Pediatric Radiology

Correction to: Plea for a standardized imaging approach to disorders of sex development in neonates: Consensus proposal from European Society of Paediatric Radiology task force The above article was published online with an incorrect author name.

Physeal separation in pediatric osteomyelitis Abstract In children, acute osteomyelitis, an infection of the bone, is most commonly hematogeneous in origin. Osteomyelitis is most often diagnosed with magnetic resonance imaging (MRI) and findings may include marrow signal changes on T1 and T2, with abnormal enhancement after gadolinium. Imaging helps detect any associated intraosseous or subperiosteal abscesses, which may require orthopedic drainage. In this pictorial essay, we demonstrate the association of acute pediatric osteomyelitis with physeal separation, resulting in what may be confused for simple trauma, although there was no known history of trauma in any of the cases we researched. All of the cases had a large subperiosteal fluid collection with marked separation of the epiphysis from the metaphysis. It is important to recognize this potential association in osteomyelitis, as it is readily visible by radiographs and may lead to diagnostic uncertainty.

A portrait of pediatric leadership: Dr. Benjamin Spock

A novel percutaneous approach to retrieve an ingested extra-esophageal foreign body Abstract We report a case of an 8-year-old boy who presented to our emergency department with progressive onset of dysphagia and odynophagia after eating barbecued steak that evening. Radiographs revealed a metal bristle from a barbecue brush at the level of the proximal esophagus. The otolaryngologist attempted to retrieve this bristle using flexible esophagoscopy, but unfortunately it pushed the bristle extra-esophageal. In order to avoid major open surgery with associated morbidity, a novel percutaneous image-guided minimally invasive percutaneous approach was used to successfully retrieve the bristle.

Hermes

Plea for a standardized imaging approach to disorders of sex development in neonates: consensus proposal from European Society of Paediatric Radiology task force Abstract This consensus article elaborated by the European Society for Paediatric Radiology task force on gastrointestinal and genitourinary imaging is intended to standardize the imaging approach in newborns with disorders of sex development. These newborns represent a difficult and stressful situation necessitating a multidisciplinary team approach. Imaging plays an important role in the work-up but needs to be optimized and customized to the patient. Ultrasound plays the central role in assessing the genital anatomy. The examination must be conducted in a detailed and systematic way. It must include transabdominal and transperineal approaches with adapted high-resolution transducers. The pelvic cavity, the genital folds, the inguinal areas and the adrenals must be evaluated as well as the rest of the abdominal cavity. A reporting template is proposed. The indications of magnetic resonance imaging and cysto- and genitography are discussed as well as they may provide additional information. Imaging findings must be reported cautiously using neutral wording as much as possible.

Pediatric postmortem computed tomography: initial experience at a children's hospital in the United States Abstract Postmortem CT might provide valuable information in determining the cause of death and understanding disease processes, particularly when combined with traditional autopsy. Pediatric applications of postmortem imaging represent a new and rapidly growing field. We describe our experience in establishing a pediatric postmortem CT program and present a discussion of the distinct challenges in developing this type of program in the United States of America, where forensic practice varies from other countries. We give a brief overview of recent literature along with the common imaging findings on postmortem CT that can simulate antemortem pathology.

Minimally invasive treatment of pediatric head and neck dermoids: percutaneous drainage and radiofrequency coblation Abstract Background Dermoids are common benign head and neck cysts in children containing a variety of different skin elements. Current standard treatment is surgical removal that sometimes requires extensive dissection to ensure complete resection and often leaves unwanted facial scarring. A minimally invasive treatment alternative should offer a similar rate of success with a decrease in operative complexity, recovery time and postoperative scarring. Objective To assess the outcomes of our minimally invasive percutaneous treatment of head and neck dermoids, we reviewed our 9-year interventional radiology (IR) department experience. Materials and methods The medical records, imaging and procedural details were reviewed from a cohort of pediatric patients with dermoids treated in our IR department from January 2009 through February 2018. Patients in the study underwent ultrasound (US)-guided cyst puncture, 3% Sotradecol (sodium tetradecyl sulfate [STS]) emulsification of the thick cyst contents allowing complete drainage, and radiofrequency coblation of the cyst wall. Results In this retrospective study, we report on 22 dermoids in 21 patients. The average patient age was 3 years. Twenty-one of the 22 dermoids were successfully treated for an overall success rate of 95%. Four intraosseous dermoids were successfully treated using computed tomography (CT) guidance instead of, or in addition to, US. Average follow-up time was 22 months. Conclusion The combination of percutaneous cyst drainage using STS as an emulsifying agent followed by radiofrequency coblation is a safe, effective, minimally invasive treatment for pediatric patients with head and neck dermoids.

Proximal radius fractures in children: evaluation of associated elbow fractures Abstract Background Additional fractures occur in association with proximal radius fractures, but the extent of these secondary injuries has not been systematically assessed. Objective To ascertain the frequency and nature of additional fractures associated with proximal radius injuries in a large pediatric cohort. Materials and methods Radiographs meeting search criteria for proximal radius fracture during a 5-year period were reviewed. Fracture characteristics and the coexistence of additional elbow fractures were recorded and analyzed. The retrospective review was compared with initial interpretation and a blinded review by two pediatric musculoskeletal radiologists. Results Four hundred ninety-four proximal radius fractures were included. The radial neck was the most common fracture site (89%). Neck fractures occurred in younger patients (mean: 7.3 years) than head fractures (mean: 13.3 years) (P<0.001). Additional elbow fractures occurred in 39%, most commonly at the olecranon (22%). Additional fractures occurred in younger patients (mean: 7.2 years) than isolated proximal radius fractures (mean: 8.5 years) (P<0.001). Elbow joint effusion and complete or displaced radius fractures were each associated with additional elbow fractures (P<0.001). When compared with initial interpretation, 25% of additional fractures were not identified on initial radiographs, of which 44% were occult retrospectively. Fracture identification demonstrated excellent inter-reader reliability (interclass correlation coefficient [ICC]: 0.88, 0.94), but joint effusion interobserver agreement was only fair (ICC: 0.52, 0.41). Conclusion Proximal radius fractures in children often occur in association with other elbow fractures, most commonly involving the olecranon. Enhanced awareness of these fracture patterns, especially in the setting of joint effusion or complete and displaced radius fractures, may improve detection to guide appropriate management.

Clinico-radiologic features of pleuroparenchymal fibroelastosis in children Abstract Background Pleuroparenchymal fibroelastosis (PPFE) may be underdiagnosed clinically and radiographically in children with a remote history of cancer, leading to a delay in care and unnecessary lung biopsies. Objective To describe the characteristic clinical and radiologic findings of PPFE in a cohort of children to facilitate recognition and noninvasive diagnosis. Materials and methods Clinical presentation, history of chemotherapy or radiation therapy, lung or bone marrow transplantation, and lung function testing and outcome were retrospectively extracted from the electronic medical records of eight children treated at our institution's pulmonary medicine clinic with histopathology confirmation of PPFE from 2008 to 2018. Two pediatric radiologists evaluated the chest imaging studies for the presence or absence of published radiologic findings of PPFE in adults, including platythorax, pneumothorax, upper lobe predominant pleural and septal thickening, and bronchiectasis. Platythorax indices were calculated from the normal chest CT exams of eight age- and gender-matched individuals obtained via the radiology search engine. Results The mean presentation age was 12.9 years (range: 7–16 years). Seven of the eight had a history of chemotherapy and radiation therapy for cancer. Three of the eight had undergone bone marrow transplantation and none had undergone lung transplantation. The mean time between chemotherapy, radiation therapy, and/or bone marrow transplantation and the presentation of PPFE was 8.4 years (range: 5.6–12.1 years). Most of the patients presented with dyspnea (63%), cough (50%) and/or pneumothorax (38%). The mean percentage of predicted FEV1 (forced expiratory volume in one second) was 14.1 (range: 7.7–27.5). All eight patients demonstrated platythorax, bronchiectasis, pleural and septal thickening (upper lobes in four, upper and lower lobes in four) and six had pneumothorax. Five underwent lung biopsies, four of whom developed pneumothoraces. Conclusion Clinical and radiologic findings of pediatric PPFE are similar to those in adults, although a majority of the former have a history of treated cancer. Clinical presentation of restrictive lung disease, dyspnea, cough or spontaneous pneumothorax years after treatment for childhood cancer combined with platythorax, upper lobe pleural and septal thickening and traction bronchiectasis on chest CT establishes a presumptive diagnosis of PPFE.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Obesity Surgery

Timing of Gestation After Laparoscopic Sleeve Gastrectomy (LSG): Does it Influence Obstetrical and Neonatal Outcomes of Pregnancies?

