Publications by authors named "Pankaj Garg"

587 Publications

Importance of cardiac magnetic resonance imaging assessment of left ventricular filling pressure at resting state.

Eur Heart J 2022 Aug 4. Epub 2022 Aug 4.

Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.

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http://dx.doi.org/10.1093/eurheartj/ehac420DOI Listing
August 2022

Quality of reporting in AI cardiac MRI segmentation studies - A systematic review and recommendations for future studies.

Front Cardiovasc Med 2022 15;9:956811. Epub 2022 Jul 15.

Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom.

Background: There has been a rapid increase in the number of Artificial Intelligence (AI) studies of cardiac MRI (CMR) segmentation aiming to automate image analysis. However, advancement and clinical translation in this field depend on researchers presenting their work in a transparent and reproducible manner. This systematic review aimed to evaluate the quality of reporting in AI studies involving CMR segmentation.

Methods: MEDLINE and EMBASE were searched for AI CMR segmentation studies in April 2022. Any fully automated AI method for segmentation of cardiac chambers, myocardium or scar on CMR was considered for inclusion. For each study, compliance with the Checklist for Artificial Intelligence in Medical Imaging (CLAIM) was assessed. The CLAIM criteria were grouped into study, dataset, model and performance description domains.

Results: 209 studies published between 2012 and 2022 were included in the analysis. Studies were mainly published in technical journals (58%), with the majority (57%) published since 2019. Studies were from 37 different countries, with most from China (26%), the United States (18%) and the United Kingdom (11%). Short axis CMR images were most frequently used (70%), with the left ventricle the most commonly segmented cardiac structure (49%). Median compliance of studies with CLAIM was 67% (IQR 59-73%). Median compliance was highest for the model description domain (100%, IQR 80-100%) and lower for the study (71%, IQR 63-86%), dataset (63%, IQR 50-67%) and performance (60%, IQR 50-70%) description domains.

Conclusion: This systematic review highlights important gaps in the literature of CMR studies using AI. We identified key items missing-most strikingly poor description of patients included in the training and validation of AI models and inadequate model failure analysis-that limit the transparency, reproducibility and hence validity of published AI studies. This review may support closer adherence to established frameworks for reporting standards and presents recommendations for improving the quality of reporting in this field.

Systematic Review Registration: [www.crd.york.ac.uk/prospero/], identifier [CRD42022279214].
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http://dx.doi.org/10.3389/fcvm.2022.956811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9334661PMC
July 2022

Letter to the Editor.

J Paediatr Child Health 2022 Jul 23. Epub 2022 Jul 23.

Specialist Intellectual Disability Health Team, South Western Sydney Local Health District, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/jpc.16135DOI Listing
July 2022

Normothermic Regional Perfusion is an Emerging Cost-Effective Alternative in Donation After Circulatory Death (DCD) in Heart Transplantation.

Cureus 2022 Jun 29;14(6):e26437. Epub 2022 Jun 29.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

In donation after circulatory death (DCD) organ transplantation, normothermic regional perfusion (NRP) restores oxygenated blood flow following cardiac arrest and reverses warm ischemia. Recently, NRP has also been used to help recover DCD hearts in addition to the abdominal organs. While DCD donation has increased the number of abdominal organs and lungs pool, it has not been able to increase the number of heart transplants, despite the fact that it has the potential to increase the number of heart transplants by 15-30%. Thoracoabdominal normothermic regional perfusion makes heart transplantation feasible and permits assessing heart function before an organ procurement without affecting the preservation of abdominal organs. NRP can be used in two ways for DCD donor heart transplants: normothermic regional perfusion followed by machine perfusion (NRP-MP) and normothermic regional perfusion followed by static cold storage (NRP-SCS). Normothermic regional perfusion is an emerging technology, a cost-effective alternative in donation after circulatory death (DCD), and will increase the pool of donors in heart transplantation.
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http://dx.doi.org/10.7759/cureus.26437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9246458PMC
June 2022

Evolution of Xenotransplantation as an Alternative to Shortage of Donors in Heart Transplantation.

