Benefits of upgrading right ventricular to biventricular pacing in heart failure patients with atrial fibrillation.

BACKGROUND AND AIMS: Recommendations on Cardiac Resynchronization Therapy (CRT) in patients with atrial fibrillation or flutter (AF) are based on less robust evidence than those in sinus rhythm. We aimed to assess the efficacy of CRT upgrade in the BUDAPEST-CRT Upgrade trial population by their baseline rhythm. METHODS: Heart Failure patients with reduced ejection fraction (HFrEF) and priorly implanted pacemaker (PM) or implantable cardioverter defibrillator (ICD) and ≥20% right ventricular (RV) pacing burden were randomized to CRT-D upgrade (n=215) or ICD (n=145). Primary- [HF hospitalization (HFH), all-cause mortality, or <15% reduction of left ventricular end-systolic volume] and secondary outcomes were investigated. RESULTS: At enrolment 131 (36%) patients had AF, who had an increased risk for HFH as compared to those with sinus rhythm (SR) [adjusted hazard ratio (aHR) 2.99; 95%CI 1.26-7.13; P=0.013]. The effect of CRT-D upgrade was similar in patients with AF as in those with SR [AF adjusted odds ratio (aOR) 0.06; 95%CI 0.02 to 0.17; P<0.001; SR aOR 0.13; 95%CI 0.07 to 0.27; P<0.001; interaction P=0.29] during the mean follow-up time of 12.4 months. Also it decreased the risk of HFH or all-cause mortality (aHR 0.33; 95%CI 0.16 to 0.70; P=0.003; interaction P=0.17) and improved the echocardiographic response (left ventricular end-diastolic volume difference -49.21mL; 95%CI -69.10 to -29.32; P<0.001; interaction P=0.21). CONCLUSION: In HFrEF patients with AF and PM/ICD with high RV pacing burden, CRT-D upgrade decreased the risk of HFH and improved reverse remodeling when compared to ICD, similar to that seen in patients in SR.

Stromal lymphocytes are associated with upgrade of B3 breast lesions.

Various histopathological, clinical and imaging parameters have been evaluated to identify a subset of women diagnosed with lesions with uncertain malignant potential (B3 or BIRADS 3/4A lesions) who could safely be observed rather than being treated with surgical excision, with little impact on clinical practice. The primary reason for surgery is to rule out an upgrade to either ductal carcinoma in situ or invasive breast cancer, which occurs in up to 30% of patients. We hypothesised that the stromal immune microenvironment could indicate the presence of carcinoma associated with a ductal B3 lesion and that this could be detected in biopsies by counting lymphocytes as a predictive biomarker for upgrade. A higher number of lymphocytes in the surrounding specialised stroma was observed in upgraded ductal and papillary B3 lesions than non-upgraded (p < 0.01, negative binomial model, n = 307). We developed a model using lymphocytes combined with age and the type of lesion, which was predictive of upgrade with an area under the curve of 0.82 [95% confidence interval 0.77-0.87]. The model can identify some patients at risk of upgrade with high sensitivity, but with limited specificity. Assessing the tumour microenvironment including stromal lymphocytes may contribute to reducing unnecessary surgeries in the clinic, but additional predictive features are needed.

Quality assurance of an established online adaptive radiotherapy program: patch and software upgrade.