Ivor Lewis Oesophagectomy for a Distal Adenocarcinoma of the Oesophagus 10 Years After Roux-en-Y Gastric Bypass (RYGB)

Correction to: Longitudinal Impacts of Gastric Bypass Surgery on Pharmacodynamics and Pharmacokinetics of Statins In the original article the authors failed to include the following footnote:

Christine Ren Fielding

Correction to: Incidence and Risk Factors for Cholelithiasis After Bariatric Surgery Due to a metadata tagging error the name of author Andrés Esteban San Martín was indexed incorrectly. The author's given name is Andrés Esteban and his family name is San Martín.

Correction to: Surgical Morbidity in the Elderly Bariatric Patient: Does Age Matter? Due to a metadata tagging error the name of author Andrés Esteban San Martín was indexed incorrectly. The author's given name is Andrés Esteban and his family name is San Martín.

Response to Letter to the Editor: Impact of Bariatric Surgery on Outcomes of Patients with Sickle Cell Disease: a Nationwide Inpatient Sample Analysis, 2004–2014

Endoscopic Tunneled Stricturotomy with Full-Thickness Dissection in the Management of a Sleeve Gastrectomy Stenosis Abstract Introduction Laparoscopic sleeve gastrectomy is becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events have gradually increase due to its rapid adoption. Sleeve stenosis is the second most common adverse event, occurring in 0.7 to 4% of patients undergoing laparoscopic sleeve gastrectomy (LSG). Endoscopic management with pneumatic balloon dilation (PBD) or stent placement is commonly performed, with a success rate of up to 88%. Recently, Moura et al. (VideoGIE 4(2):68–71, 2018) described a new technique, named as endoscopic tunneled stricturotomy. In this video, we demonstrated the evolution of this technique including full-thickness dissection with staple line disruption. Methods A 28-year-old woman with a BMI of 35.3 kg/m2 who underwent LSG, presented with dysphagia to solid food. An upper GI series showed a stenosis at the level of the incisura angularis. The patient was then referred for endoscopic evaluation. Results She underwent three endoscopic PBD in an attempt to treat the stenosis. Unfortunately, her symptoms did not improve. After failed PBD treatment, an endoscopic tunneled stricturotomy with full-thickness dissection was performed. The procedure is performed in 6 steps: (1) identification of the stenosis, (2) submucosal injection 3–5 cm before the stenosis, (3) incision, (4) submucosal tunneling, (5) stricturotomy with full-thickness dissection, and (6) mucosal closure. During follow-up, the patient maintained a 1200-cal diet, without recurrence of symptoms. Conclusion Endoscopic tunneled stricturotomy with full-thickness dissection is feasible and appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure may be an option after conventional treatment failure or may be considered as a primary alternative.

Patient Recall of Education about the Risks of Alcohol Use Following Bariatric Surgery Abstract Patients who undergo bariatric surgery are at increased risk of developing alcohol problems. The purpose of this study was to evaluate whether patients who underwent bariatric surgery recalled receiving education about alcohol prior to having surgery and to investigate their alcohol use patterns. Patients (N = 567) who underwent bariatric surgery completed a survey regarding their knowledge of risks related to post-surgical alcohol use. Although most patients recalled receiving education about abstinence from alcohol after surgery, at least one-third of patients do not appear to understand the risks involved with alcohol consumption, suggesting that patients did not retain the information. Despite recalling receiving education, many patients still consumed alcohol after surgery. It appears that additional interventions are needed to decrease alcohol use after bariatric surgery.

Internal Hernia and Roux-en-Y Gastric Bypass: Should the Routine Closure of Defects Still Be a Matter of Debate?

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Pediatric Orthopaedics

Bone maturation of MRI residual developmental dysplasia of the hip with discrepancy between osseous and cartilaginous acetabular index Quality of spontaneous amelioration of residual developmental dysplasia of the hip (DDH) is nowadays not possible to predict. Normal age-related values of the osseous acetabular index (OAI), cartilaginous acetabular index and labral acetabular index have been established on MRI. In this study, MRI of dysplastic hips has been evaluated, and further osseous acetabular maturation was followed-up over time on pelvic radiography to find a correlation between MRI findings and radiological evolution. This is a retrospective single-centre study. Children with DDH who had a pelvic MRI between February 2007 and June 2014 were included. AI was measured for osseous (OAI), cartilaginous (cartilaginous acetabular index) and labral (labral acetabular index) values on MRI. OAI was thereafter recorded on each available radiograph during follow-up. A total of 20 hips were included. The mean age at MRI diagnosis was 3.55 years. Two types of DDH were observed: harmonious dysplasia, associated with an osseous and cartilaginous defect (group A, n = 14), and divergent dysplasia, associated with an osseous defect but with sufficient cartilaginous coverage (group B, n = 6). The mean age at final radiological follow-up was 7.6 and 8.3 years (P = 0.7408), respectively. In group A, four (28.6%) children older than 6 years had an OAI of less than 18°, whereas only two (33.3%) children older than 6 years had an OAI less than 18° in group B (P = 0.0117). This study shows that, in one-third of cases, divergent dysplasia leads to a spontaneous recovery. MRI should be used early to accurately diagnose and follow-up DDH cases and allow surgeons to justify the required surgical treatment. Level of Evidence: IV.

Spica MRI predictors for epiphyseal osteonecrosis after closed reduction treatment of dysplasia of the hip Spica MRI with intravenous gadolinium contrast after closed reduction for developmental dysplasia of the hip (DDH) helps to determine successful reduction and attempts to identify patients at risk for epiphyseal osteonecrosis. The objective of our study was to evaluate spica MRI predictors for epiphyseal osteonecrosis after closed reduction. This was a retrospective study of all patients undergoing closed reduction for DDH followed by gadolinium-enhanced spica MRI between July 2011 and November 2014. Patient demographics and clinical follow-up through 2017, including the development of epiphyseal osteonecrosis and need for reintervention after the initial reduction, were recorded. MRI data included hip abduction angles and quantifying the percentage of femoral head enhancement. Twenty-five hips in 21 patients (16 girls, five boys, mean age: 0.99 years, range: 0.4–3.1 years) were included in our study. The mean follow-up period was 3 ± 1.5 years (range: 0.65–6.1 years). Eight (32%) of 25 hips went on to develop osteonecrosis. Epiphyseal osteonecrosis was more likely with less than 80% enhancement (sensitivity 87.5%, specificity 88.25%, positive predictive value 78%, negative predictive value 94%). The mean contrast enhancement for patients developing osteonecrosis compared with those who did not was 37.5 and 86.5%, respectively; P = 0.001. Immediate postspica MRI with gadolinium is a useful prognostic tool for determining future risk for epiphyseal osteonecrosis in children treated for DDH. Our data complement existing literature and suggest that even in cases with partial epiphyseal enhancement, osteonecrosis may still develop. When the epiphyseal enhancement is less than 80%, it is recommended that spica cast revision is considered.

MRI reveals unrecognized treatment failures after application of Fettweis plaster in children with unstable hip joints We evaluated the success of treatment of unstable hip joints with the Fettweis plaster followed by MRI to detect potential treatment failures. A total of 132 ultrasound-detected unstable hips of type D, III, or IV according to Graf were treated with closed reduction and Fettweis plaster, followed by MRI. We examined 19 type D, 55 type III, and 58 type IV. Mean age at diagnosis was 84.5 days (SD: ± 55.4). Treatment period was 63.2 days (SD: ± 22.2). In 13 cases, the MRI showed a poor reduction. After repetition of this treatment, all 13 showed a concentric reduction. The use of MRI detects 9.8% of treatment failures. We recommend an MRI examination after each closed reduction to ensure the success of the therapy.