Cureus 2022 Jun 24;14(6):e26284. Epub 2022 Jun 24.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

This review aims to show and illustrate the history, current, ethical considerations, and limitations concerning xenotransplantation. Due to the current shortage of available donor organs for transplantation, many alternative sources are being examined to solve the donor shortage. One of them is xenotransplantation which refers to the transplantation of organs from one species to another. Compared to other nonhuman primates (NHP), pigs are ideal species for organ harvesting as they rapidly grow to human size in a handful of months. There is much advancement in the genetic engineering of pigs, which have hearts structurally and functionally similar to the human heart. The role of genetic engineering is to overcome the immune barriers in xenotransplantation and can be used in hyperacute rejection and T cell-mediated rejection. It is technically difficult to use large animal models for orthotopic, life-sustaining heart transplantation. Despite the fact that some religious traditions, such as Jewish and Muslim, prohibit the ingestion of pork products, few religious leaders consider that donating porcine organs is ethical because it saves human life. Although recent technologies have lowered the risk of a xenograft producing a novel virus that causes an epidemic, the risk still exists. It has major implications for the informed consent procedure connected with clinical research on heart xenotransplantation.
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http://dx.doi.org/10.7759/cureus.26284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9230910PMC
June 2022

Is the Organ Care System (OCS) Still the First Choice With Emerging New Strategies for Donation After Circulatory Death (DCD) in Heart Transplant?

Cureus 2022 Jun 24;14(6):e26281. Epub 2022 Jun 24.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

The scarcity of donor hearts continues to be a challenge in transplants for advanced heart failure patients. With an increasing number of patients on the waiting list for a heart transplant, the discrepancy in the number between donors and recipients is gradually increasing and poses a new challenge that plagues the healthcare systems when it comes to the heart. Several technologies have been developed to expand the donor pool in recent years. One such method is the organ care system (OCS). The standard method of organ preservation is the static cold storage (SCS) method which allows up to four hours of safe preservation of the heart. However, beyond four hours of cold ischemia, the incidence of primary graft dysfunction increases significantly. OCS keeps the heart perfused close to the physiological state beyond the four hours with superior results, which allows us to travel further and longer distances, leading to expansion in the donor pool. In this review, we discuss the OCS system, its advantages, and shortcomings.
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http://dx.doi.org/10.7759/cureus.26281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9229932PMC
June 2022

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract transanal opening of intersphincteric space.

Authors:
Pankaj Garg

World J Gastrointest Surg 2022 May;14(5):374-382

Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, India.

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.
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http://dx.doi.org/10.4240/wjgs.v14.i5.374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9160686PMC
May 2022

Validation of time-resolved, automated peak trans-mitral velocity tracking: Two center four-dimensional flow cardiovascular magnetic resonance study.

Int J Cardiol 2022 Oct 16;364:148-156. Epub 2022 Jun 16.

University of East Anglia, Norwich Medical School, Norfolk, United Kingdom; Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, United Kingdom. Electronic address:

Objective: We aim to validate four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) peak velocity tracking methods for measuring the peak velocity of mitral inflow against Doppler echocardiography.

Method: Fifty patients were recruited who had 4D flow CMR and Doppler Echocardiography. After transvalvular flow segmentation using established valve tracking methods, peak velocity was automatically derived using three-dimensional streamlines of transvalvular flow. In addition, a static-planar method was used at the tip of mitral valve to mimic Doppler technique.

Results: Peak E-wave mitral inflow velocity was comparable between TTE and the novel 4D flow automated dynamic method (0.9 ± 0.5 vs 0.94 ± 0.6 m/s; p = 0.29) however there was a statistically significant difference when compared with the static planar method (0.85 ± 0.5 m/s; p = 0.01). Median A-wave peak velocity was also comparable across TTE and the automated dynamic streamline (0.77 ± 0.4 vs 0.76 ± 0.4 m/s; p = 0.77). A significant difference was seen with the static planar method (0.68 ± 0.5 m/s; p = 0.04). E/A ratio was comparable between TTE and both the automated dynamic and static planar method (1.1 ± 0.7 vs 1.15 ± 0.5 m/s; p = 0.74 and 1.15 ± 0.5 m/s; p = 0.5 respectively). Both novel 4D flow methods showed good correlation with TTE for E-wave (dynamic method; r = 0.70; P < 0.001 and static-planar method; r = 0.67; P < 0.001) and A-wave velocity measurements (dynamic method; r = 0.83; P < 0.001 and static method; r = 0.71; P < 0.001). The automated dynamic method demonstrated excellent intra/inter-observer reproducibility for all parameters.