Introduction: The ability to dynamically adjust target contours, derived Boolean structures, and ultimately, the optimized fluence is the end goal of online adaptive radiotherapy (ART). The purpose of this work is to describe the necessary tests to perform after a software patch installation and/or upgrade for an established online ART program. Methods: A patch upgrade on a low-field MR Linac system was evaluated for post-software upgrade quality assurance (QA) with current infrastructure of ART workflow on (1) the treatment planning system (TPS) during the initial planning stage and (2) the treatment delivery system (TDS), which is a TPS integrated into the delivery console for online ART planning. Online ART QA procedures recommended for post-software upgrade include: (1) user interface (UI) configuration; (2) TPS beam model consistency; (3) segmentation consistency; (4) dose calculation consistency; (5) optimizer robustness consistency; (6) CT density table consistency; and (7) end-to-end absolute ART dose and predicted dose measured including interruption testing. Differences of calculated doses were evaluated through DVH and/or 3D gamma comparisons. The measured dose was assessed using an MR-compatible A26 ionization chamber in a motion phantom. Segmentation differences were assessed through absolute volume and visual inspection. Results: (1) No UI configuration discrepancies were observed. (2) Dose differences on TPS pre-/post-software upgrade were within 1% for DVH metrics. (3) Differences in segmentation when observed were small in general, with the largest change noted for small-volume regions of interest (ROIs) due to partial volume impact. (4) Agreement between TPS and TDS calculated doses was 99.9% using a 2%/2-mm gamma criteria. (5) Comparison between TPS and online ART plans for a given patient plan showed agreement within 2% for targets and 0.6 cc for organs at risk. (6) Relative electron densities demonstrated comparable agreement between TPS and TDS. (7) ART absolute and predicted measured end-to-end doses were within 1% of calculated TDS. Discussion: An online ART QA program for post-software upgrade has been developed and implemented on an MR Linac system. Testing mechanics and their respective baselines may vary across institutions, but all necessary components for a post-software upgrade QA have been outlined and detailed. These outlined tests were demonstrated feasible for a low-field MR Linac system; however, the scope of this work may be applied and adapted more broadly to other online ART platforms.

Synthesis of palladium-decorated defective tungsten oxide heterostructures with enhanced photothermal catalytic activity for hydrodeoxygenation of vanillin.

The selective hydrodeoxygenation (HDO) of sustainable lignocellulosic biomass plays a pivotal role in the conversion of biomass into high-value fuels and chemicals. Nevertheless, HDO for biomass upgrading always demands high temperatures and high hydrogen (H2) pressure. Photothermal catalysis has been recognized as an effective approach for boosting chemical reactions under mild conditions while maintaining superior selectivity. Herein, we report the design of palladium-decorated defective tungsten oxide (Pd/WO3-x) catalysts with enhanced photothermal catalytic performances for the efficient HDO of vanillin. Pd/WO3-x nanoflowers have been synthesized through a solvothermal/in-situ reduction two-step strategy, and they exhibit notable photoabsorption in a wide range (200-1100 nm), high photothermal conversion and efficient charge separation efficiency. Under simulated sunlight irradiation (0.3 W cm-2), Pd/WO3-x exhibits a maximum vanillin conversion up to 86.8 % with a 2-methoxy-4-methylphenol (MMP) selectivity of 100 %, which is obviously higher than that (vanillin conversion = 33.1 %, MMP selectivity = 100 %) in the oil bath at the same temperature. Such higher conversion efficiency and selectivity under sunlight should result from the synergistic integration of hot electrons and photothermal heating, both of which are derived from localized surface plasmon resonance (LSPR) in WO3-x. Importantly, Pd/WO3-x catalyst demonstrates good stability and high selectivity to MMP even after 5 cycles. This work may offer a novel viewpoint on the advancement of photothermal catalysts and the realization of photothermal catalytic biomass conversion under mild conditions.

Radial sclerosing lesions found on core needle biopsy: excision can be safely avoided.

AIMS: Radial sclerosing lesions (RSLs) are benign breast lesions composed of glandular and epithelial proliferations with stellate architecture and fibro-elastotic stroma, which can mimic invasive carcinoma on imaging. Surgical management following a core biopsy diagnosis of RSLs remains controversial. METHODS AND RESULTS: We retrospectively identified core biopsies with RSLs without atypia who underwent subsequent surgical excision between 2015 and 2021. All core biopsy slides were reviewed to confirm the diagnosis. Imaging was reviewed to determine radiological-pathological concordance. An upgrade was defined as invasive carcinoma or ductal carcinoma in situ (DCIS) in the excision. The final cohort consisted of 130 core biopsies from 124 women (median age = 52 years, range = 27-76). The imaging modality was mammogram in 52 (40%) cases, MRI in 52 (40%) and ultrasound in 26 (20%). One hundred and seven (82%) core biopsies were vacuum-assisted and 23 (18%) were ultrasound-guided without vacuum assistance. The median lesion size on imaging was 9 mm (range = 2-41). Overall, two (1%) cases were upgraded at excision, including one microinvasive lobular carcinoma and one 2 mm focus of invasive mammary carcinoma with associated DCIS. In both cases, the upgraded foci of carcinoma were not closely associated with the biopsy site and were considered incidental upgrades. CONCLUSIONS: This study adds to the body of literature supporting observation, rather than routine excision of radial sclerosing lesions without atypia.