Traction does not decrease failure of reduction and femoral head avascular necrosis in patients aged 6–24 months with developmental dysplasia of the hip treated by closed reduction: a review of 385 patients and meta-analysis This study aimed to investigate the effects of preliminary traction on the rate of failure of reduction and the incidence of femoral head avascular necrosis (AVN) in patients with late-detected developmental dysplasia of the hip treated by closed reduction. A total of 385 patients (440 hips) treated by closed reduction satisfied the inclusion criteria. Patients were divided in two groups according to treatment modality: a traction group (276 patients) and a no-traction group (109 patients). Tönnis grade, rate of failure reduction, AVN rate, acetabular index, center-edge angle of Wiberg, and Severin's radiographic grade were assessed on plain radiographs, and the results were compared between the two groups of patients. In addition, a meta-analysis was performed based on the existing comparative studies to further evaluate the effect of traction on the incidence of AVN. Tönnis grade in the traction group was significantly higher than in the no-traction group (P = 0.021). The overall rate of failure reduction was 8.2%; no significant difference was found between the traction (9.2%) and no-traction groups (5.6%) (P = 0.203). The rates of failure reduction were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The rate of AVN in the traction group (14%) was similar to that of the no-traction group (14.5%; P = 0.881). Moreover, the rates of AVN were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The meta-analysis did not identify any significant difference in the AVN rate whether preliminary traction was used or not (odds ratio = 0.76, P = 0.32). At the last follow-up visit, the two groups of patients had comparable acetabular indices, center-edge angles, and Severin's radiographic grades (P > 0.05). In conclusion, preliminary traction does not decrease the failure of reduction and the incidence of AVN in developmental dysplasia of the hip treated by closed reduction between 6 and 24 months of age.

Oligohydramnios: should it be considered a risk factor for developmental dysplasia of the hip? Breech, family history, first born and female sex are the main risk factors described for developmental dysplasia of the hip (DDH). Foot abnormalities and oligohydramnios have also been listed. Recent studies have discredited torticollis, multiple gestation pregnancy, mode of delivery and prematurity as risk factors. Definition of oligohydramnios in the literature is inconsistent. Our aim was to investigate the term oligohydramnios and evaluate whether it should be considered a risk factor for DDH. All live births in our institution between 2001 and 2014 were included. We identified all pregnancies classed as reduced amniotic fluid (AF) or oligohydramnios over that period. Data on DDH, breech presentation, female sex and positive family history were collected. The significance level was set to 5%. We identified 73 990 live births, 3408 pregnancies were classed as reduced AF or oligohydramnios. The incidence of DDH (Graf type IIb and higher) was 1: 1000 (75 babies, 18 bilateral). Oligohydramnios/reduced AF was found in 12 (16%) DDH babies. Breech presentation was found in 24 (32%), positive family history in 19 (25%) and female sex in 71 (94.7%). Oligohydramnios was found to be associated with a higher odds ratio (OR) for DDH [OR = 3.9, 95% confidence interval (CI): 2.1–7.3] as were breech presentation (OR = 10.6, 95% CI: 6.5–17.1) and female sex (OR = 19.1, 95% CI: 7–52.4). All examined risk factors showed statistical significance (P < 0.05). A regression analysis was performed to control for interactions and confounding factors and confirmed the findings. On the basis of our findings the diagnosis of reduced AF/oligohydramnios in consecutive antenatal sonographic scans should be regarded as an independent risk factor for DDH and be considered in any future studies regarding DDH. Level of evidence: Level IV: Case series.

Developmental dysplasia of the hip and clubfoot treated by Pavlik and Ponseti methods Children having both typical developmental dysplasia of the hip (DDH) and clubfoot are rare, and early treatments of both conditions are recommended. The aim of this study was to evaluate the effects of the Ponseti method of clubfoot treatment on hips with DDH. After institutional review board approval, we identified children treated by the Ponseti and Pavlik methods between 2003 and 2016. During the Ponseti method treatment, the duration of manipulations, number of casts, tenotomies performed, and days in clubfoot orthosis were recorded. During DDH treatment, we registered duration for Pavlik and hip brace usage. Hips had dynamic sonography and radiographic evaluations. The cases were grouped according to the combination of DDH and clubfoot treatments: (a) concurrent, (b) sequential, and (c) hip observation. Seven cases of DDH and clubfoot were identified. The average number of Ponseti casts was 5.8 (range: 4–8 casts). The average number of days following the post-Achilles-tenotomy casting to the end of clubfoot bracing was 870 days (range: 90–1605 days). Eleven (four bilateral cases and three unilateral) clubfeet were corrected initially by the Ponseti method. The average number of days for Pavlik harness treatment was 74 (range: 10–126 days). Additionally, a hip orthosis was utilized in three children for an average of 131 days. At follow-up, all children had a high femoral neck-shaft angle averaging 152° (range: 144°–164°). One child (case 5) developed avascular necrosis of the femoral head, Kalamchi type I. Children with typical and nonsyndromic DDH and clubfoot treated by Pavlik harness and Ponseti methods are associated with abnormal hip development (coxa valga).

The outcome of in-situ fixation of unstable slipped capital femoral epiphysis There is limited information regarding the outcome of in-situ fixation of unstable slipped capital femoral epiphysis (U-SCFE). We aimed to report the outcome of a cohort of patients with U-SCFE that were treated with in-situ fixation, by comparing it to the outcome of patients with stable slipped capital femoral epiphysis (S-SCFE). After Institutional Review Board approval, a retrospective analysis of patients with SCFE that were treated with in-situ fixation at a single institution between 2005 and 2016 was performed. Preoperative and postoperative clinical and radiographic data was collected. The rate of complications, including avascular necrosis (AVN), and the presence of impingement were recorded. The outcome of U-SCFEs was compared to that of S-SCFEs. A total of 184 SCFEs in 154 patients (64% male; mean age 11.9 years) with a mean follow-up of 27 months were included. The SCFE was classified as stable in 90.2% of cases, and unstable in 9.8% of. The mean duration of symptoms prior to presentation was 3.2 months. The mean Southwick slip angle at the time of presentation was 33°. A single screw was used to fix all S-SCFEs, while U-SCFEs were treated with either one (66.7%) or two (33.3%) screws. For U-SCFEs, the joint was decompressed at the time of surgery by either needle aspiration or small capsular incision. The final range of motion of the affected hip was comparable in both groups. The overall rate of impingement was 29%. The rate of impingement in S-SCFE and U-SCFE was 27.6 and 44.4%, respectively (P = 0.1). Eight patients required a subsequent surgery (4.4%), all of whom originally have had a S-SCFE. Radiographic signs of AVN of the femoral head were seen in 2.2% of cases. The incidence of AVN of the femoral head in S-SCFEs and U-SCFEs was 1.2 and 11.1%, respectively (P = 0.04). The results of this study support previous findings that the risk of AVN is significantly higher in U-SCFE as compared to S-SCFEs.

The unstable slipped capital femoral epiphysis: does the rate of osteonecrosis really depend on the timing of surgery and surgical technique? The aim of this study was to investigate whether the timing of surgery and surgical technique affect the rate of osteonecrosis in unstable slipped capital femoral epiphysis (SCFE). This is a retrospective review of all unstable slips that were treated at our institution over 8.5 years with a minimum follow-up period of 12 months. Patients with stable slips were excluded from this analysis. Demographic data, time to surgery, and surgical technique were analyzed. Twenty-three unstable slips were included for study after excluding 40 stable slips. There were 17 males and six females, with an average age of 11.9 years; 13 patients had right SCFEs. The average time from diagnosis to surgery was 57.7 h. Nine (39.1%) surgeries were performed within 24 h of admission, whereas 14 (60.9%) surgeries were performed after 24 h. Minimum follow-up was 23 months. Two patients developed osteonecrosis: one underwent surgery within 24 h of admission and the other after 24 h. Both underwent in-situ screw fixation. In the group that did not develop osteonecrosis, 76.2% underwent in-situ screw fixation and 23.8% underwent manipulative reduction. The rate of developing osteonecrosis following screw fixation in unstable SCFE was unrelated to whether surgery was performed before or after 24 h of admission (P = 1.0), or whether in-situ screw fixation or manipulative reduction pre-fixation was performed (P = 0.605). The results of this small series challenge the practice of stabilizing unstable SCFEs emergently and the belief that gentle manipulative reduction pre-fixation is not recommended because it may increase the rate of osteonecrosis. Level of Evidence: Level IV Evidence.