Conclusion: Automated dynamic peak velocity tracing method using 4D flow CMR is comparable to Doppler echocardiography for mitral inflow assessment and has excellent reproducibility for clinical use.
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http://dx.doi.org/10.1016/j.ijcard.2022.06.032DOI Listing
October 2022

The role of rivaroxaban in eosinophilic myocarditis.

Eur Heart J Case Rep 2022 Jun 26;6(6):ytac219. Epub 2022 May 26.

Norwich Medical School, University of East Anglia, Norwich S10 2RX, UK.

This is a case of eosinophilic myocarditis which had large left-ventricular thrombus seen on echocardiography and cardiac magnetic resonance imaging which was successfully treated with a highly selective direct Factor Xa inhibitor-rivaroxaban.
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http://dx.doi.org/10.1093/ehjcr/ytac219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9194803PMC
June 2022

TROPIS (Transanal Opening of Intersphincteric Space) Procedure for the Treatment of Horseshoe Anal Fistulas.

J Gastrointest Surg 2022 Jun 16. Epub 2022 Jun 16.

Department of General Surgery, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India.

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http://dx.doi.org/10.1007/s11605-022-05384-zDOI Listing
June 2022

Validation of Artificial Intelligence Cardiac MRI Measurements: Relationship to Heart Catheterization and Mortality Prediction.

Radiology 2022 Jun 14:212929. Epub 2022 Jun 14.

From the Department of Infection, Immunity, and Cardiovascular Disease (S.A., F.A., K.D., M.A., P.G., Y.S., C.J., S.S., D.C., A.M.K.R., R.C., N.H., J.M.W., D.G.K., A.J.S.), INSIGNEO, Institute for in silico Medicine (S.A., J.M.W., D.G.K., A.J.S.), and Department of Computer Science (M.M., H.L.), University of Sheffield, Glossop Road, Sheffield S10 2JF, UK; Department of Clinical Radiology, Sheffield Teaching Hospitals, Sheffield, UK (S.A., K.D., K.K., M.S., Y.S., C.J., S.W., P.M.); Leiden University Medical Center, Leiden, the Netherlands (P.J.H.d.K., R.J.v.d.G.); Semmelweis University Heart and Vascular Center, Budapest, Hungary (A.T.); Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK (R.C., D.G.K.); and MRC London Institute of Medical Sciences, Imperial College London, London, UK (D.P.O.).

Background Cardiac MRI measurements have diagnostic and prognostic value in the evaluation of cardiopulmonary disease. Artificial intelligence approaches to automate cardiac MRI segmentation are emerging but require clinical testing. Purpose To develop and evaluate a deep learning tool for quantitative evaluation of cardiac MRI functional studies and assess its use for prognosis in patients suspected of having pulmonary hypertension. Materials and Methods A retrospective multicenter and multivendor data set was used to develop a deep learning-based cardiac MRI contouring model using a cohort of patients suspected of having cardiopulmonary disease from multiple pathologic causes. Correlation with same-day right heart catheterization (RHC) and scan-rescan repeatability was assessed in prospectively recruited participants. Prognostic impact was assessed using Cox proportional hazard regression analysis of 3487 patients from the ASPIRE (Assessing the Severity of Pulmonary Hypertension In a Pulmonary Hypertension Referral Centre) registry, including a subset of 920 patients with pulmonary arterial hypertension. The generalizability of the automatic assessment was evaluated in 40 multivendor studies from 32 centers. Results The training data set included 539 patients (mean age, 54 years ± 20 [SD]; 315 women). Automatic cardiac MRI measurements were better correlated with RHC parameters than were manual measurements, including left ventricular stroke volume ( = 0.72 vs 0.68; = .03). Interstudy repeatability of cardiac MRI measurements was high for all automatic measurements (intraclass correlation coefficient range, 0.79-0.99) and similarly repeatable to manual measurements (all paired test > .05). Automated right ventricle and left ventricle cardiac MRI measurements were associated with mortality in patients suspected of having pulmonary hypertension. Conclusion An automatic cardiac MRI measurement approach was developed and tested in a large cohort of patients, including a broad spectrum of right ventricular and left ventricular conditions, with internal and external testing. Fully automatic cardiac MRI assessment correlated strongly with invasive hemodynamics, had prognostic value, were highly repeatable, and showed excellent generalizability. Clinical trial registration no. NCT03841344 Published under a CC BY 4.0 license. See also the editorial by Ambale-Venkatesh and Lima in this issue.
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http://dx.doi.org/10.1148/radiol.212929DOI Listing
June 2022

