Mitral interventions remain technically challenging owing to the anatomical complexity and heterogeneity of mitral pathologies. As such, multi-disciplinary pre-procedural planning assisted by advanced cardiac imaging is pivotal to successful outcomes. Modern imaging techniques offer accurate 3D renderings of cardiac anatomy; however, users are required to derive a spatial understanding of complex mitral pathologies from a 2D projection thus generating an ‘imaging gap’ which limits procedural planning. Physical mitral modelling using 3D printing has the potential to bridge this gap and is increasingly being employed in conjunction with other transformative technologies to assess feasibility of intervention, direct prosthesis choice and avoid complications. Such platforms have also shown value in training and patient education. Despite important limitations, the pace of innovation and synergistic integration with other technologies is likely to ensure that 3D printing assumes a central role in the journey towards delivering personalised care for patients undergoing mitral valve interventions. Heart Team based pre-procedural planning using advanced cardiac imaging is crucial to successful mitral interventions.Cardiac imaging requires users to spatially appreciate structures on 2D projections generating an ‘imaging gap’. 3D printing can surmount the imaging gap to enhance procedural planning and offer personalised care.Integration of 3D printing technologies with other transformative technologies and large-scale clinical trial data may facilitate widespread clinical translation. Mitral regurgitation (MR) is the commonest heart valve lesion in the developed world and is associated with considerable morbidity and mortality , 2. SurgTranscatheter mitral valve interventions have shown promise as alternative interventions to mitigate the burden of MR in those deemed unsuitable for conventional surgery. Indeed, transcatheter mitral valve repair (TMVr) is now an established treatment strategy with over 100,000 procedures performed globally. Meanwhile, transcatheter mitral valve replacement (TMVR) may offer a viable alternative for those unsuitable for TMVr and in patients with failed surgical bioprostheses, severe mitral annular calcification (MAC) and unsuccessful surgical mitral repair .Despite significant innovation and evolution, surgical and transcatheter mitral valve interventions face considerable technical challenges arising from the anatomical complexities of the mitral valve apparatus and its dynamic interaction with adjacent structures, as well as the heterogeneity within mitral pathologies. Indeed, the saddle shaped mitral annulus has variable dimensions dependent on haemodynamic status and left ventricular (LV) cavity dimensions rendering device sizing challenging. The complex sub-valvular apparatus may hinder device manoeuvrability and risks entrapment. The intimate anatomical relationship between the left ventricular outflow tract (LVOT) and the mitral valve introduces the catastrophic risk of LVOT obstruction in TMVR –9. MeanwHeart Team-based pre-procedural planning using advanced multi-modality imaging is crucial for achieving optimal procedural outcomes, especially in transcatheter mitral interventions due to their inherent complexities and challenges. Although advances in cardiac imaging (notably in multi-detector cardiac CT (MDCT) and three-dimensional (3D) transoesophageal echocardiography (TOE)) now enable rendering of highly accurate 3D images of cardiac structures, there are important limitations arising from the lack of dynamic feedback and tactile interaction. Users are also required to spatially appreciate complex 3D anatomical structures on a two-dimensional screen. As such, there is a growing recognition of an ‘imaging gap’ within structural heart interventions which hamstrings effective procedural planning , 13.The advent and rapid evolution of ‘transformative technologies’ in medicine- namely 3D printing, computer-aided modelling (CAD), computational modelling, artificial intelligence (AI) and extended realities- have the potential to bridge the imaging void gap in structural heart interventions. They may herald a paradigm shift in procedural planning by facilitating patient-specific modelling of mitral pathologies and guiding interventional strategy thus potentially improving procedural outcomes. The integration and clinical translation of such technologies may hold considerable value for future training, evaluation of novel mitral technologies and facilitate the delivery of personalised cardiac care , 14.This work provides an overview of 3D printing technologies and workflows followed by an appraisal of the current status and future clinical translation of this technology in modelling mitral interventions.Three-dimensional printing transforms digital objects into physical 3D replicas through multi-layered material deposition over a digitally defined geometry. Figure A volumetric imaging dataset in DICOM  format is a prerequisite for segmentation. As such, relevant imaging modalities include ECG gated MDCT, 3D echocardiography and Cardiac MRI (CMR) .MDCT is now the modality of choice for modelling mitral