The effect of femoral orientation on the measurement of the head shaft angle: an ex-vivo study This laboratory study evaluates head shaft angle (HSA) reliability using ranges of simulated femoral orientation often seen in children with cerebral palsy. A dry femur was mounted in a jig that enabled the bone to be positioned in a range of internal and external rotation (−40° to + 40°) and flexion (0°–60°), alone or in combination. A metal wire was placed as a surrogate physis to give two HSA angles of 140° and 160°. Radiographs were taken of the femur in differing combinations of rotation, flexion and the two HSA angles. The HSA was measured by four independent observers on two separate occasions. Intraclass correlation coefficients (ICCs) were used to assess interobserver and intraobserver reliability. The HSA was accurately measured within ± 5° when the femur was positioned between 20° internal rotation and 40° external rotation. Flexion up to 60° did not affect the accuracy of the measurement. The interobserver reliability for the HSA was excellent with an ICC of 0.9970 [95% confidence interval (CI): 0.9995–0.9983] for the first measurement and 0.9988 for the second (95% CI: 0.9979–0.9993, all P < 0.01). The intraobserver reliability was also excellent with an ICC of not less than 0.990 for all four observers (95% CI: 0.9806–0.9986, all P < 0.01). There was excellent interobserver and intraobserver reliability when measuring the HSA in an experimental model provided femoral rotation lay within 20° internal and 40° external rotation and less than 60° of flexion.

A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Rheumatology

Editorial introductions No abstract available

Implications of juvenile idiopathic arthritis genetic risk variants for disease pathogenesis and classification Purpose of review We assess the implications of recent advances in the genetics of juvenile idiopathic arthritis (JIA) for the evolving understanding of inflammatory arthritis in children. Recent findings JIA exhibits prominent genetic associations with the human leukocyte antigen (HLA) region, extending perhaps surprisingly even to the hyperinflammatory systemic JIA category. Some HLA associations resemble those for adult-onset inflammatory arthritides, providing evidence for pathogenic continuity across the age spectrum. Genome-wide association studies have defined an increasing number of JIA-linked non-HLA loci, many again shared with adult-onset arthritis. As most risk loci contain only noncoding variants, new experimental methods such as SNP-seq and innovative big-data strategies help identify responsible causative mutations, termed functional SNPs (fSNPs). Alternately, gene hunting in multiplex families implicates new genes in monogenic childhood arthritis, including MYD88 and the intriguing innate immune gene LACC1. Summary Genetic data indicate a continuity between JIA and adult arthritis poorly reflected in current nomenclature. Advancing methodologies will help to identify new pathogenic mechanisms that inform the understanding of biologic subdivisions within JIA. Resulting insights will facilitate the application of lessons learned across the age spectrum to the treatment of arthritis in children and adults.

Cutaneous manifestations of pediatric lupus Purpose of review To review recent evidence on cutaneous manifestations of lupus, with a focus on evidence for pediatric patients. Recent findings Cutaneous manifestations of SLE are common and may precede signs or symptoms of systemic disease. Early recognition and initiation of therapy improves quality of life by reducing cutaneous disease activity. Antimalarials are first line for moderate-to-severe disease. Photo protection is a critical component of therapy and perhaps the only modifiable risk factor for SLE. Recognition of cutaneous vasculopathy may reduce mortality from vascular occlusion. Summary There is a critical need for better understanding of pathogenesis, risk factors and outcomes in cutaneous lupus to determine optimal treatment and surveillance strategies. Correlation of clinical phenotypes with biomarkers may help to stratify patients, optimize targeted interventions, and influence prognosis.

Interleukin-18 in pediatric rheumatic diseases Purpose of review IL-18 is a pleiotropic cytokine involved in the regulation of innate and adaptive immune responses. IL-18 pro-inflammatory activities are finely regulated in vivo by the inhibitory effects of the soluble IL-18-binding protein (IL-18BP). The elevation of circulating levels of IL-18 has been described in children with systemic juvenile idiopathic arthritis (sJIA). In the recent years, the role of IL-18 in the pathogenesis of secondary haemophagocytic lymphohistiocytosis (sHLH), also referred to as macrophage activation syndrome (MAS), in the context of autoinflammatory diseases, including sJIA, is emerging. Recent findings A large number of studies in patients and animal models pointed to the imbalance in IL-18/IL-18BP levels, causing increased systemic levels of free bioactive IL-18, as a predisposing factor in the development of MAS. Although the exact mechanisms involved in the development of MAS are not clearly understood, increasing evidence demonstrate the role of IL-18 in upregulating the production of interferon (IFN)-γ. Summary On the basis of the first emerging data on the possibility of blocking IL-18, we here discuss the scientific rationale for neutralizing the IL-18/IFNγ axis in the prevention and treatment of sHLH and MAS.

Treatment of juvenile idiopathic arthritis: what's new? Purpose of review The present review highlights the advances in disease outcome achieved with currently available biologic medications and future perspectives for JIA management. Recent findings In the last two decades, the management of juvenile idiopathic arthritis (JIA) has been revolutionized by appropriate legislative initiatives, the existence of very large collaborative networks and the increased availability of the novel biologic medications. Summary A more rational approach to the management of JIA is being fostered by the recent publication of therapeutic recommendations, consensus treatment plans and for a treat-to-target strategy.

Predicting disease severity and remission in juvenile idiopathic arthritis: are we getting closer? Purpose of review To summarize current research on the prediction of severe disease or remission in children with juvenile arthritis, and define further steps needed towards developing prediction tools with sufficient accuracy for clinical use. Recent findings High disease activity, poor patient-reported outcomes, ankle or wrist involvement, and a longer time from onset to the start of treatment herald a severe disease course and a low chance of remission. Other studies confirmed that age less than 7 years and positive ANA are the strongest predictors of uveitis development. Preliminary evidence suggests ultrasound findings may predict flare in patients with clinically inactive disease, and several new biomarkers show promise. A few prediction tools that combine predictors to estimate the chance of remission or a severe disease course in the medium-term to long-term have shown good accuracy when internally validated in the population in which they were developed. Summary Promising candidate tools for predicting disease severity and long-term remission in juvenile arthritis are now available. These tools need external validation in other populations, and ideally formal trials to assess whether their use in practice improves patient outcomes. We are definitively getting closer, but we are not there yet.

The role of epigenetics in paediatric rheumatic disease Purpose of review Autoimmune/inflammatory disorders can be stratified along a spectrum based on the primary involvement of innate vs. adaptive mechanisms. Stratifying patients based on molecular mechanisms rather than clinical phenotypes may allow for target-directed and individualized treatment. Recent findings Epigenetic events are gene regulatory mechanisms that contribute to inflammation across inflammatory diseases and resemble shared mechanisms that may be used as disease biomarkers and treatment targets. Significant progress has been made dissecting the epigenome in paediatric rheumatic diseases and identifies associations with clinical phenotypes, treatment responses and disease outcomes. Here, we will summarize and discuss epigenetic patterns in autoimmune/inflammatory disorders, underlying molecular alterations and their effects on gene expression and immune phenotypes. Summary Structured investigation of epigenetic events, their causes and effects on immune phenotypes in autoimmune/inflammatory, will improve our understanding of disease, deliver new diagnostic tools and treatment options.