Re: Neuroendocrine tumour within a Meckel's diverticulum.

ANZ J Surg 2022 06;92(6):1577

Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India.

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http://dx.doi.org/10.1111/ans.17596DOI Listing
June 2022

Including video and novel parameter-height of penetration of external anal sphincter-in magnetic resonance imaging reporting of anal fistula.

World J Gastrointest Surg 2022 Apr;14(4):271-275

Department of Surgery, SSR Medical College, Belle Rive 744101, Belle Rive, Mauritius.

The main purpose of a radiologist's expertise in evaluation of anal fistula magnetic resonance imaging (MRI) is to benefit patients by decreasing the incontinence rate and increasing the healing rate. Any loss of vital information during the transfer of this data from the radiologist to the operating surgeon is unwarranted and is best prevented. In this regard, two methods are suggested. First, a short video to be attached with the standardized written report highlighting the vital parameters of the fistula. This would ensure minimum loss of information when it is conveyed from the radiologist to the operating surgeon. Second, inclusion of a new parameter, the amount of external sphincter involvement by the anal fistula. This parameter is usually not included in the MRI report. This can be evaluated as the height of penetration of the external anal sphincter (HOPE) by the fistula. The external anal sphincter plays a pivotal role in maintaining continence. This parameter (HOPE) is distinct from the 'height of internal opening' and assumes immense importance as its knowledge is paramount to prevent damage to the external anal sphincter by the surgeon during surgery.
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http://dx.doi.org/10.4240/wjgs.v14.i4.271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9131832PMC
April 2022

Expanding Selection Criteria to Repairable Diseased Hearts to Meet the Demand of Shortage of Donors in Heart Transplantation.

Cureus 2022 May 30;14(5):e25485. Epub 2022 May 30.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

Heart transplant surgery is considered the destination therapy for end-stage heart disease. Unfortunately, many patients in the United States of America who are eligible candidates for transplants cannot undergo surgery due to donor shortage. In addition, some donors' hearts are being labeled as unacceptable for transplant surgery because of the rigorous and restricted rules placed on the approval process of using a donor's heart. Over the last few decades, the rising discrepancy between the scarcity of donor hearts and the demand for such organs has led to the discussion of expanding the donor heart selection criteria. A softer view on using marginal hearts for transplants would help those on the waitlist to receive a heart transplant. Marginal hearts that contain the hepatitis c virus (HCV), COVID-19, older age, or repairable heart defects have become viable options to use for a heart transplant. Also, the prioritization based on the new heart allocation system would help efficiently decide which recipients would be the first to get a donor's heart. Recently there has been a consensus to broaden the eligibility of donor's hearts by accepting valvular abnormalities, coronary artery disease, and congenital abnormalities. This review highlights some of those expansions in selection criteria in particular using repairable hearts, which could be fixed in the operating room on the back table before transplantation.
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http://dx.doi.org/10.7759/cureus.25485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9150717PMC
May 2022

Patient safety and quality care for children with intellectual disability: An action research study.

J Intellect Disabil 2022 Jun 3:17446295221104619. Epub 2022 Jun 3.

Academic Unit of Child Psychiatry South West Sydney (AUCS), UNSW Sydney & Ingham Institute, Sydney, Australia.