interventions particularly in the transcatheter domain. Indeed, advances in MDCT technology have enabled sub-millimetre spatial resolution (0.3–0.625 mm) which can be obtained with rapid image acquisition speeds. Meanwhile, progress in reconstruction algorithms enable highly accurate virtual 3D renderings of cardiac structures. The use of iodinated contrast agents in MDCT still requires caution in those with chronic renal impairment and CT based modelling involves image acquisition throughout the cardiac cycle thereby conferring additional exposure to ionising radiation. MDCT acquisition can also be limited by arrhythmia and low cardiac output states . MDCT en3D echocardiography continues to remain an appealing imaging modality in heart valve modelling due to its widespread availability and cost effectiveness. Additionally, it avoids the use of contrast agents and ionising radiation, the latter of particular significance for younger patient groups –23. The The choice of imaging modality requires careful consideration when planning 3D printing as the accuracy and quality of printed replicas are a direct function of the virtues of the imaging modality employed. More recent work has demonstrated the potential of fusion imaging whereby imaging data from multiple modalities can be integrated and then 3D printed to model complex anatomical detail. These techniques seek to offset the limitations of individual imaging modalities and enhance the accuracy and quality of printed replicas .https://www.mitk.org/wiki/The_Medical_Imaging_Interaction_Toolkit) and ITK-snap (http://www.itksnap.org/pmwiki/pmwiki.php) as well as proprietary platforms such as Mimics , Intuition  and Amira  [Volumetric imaging data acquired in DICOM format requires processing such that the region of interest can be isolated in a process known as segmentation. There are a constellation of segmentation platforms available including open-source packages such as 3DSlicer, Medical Imaging Interaction Toolkit (MITK) (husetts) .Segmentation is often a laborious step with a steep learning curve and requires a high degree of imaging and software expertise. Manual segmentation using editing, cropping and extraction is often arduous, time consuming and has high interobserver variability particularly in the context of mitral valve disease which often features complex anatomy. Several automated segmentation tools have been developed for varying applications such as deriving quantitative valve measures and extracting annular and leaflet geometry for physical printing, or virtual modelling. Automated segmentation tools which often rely on region growing and simple intensity thresholding segmentation methods may struggle in characterising boundaries of cardiac structures of similar intensity profiles such as mitral valve leaflets. Semi-automated segmentation techniques therefore are the most frequently utilised where acquired volumetric images initially undergo automated segmentation followed by manual optimisation by the user , 28.Fully automated mitral valve segmentation however has seen advancements using atlas-based approaches and deep learning-based methods. Atlas-based approaches utilize a large database of manually labelled images, which are used to generate a deformable template which can then be guided to the leaflet geometry. Atlas-based methods relying on sparse geometry or landmarks are potentially limited in the amount of patient-specific detail that can be extracted and may be biased towards the atlas geometry , 30. DeeOptimisation of the post segmentation virtual model is often required using dedicated platforms which enables editing and smoothing. Computer Aided Design (CAD) tools may also be employed to process virtual geometries for example colour coding regions of interest. The virtual rendering is then converted into the file formats  which are recognised by 3D printers to enable printing a physical replica of the segmented structure. Alternatively, these file formats can be integrated into virtual platforms for computer-aided mitral modeling purposes. , 33.3D printing technologies are well established having been first introduced by Charles Hull in 1984 by the application of optical technology to rapid prototyping . Figure Fusion Deposition modelling (FDM) is the most frequently used technology for cardiovascular 3D printing due to its low cost and ease of use. FDM extrudes molten thermoplastic filaments layer by layer to generate a 3D print. FDM requires the use of a supporting material to provide stability for complex structures during the printing process which can later be removed. FDM printing is limited by low accuracy and offers a poor finish for softer surfaces.Stereolithography (SLA) uses a liquid photosensitive resin which rapidly coalesces when exposed to laser irradiation or light. SLA printers can generate complex structures with high feature resolution (~ 1.2 mm) however this printing modality is expensive and is restricted by the limited number of available photosensitive resins , 34.TM by Stratasys) or wax (3D systems) as removable support during the printing process. PJ printers offer high resolution with good quality surface finishes and