Update on the treatment and outcome of systemic lupus erythematous in children Purpose of review Provide an update of studies published in last 2 years on the outcomes and therapies in childhood-onset systemic lupus erythematous (cSLE). Recent findings Additional evidence has been provided about the benefits of universal hydroxychloroquine in SLE patients, although antimalarial maculopathy may be more prevalent than previously thought. Recent studies support lower glucocorticoid doses than used in the past may provide comparable therapeutic benefits, and cSLE patients can mount adequate immunogenic response and sustain long-term seroprotective titers when vaccinated. Long-term studies of adults with cSLE confirmed that damage accrual increases with disease duration. Cardiovascular disease, renal transplants, replacement arthroplasties, and myocardial infarctions occur between 20 and 40 years of age. Higher prednisone doses predicted higher damage trajectory and antimalarial exposure was protective. There were no prospective clinical trials published in pediatric patients with cSLE, but positive results from phase II trials with bariticinib and ustekinumab in adult SLE may raise the expectation that these drugs could be beneficial when used in cSLE. Summary The dire need for more clinical trials and licensed medications for cSLE persist as well as decreasing damage accrual.

Microbiome and autoimmune diseases: cause and effect relationship Purpose of review The human body is the host of trillions of different prokaryotic microorganisms that colonize the skin and the mucosae. The interaction between human cells and these organisms is mediated by the immune system, sustaining a very complex and fragile balance. The immune cells need to prevent uncontrolled growth of pathogenic microbes and promote tolerance toward the existence of the beneficial ones. Growing evidence associates the disruption of this symbiotic relationship with the development of autoimmune diseases. Recent findings Human studies led to the identification of gut dysbiosis patterns in patients with rheumatoid arthritis, lupus and multiple sclerosis. Interestingly, the inoculation of pathogenic bacteria in animal models was associated with the development of these autoimmune diseases. Summary A better understanding of the microbiota–human interaction will enable the development of novel treatment choices. Currently, new molecules using helminth compounds are under investigation and have already revealed promising results.

The role of Epstein–Barr virus infection in primary Sjögren's syndrome Purpose of review The purpose of this article is to draw attention to the role of Epstein–Barr virus (EBV) virus in the pathogenesis of the primary Sjögren's syndrome. The article introduces the problem of consequences of EBV acute infection, and its reactivation, in association with the immune response modulation by the virus and with an increased risk of developing systemic autoimmune diseases and EBV-associated cancers. Recent findings The knowledge about the mechanisms by which the virus may stay for years in a latent phase, unrecognized by the host response immune cells is constantly expanding. There are several mechanisms and theories about EBV influence on the autoimmune process in Sjogren's syndrome (pSS), including the similarity (molecular mimicry) between viral EBNA-2 protein and Ro-60 antigen or EBER-1 and EBER-2 viral proteins and La antigen. Summary The influence of EBV infection on the development and course of pSS has been proven. It has also been established that both EBV and pSS result in the increased risk of tumor (especially lymphoma) development. In the light of these findings, new ways to manage EBV infections are being sought. Optimal methods for assessing EBV infection status are being devised. Research also aims at finding therapies, which target EBV through the inhibition of the autoimmune process and of viral activity. The present article is an attempt to discuss the most important phenomena and elements linking EBV infection to the primary Sjögren's syndrome.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Anaesthesiology

Analgesic efficacy of ultrasound-guided interscalene block vs. supraclavicular block for ambulatory arthroscopic rotator cuff repair: A randomised noninferiority study BACKGROUND Ultrasound-guided interscalene block (ISB) is the reference technique for pain control after ambulatory upper limb surgery, but supraclavicular block (SCB) is an alternative. OBJECTIVES The aim of this study was to compare the efficacy of SCB vs. ISB in patients undergoing ambulatory arthroscopic rotator cuff repair (ARCR), with the hypothesis of noninferiority of SCB analgesia compared with ISB. DESIGN A randomised, single-blind, noninferiority study. SETTING Hôpital Privé Jean Mermoz, Centre Paul Santy, Lyon, France. PATIENTS Ambulatory ARCR patients. INTERVENTION Patients were randomly allocated (1 : 1) to receive a single injection SCB or ISB, as well as general anaesthesia. All patients received a postoperative analgesic prescription for home use before leaving hospital (including fast-acting oral morphine sulphate). Patients completed a telephone questionnaire on days 1 and 2 postsurgery. MAIN OUTCOME MEASURES Primary endpoint was oral morphine consumption (mg) during the first 2 days postsurgery. If the difference between mean morphine consumption in the SCB vs. ISB group was less than 30 mg, noninferiority of SCB compared with ISB would be demonstrated. Secondary evaluation criteria included pain scores (numerical rating scale), duration of motor and sensory blockade, and satisfaction with treatment. RESULTS The per-protocol cohort included 103 patients (SCB = 52, ISB = 51) (57% men, median age 58 years). Mean morphine consumption in the 48 h postsurgery was 9.4 vs. 14.7 mg in the SCB and ISB groups, respectively (difference −5.3, P < 0.001). The upper limit of the 95% CI was less than 30 mg, demonstrating noninferiority of SCB compared with ISB. No difference was observed between the two groups in terms of pain scores or the duration of motor or sensory blockade. Overall, 98% of patients in the SCB group vs. 90% in the ISB group were satisfied with their treatment. CONCLUSION SCB is as effective as ISB in terms of postoperative analgesia based on oral morphine consumption in patients undergoing ambulatory ARCR. Trial registration: EudraCT number: 2016-A00747-47. Correspondence to Julien Cabaton, MD, Department of Anaesthesiology, Hôpital Privé Jean Mermoz, Centre Paul Santy, 24, avenue Paul Santy, Lyon 69008, France E-mail: cabaton.md@orthosanty.fr This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial BACKGROUND Pre-operative anxiety in children is very common and is associated with adverse outcomes. OBJECTIVE The aim of this study was to investigate if virtual reality exposure (VRE) as a preparation tool for elective day care surgery in children is associated with lower levels of anxiety, pain and emergence delirium compared with a control group receiving care as usual (CAU). DESIGN A randomised single-blind controlled trial. SETTING A single university children's hospital in the Netherlands from March 2017 to October 2018. PATIENTS Two-hundred children, 4 to 12 years old, undergoing elective day care surgery under general anaesthesia. INTERVENTION On the day of surgery, children receiving VRE were exposed to a realistic child-friendly immersive virtual version of the operating theatre, so that they could get accustomed to the environment and general anaesthesia procedures. MAIN OUTCOME MEASURES The primary outcome was anxiety during induction of anaesthesia (modified Yale Preoperative Anxiety Scale, mYPAS). Secondary outcomes were self-reported anxiety, self-reported and observed pain, emergence delirium, need for rescue analgesia (morphine) and parental anxiety. RESULTS A total of 191 children were included in the analysis. During induction of anaesthesia, mYPAS levels (median [IQR] were similar in VRE, 40.0 [28.3 to 58.3] and CAU, 38.3 [28.3 to 53.3]; P = 0.862). No differences between groups were found in self-reported anxiety, pain, emergence delirium or parental anxiety. However, after adenoidectomy/tonsillectomy, children in the VRE condition needed rescue analgesia significantly less often (55.0%) than in the CAU condition (95.7%) (P = 0.002). CONCLUSION In children undergoing elective day care surgery, VRE did not have a beneficial effect on anxiety, pain, emergence delirium or parental anxiety. However, after more painful surgery, children in the VRE group needed rescue analgesia significantly less often, a clinically important finding because of the side effects associated with analgesic drugs. Options for future research are to include children with higher levels of anxiety and pain and to examine the timing and duration of VRE. TRIAL REGISTRATION Netherlands Trial Registry: NTR6116 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6116). Correspondence to Elisabeth M.W.J. Utens, (Kp-2865), P.O. Box 2060, 3000 CB Rotterdam, the Netherlands E-mail: e.utens@erasmusmc.nl This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Comparison of neostigmine vs. sugammadex for recovery of muscle function after neuromuscular block by means of diaphragm ultrasonography in microlaryngeal surgery: A randomised controlled trial BACKGROUND Postoperative residual neuromuscular blockade or curarisation (PORC) is a risk directly related to the use of neuromuscular blocking agents during surgical procedures. Acceleromyography is distressing for conscious patients when assessing PORC. Diaphragm ultrasonography could be a valid alternative. OBJECTIVES The primary objective was to achieve a 28% lower incidence of PORC in patients who, after rocuronium administration, received neostigmine or sugammadex at 30 min after surgery. To assess PORC, diaphragm ultrasonography was used, and thickening fractioning [the difference of thickness at the end of inspiration (TEI) and at the end of expiration (TEE), normalised for TEE (TEI − TEE/TEE)] was measured. PORC was defined as thickening fractioning of 0.36 or less. The secondary object was the comparison, in the two treatment groups, of the return to baseline thickening fractioning at 30 min after surgery (ΔTF30). DESIGN Prospective, double-blind, single-centre randomised study. SETTING University Hospital Careggi, Florence, Italy. PATIENTS Patients of American Society Anesthesiologists' physical status 1 or 2, 18 to 80 years, receiving rocuronium during microlaryngeal surgery. INTERVENTIONS At the end of surgery participants were randomised to receive neostigmine (NEO group) or sugammadex (SUG group) as the reversal drug. Thickening fractioning and ΔTF30 were evaluated at baseline and at 0, 10 and 30 min after surgery. MAIN OUTCOME MEASURES TEE and TEI at each time point. RESULTS A total of 59 patients with similar demographic characteristics were enrolled. An association between lack of recovery (thickening fractioning ≤0.36) and drug treatment was only observed at 0 min (SUG vs. NEO, P < 0.05). Concerning ΔTF, at 30 min more patients in the SUG group returned to baseline than those in the NEO group (P < 0.001), after adjusting for side (P = 0.52), baseline thickening fractioning (P < 0.0001) and time of measurement (P < 0.01). CONCLUSION We found an early (0 min) but not long-lasting (30 min) association between diaphragm failure and treatment allocation; a full recovery in baseline diaphragm function was observed only in patients receiving sugammadex. We cannot exclude that further differences have not been found due to interpatients variability in assessing diaphragm contractility by ultrasonography. TRIAL REGISTRATION EudraCT Identifier: 2013-004787-62, Clinicaltrials.gov Identifier: NCT02698969. Correspondence to Iacopo Cappellini, Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Largo Brambilla 3, 50134 Florence, Italy E-mail: jacopocappellini@gmail.com © 2019 European Society of Anaesthesiology