Children with intellectual disability experience significant challenges in accessing and receiving high-quality healthcare leading to poorer health outcomes and negative patient experiences. Families of these children often report a need for healthcare staff to better understand, communicate, and collaborate for better care while staff acknowledge a lack of training. To address this, we utilised an action research framework with a pre- and post- survey to evaluate an integrated continuing professional development and quality improvement program combining strategies from education, behavioural psychology and quality improvement that was delivered in two departments within a tertiary children's Hospital in Metropolitan Sydney in 2019-2020. Parents reported noticeable changes in the clinical practice of staff, and staff acknowledged and attributed their shift in behaviour to raising awareness and discussions around necessary adaptations. The program demonstrates a novel method for knowledge translation to practice and systems improvements.
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http://dx.doi.org/10.1177/17446295221104619DOI Listing
June 2022

Cardiovascular medication in patients with raised NT-proBNP, but no heart failure in the SHEAF registry.

Open Heart 2022 06;9(1)

Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Medical School, Sheffield, UK

Objectives: We aim to assess the association of cardiovascular medications with outcomes of patients referred to the diagnostic heart failure (HF) clinic with symptoms or signs of possible HF, raised N-terminal pro-brain-type natriuretic peptide (NT-proBNP) but no evidence of HF on transthoracic echocardiography (TTE).

Methods: Data were collected prospectively into the Sheffield HEArt Failure (SHEAF) registry between April 2012 and January 2020. The inclusion criteria were symptoms or signs suggestive of HF, NT-proBNP >400 pg/mL, but no evidence of HF on TTE. Cox proportional-hazards regression model was used to investigate the association between the survival time of patients and different cardiovascular medications. The outcome was defined as all-cause mortality.

Results: From the SHEAF registry, we identified 1766 patients with raised NT-proBNP with no evidence of HF on TTE. Survival was higher among the younger patients, and among those with hypertension or atrial fibrillation (AF). Mortality was increased with male gender, valvular heart disease and chronic kidney disease. Using univariate Cox proportional-hazards regression, the only cardiac therapeutic agent independently associated with all-cause mortality was beta-blocker (HR 0.86; 95% CI: 0.77 to 0.97; p=0.02). The use of beta-blockers was significantly higher in patients with AF (63% vs 39%, p<0.01) and hypertension (51% vs 42%, p<0.01). However, using multivariate Cox proportional-hazards regression to adjust for all variables associated with mortality, the influence of beta-blockers became non-significant (HR 0.96; 95% CI: 0.85 to 1.1, p=0.49).

Conclusion: When all variables associated with mortality are considered, none of the cardiovascular agents are associated with the improved survival of patients with suspected HF, raised NT-proBNP but no HF on echocardiography.
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http://dx.doi.org/10.1136/openhrt-2022-001974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9161074PMC
June 2022

Is a Bioengineered Heart From Recipient Tissues the Answer to the Shortage of Donors in Heart Transplantation?

Cureus 2022 May 25;14(5):e25329. Epub 2022 May 25.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

With the increase in life expectancy worldwide, end-organ failure is becoming more prevalent. In addition, improving post-transplant outcomes has contributed to soaring demand for organs. Unfortunately, thousands have died waiting on the transplant list due to the critical shortage of organs. The success of bioengineered hearts may eventually lead to the production of limitless organs using the patient's own cells that can be transplanted into them without the need for immunosuppressive medications. Despite being in its infancy, scientists are making tremendous strides in "growing" an artificial heart in the lab. We discuss these processes involved in bioengineering a human-compatible heart in this review. The components of a functional heart must be replicated in a bioengineered heart to make it viable. This review aims to discuss the advances that have already been made and the future challenges of bioengineering a human heart suitable for transplantation.
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http://dx.doi.org/10.7759/cureus.25329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9132496PMC
May 2022

Consumer and health professional perceptions of Watch Me Grow - Electronic (WMG-E) platform for developmental surveillance in early childhood: A qualitative study.

Aust J Gen Pract 2022 06;51(6):439-445

PhD, Professor, School of Psychiatry, UNSW, Sydney, NSW.

Background And Objectives: Watch Me Grow - Electronic (WMG-E) platform is an online resource to enhance the capacity of general practitioners (GPs) to involve parents in developmental surveillance. The aim of this study was to evaluate the acceptability and perceived utility of WMG-E.