importantly offer the ability to combine different polymers within a single print. PJ printers therefore show considerable promise in the high-resolution printing of complex cardiac structures with multiple tissue properties such as calcification. PJ printers are currently limited by high cost of hardware and printing consumables.Polyjet (PJ) printers are based on the same principle of photopolymer technology used in SLA printers. PJ printers utilize an extrusion process to push out a photopolymer, which is the primary material used for creating the physical model. This photopolymer subsequently solidifies when exposed to laser or light. Furthermore, PJ printers incorporate a photo-curable gel (PolyJetSelective Laser Sintering (SLS) utilizes a laser to selectively heat and fuse powder-based materials. The SLS process involves converting these materials into particles and subsequently fusing them together in successive layers to form the final 3D printed object. While the primary focus is on powder-based polymers, SLS printers can accommodate a diverse range of materials, including ceramics and metals. Although expensive and resulting in a rough finish, SLS printing allows the generation of highly robust 3D structures .A comprehensive understanding of materials technologies and the properties of native tissues is crucial in creating biomechanically realistic 3D printed models.The mitral valve leaflets comprise of three layers each containing a heterogenous matrix of constituents with different biomechanical properties to serve specific functional requirements. The atrialis layer is covered with endothelium below which lies connective tissue composed of elastin sheets and laminar collagen. The composition of the atrialis layer allows it to sustain the significant tensile deformation forces associated with systole whilst enabling a degree of recoil in diastole. The presence of smooth muscle in the atrialis layer with its attendant innervation enables some modulation of leaflet stiffness. The glycosaminoglycan rich spongiosa underlies the atrialis layer and contains irregularly arranged collagen. The spongiosa layer helps resist the compressive forces from mitral leaflet coaptation by retaining water. The Fibrosa layer contains densely packed collagen fibres aligned parallel to the leaflet free edge and flexibly crimped. At the site of chordal insertion, the fibrosa transitions from a planar to a cylindrical arrangement which prevents leaflet kinking by enabling a gradual transition of forces from the chordae and leaflets. The chordae tendineae are complex structures featuring an elastin sheath housing a cylindrical collagenous chord –38.Table The development of flexible elastomeric materials such as HeartFlex and TangoPlus along with the advent of polyjet printers which enable manufacture of complex models by blending printing materials  may herald a paradigm shift in towards the direct manufacture of biomechanically realistic mitral replicas capable of being integrated into functional and static mitral modelling for prospective interventions. Wang et al. were one of the first to demonstrate the feasibility of using metamaterials to realistically simulate the stress–strain properties of human valvular tissue. The authors used TangoPlus (simulating human extracellular matrix) embedded with VeroBlackPlus (simulating stiff collagen fibres within extracellular matrix) either in sinusoidal or double helix geometries. They then compared the stress–strain relationship of human aortic tissue to TangoPlus alone and the metamaterial incorporating a sinusoidal wave geometry to find the metamaterial to emulate human aortic tissue more closely. The authors also demonstrated that stress–strain relationships of the metamaterials can be ‘tuned’ by changing the characteristics of the ingrained double helix or sinusoidal patterns In the mitral domain, Vukicevic et al. demonstrated the feasibility of patient-specific manufacture of the entire mitral valve apparatus using metamaterials and their ability to permit implantation of transcatheter devices. Significantly, they attempted to simulate the material properties of surrounding structures and the unique layered microanatomy of mitral leaflets by incorporating different shores (hardness) of TangoPlus. Calcification was modelled using very hard VeroWhite material. The authors compared stress–strain relationships of healthy porcine mitral leaflets to that of two individual grades of TangoPlus and a combination of the two grades to find that TangoPlus was able to model the stress–strain relationship of healthy porcine leaflet tissue within the zone of physiological function and at the transitional region where collagen fibres are recruited . More reAlthough polyjet printing and the development of metamaterials offer promise in realistically simulating mitral behaviour, such technologies are currently expensive and require specialist expertise greatly limiting their wider clinical translation. Moreover, such rigid mitral replicas are unable to reproducibly simulate complete mitral valve tissue properties and therefore essentially serve as morphological displays precluding functional replica evaluation. As