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Automatic 4D mitral valve segmentation from transesophageal echocardiography: a semi-supervised learning approach
Get PDF: Performing automatic and standardized 4D TEE segmentation and mitral valve analysis is challenging due to the limitations of echocardiography and the scarcity of manually annotated 4D images. This work proposes a semi-supervised training strategy using pseudo labelling for MV segmentation in 4D TEE; it employs a Teacher-Student framework to ensure reliable pseudo-label generation. 120 4D TEE recordings from 60 candidates for MV repair are used. The Teacher model, an ensemble of three convolutional neural networks, is trained on end-systole and end-diastole frames and is used to generate MV pseudo-segmentations on intermediate frames of the cardiac cycle. The pseudo-annotated frames augment the Student model's training set, improving segmentation accuracy and temporal consistency. The Student outperforms individual Teachers, achieving a Dice score of 0.82, an average surface distance of 0.37 mm, and a 95% Hausdorff distance of 1.72 mm for MV leaflets. The Student model demonstrates reliable frame-by-frame MV segmentation, accurately capturing leaflet morphology and dynamics throughout the cardiac cycle, with a significant reduction in inference time compared to the ensemble. This approach greatly reduces manual annotation workload and ensures reliable, repeatable, and time-efficient MV analysis. Our method holds strong potential to enhance the precision and efficiency of MV diagnostics and treatment planning in clinical settings
Predisposing Factors and Strategies to Address Moral Distress in Dialysis Nurses: A Literature Review
No full textIntroduction. Moral Distress in the nursing profession represents an increasingly important issue. Patients undergoing dialysis treatment have a long and complex clinical path and the nurse is required to express clinical decisions balancing the obligations of care not only towards patients and family members, but also towards himself and the organization. It therefore happens that the nurse finds himself in situations in which he is not able to translate his moral beliefs into ethically concrete actions causing a sense of anguish and frustration. Objective. To identify and describe the predisposing factors and strategies to address the phenomenon of Moral Distress in nurses who work in dialysis. Method. A literature review was conducted from 01/01/2024 to 09/30/2024 by consulting four databases: PubMed, Embase, CINAHL and Scopus. The study included primary experimental, quasi-experimental, observational, qualitative studies and secondary studies such as reviews, meta-analyses and scoping reviews, which described the phenomenon of Moral distress, its predisposing factors and the related strategies to deal with it in the context of dialysis. Results. The studies confirmed that the phenomenon of Moral Distress is very prevalent in the context of dialysis. The predisposing factors are related to: direct assistance with the dialysis patient (a), the work and organizational context (b) hierarchical barriers and impaired communication between nurses and the ward team (c). The strategies used suggest promoting the well-being of dialysis nursing staff; strategies such as: open communication with patients and relatives; opening of services that provide support on ethical reasoning and stress management; implementation of training activities regarding palliative care and end-of-life management. Discussion. Moral distress causes nursing staff working in dialysis to feel helpless, which can evolve into emotional exhaustion with physical and psychological repercussions that can affect the quality of care provided and increase abandonment of the profession. Conclusions. This literature review has identified the factors that determine the onset of Moral distress in the context of dialysis with the aim of outlining strategies to limit this phenomenon. In light of the results achieved, it becomes essential to implement research within nephrological contexts to prevent and contain the problem with the aim of ensuring high-quality care and at the same time the well-being of the professional
[Treatment of heart failure with sodium-glucose cotransporter 2 inhibitors across the spectrum of left ventricular function]
No full textA cross-sectional multicentre study of multishell diffusion MRI in multiple sclerosis