Neuraxial labour analgesia is associated with a reduced risk of maternal depression at 2 years after childbirth: A multicentre, prospective, longitudinal study BACKGROUND Severe labour pain is an important risk factor of postpartum depression, and early depression is associated with an increased risk of long-term depression; whereas the use of epidural analgesia during labour decreases the risk of postpartum depression. OBJECTIVE To investigate whether neuraxial labour analgesia was associated with a decreased risk of 2-year depression. DESIGN This was a multicentre, prospective, longitudinal study. SETTING The study was performed in Peking University First Hospital, Beijing Obstetrics and Gynecology Hospital and Haidian Maternal and Child Health Hospital in Beijing, China, between 1 August 2014 and 25 April 2017. PATIENTS Five hundred ninety-nine nulliparous women with single-term cephalic pregnancy preparing for vaginal delivery were enrolled. MAIN OUTCOME MEASURE Depressive symptoms were screened with the Edinburgh Postnatal Depression Scale at delivery-room admission, 6-week postpartum and 2 years after childbirth. A score of 10 or higher was used as the threshold of depression. The primary endpoint was the presence of depression at 2 years after childbirth. The association between the use of neuraxial labour analgesia and the development of 2-year depression was analysed with a multivariable logistic regression model. RESULTS Five hundred and eight parturients completed 2-year follow-up. Of these, 368 (72.4%) received neuraxial analgesia during labour and 140 (27.6%) did not. The percentage with 2-year depression was lower in those with neuraxial labour analgesia than in those without (7.3 [27/368] vs. 13.6% [19/140]; P = 0.029). After correction for confounding factors, the use of neuraxial analgesia during labour was associated with a significantly decreased risk of 2-year depression (odds ratio 0.455, 95% confidence interval 0.230 to 0.898; P = 0.023). CONCLUSION For nulliparous women with single-term cephalic pregnancy planning for vaginal delivery, the use of neuraxial analgesia during labour was associated with a reduced risk of maternal depression at 2 years after childbirth. TRIAL REGISTRATION www.chictr.org.cn: ChiCTR-OCH-14004888 and ClinicalTrials.gov: NCT02823418. Correspondence to Dong-Xin Wang, MD, PhD, Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8 Xishiku Street, Beijing 100034, China Tel: +86 10 83572784; fax: +86 10 66551057; e-mail: wangdongxin@hotmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Guidewire-assisted vs. direct radial arterial cannulation in neonates and infants: A randomised controlled trial BACKGROUND Cannulation of the radial artery is challenging to perform in neonates and infants because of the small vessel size. OBJECTIVE To compare guidewire-assisted with direct radial artery cannulation in neonates and infants. DESIGN A randomised controlled study. SETTING A tertiary university hospital from 7 August 2017 to 4 July 2018. PATIENTS Ninety neonates and infants who required radial artery cannulation during general anaesthesia. INTERVENTIONS All patients were allocated randomly into the guidewire group (guidewire-assisted cannulation, n=45) or control group (direct cannulation, n=45). Radial artery cannulation was performed under general anaesthesia. The contralateral radial artery was used if the arterial cannulation was not successful within two attempts. After the second failure in the contralateral radial artery, the case was considered a failure. MAIN OUTCOME MEASURES The primary outcome was the first-attempt success rate of radial artery cannulation. The secondary outcomes included the overall success rate, overall procedure time, number of attempts and use of the contralateral radial artery for radial artery cannulation. RESULTS The guidewire group showed a higher first-attempt success rate [76 vs. 56%; P = 0.046; odds ratio (OR) 2.47, 95% confidence interval (CI) of odds 1.01 to 6.08] and overall success rate (96 vs. 76%; P = 0.007; OR 6.96; 95% CI 1.44 to 33.52) than the control group. The overall procedure time was not significantly different between the guidewire group (median [IQR] 36 [28.0 to 70.5] s) and control group (98 [23.5 to 465.0] s; P = 0.400). There was no difference in the median number of attempts between the two groups (P = 0.454). However, use of the contralateral radial artery was significantly lower in the guidewire group (17.8%) than in the control group (40%; P = 0.020; OR 0.324, 95% CI 0.12 to 0.86). Kaplan–Meier analysis of the overall procedure time to successful radial artery cannulation showed that the overall success rate was significantly higher in the guidewire group than in the control group (P = 0.019). CONCLUSION For radial artery cannulation in neonates and infants, guidewire-assisted radial artery cannulation showed superiority over the direct technique in terms of first-attempt success rate and overall success rate without delaying the procedure time. TRIAL REGISTRATION Clinicaltrials.gov (identifier: NCT03217019). Correspondence to Prof Jin-Tae Kim, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul 03080, Republic of Korea Tel: +82 2 2072 3295; fax: +82 2 745 5587; e-mail: jintae73@gmail.com © 2019 European Society of Anaesthesiology

Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, prospective, controlled, randomised, triple-blind study BACKGROUND Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space. OBJECTIVE To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion. DESIGN Prospective, controlled, randomised, triple-blind study. SETTING Multicentre study including four level III maternity units, January 2014 until June 2016. PATIENTS A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group. INTERVENTION After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 μg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h−1 (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 μg ml−1. MAIN OUTCOME MEASURES The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded. RESULTS From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04. CONCLUSION The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation. TRIAL REGISTRATION Clinical trial number: NCT01856166. Correspondence to Estelle Morau, CHU Arnaud de Villeneuve, 34295 Montpellier Cedex 5, France E-mail: estelle.morau@hotmail.fr © 2019 European Society of Anaesthesiology

Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial BACKGROUND Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown. OBJECTIVE We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula. DESIGN Randomised study. SETTING Single-centre, June 2017 to October 2017. PATIENTS A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis. INTERVENTION Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min−1. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min−1. MAIN OUTCOME MEASURES The primary outcome was elapsed time from anaesthesia induction to the first airway intervention. RESULTS The elapsed time from anaesthesia induction to the first airway intervention was 19 ± 10 min in the Mask group (n=63) vs. 10 ± 12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively). CONCLUSION Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia. TRIAL REGISTRATION NCT03139448, registered at ClinicalTrials.gov. Correspondence to Koffi Kla, MD, Department of Anaesthesiology, Vanderbilt University Medical Centre, 1301 Medical Centre Drive, 4648 TVC, Nashville, TN 37232-5614, USA Tel: +1 615 343 9419; e-mail: koffi.m.kla@vanderbilt.edu © 2019 European Society of Anaesthesiology