such, ‘soft’ deformable silicone based mitral replicas derived from moulding techniques have been favoured for dynamic mitral modelling and simulation. Moulds are often 3D printed and have patient-specific properties however they lack the anatomical precision of directly 3D printed mitral replicas and therefore offer a heuristic approach to modelling , 41, 43.The translation of 3D printing technology in modelling mitral interventions can broadly be divided into the use of static mitral replicas and in vitro functional platforms.Static replicas seek only to replicate patient-specific anatomy and can be used as adjunctive aids in the comprehension of complex mitral anatomy, procedure planning and patient education. In vitro functional platforms seek to replicate patient-specific mitral anatomy and the haemodynamic milieu of mitral disease. Functional platforms can serve as research testbeds to study mitral pathophysiology and evaluate novel mitral technologies. They also have the potential to be used for dynamic procedure planning and immersive patient-specific simulation training .Static 3D-printed replicas offer haptic and spatial appreciation of complex anatomy, with potential dividends in procedural planning, especially given the steep learning curves associated with mitral interventions , 47. MorAlthough of value, rigid 3D printed mitral replicas are bound by the current limitations of materials technology. As such, directly 3D printed replicas currently preclude surgical instrumentation such as the deployment of annuloplasty rings, suturing and leaflet resection limiting their translational value for surgical planning and simulation. ‘Soft’ silicone based mitral replicas derived from moulding techniques can simulate the gross properties of mitral tissue whilst being sufficiently deformable to facilitate surgical or trans-catheter instrumentation. The properties of ‘soft’ mitral replicas may therefore lend themselves more favourably to procedural planning. Indeed, in proof of concept work Nia et al. were able to simulate the prospective surgical repair of a P2 prolapse within a static bench top simulator using a deformable patient-specific mitral replica derived from 3D TOE. The authors were subsequently able to undertake successful real-life surgical repair with no alterations to the simulated surgical technique. Interestingly, note was made of anterior leaflet prolapse on intraoperative saline testing post-repair. This was not apparent on the pre-operative TOE or the simulated model and deemed to be pseudo prolapse which was confirmed on intraoperative TOE. In some instances, junior surgeons have been compelled to intervene upon leaflet pseudo prolapse adversely impacting outcomes. The authors argued that this event revealed the potential value of integrating physical 3D modelling with pre-operative imaging in intra-procedural decision making . SimilarUnlike surgical interventions, transcatheter procedures preclude intraprocedural examination of mitral pathologies therefore depriving interventionalists the opportunity to alter procedural strategy at the point of intervention, making such interventions less predictable than their surgical equivalents. As such, there is arguably greater reliance on preprocedural planning and greater exposure to the limitations of cardiac imaging in transcatheter interventions compared to surgical techniques. Moreover, given their high-risk nature, patients undergoing transcatheter interventions are less likely to be offered surgical ‘bail-out’ in the event of complications. There has therefore been an evolving interest in integrating 3D printing and modelling into transcatheter Heart Team procedure planning for increasingly complex transcatheter mitral valve interventions. Dankowski et al. were one of the first to apply 3D printing techniques as an adjunct to procedure planning for percutaneous mitral annuloplasty using a static phantom derived from MDCT. They found the printed replica enabled them to accurately examine the underside of the mitral valve and identify the precise location, number and size of papillary muscles which has a bearing on initial crossing wire placement. The degree of basal dilatation was also apparent on the replica therefore guiding optimal placement of Mitralign pledgets. The derived model also allowed characterisation of parameters such as the aortic entry angle into the LV and analysis of subvalvular apparatus to guide equipment selection and placement . More reThere are several key limitations precluding the widespread clinical translation of static 3D printed mitral replicas in procedural planning. The materials employed for printing do not entirely mimic native tissue and therefore the impact of dynamic device-host interaction cannot be accurately modelled especially due to the static nature of modelling which has implications for their use in crucial areas such as sizing prostheses. There is no standardised or validated technique available to manufacture mitral replicas which greatly limits the translational potential of research within this area. As such incorporation into procedure planning especially in complex interventions requires careful