity. CONCLUSION: Proximal aorta flow dynamics of children treated with the Ozaki and the Ross procedure are comparable. Similarly to the Ross, Ozaki technique restores a physiological laminar flow pattern in the short-term follow-up, with the advantage of not inducing a bivalvular disease, although further studies are warranted to evaluate its long-term results.

Idiopathic chylous peritonitis mimicking acute appendicitis A case report.

We report an uncommon case of idiopathic acute chylous peritonitis mimicking an acute appendicitis in a 30-year-old female patient with a 2-day history of abdominal pain, nausea and vomiting. Chylous ascites is a rare form of ascites characterized by the presence of a milky fluid rich in triglycerides. It occurs as a result of a damage to the lymphatic system due to trauma or other benign and malignant pathologies. Although the most common clinical presentation is progressive painless abdominal distension, less frequently it can cause acute abdomen symptoms. The management is based on identifying and treating the underlying pathology. Aspiration of the fluid and drainage are the only therapy required if a clinically diagnosis cannot be made. Surgical laparoscopic exploration is necessary to make a diagnosis and to treat effectively acute abdomen cases.In the absence of a significant determining pathology, we talk about idiopathic chylous peritonitis. KEY WORDS: Chylous ascites, peritonitis, laparoscopy.

The using of sealants in pancreatic surgery: A Systematic Review.

BACKGROUND: POPF derives from the pancreatic stump, which follows pancreatic resection and the pancreatoenteric anastomosis following pancreaticoduodenectomy. Since 1978 sealants have been used in pancreatic surgery to prevent pancreatic fistula after resection of the pancreatic head and tail or for the management of trauma and the treatment of low-output pancreatic fistula. Different types of fibrin sealants have been evaluated for their potential to reduce the occurrence of POPF. METHODS: A systematic search of the electronic literature was performed using PubMed, Cochrane Library, and Scopus databases to obtain access to all publications, especially clinical trials, randomised controlled trials, and systematic reviews concerning fibrin sealants pancreatic surgery. Searching for "fibrin sealants pancreas," we found a total of 73 results on Pubmed, 61 on Scopus, and 14 on Cochrane Library (148 total results). RESULTS: Eighteen studies were found on literature, following the criteria already described, concerning the use of fibrin sealants in pancreatic surgery. All articles described were published in the period between 1989 and 2019.Most of these were single centre studies. A total of 1032 patients were enrolled in this review. In the studies, sealants were used to reinforce pancreatic anastomoses and for the occlusion of the main pancreatic duct. CONCLUSION: CR-POPF is a fearful complication of pancreatic surgery; among the possible solutions to reduce the risk of onset, sealants were used on the pancreatic stump; today the sealants should be considered such as an option to reduce the CR-POPF, but the routine use in clinical practice has to be validated.

Wave Reflection and Ventriculo-Arterial Coupling in Bicuspid Aortic Valve Patients With Repaired Aortic Coarctation.

BACKGROUND: Ventriculo-arterial (VA) coupling in bicuspid aortic valve (BAV) patients can be affected by the global aortopathy characterizing BAV disease and the presence of concomitant congenital lesions such as aortic coarctation (COA). This study aimed to isolate the COA variable and use cardiovascular magnetic resonance (CMR) imaging to perform wave intensity analysis non-invasively to shed light on VA coupling changes in BAV. The primary hypothesis was that BAV patients with COA exhibit unfavorable VA coupling, and the secondary hypothesis was that BAV patients with COA exhibit increased wave speed as a marker of reduced aortic distensibility despite successful surgical correction. METHODS: Patients were retrospectively identified from a CMR database and divided into two groups: isolated BAV and BAV associated with repaired COA. Aortic and ventricular dimensions, global longitudinal strain (GLS), and ascending aortic flow data and area were collected and used to derive wave intensity from CMR data. The main variables for the analysis included all wave magnitudes (forward compression/expansion waves, FCW and FEW, respectively, and reflected backward compression wave, BCW) and wave speed. RESULTS: In the comparison of patients with isolated BAV and those with BAV associated with repaired COA (n = 25 in each group), no differences were observed in left ventricular ejection fraction, GLS, or ventricular volumes, whilst significant increases in FCW and FEW magnitude were noted in the BAV and repaired COA group. The FCW inversely correlated with age and aortic size. Whilst the BCW was not significantly different compared with that in patients with/without COA, its magnitude tends to increase with a lower COA index. Patients with repaired COA exhibited higher wave speed velocity. Aortic wave speed (inversely related to distensibility) was not significantly different between the two groups. CONCLUSION: In the absence of a significant restenosis, VA coupling in patients with BAV and COA is not negatively affected compared to patients with isolated BAV. A reduction in the magnitude of the early systolic FCW was observed in patients who were older and with larger aortic diameters.