Get PDFBackground and objectives: White matter (WM) microstructural properties from advanced multishell diffusion MRI (dMRI) have been linked to clinical disability in multiple sclerosis (MS). This multicentre study used multishell dMRI to compute WM metrics and test for differences between people with MS (pwMS) and healthy controls (HCs). Methods: We included multishell dMRI data from 251 pwMS or clinically isolated syndrome (CIS) (mean age 40.7 years, 72.4 % women, 88.8 % relapsing remitting MS) at six MAGNIMS centres and 543 HCs. Eleven scalar metric maps were estimated from multishell dMRI sequences, based on diffusion tensor imaging (DTI) and restriction spectrum imaging (RSI). The maps were analysed using tract-based spatial statistics (TBSS). The diffusion output was submitted to paired sampled t-tests to test for case-control differences and linear regression models to test for associations with Expanded Disability Status Scale (EDSS) scores, while accounting for confounders. In a sub-sample from Oslo, we tested for correlations between EDSS and dMRI metrics within WM lesions. Results: Significant group differences were found in nine out of eleven dMRI metrics. Linear regression models revealed significant correlations between EDSS and fractional anisotropy (FA) fast (β=-4.54, p = 0.01) and apparent diffusion coefficient (ADC) fast (β=10.92, p = 8.7 × 10−3). Conclusions: Diffusion MRI based on clinically feasible multishell sequences uncovers WM group differences between pwMS and HCs, but only a selection of the advanced multishell parameters were sensitive to disability, and no statistically significant correlations with disability remained after Bonferroni correction
Baseline radiological parameters associated with good neurological outcome following ventriculoperitoneal shunt in normal pressure hydrocephalus: A single-center study on 82 patients
Get PDFBackground: Idiopathic normal pressure hydrocephalus (iNPH) is a benign neurologic condition with treatment response rates ranging only between 30 and 50%. Several studies have attempted to identify clinical or radiological predictive factors of a favorable and sustained response to shunting, with conflicting and inconclusive results. With this report, we aimed to define the role of the Evans index (EI), enlargement of temporal horns, lateral ventricular bulges, and isolated elements of disproportionally enlarged subarachnoid spaces (high-convexity tightness and sulcal focal dilation) in predicting outcomes following ventriculoperitoneal shunt (VPS) placement. Methods: All patients referred to Ospedali Riuniti of Ancona, Italy, from 2010 to 2021 were retrospectively examined for evaluation of iNPH. Clinical notes and neuroimaging were reviewed. After screening, 82 patients undergoing VPS procedures for iNPH were included in this series. Most (82.9%) patients were aged >65, with a male-to-female ratio of 1.92:1. Results: Small baseline EI was associated with a significant improvement in gait apraxia scores (0.36 ± 0.04 vs. 0.40 ± 0.05, P = 0.04) and urinary incontinence episodes (0.38 ± 0.03 vs. 0.40 ± 0.05, P = 0.04). An EI > 0.40 was associated with a reduced likelihood of gait improvement (30.2%) in contrast to symptom stability or worsening (53%, P = 0.03). Similarly, an EI > 0.40 was associated with a reduced likelihood of continence improvement compared to stability or worsening of episode frequency (21.8% vs. 54%, P = 0.004). The presence of moderately compressed or obliterated cortical sulci was associated with a significant improvement of modified Rankin scale (mRS) functional status following surgery compared to patients with no convexity tightness (78% vs. 49.1%, P = 0.02 and 39.1% vs. 16.9%, P = 0.03, respectively). A large preoperative EI was predictive of poor response in the domains of gait apraxia (odds ratio [OR] = 0.001, 95% confidence interval [CI]: 0.001-0.4, P = 0.004) and urinary continence (OR = 0.001, 95% CI: 0.001-0.3, P = 0.003). The strongest predictors of improved mRS performance status were moderately (OR= 3.72, 95% CI: 1.22-11.35, P = 0.02) or severely compressed cortical sulci (OR= 3.15, 95% CI: 1.07-9.26, P = 0.03). Conclusion: The EI is a significant parameter predictive of enhanced gait function and urinary continence postsurgery. Furthermore, noteworthy evidence supports the association of high-convexity tightness with improved overall functional scores following surgical intervention
Trastuzumab Duocarmazine in Pretreated Human Epidermal Growth Factor Receptor 2-Positive Advanced or Metastatic Breast Cancer: An Open-Label, Randomized, Phase III Trial (TULIP)