Carbon performance analysis of upgraded wastewater treatment plants in key control areas of the Ziya River Basin in China.

Wastewater treatment plants (WWTPs) are one of the largest sources of greenhouse gas (GHG) emissions, and they are also one of the largest energy consumption industries in urban systems. With the progression of upgrading and standard-rising, WWTPs both directly and indirectly increase carbon emissions from the increased investments in facilities and usages in electricity as well as chemical agents. Here, we collected operational data from 15 WWTPs in the key control areas of the Ziya River Basin in North China and accounted for the changes in carbon performance at different technical upgrade methods. Results showed that the average carbon emission performance increased by 0.487 kg CO2/m3 after the upgrade. Carbon emissions from electricity consumption, chemical usage, biochemical process and sludge treatment accounted for 42%, 17%, 24%, and 17% of the total improvement in carbon emission performance, respectively. Reducing energy consumption, regulating chemical use and sludge comprehensive utilization are the key to carbon emission reduction. It further proposes that the development of wastewater treatment discharge standards should fully consider the comprehensive utilization of water quality classification. Regions with favorable natural conditions should make full use of their advantages by adopting economically feasible, low-energy-consuming technologies such as constructed wetlands, which offer carbon sequestration and landscaping benefits. This study provides guidance on the selection of technological pathways for pollution reduction and carbon mitigation in the wastewater treatment industry and on achieving sustainable water resource utilization.

Surfactant Directionally Assembled at the Electrode-Electrolyte Interface for Facilitating Electrocatalytic Aldehyde Hydrogenation.

Electrocatalytic hydrogenation of unsaturated aldehydes to unsaturated alcohols is a promising alternative to conventional thermal processes. Both the catalyst and electrolyte deeply impact the performance. Designing the electrode-electrolyte interface remains challenging due to its compositional and structural complexity. Here, we employ the electrocatalytic hydrogenation of 5-hydroxymethylfurfural (HMF) as a reaction model. The typical cationic surfactant, cetyltrimethylammonium bromide (CTAB), and its analogs are employed as electrolyte additives to tune the interfacial microenvironment, delivering high-efficiency hydrogenation of HMF and inhibition of the hydrogen evolution reaction (HER). The surfactants experience a conformational transformation from stochastic distribution to directional assembly under applied potential. This oriented arrangement hampers the transfer of water molecules to the interface and promotes the enrichment of reactants. In addition, near 100 % 2,5-bis(hydroxymethyl)furan (BHMF) selectivity is achieved, and the faradaic efficiency (FE) of the BHMF is improved from 61 % to 74 % at -100 mA cm-2. Notably, the microenvironmental modulation strategy applies to a range of electrocatalytic hydrogenation reactions involving aldehyde substrates. This work paves the way for engineering advanced electrode-electrolyte interfaces and boosting unsaturated alcohol electrosynthesis efficiency.

When and how to perform venoplasty for lead placement.

Because of the increasing use of cardiac implantable electronic devices (CIEDs) with one or more intracardiac electrodes, the rate of lead failure is increasing. Moreover, upgrade of the CIED frequently is indicated for cardiac resynchronization therapy or other reasons. Both these situations require a new intervention, preferably using ipsilateral venous access. However, venous obstruction after CIED insertion occurs in 10%-20% of patients and poses a major obstacle for implantation of additional leads. Possible solutions include lead extraction, contralateral lead insertion, and venoplasty. Preprocedural venoplasty is associated with the lowest short- and long-term risks. Here we describe a step-by-step approach to this technique, which can be introduced and safely performed in most interventional catheterization laboratories.

Digital carbon neutrality: evidence of carbon emission reduction based on digital inclusive finance.