Enhanced 3D visualization for planning biventricular repair of double outlet right ventricle: a pilot study on the advantages of virtual reality.

Aims: We aim to determine any additional benefit of virtual reality (VR) experience if compared to conventional cross-sectional imaging and standard three-dimensional (3D) modelling when deciding on surgical strategy in patients with complex double outlet right ventricle (DORV). Methods and results: We retrospectively selected 10 consecutive patients with DORV and complex interventricular communications, who underwent biventricular repair. An arterial switch operation (ASO) was part of the repair in three of those. Computed tomography (CT) or cardiac magnetic resonance imaging images were used to reconstruct patient-specific 3D anatomies, which were then presented using different visualization modalities: 3D pdf, 3D printed models, and VR models. Two experienced paediatric cardiac surgeons, blinded to repair performed, reviewed each case evaluating the suitability of repair following assessment of each visualization modalities. In addition, they had to identify those who had ASO as part of the procedure. Answers of the two surgeons were compared to the actual operations performed. There was no mortality during the follow-up (mean = 2.5 years). Two patients required reoperations. After review of CT/cardiac magnetic resonance images, the evaluators identified the surgical strategy in accordance with the actual surgical plan in 75% of the cases. When using 3D pdf this reached only 70%. Accordance improved to 85% after revision of 3D printed models and to 95% after VR. Use of 3D printed models and VR facilitated the identification of patients who required ASO. Conclusion: Virtual reality can enhance understanding of suitability for biventricular repair in patients with complex DORV if compared to cross-sectional images and other 3D modelling techniques.

Determinants of aortic growth rate in patients with bicuspid aortic valve by cardiovascular magnetic resonance.

Objectives: This study aimed to identify determinants of aortic growth rate in bicuspid aortic valve (BAV) patients. We hypothesised that (1) BAV patients with repaired coarctation (CoA) exhibit decreased aortic growth rate, (2) moderate/severe re-coarctation (reCoA) results in increased growth rate, (3) patients with right non-coronary (RN) valve cusps fusion pattern exhibit increased aortic growth rate compared with right-left cusps fusion and type 0 valves. Methods: Starting from n=521 BAV patients with cardiovascular magnetic resonance data, we identified n=145 patients with at least two scans for aortic growth analysis. Indexed areas of the sinuses of Valsalva and ascending aorta (AAo) were calculated from cine images in end-systole and end-diastole. Patients were classified based on dilation phenotype, presence of CoA, aortic valve function and BAV morphotype. Comparisons between groups were performed. Linear regression was carried out to identify associations between risk factors and aortic growth rate. Results: Patients (39±16 years of age, 68% male) had scans 3.7±1.8 years apart; 32 presented with AAo dilation, 18 with aortic root dilation and 32 were overall dilated. Patients with repaired CoA (n=61) showed decreased aortic root growth rate compared with patients without CoA (p≤0.03) regardless of sex or age. ReCoA, aortic stenosis, regurgitation and history of hypertension were not associated with growth rate. RN fusion pattern showed the highest aortic root growth rate and type 0 the smallest (0.30 vs 0.08 cm2/m*year, end-systole, p=0.03). Conclusions: Presence of CoA and cusp fusion morphotype were associated with changes in rate of root dilation in our BAV population.

Beyond apical ballooning: computational modelling reveals morphological features of Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is characterized by transient myocardial dysfunction, typically at the left ventricular (LV) apex. Its pathophysiology and recovery mechanisms remain unknown. We investigated LV morphology and deformation in n = 28 TCM patients. Patients with MRI within 5 days from admission ("early TCM") showed reduced LVEF and higher ventricular volumes, but no differences in ECG, global strains or myocardial oedema. Statistical shape modelling described LV size (Mode 1), apical sphericity (Mode 2) and height (Mode 3). Significant differences in Mode 1 suggest that "early TCM" LV remodeling is mainly influenced by a change in ventricular size rather than apical sphericity.

Evaluating 3D-printed models of coronary anomalies: a survey among clinicians and researchers at a university hospital in the UK.