No full textPURPOSEHuman epidermal growth factor receptor 2 (HER2)-targeted therapy is standard of care for HER2-positive (HER2+) breast cancer, but most patients develop progressive disease with persistent HER2 expression. No definitive treatment guidance currently exists beyond second line. Trastuzumab duocarmazine (T-Duo) is a third-generation, HER2-targeted antibody-drug conjugate that demonstrated efficacy and acceptable safety in phase I studies of heavily pretreated patients with HER2+/HER2-low breast cancer.METHODSIn this open-label, randomized, phase III trial, T-Duo was compared with physician's choice (PC) in patients with unresectable locally advanced/metastatic HER2+ breast cancer with progression during/after ≥2 HER2-targeted therapies or after trastuzumab emtansine (T-DM1). The primary endpoint was progression-free survival (PFS) by blinded independent central review.RESULTSIn total, 437 patients were randomly assigned 2:1 to T-Duo (n = 291) or PC (n = 146). The median age was 56.0 years (range, 24-86); most patients (93.6%) had metastatic disease. The median time from diagnosis of metastatic disease to trial entry was 3.5 years; the median number of prior HER2-targeted therapies in metastatic setting was three. The median PFS was 7.0 months (95% CI, 5.4 to 7.2) with T-Duo versus 4.9 months (95% CI, 4.0 to 5.5; hazard ratio [HR], 0.64 [95% CI, 0.49 to 0.84]; P =.002) with PC. PFS benefit was maintained across most predefined subgroups. The median overall survival (first analysis) was 20.4 (T-Duo) versus 16.3 months (PC; HR, 0.83 [95% CI, 0.62 to 1.09]; P =.153). Objective response rate was 27.8% (T-Duo) versus 29.5% (PC); other efficacy end points - clinical benefit rate, duration of response, and reduction in target lesion measurement - tended to favor T-Duo. Grade ≥3 treatment-emergent adverse events occurred in 52.8% (T-Duo) versus 48.2% (PC).CONCLUSIONTreatment with T-Duo was manageable, but tolerability was affected by prevalent ocular toxicity, leading to a higher discontinuation rate in the T-Duo arm. T-Duo significantly reduced the risk of progression in patients with advanced HER2+ breast cancer who have progressed during/after ≥2 HER2-targeted therapies or after T-DM1
The New Guarantee System for Monitoring Healthcare Services Delivery in Italy: technical remarks and recommendations
No full textBackground: Over the past 15 years, Italy's National Health Service has been the object of increased governmental attention, due to the need to control public spending, reduce waste, and maintain acceptable levels of quality, accessibility and appropriateness of healthcare services. Methods: One of the key mechanisms to achieve this has been the implementation of performance assessment systems. Among these is the New Guarantee System, introduced in 2019, which utilizes 88 indicators across three key macro-areas - public health and prevention, primary health care, and hospital care - to assess the quality and equity of essential healthcare services. Results: This paper critically analyzes the 2025 New Guarantee System report, identifying strengths, limitations, and potential improvements for a more effective monitoring system. The findings reveal significant gaps in the current healthcare performance evaluation system. The reliance on descriptive statistics limits the ability to interpret healthcare outcomes accurately. The absence of indicators addressing chronic diseases, health inequalities, new technologies and qualitative patient experiences suggests the urgent need of a more comprehensive evaluation approach. Conclusions: To improve the healthcare performance evaluation system, it is recommended to incorporate more comprehensive indicators that address the identified gaps. Enhanced data integration, qualitative assessments, and an increased focus on chronic diseases and health disparities are essential to provide a more accurate evaluation of healthcare services
Future Directions and Clinical Trial Considerations for Novel Islet β-Cell Replacement Therapies for Type 1 Diabetes