Method: Semi-structured interviews were conducted with GPs/paediatricians (n = 6) and parents (n = 6). Focus groups were conducted with child and family health nurses (n = 25). Transcripts were analysed thematically.

Results: Participants indicated that WMG-E could empower clinicians and parents by enhancing health literacy about child developmental issues, but that it could also be disempowering if not used carefully. Clinicians mentioned being strategic at health service and public policy levels. A final theme was that of the need to balance widespread promotion with its targeted use.

Discussion: This study established the face validity of WMG-E, and reveals key lessons to inform the ways in which it is promoted and used.
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http://dx.doi.org/10.31128/AJGP-06-21-6043DOI Listing
June 2022

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study.

Cir Esp (Engl Ed) 2022 May;100(5):295-301

SSRD MRI Centre, Chandigarh, India.

Introduction: Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

Methods: All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

Results: Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

Conclusions: The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.
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http://dx.doi.org/10.1016/j.cireng.2022.05.011DOI Listing
May 2022

Comparative and analytical characterization of the oral bacteriome of smokeless tobacco users with oral squamous cell carcinoma.

Appl Microbiol Biotechnol 2022 Jun 21;106(11):4115-4128. Epub 2022 May 21.

Department of Environmental Microbiology, Babasaheb Bhimrao Ambedkar University, Lucknow, India.

Oral cavity squamous cell carcinoma (OSCC) is the most common type of head and neck cancer worldwide. Smokeless tobacco (SLT) has been well proven for its role in oral carcinogenesis due to the abundance of several carcinogens. However, the role of inhabitant microorganisms in the oral cavity of smokeless tobacco users has not yet been well explored in the context of OSCC. Therefore, the present investigation was conceived to analyze the oral bacteriome of smokeless tobacco users having OSCC (CP group). With the assistance of illumina-based sequencing of bacterial-specific V3 hypervariable region of 16S rDNA gene, 71,969 OTUs (operational taxonomic units) were categorized into 18 phyla and 166 genera. The overall analysis revealed that the oral bacteriome of the patients with OSCC, who were smokeless tobacco users, was significantly different compared to the healthy smokeless tobacco users (HTC group) and non-users (HI users). The appearance of 14 significantly abundant genera [FDR (false discovery rate) adjusted probability value of significance (p value) < 0.05] among the CP group showed the prevalence of tobacco-specific nitrosamines forming bacteria (Staphylococcus, Fusobacterium, and Campylobacter). The functional attributes of the oral bacteriome of the CP group can also be correlated with the genes involved in oncogenesis. This study is the first report on the oral bacteriome of Indian patients with OSCC who were chronic tobacco chewers. The results of the present study will pave the way to understand the influence of smokeless tobacco on the oral bacteriome of OSCC patients. KEY POINTS: • Oral bacteriome of OSCC patients differ from healthy smokeless tobacco (SLT) users and SLT non-users. • Smokeless tobacco influences the oral bacteriome of OSCC group. • Oral bacteriome specific diagnostics may be developed for pre-diagnosis of oral cancer.
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http://dx.doi.org/10.1007/s00253-022-11980-5DOI Listing
June 2022

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas.

World J Gastroenterol 2022 Apr;28(16):1608-1624

Department of Statistics, Indian Council of Medical Research,New Delhi 110029, India.

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.
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http://dx.doi.org/10.3748/wjg.v28.i16.1608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9048780PMC
April 2022

Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis.

Open Heart 2022 05;9(1)

Cardiology, Norfolk and Norwich University Hospital, Norwich, UK.

Objectives: The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies.

Methods: PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'.

Results: Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I 77%).

Conclusion: This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention.

Prospero Registration Number: CRD42022301037.
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http://dx.doi.org/10.1136/openhrt-2022-001982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9109115PMC
May 2022

Mitral regurgitation quantified by CMR 4D-flow is associated with microvascular obstruction post reperfused ST-segment elevation myocardial infarction.

BMC Res Notes 2022 May 15;15(1):181. Epub 2022 May 15.

Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Colney Lane, Norwich, NR4 7UQ, UK.