OBJECTIVE: To evaluate the feasibility of three-dimensional (3D) printing models of coronary artery anomalies based on cardiac CT data and explore their potential for clinical applications. DESIGN: Cardiac CT datasets of patients with various coronary artery anomalies (n=8) were retrospectively reviewed and processed, reconstructing detailed 3D models to be printed in-house with a desktop 3D printer (Form 2, Formlabs) using white resin. SETTING: A University Hospital (division of cardiology) in the UK. PARTICIPANTS: The CT scans, first and then 3D-printed models were presented to groups of clinicians (n=8) and cardiovascular researchers (n=9). INTERVENTION: Participants were asked to assess different features of the 3D models and to rate the models' overall potential usefulness. OUTCOME MEASURES: Models were rated according to clarity of anatomical detail, insight into the coronary abnormality, overall perceived usefulness and comparison to CT scans. Assessment of model characteristics used Likert-type questions (5-point scale from 'strongly disagree' to 'strongly agree') or a 10-point rating (from 0, lowest, to 10, highest). The questionnaire included a feedback form summarising overall usefulness. Participants' imaging experience (in a number of years) was also recorded. RESULTS: All models were reconstructed and printed successfully, with accurate details showing coronary anatomy (eg, anomalous coronary artery, coronary roofing or coronary aneurysm in a patient with Kawasaki syndrome). All clinicians and researchers provided feedback, with both groups finding the models helpful in displaying coronary artery anatomy and abnormalities, and complementary to viewing 3D CT scans. The clinicians' group, who had substantially more imaging expertise, provided more enthusiastic ratings in terms of models' clarity, usefulness and future use on average. CONCLUSIONS: 3D-printed heart models can be feasibly used to recreate coronary artery anatomy and enhance understanding of coronary abnormalities. Future studies can evaluate their cost-effectiveness, as well as potentially explore other printing techniques and materials.

Aortic morphological variability in patients with bicuspid aortic valve and aortic coarctation.

OBJECTIVES: This study aimed to explore aortic morphology and the associations between morphological features and cardiovascular function in a population of patients with bicuspid aortic valve, while further assessing differences between patients with repaired coarctation, patients with unrepaired coarctation and patients without coarctation. METHODS: This is a single-centre retrospective study that included patients with available cardiovascular magnetic resonance imaging data and native bicuspid aortic valve diagnosis (n = 525). A statistical shape analysis was performed on patients with a 3-dimensional magnetic imaging resonance (MRI) dataset (n = 108), deriving 3-dimensional aortic reconstructions and computing a mean aortic shape (template) for the whole population as well as for the 3 subgroups of interest (no coarctation, repaired coarctation and unrepaired coarctation). Shape deformations (modes) were computed and correlated with demographic variables, 2-dimensional MRI measurements and volumetric and functional data. RESULTS: Overall, the results showed that patients with coarctation tended towards a more Gothic arch architecture, with decreased ascending and increased descending aorta diameters, with the unrepaired-aortic coarctation subgroup exhibiting more ascending aorta dilation. Careful assessment of patients with repaired coarctation only revealed that a more Gothic arch, increased descending aorta dimensions and ascending aorta dilation were associated with reduced ejection fraction (P ≤ 0.04), increased end-diastolic volume (P ≤ 0.04) and increased ventricular mass (P ≤ 0.02), with arch morphology distinguishing patients with and without recoarctation (P = 0.05). CONCLUSIONS: A statistical shape modelling framework was applied to a bicuspid aortic valve population revealing nuanced differences in arch morphology and demonstrating that morphological features, not immediately described by conventional measurements, can indicate those shape phenotypes associated with compromised function and thus possibly warranting closer follow-up.

Current and future applications of 3D printing in congenital cardiology and cardiac surgery.

Three-dimensional (3D) printing technology in congenital cardiology and cardiac surgery has experienced a rapid development over the last decade. In presence of complex cardiac and extra-cardiac anatomies, the creation of a physical, patient-specific model is attractive to most clinicians. However, at the present time, there is still a lack of strong scientific evidence of the benefit of 3D models in clinical practice and only qualitative evaluation of the models has been used to investigate their clinical use. 3D models can be printed in rigid or flexible materials, and the original size can be augmented depending on the application the models are needed for. The most common applications of 3D models at present include procedural planning of complex surgical or interventional cases, in vitro simulation for research purposes, training and communication with patients and families. The aim of this pictorial review is to describe the basic principles of this technology and present its current and future applications.

Contrast-enhanced ultrasound for ovary assessment in a murine model: preliminary findings on the protective role of a gonadotropin-releasing hormone analogue from chemotherapy-induced ovarian damage.

The prolonged, gonadotoxic effect of chemotherapy can finally lead to infertility in female cancer survivors. There is controversial evidence regarding the protective role of gonadotropin-releasing hormone analogue (GnRH-a) on chemotherapy-induced ovarian damage. In the present study on a murine model, ultrasound (US) and contrast-enhanced US (CEUS) were firstly used to characterise ovarian glands in normal conditions to validate a preclinical model. In addition, preliminary findings were obtained on anatomical and vascular ovarian changes induced by GnRH-a based on decapeptyl administration. Ovaries were accurately assessed with US and CEUS in a murine model placed in prone position, providing quantitative and reproducible information. Ovaries were identified in 40/40 cases and CEUS analysis was successfully performed in 20/20 cases with 100% technical success. A statistically significant increase of the diameter of the dominant follicle at US and a statistically significant reduced vascularisation at CEUS in decapeptyl-treated mice compared to untreated control mice were recorded. Further studies using US and CEUS in the murine model combining GnRH-a and chemotherapeutic agents will be needed to obtain more translational information useful for clinical practice.