As a powerful engine for economic reform and curbing carbon emissions, digital inclusive finance provides solid support for achieving the goal of digital carbon neutrality. This study reveals the positive effect of digital inclusive finance on carbon emission reduction and the deeper reasons behind it by digging deeper into the panel data of 213 cities in China. The study adopts advanced empirical analysis methods to rigorously test the association between digital inclusive finance and carbon emissions. The results show that there is a strong positive correlation between the booming development of digital inclusive finance and the significant decline in carbon emissions. This finding remains solid after several rounds of robustness tests, which fully proves the reliability of the research results. Further mechanism analysis reveals the multiple paths of digital financial inclusion on carbon emission reduction. First, it promotes the optimization and upgrading of industrial structure by optimizing the allocation of financial resources, thus reducing the proportion of high-carbon emission industries. Second, digital inclusive finance attracts more foreign capital inflows and introduces advanced low-carbon technologies and management experience, further promoting the development of low-carbon economy. In addition, the study also found that the differences between different cities in terms of geographic location and city size have a significant impact on the carbon emission reduction effect of digital inclusive finance. In particular, the carbon emission reduction effect of digital inclusive finance is particularly significant in western regions, central cities, and first-tier cities. In response to these findings, this paper proposes a series of targeted policy recommendations. First, the financial service system should be further optimized to increase the coverage and penetration of digital inclusive finance, especially in less developed regions and small- and medium-sized cities. Second, regional policy synergies should be strengthened to form a strong synergy to promote the development of a low-carbon economy. In addition, it should guide capital flows to low-carbon industries and encourage enterprises to increase green technology research and development and application, while actively promoting low-carbon consumption concepts and guiding consumers to form green consumption habits. Through the implementation of these measures, it is expected that the potential of digital inclusive finance in the development of a low-carbon economy will be further stimulated, making a greater contribution to the realization of the goals of carbon peaking and carbon neutrality.

Predictive Performance of Radiomic Features Extracted from Breast MR Imaging in Postoperative Upgrading of Ductal Carcinoma in Situ to Invasive Carcinoma.

PURPOSE: To investigate the predictive performance of radiomic features extracted from breast MRI for upgrade of ductal carcinoma in situ (DCIS) to invasive carcinoma. METHODS: This retrospective study included 71 women with DCIS lesions diagnosed preoperatively by biopsy. All women underwent breast dynamic contrast-enhanced (DCE) MRI of the breast, which included pre-contrast and five post-contrast phases continuously with a time resolution of 60s. Lesion segmentation was performed manually, and 144 radiomic features of the lesions were extracted from T2-weighted images (T2WI), pre-contrast T1-weighted images (T1WI), and post-contrast 1st, 2nd, and 5th phase subtraction images on DCE-MRI. Qualitative features of mammography, ultrasound, and MRI were also assessed. Clinicopathological features were evaluated using medical records. The least absolute shrinkage and selection operator (LASSO) algorithm was applied for features selection and model building. The predictive performance of postoperative upgrade to invasive carcinoma was assessed using the area under the receiver operating characteristic curve. RESULTS: Surgical specimens revealed 13 lesions (18.3%) that were upgraded to invasive carcinoma. Among clinicopathological and qualitative features, age was the only significant predictive variable. No significant radiomic features were observed on T2WI and post-contrast 2nd phase subtraction images on DCE-MRI. The area under the curves (AUCs) of the LASSO radiomics model integrated with age were 0.915 for pre-contrast T1WI, 0.862 for post-contrast 1st phase subtraction images, and 0.833 for post-contrast 5th phase subtraction images. The AUCs of the 200-times bootstrap internal validations were 0.885, 0.832, and 0.775. CONCLUSION: A radiomics approach using breast MRI may be a promising method for predicting the postoperative upgrade of DCIS. The present study showed that the radiomic features extracted from pre-contrast T1WI and post-contrast subtraction images in the very early phase of DCE-MRI were more predictable.

Parameters optimization for decontamination and fine physical regeneration pathways of polypropylene plastics from waste lunchboxes.

Due to the development of the food delivery industry, a large amount of waste lunchboxes made of homo polypropylene (PP) plastic have been generated. This study developed a new technological strategy to effectively regenerate PP from waste lunchboxes. Through response surface curve analysis, it was found that under the optimal process conditions of hot alkali washing at 80 â„ƒ, 30 min, and pH 13, the optimal contact angle was 65.55°, indicating a good oil stain removal effect. By identifying and analyzing the characteristics of impurities in waste lunchboxes, a physical sorting and granulation regeneration process was constructed. And through large-scale statistical analysis and data collection, it was further verified that recycled PP plastics maintained their physical stability and excellent processing performance. The quality stability of recycled PP plastics in terms of impurities content was also verified. By designing different formulations specifically, recycled PP was mixed with different virgin PP and antioxidants in appropriate proportions, and extruded into particles under 150-300 mesh filtration conditions to obtain modified recycled PP. Modified recycled PP was applied in textiles, clothing, and injection molded products. In conclusion, we achieve the up-cylcing of waste PP lunchboxes instead of down-cylcing.