Objectives: Mitral regurgitation (MR) and microvascular obstruction (MVO) are common complications of myocardial infarction (MI). This study aimed to investigate the association between MR in ST-elevation MI (STEMI) subjects with MVO post-reperfusion. STEMI subjects undergoing primary percutaneous intervention were enrolled. Cardiovascular magnetic resonance (CMR) imaging was performed within 48-hours of initial presentation. 4D flow images of CMR were analysed using a retrospective valve tracking technique to quantify MR volume, and late gadolinium enhancement images of CMR to assess MVO.

Results: Among 69 patients in the study cohort, 41 had MVO (59%). Patients with MVO had lower left ventricular (LV) ejection fraction (EF) (42 ± 10% vs. 52 ± 8%, P < 0.01), higher end-systolic volume (98 ± 49 ml vs. 73 ± 28 ml, P < 0.001) and larger scar volume (26 ± 19% vs. 11 ± 9%, P < 0.001). Extent of MVO was associated with the degree of MR quantified by 4D flow (R = 0.54, P = 0.0003). In uni-variate regression analysis, investigating the association of CMR variables to the degree of acute MR, only the extent of MVO was associated (coefficient = 0.27, P = 0.001). The area under the curve for the presence of MVO was 0.66 (P = 0.01) for MR > 2.5 ml. We conclude that in patients with reperfused STEMI, the degree of acute MR is associated with the degree of MVO.
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http://dx.doi.org/10.1186/s13104-022-06063-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9107700PMC
May 2022

Streamline-based three-dimensional peak-velocity tracing of transvalvular flow using four-dimensional flow cardiac magnetic resonance imaging for left ventricular diastolic assessment in aortic regurgitation: a case report.

J Med Case Rep 2022 May 16;16(1):205. Epub 2022 May 16.

Cardiology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.

Background: Doppler transthoracic echocardiography is routinely performed to measure peak mitral inflow velocities in the assessment of left ventricular diastolic function. The limitations of echocardiography are well documented, but its accuracy in the measurement of transmitral peak velocity in the presence of aortic valve regurgitation has not yet been compared with four-dimensional flow cardiac magnetic resonance imaging. Four-dimensional flow cardiac magnetic resonance imaging offers time-resolved cross-sectional velocity information that can be used to investigate mitral inflow peak velocity. We present a case report demonstrating the potential superior capabilities of four-dimensional flow cardiac magnetic resonance imaging in accurately detecting mitral inflow velocities over Doppler echocardiography in patients with aortic regurgitation.

Case Presentation: A 67-year-old Caucasian female presented to our outpatient cardiology clinic with exertional dyspnea. Doppler transthoracic echocardiography identified moderate to severe aortic regurgitation. Mapping of mitral inflow peak velocities proved challenging with Doppler echocardiography. Additionally, four-dimensional flow cardiac magnetic resonance imaging with automated three-dimensional flow streamlines was performed, which allowed for more accurate detection of mitral inflow peak velocities.

Conclusions: Doppler echocardiography has a limited role in mitral inflow assessment where aortic regurgitation is present. In such cases, four-dimensional flow cardiac magnetic resonance imaging is an alternative imaging technique that may circumvent this issue and allow mitral inflow assessment.
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http://dx.doi.org/10.1186/s13256-022-03422-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9109406PMC
May 2022

Conservative (non-surgical) management of cryptoglandular anal fistulas: is it possible? A new insight and direction.

ANZ J Surg 2022 05;92(5):1284-1285

Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan, India.

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http://dx.doi.org/10.1111/ans.17538DOI Listing
May 2022

Re: Bowel perforation: a 'not so rare' complication of biliary stent migration.

ANZ J Surg 2022 05;92(5):1283

Department of Medicine, Sadbhav hospital, Patan, Gujarat, India.

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http://dx.doi.org/10.1111/ans.17466DOI Listing
May 2022

Isolated OPCABG in moderate chronic ischemic mitral regurgitation: is it a justifiable alternative approach ?

Gen Thorac Cardiovasc Surg 2022 May 6. Epub 2022 May 6.

Indian Institute of Public health Gandhinagar, Gandhinagar, 382042, Gujarat, India.

Objective: Current evidence does not allow a consensus on the management of moderate chronic ischemic mitral regurgitation (CIMR). We compared moderate CIMR patients undergoing off-pump CABG (OPCABG) alone and CABG + MV repair for early mortality, major adverse systemic events (MASE) and mid-term functional outcomes.