No full textType 1 diabetes results from the immune-mediated loss of insulin-producing pancreatic islet β-cells, rendering those affected dependent on exogenous insulin to survive. Despite the array of choices available for insulin delivery, treatment to maintain near-normal glucose metabolism while avoiding hypo-and hyperglycemia remains a chal-lenge. After two decades of clinical trials across four conti-nents, the transplantation of islets isolated from deceased donor pancreases has been shown to be both safe and efficacious in patients experiencing severe hypoglycemia (level 3) or already requiring immunosuppression to support a kidney transplant, offering a distinct set of advan-tages to appropriate candidates. We are entering a phase of clinical development where islet β-cell replacement approaches should be recognized and studied as more than just a rescue therapy for those with severe hypoglycemia and could be expanded to all individuals with type 1 diabe-tes. Our aim is to expedite translation of cellular therapy for all individuals living with type 1 diabetes by focusing on new emerging islet β-cell replacement approaches and proposing clinical trial designs that accelerate their development. As we support expansion of the population to be included in the investigation of novel thera-pies, this perspective presents a road map and clinical trial considerations to guide the development of the next generations of islet β-cell replacement therapies that address the unmet needs of the broader type 1 diabetes community
Genomic Epidemiology of the Main SARS‐CoV‐2 Variants Circulating in Italy During the Omicron Era
No full textSince early 2022 the Omicron variant has rapidly spread worldwide, becoming the dominant variant to date. The study aimed to investigate the clinical and epidemiological characteristics of COVID-19 patients and reconstruct the genomic epidemiology of main SARS-CoV-2 Omicron sublineages in Italy in 2022. A total of 8970 SARS-CoV-2 samples were studied, and phylogenetic analyses were focused on BA.1, BA.2, and BA.5 subvariants. More than half of subjects received three doses of vaccine and experienced a reinfection. A significant larger proportion of unvaccinated subjects presented reinfection compared with vaccinated. Clusters presented a tMRCA between September–November 2021 (BA.1), November 2021–January 2022 (BA.2), and October 2021–May 2022 (BA.5). Re values showed the highest level between September–October, January–February 2022, and May 2022 for BA.1, BA.2 and BA.5, respectively. Limited number of studied variant sequences are included in clusters. The spread rate of the studied variant exceeded its evolutionary rate. No single sublineage had sufficient time to differentiate into large clusters, but only into small and fragmented groups sharing the same recent ancestor. These analyses dissect the epidemiological dynamics of Omicron sublineages in Italy over a period of great epidemiological changes in the COVID-19 epidemic
Transcranial Direct Current Stimulation over the Orbitofrontal Cortex Enhances Self-Reported Confidence but Reduces Metacognitive Sensitivity in a Perceptual Decision-Making Task
No full textBackground: Metacognition refers to the ability to reflect on and regulate cognitive processes. Despite advances in neuroimaging and lesion studies, its neural correlates, as well as their interplay with other cognitive domains, remain poorly understood. The orbitofrontal cortex (OFC) is proposed as a potential substrate for metacognitive processing due to its contribution to evaluating and integrating reward-related information, decision-making, and self-monitoring. Methods: This study examined OFC involvement in metacognition using transcranial direct current stimulation (tDCS) while participants performed a two-alternative forced choice task with confidence ratings to assess their metacognitive sensitivity. Before stimulation, the subjects completed the Metacognitions Questionnaire-30 and a monetary intertemporal choice task for the quantification of delay discounting. Results: Linear mixed-effects models showed that anodal tDCS over the left OFC reduced participants' metacognitive sensitivity compared to sham stimulation, leaving perceptual decision-making accuracy unaffected. Moreover, real stimulation increased self-reported confidence ratings compared to the sham. Significant correlations were found between metacognitive sensitivity and negative beliefs about thinking. Conclusions: These results highlight the potential involvement of the OFC in the processing of retrospective second-order judgments about decision-making performance. Additionally, they support the notion that OFC overstimulation contributes to metacognitive dysfunctions detected in clinical conditions, such as difficulties in assessing the reliability of one's thoughts and decision outcomes