Understanding microplastic presence in different wastewater treatment processes: Removal efficiency and source identification.

Municipal effluents discharged from wastewater treatment plants (WWTPs) are a considerable source of microplastics in the environment. The dynamic profiles of microplastics in treatment units in WWTPs with different treatment processes remain unclear. This study quantitatively analyzed microplastics in wastewater samples collected from different treatment units in two tertiary treatment plants with distinct processes. The influents contained an average of 15.5 ± 3.5 particles/L and 38.5 ± 2.5 particles/L in the two WWTPs with in the oxidation ditch process and the integrated fixed-film activated sludge process, respectively. Interestingly, microplastic concentrations in the influent were more influenced by the population density in the served area than sewage volume or served population equivalent. Throughout the treatment process, concentrations were reduced to 1.5 ± 0.5 particles/L and 1.0 ± 1.0 particles/L in the final effluents, representing an overall decrease of 90% and 97%, in WWTPs with the oxidation ditch process and integrated fixed-film activated sludge process, respectively. A significant proportion of the microplastics were removed during the primary treatment stage in both WWTPs, with better performance for foam, film, line-shaped and large-sized microplastics. Most microplastics were accumulated in activated sludge, indicating its key role as the primary sink in WWTPs. The multiple correspondence analysis identified laundry washing and daily necessities such as packaging and containers as the major contributors to microplastics in WWTPs. The study proposed recommendations for upgrading WWTPs, modifying designs, and implementing strategies to reduce microplastic sources, aiming to minimize the release of microplastics into the environment. These findings can shed lights on the sources of microplastics in WWTPs, and advance our understanding of the mechanisms for more effective microplastic removals in wastewater treatment technologies in future applications.

Upgrading anode graphite from retired lithium ion batteries via solid-phase exfoliation by mechanochemical strategy.

Vast quantities of anode graphite from waste lithium ion batteries (LIBs), as a type of underrated urban mine, has enormous potential to be exploited for resource recovery. Herein, we propose a benign process integrating low-temperature pyrolysis and mechanochemical techniques to upcycle spent graphite (SG) from end-of-life LIBs. Pyrolysis at 500 °C leads to about 82.2 % PVDF dissociation in thermal treated graphite (TG). Solid-phase exfoliation via ball milling assisted by urea successfully produces abundant graphite flakes and a small amount of monolayer graphene nanosheet at the edge of mechanochemically processed graphite (MG). Subsequent rinsing removes the residual LiF salts. High purity and unique edge structural features of the as-prepared MG offer more active sites and storage reservoir for intercalation and de-intercalation of lithium ions, resulting in enhanced lithium-ion diffusion kinetics, excellent reversible specific capacity and desirable rate capability. Inspiringly, MG exhibits a remarkably enhanced initial specific charge capacity of 521.3 mAh g-1 during the first charge-discharge, and only declines from 569.9 mAh g-1 to 538 mAh g-1 with slight attenuation after 50 consecutive cycles at 0.1 A/g, indicating satisfactory cycle stability. Additionally, the purification and reconstruction mechanism for MG have been illustrated in detail. This study offers a green strategy to reconstruct and upgrade anode graphite from LIBs, which can realize sustainable waste management.

Patient characteristics, predictors and outcome of pacemaker patients upgraded to an implantable cardioverter defibrillator.