Functional MRI: basic principles and emerging clinical applications for anaesthesiology and the neurological sciences No abstract available

Validation of 3-minute diagnostic interview for CAM-defined Delirium to detect postoperative delirium in the recovery room: A prospective diagnostic study BACKGROUND Recent guidelines on postoperative delirium (POD) recommend POD screening in all patients, using a validated tool, starting in the recovery room. An operationalisation of the Confusion Assessment Method (CAM) criteria, the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM), has been developed for use in general medical units. OBJECTIVES The aim of this study was to evaluate 3D-CAM performance in an adult patient population to detect POD in the recovery room. DESIGN A prospective diagnostic study. SETTING Recovery room of a tertiary care university hospital in Berlin, Germany, in 2017. PATIENTS Patients at least 18 years of age undergoing elective surgery. MAIN OUTCOME MEASURES Patients were subjected to evaluation by blinded investigators using the 3D-CAM and the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5, reference standard). Sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were analysed for 3D-CAM, in addition to test–retest and inter-rater reliability analyses. RESULTS Sixteen out of 176 patients (9.1%) developed POD. The 3D-CAM demonstrated strong test performance (specificity 0.88, sensitivity 1.0, area under the curve 0.94, PPV 0.44 and NPV 1.0), with a test–retest reliability of 90% (n = 10) and inter-rater reliability of 80% (n = 10). CONCLUSION In this diagnostic study, 3D-CAM showed strong performance for detection of POD in the recovery room. Due to the low training requirements, fast application and high sensitivity, it might be particularly appropriate for clinical staff with limited experience in the assessment of POD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02992717 Correspondence to Claudia D. Spies, MD, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin D-13353, Germany Tel: +49 30 450 551102/+49 30 450 531012; e-mail: claudia.spies@charite.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Comparison of low and high positive end-expiratory pressure during low tidal volume ventilation in robotic gynaecological surgical patients using electrical impedance tomography: A randomised controlled trial BACKGROUND The appropriate level of positive end-expiratory pressure (PEEP) during intra-operative mechanical ventilation remains unclear. OBJECTIVE The aim of this study was to investigate the effects of different levels of PEEP with low tidal volume (low-VT) ventilation in a steep Trendelenburg position (30°) and pneumoperitoneum on oxygenation, respiratory mechanics and ventilation distribution using electrical impedance tomography. DESIGN A randomised controlled trial. SETTING Single university secondary care centre, conducted from January 2017 to December 2017. PATIENTS Forty female patients, aged 20 to 60 years, and of American Society of Anesthesiologists' (ASA) physical status 1 or 2, undergoing elective robotic gynaecological surgery were included. INTERVENTION Forty patients were allocated randomly to a PEEP4 (PEEP 4 cmH2O) group or a PEEP8 (PEEP 8 cmH2O) group. MAIN OUTCOME MEASURES The primary outcomes were respiratory mechanics. The secondary outcomes included changes in ventilation distribution across the ventral and dorsal regions of interest and postoperative pulmonary complications (PPCs) using a modified clinical pulmonary infection score. RESULTS There was no difference in PaO2 at any time point. The peak inspiratory pressure (PIP) and mean airway pressure (Paw) of the PEEP4 group were lower than those of the PEEP8 group (P < 0.001). The oxygenation factor in the PEEP4 group was higher than that in the PEEP8 group during mechanical ventilation at all times. There was no difference in the fractional distribution of end-expiratory ventilation according to region of interest between the two groups. CONCLUSION Both 4 and 8 cmH2O of PEEP with low-VT ventilation can be used for robotic gynaecological surgery that requires a steep Trendelenburg position and pneumoperitoneum. However, 8 cmH2O of PEEP had no benefit over 4 cmH2O of PEEP with respect to oxygenation and improvement of dorsal regional ventilation. TRIAL REGISTRATION The trial was registered at the Clinical Trial Registry of Korea (KCT0002255). https://cris.nih.go.kr Correspondence to Hee Jung Baik, MD, PhD, Department of Anaesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea Tel: +82 2 2650 2868; fax: +82 2 2655 2924; e-mail: baikhj@ewha.ac.kr © 2019 European Society of Anaesthesiology

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cardiovascular Medicine

Percutaneous coronary interventions for stable ischemic heart disease in Italy Aims Although the benefits of percutaneous coronary interventions (PCIs) in patients with stable chronic ischemic heart disease (SIHD) are controversial, a large number of PCIs are currently performed in SIHD patients, frequently after coronary angiography (ad-hoc procedures), without the use of fractional flow reserve (FFR) to identify patients most likely to benefit from PCI. Methods Assessment of regional variations in PCI for SIHD performed in Italy in 2017 and correlation of the regional number of PCI per million inhabitants with the use of FFR were performed using the data reported in the registry of the Italian Society of Interventional Cardiology (SICI-GISE) registry for the year 2017. Results PCI for SIHD accounted for 44.5% of all PCI performed in Italy with large variations among the Italian regions. There was a significant and inverse relationship between the use of FFR and the PCI number per million inhabitants performed for SIHD in the various Italian regions (P = 0.01). In the Veneto region, where local authorities mandated Heart Team reports to select the most appropriate treatment choice in multivessel disease patients, the rate of ad-hoc procedures was significantly lower than the national average. Conclusion PCI for SIHD patients represent almost half of all procedures currently performed in Italy with regional variations inversely related to physiologic guidance use. The mandatory assessment by the Heart Team to select the most appropriate treatment choice in multivessel disease patients is associated with a significantly lower number of ad-hoc procedures. Correspondence to Stefano De Servi, MD, FESC, Unita' di Cardiologia, IRCCS Multimedica, Milan, Italy Tel: +39 02 24209590; e-mail: stefano.deservi@multimedica.it Received 24 February, 2019 Revised 25 March, 2019 Accepted 28 April, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Does mitral regurgitation reduce the risk of thrombosis in atrial fibrillation and flutter? Aims Blood stasis is the main cause of left atrial thrombosis (LAT) in atrial tachyarrhythmias. The high-velocity flow inside the left atrium, due to mitral valve regurgitation, may prevent clot formation but the topic has never been investigated in large-scale studies. The aim of our study was to evaluate whether the presence and degree of mitral regurgitation have a protective role against LAT risk. Methods A total of 1302 consecutive adult patients with paroxysmal or persistent atrial fibrillation or flutter undergoing cardioversion, submitted to transesophageal echocardiography, were retrospectively enrolled in the study. The study population was divided into three groups according to the mitral regurgitation degree: absent, mild-to-moderate and severe. Results Among 1302 patients enrolled in the study, patients without mitral regurgitation were 248 (19%), those with mild-to-moderate 970 (75%), whereas 84 had severe mitral regurgitation (6%). LAT incidence was significantly lower in patients with severe mitral regurgitation compared with those with mild-to-moderate (mitral regurgitation) (2.4 vs. 8.9%, P < 0.05), and similar to subjects without mitral regurgitation (2.4%). Conclusion Despite patients with severe regurgitation having clinical and echo characteristics predisposing to LAT (higher age, heart failure, higher atrial size, lower ventricular function) thrombosis prevalence was significantly lower than for those with mild-to-moderate mitral regurgitation. The percentage of LAT in severe mitral regurgitation cases was very low and similar to that of cases without regurgitation which were characterized by lower age, normal left ventricular function or other risk factors, reinforcing the hypothesis of a protecting role against atrial thrombosis of mitral regurgitation. Correspondence to Ugo Limbruno, MD, Cardiological Department, Misericordia Hospital, Via Senese, 58100 Grosseto, Italy E-mail: ulimbru@tin.it Received 26 March, 2019 Revised 1 May, 2019 Accepted 1 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Reliability of noninvasive hemodynamic assessment with Doppler echocardiography: comparison with the invasive evaluation Aims The study aimed at evaluating the reliability and reproducibility of various noninvasive echocardiographic techniques for the estimation of the main hemodynamic parameters in clinical practice. Methods A total of 84 patients with a generic indication of right heart catheterization (RHC) executed a transthoracic echocardiography shortly before or after the RHC. All the parameters necessary for a noninvasive hemodynamic evaluation of right atrial pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure, pulmonary vascular resistance and cardiac output were acquired and the agreement with the invasive measures was evaluated by a Bland–Altman analysis. Results Noninvasive evaluation of right atrial pressure showed a moderate and low correlation with RHC using inferior vena cava parameters (r = 0.517) and tricuspid E/E′ ratio (sensitivity 0.23, specificity 0.72), respectively. PAPs estimation from the tricuspid regurgitation peak velocity had a good correlation (r = 0.836) and feasibility (82.1%), as well as PAPm from tricuspid regurgitation mean gradient (r = 0.78, applicability 72.6%) and from pulmonary acceleration time (sensitivity 0.85, specificity 0.5, applicability 92.9%). Pulmonary capillary wedge pressure multiparametric evaluation, as suggested by the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations, showed a good correlation (sensitivity 0.96, specificity 0.59). The noninvasive evaluation of pulmonary vascular resistance and cardiac output did not prove to be clinically accurate. Conclusion Various hemodynamic parameters can be adequately estimated with noninvasive methods. In particular, a multiparametric approach for the evaluation of left ventricle filling pressures is advisable and the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations are reliable even in a heterogeneous population with a significant quota of precapillary pulmonary hypertension. Correspondence to Marco de Scordilli, Department of Medical Science, Surgery and Health (DCSMCS), University of Trieste, Ospedale di Cattinara, Via Rossetti, 51, 34141 Trieste, Italy Tel: +39 3497644274; e-mail: marco.descordilli@gmail.com Received 14 March, 2019 Revised 4 July, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Multimodality imaging for early diagnosis and treatment of primary cardiac diffuse 'double-expressor' lymphoma Primary cardiac double-expressor lymphoma represents a rare subtype of diffuse large B-cell lymphoma, especially in immunocompetent patients. To date, only a few sporadic cases of primary cardiac double-expressor lymphoma have been reported in medical literature. Multimodality imaging can be very helpful in these patients for early diagnosis and treatment of this type of lymphoma, allowing potential improvement of the outcome. Correspondence to Loris Roncon, MD, Department of Cardiology, Santa Maria della Misericordia Hospital, Via Tre Martiri 140, 45100 Rovigo, Italy Tel: +39 0425393286; e-mail: loris.roncon@aulss5.veneto.it Received 30 April, 2019 Revised 9 July, 2019 Accepted 10 July, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcardiovascularmedicine.com). © 2019 Italian Federation of Cardiology. All rights reserved.

Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation Background The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. Methods and results Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ± 241 vs. 1273 ± 359 mm2, P = 0.02 and 125 ± 11 vs. 117 ± 16%, P = 0.02), a smaller left atrial volume (54.1 ± 26 vs. 71.5 ± 20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ± 11 vs. 49 ± 12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ± 17 vs. 141 ± 23%, P = 0.014). Conclusion Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure. Correspondence to Sara Cimino, MD, Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, 'Sapienza' University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Roma, Italy Tel: +39 6 49979048; fax: +39 6 49979060; e-mail: sara.cimino@uniroma1.it Received 3 January, 2019 Revised 1 July, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Prognosis in patients with microvascular angina: a clinical follow-up The prognosis of patients with microvascular angina (MVA) has been reported to be good. In 10–20% of the cases, the symptoms of angina progressively worsen during follow-up, becoming more frequent and prolonged, absorbing lower workloads or even increasing at rest and becoming less sensitive, or even refractory, to drug therapy. The frequency and intensity of angina episodes require frequent medical visits, hospital admissions, absences from work, thus determining a high social cost of the disease. To obtain further information on this clinical controversy, we performed a clinical follow-up of of 132 patients with diagnosis of microvascular angina. Correspondence to Vincenzo Sucato, MD, Unit of Cardiology, ProMISE Department, Paolo Giaccone Hospital, University of Palermo, Via Del Vespro n 129, 90127 Palermo, Italy E-mail: odisseos86@gmail.com Received 11 February, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Performance of the Durata implantable cardioverter defibrillator lead: results of an independent multicenter study Aims The high rate of implantable cardioverter defibrillator (ICD) lead failures related to the Sprint Fidelis' and Riata's design have raised serious concerns about the reliability of ICD leads. The St. Jude Medical Durata family of leads replaced the preceding Riata line following increased rates of lead failure (1.17% per year). The aim of our study was to evaluate the long-term performance of the Durata lead. Methods Eight hundred and eighteen Durata ICD leads were implanted in 11 Italian centers. The incidence of lead failure, defined as a sudden rise in long-term pacing or defibrillation impedance and/or a sudden change in R-wave amplitude and capture thresholds, was assessed. The incidences of lead dislodgment and lead perforation were also evaluated. Results During a median follow-up of 1353 days (3.7 years; 25–75th interquartile range 806–1887 days) lead failure occurred in 16/818 leads (0.54%/year). The overall survival, free of lead failure, was 98.9% at 3 years, 98.2% at 4 years and 97.5% at 5 years. Lead dislodgment occurred in 12/818 leads with an incidence of 0.4%/year. No cases of cardiac perforation were reported. No major adverse events were reported except for two cases of inappropriate shocks as a consequence of failure or dislodgment. Conclusion Our study suggests that the Durata lead does not engender a higher risk of failure. Overall survival, free from lead failure, was found to be higher than previously reported for the Riata lead. Correspondence to Roberto Rordorf, MD, Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology – Foundation IRCCS Policlinico San Matteo, P.le Golgi 19, 27100 Pavia, Italy Tel: +39 0382 501276; fax: +39 0382 503161; e-mail: r.rordorf@smatteo.pv.it Received 19 February, 2019 Revised 27 May, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Unresolved issues in left ventricular postischemic remodeling and progression to heart failure In the past decades, myocardial infarction periacute mortality markedly declined since coronary reperfusion therapy has been adopted. Despite immediate benefits of coronary blood flow restoration, the percentage of new onset heart failure has increased over time suggesting that ischemia can run detrimental consequences beyond the immediate anoxic hit. By accepting to aggregate all types of heart failure regardless of underlying cause, the current practice did not help to shed light on the complex postischemic cardiac biology indicating that heart failure is somewhat unavoidable. In the ischemic sequel, the activated mechanisms aim to repair the infarcted zone and to compensate for the lost myocyte functions, thus allowing the heart to maintain the efficient cardiac output for vital organs. The variety of underlying preexisting conditions, as well as the multifaceted components of cardiac molecular structure, cellular state, and electrophysiological postischemic events pave the way for long-term adverse cardiac remodeling. We focused our attention on multiple factors, which include myocyte loss, hypertrophy, hyperplasia, extracellular matrix changes linked to myocardial fibrosis and scar, metabolic imbalance, as well as immunologic response occurring in the acute myocardial aftermath. Moreover, we reported both current pharmacological strategies and future perspectives that might be useful in clinical practice. Furthermore, we discussed the cardiac magnetic resonance as the most promising noninvasive imaging tool, which could be helpful in identifying the amount of myocardial damage. Despite the redundancy of molecular pathogenic mechanisms making it impossible to estimate the proportionate contributions in generating the heart failure phenotype, a deeper understanding will contribute to more customized patient management. Correspondence to Dr Giuditta Benincasa, Department of Advanced Clinical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', 80138 Naples, Italy Tel: +39 0815667916; fax: +39 08119700943; e- mail: dr.benincasa.giuditta@gmail.com Received 21 March, 2019 Revised 17 May, 2019 Accepted 20 June, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

The silent cardiac mass Primary tumours of the heart are a very rare finding. We present a case of cardiac lipoma wherein multimodality images allowed the diagnosis, preventing unnecessary surgery. Typical echocardiography, computed tomographic scan and cardiac magnetic resonance findings are reviewed and discussed. Correspondence to Massimo Slavich, Department of Cardiology, San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy Tel: +390226437395; e-mail: massimo.slavich@hsr.it Received 25 April, 2019 Revised 5 June, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Constrictive pericarditis: a common physiopathology for different macroscopic anatomies No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com