Methods: 210 patients with moderate CIMR who underwent off-pump coronary artery bypass grafting (OPCABG) Group I (n = 106) or CABG + mitral valve repair (MV rep) Group II (n = 104) were followed prospectively. For comparison, patients were further sub-divided based on the product of regurgitant fraction and ejection fraction "RFEF"(Good/Bad) and MR jet direction (Central/Eccentric). The primary end point of the study was mortality and secondary end points were MASE, percentage improvements in indexed left ventricle end-systolic volume (LVESVI %), MR grade and functional outcomes of the patients.

Results: In-hospital and overall mortality was significantly lower in Group I (1.89% vs. 13.46%, p < 0.001 and 5.66% vs. 15.38%; p = 0.024 respectively). Group II had significantly higher MASE, ventilation time, mean ICU and hospital stay. At 36 months, LVESVI% (17.56% ± 9.12% vs. 18.81% ± 7.48%; p = 0.279), MR grade improvement (80.18% vs. 83.50%; p = 0.544), NYHA class and MLHF scores were also similar in both groups. On subgroup analysis, Good RFEF with Central jet subgroup had comparable improvement in LVESVI% and MR grade with either procedure, while Bad Eccentric subgroup showed a significantly higher improvement in LVESVI% and MR grade with CABG + MV repair.

Conclusion: OPCABG is associated with significantly reduced mortality and MASE with comparable improvement in LVEDVI% and MR grade. CABG + MV Rep results in significant improvement in LVEDVI% and MR grade in patients with bad eccentric MR. The recommended procedures in the "Good Central" and "Bad Eccentric" subsets are CABG and CABG + Mvrepair, respectively.
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http://dx.doi.org/10.1007/s11748-022-01822-6DOI Listing
May 2022

Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response.

Heart 2022 Aug 11;108(17):1392-1400. Epub 2022 Aug 11.

Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.

Objectives: To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up.

Methods: Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied.

Results: A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass.

Conclusions: Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.
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http://dx.doi.org/10.1136/heartjnl-2021-320733DOI Listing
August 2022

Cardiac magnetic resonance identifies raised left ventricular filling pressure: prognostic implications.

Eur Heart J 2022 Jul;43(26):2511-2522

Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.

Aims: Non-invasive imaging is routinely used to estimate left ventricular (LV) filling pressure (LVFP) in heart failure (HF). Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping HF. However, currently, LVFP cannot be estimated from CMR. This study sought to investigate (i) if CMR can estimate LVFP in patients with suspected HF and (ii) if CMR-modelled LVFP has prognostic power.

Methods And Results: Suspected HF patients underwent right heart catheterization (RHC), CMR and transthoracic echocardiography (TTE) (validation cohort only) within 24 h of each other. Right heart catheterization measured pulmonary capillary wedge pressure (PCWP) was used as a reference for LVFP. At follow-up, death was considered as the primary endpoint. We enrolled 835 patients (mean age: 65 ± 13 years, 40% male). In the derivation cohort (n = 708, 85%), two CMR metrics were associated with RHC PCWP:LV mass and left atrial volume. When applied to the validation cohort (n = 127, 15%), the correlation coefficient between RHC PCWP and CMR-modelled PCWP was 0.55 (95% confidence interval: 0.41-0.66, P < 0.0001). Cardiovascular magnetic resonance-modelled PCWP was superior to TTE in classifying patients as normal or raised filling pressures (76 vs. 25%). Cardiovascular magnetic resonance-modelled PCWP was associated with an increased risk of death (hazard ratio: 1.77, P < 0.001). At Kaplan-Meier analysis, CMR-modelled PCWP was comparable to RHC PCWP (≥15 mmHg) to predict survival at 7-year follow-up (35 vs. 37%, χ2 = 0.41, P  = 0.52).

Conclusion: A physiological CMR model can estimate LVFP in patients with suspected HF. In addition, CMR-modelled LVFP has a prognostic role.
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http://dx.doi.org/10.1093/eurheartj/ehac207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9259376PMC
July 2022
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