AIMS: Pacemaker (PM) patients may require a subsequent upgrade to an implantable cardioverter defibrillator (ICD). Limited data exists on this patient population. We sought to characterize this population, to assess predictors for ICD upgrade, and to report the outcome. METHODS: From our prospective PM and ICD implantation registry, all patients who underwent PM and/or ICD implantations at our center were analyzed. Patient characteristics and outcomes of PM patients with subsequent ICD upgrade were compared to age- and sex-matched patients with de novo ICD implantation, and to PM patients without subsequent upgrade. RESULTS: Of 1'301 ICD implantations, 60 (5%) were upgraded from PMs. Median time from PM implantation to ICD upgrade was 2.6 years (IQR 1.3-5.4). Of 2'195 PM patients, 28 patients underwent subsequent ICD upgrades, corresponding to an estimated annual incidence of an ICD upgrade of at least 0.33%. Lower LVEF (p = .05) and male sex (p = .038) were independent predictors for ICD upgrade. Survival without death, transplant and LVAD implantation were worse both for upgraded ICD patients compared to matched patients with de novo ICD implantation (p = .05), as well as for PM patients with subsequent upgrade compared to matched PM patients not requiring an upgrade (p = .036). CONCLUSIONS: One of 20 ICD implantations are upgrade of patients with a PM. At least one of 30 PM patients will require an ICD upgrade in the following 10 years. Predictors for ICD upgrade are male sex and lower LVEF at PM implantation. Upgraded patients have worse outcomes.

Implantation and reimplantation: epidemiology, etiology and pathogenesis over the last 30 years.

INTRODUCTION: Due to the increasing number of cochlear implant (CI) recipients, growing indications, and the aging population, the reimplantation of CI recipients has become a focus of attention. The aim of this study is to examine the causes, timing, and postoperative speech understanding in a large cohort over the past 30 years. METHODS: A retrospective data analysis was conducted on over 4000 CI recipients and 214 reimplanted children and adults from 1993 to 2020. This involved collecting and comparing data on causes, manufacturer information, and demographic data. In addition, a comparison of speech understanding in Freiburg monosyllables and numbers before and after reimplantation was carried out. RESULTS: Children did not exhibit elevated rates of reimplantation. The overall reimplantation rate in the entire cohort was 5%. The CI overall survival rate after 10 years in the entire cohort was 95.2%. Device failure was the most common reason for reimplantation, with 48% occurring within the first 5 years after implantation. The second most common reason was medical complications, with the risk of reimplantation decreasing as more time passed since the initial implantation. There were no significant differences in Freiburg numbers and monosyllable comprehension before and after reimplantation, both in the overall cohort and in the subcohorts based on indications. Even a technical upgrade did not result in a significant improvement in speech understanding. DISCUSSION: There was no significant difference in the frequency of reimplantation based on patient age, especially when comparing children and adults. Device failure is by far the most common indication for reimplantation, with no significant difference in implant survival between manufacturers. Patients most often choose the same manufacturer for reimplantation. The likelihood of reimplantation decreases with increasing time since the initial implantation. The indication for reimplantation should be carefully considered, as on average, no improved speech understanding is achieved, regardless of the cause, even with a technical upgrade.

History of NHTSA's upgrade of FMVSS 208 addressing airbag induced fatalities and serious injuries.

OBJECTIVE: The objective of this paper is to provide a history of the National Highway Traffic Safety Administration's (NHTSA's) extensive efforts of incorporating advanced airbag technology capability beyond that available in first-generation airbag systems into FMVSS No. 208. METHODS: In the paper, NHTSA's actions and their collaborative efforts with automakers, automaker suppliers, insurance industry, academia, and other Federal agencies were reviewed, and the key efforts have been highlighted. Through their efforts, NHTSA developed its strategy by first undertaking near term actions and then undertaking the strategy for longer term actions. Rulemaking was undertaken in three steps. Then, as sufficient data became available, NHTSA documented the effectiveness of the rulemakings. RESULTS: The approach taken by NHTSA with the goal of preserving the safety benefits of the first-generation of frontal airbags while minimizing their danger to children and at-risk adults paved the way for the advanced airbags final rule and an interim final rule issued on May 12, 2000 (see Federal Register Notice 65 FR 30680). A follow-up final rule was issued on August 31, 2006, to change the test speed of the belted 5th percentile female dummy from 48 km/h to 56 km/h (30 mph to 35 mph). The final rule was updated on November 2, 2007, to permit manufacturers to earn advance credits for vehicles that are certified in compliance with the new higher speed requirement one year in advance of the regulatory requirements. CONCLUSION: NHTSA engagement in efforts with multiple partners toward identifying the safety issues, was an integral part of NHTSA's strategy in addressing the problem, arriving at immediate actions that NHTSA took, and detailing a comprehensive look at the longer-term approach required to resolve the safety issues. The approach taken by NHTSA paved the way for the advanced airbags final rule and an interim final rule issued on May 12, 2000 (Federal Register Notice 65 FR 30680). NHTSA had undertaken a successful collaboration of the Federal Government, the automobile industry, equipment suppliers, insurance companies, traffic safety advocates, law enforcement agencies from across the country, and the media to solve the airbag related safety issue.

Feasibility of Omitting Sentinel Lymph Node Biopsy in an Under-screened Cohort of Breast Cancer Patients With a Premastectomy Diagnosis of Ductal Carcinoma In Situ.

BACKGROUND: Nodal involvement in ductal carcinoma in situ (DCIS) is rare. In patients with DCIS diagnosis prior to mastectomy, a sentinel lymph node biopsy (SLNB) is usually performed during mastectomy, to avoid the risk of reoperation and the non-identification of SLN subsequently, should there be an upgrade to invasive cancer. We aimed to study the feasibility of omitting SLNB in an under-screened cohort, with mostly symptomatic patients and DCIS diagnosis before mastectomy, by determining the upgrade rate to invasive cancer/ DCIS microinvasion (DCISM) and its associated risk factors. METHODS: Patients with pure DCIS diagnosis premastectomy were reviewed retrospectively. Patients with known DCISM or invasive cancer before mastectomy and bilateral cancers were excluded. Patients' demographics, radiological and pathological data premastectomy were analyzed. RESULTS: A total of 189 patients were included. The mean age was 53.8 (range: 29-85) years old. About 64.4% presented with symptoms. 36.0% and 15.3% upgraded to invasive cancer and DCISM on mastectomy respectively. Palpable tumor (P = .0036), large size on ultrasound (P = .0283), tumor seen on mammogram and ultrasound (P = .0082), ultrasound-guided biopsy (P < .0001), high-grade DCIS on biopsy (P = .0350) and no open biopsy/lumpectomy before mastectomy (P < .0001) were associated with the upgrade, with the latter factor remaining significant after multivariable analysis. Nodal involvement was 8.47% and was associated with invasive cancer (P < .0001). CONCLUSION: In a cohort who had DCIS diagnosis before mastectomy and were mostly symptomatic, the upgrade rate was 51.3%. Despite the high upgrade rate, nodal involvement remained comparable. Risk factors could select patients for omission of upfront SLNB, with a delayed SLNB planned if needed.

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

OBJECTIVE: Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. METHODS: This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. RESULTS: Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. CONCLUSION: Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Adherent skin barrier drape use is associated with a reduced risk of cardiac implantable device infection: Results from a prospective study of 14,225 procedures.

Background: Cardiac implantable electronic device (CIED) infection is a costly and highly morbid complication. Perioperative interventions, including the use of antibiotic pouches and intensified perioperative antibiotic regimens, have demonstrated marginal efficacy at reducing CIED infection. Additional research is needed to identify additional interventions to reduce infection risk. Objective: We sought to evaluate whether adherent skin barrier drape use is associated with a reduction in CIED infection. Methods: A prospective registry of all CIED implantation procedures was established at our institution in January 2007. The registry was established in collaboration with our hospital infection prevention team with a specific focus on prospectively identifying all potential CIED infections. All potential CIED infections were independently adjudicated by 2 physicians blinded to the use of an adherent skin barrier drape. Results: Over a 13-year period, 14,225 procedures were completed (mean age 72 ± 14 years; female 4,918 (35%); new implants 10,005 (70%); pulse generator changes 2585 (18%); upgrades 1635 (11%). Of those, 2469 procedures (17.4%) were performed using an adherent skin barrier drape. There were 103 adjudicated device infections (0.73%). The infection rate in patients in the barrier use groups was 8 of 2469 (0.32%) as compared with 95 of 11,756 (0.8%) in the nonuse group (P = .0084). In multivariable analysis, the use of an adherent skin barrier drape was independently associated with a reduction in infection (odds ratio 0.32; 95% confidence interval 0.154-0.665; P = .002). Conclusion: The use of an adherent skin barrier drape at the time of cardiac device surgery is associated with a lower risk of subsequent infection.