consideration. Clinical translation is also precluded by cost, time taken for image processing and printing as well as the lack of widespread expertise in this arena.The integration of static 3D printed mitral phantoms with complementary transformative technologies however, have the scope to greatly enhance their combined efficacy and translational potential.TMVR technologies are in their nascency with a myriad of novel devices available for implantation. Moreover, transcatheter valve-in-MAC and valve-in-ring procedures utilise tissue heart valves tailored for transcatheter aortic valve implantation (TAVI).3D computer assisted modelling (3D-CAM) platforms enable the derivation of static virtual anatomical 3D models of patient-specific mitral pathology using volumetric imaging data. Derived virtual models can then be manipulated to evaluate complex anatomy and assist in aspects of procedural planning such as sizing of prosthesis, predicting the risk of significant complications, and devising appropriate interventional management strategies. Patient-specific static 3D printing has been used to complement 3D-CAM –58.TMVR displaces the anterior mitral valve leaflet and changes the geometry of the LVOT with the resulting morphology termed the neo-LVOT. TMVR carries a risk of LVOT obstruction (LVOTO) which can be fatal. 3D-CAM is increasingly being adopted for procedural planning and predicting the risk of LVOTO and has shown good correlation between modelled and real-world procedural outcomes  Fig. 4)4). 3D prIn addition to procedural risk prediction and mitigation, 3DCAM can also be employed to derive an enhanced understanding of patient-specific anatomy and optimise interventional strategy for those undergoing transcatheter mitral interventions. For example, 3DCAM can be used to derive an enhanced appreciation of the anatomical relations of the inferior vena cava, interatrial septum, and mitral annulus which can then be 3D printed to provide the operator a physical evaluation of the interatrial puncture site and an impression of the impact of patient-specific anatomy on delivery catheters and other equipment , 59. 3DCDespite the considerable advantages associated with incorporating 3DCAM in transcatheter mitral intervention planning, it remains a static modelling modality unable to simulate the complex dynamic anatomical changes and flow dynamics inherent to mitral valve diseases. As such, the derived modelling information must be considered within the wider scope of Heart team procedure planning and integrated with other imaging modalities and the clinical context.Mitral valve pathologies are unique in that they can only be fully appreciated within a haemodynamic environment, therefore immediately limiting the value of static physical mitral modelling. As such dynamic ex-vivo models comprising of animal mitral valve tissue integrated into mock circulatory systems (MCS) seeking to emulate human cardiac haemodynamics form the mainstay of functional mitral modelling and allow evaluation of research hypotheses, novel transcatheter devices and operator simulation training .The constituents of an MCS are outlined in Fig. The advent of 3D printing offers the prospect of incorporating and dynamically modelling patient-specific mitral valve replicas within an MCS. Such a system however is reliant upon the manufacture of mitral replicas exhibiting the biomechanical properties of human valves and accurate simulation of the haemodynamic milieu of mitral pathologies. The current status of materials and printing technologies preclude direct printing of biomechanically realistic mitral replicas. Patient-specific mitral valves created by casting silicone replicas over rigid 3D printed models have been shown to provide a heuristic approach for modelling mitral pathologies within a mock circulatory system environment. This approach arguably can be seen as a bridging technology until materials technologies are sufficiently mature to allow direct realistic mitral printing.Mashari et al. demonstrated the feasibility of the haemodynamic evaluation of a 3D printed mitral valve after TMVr within an MCS. The authors were able to derive pressure half time values from continuous wave Doppler and chamber pressures through pressure monitoring catheters. The study was limited by the ability of the MCS to only generate sufficient pressures to allow diastolic modelling .In more extensive contemporary work, Ginty et al. semi-automatically segmented 3D TOE data in diastole to derive patient-specific 3D printed PLA moulds of the atrial mitral valve surface. Silicone  was then used to create a patient-specific mitral valve assembly with incorporated gauze fabric shaped to anterior and posterior mitral leaflets as well as flayed braided Dacron threads to replicate six chordae tendinae. Gauze fabric provided additional tensile strength to adequately mimic mitral leaflets, prevent dehiscence within simulated haemodynamic conditions and allowed the application of sutures or clips to simulate mitral valve interventions Fig. . BraidedThe availability of a high-fidelity patient-specific mitral valve simulator has significant transformative potential with the scope for integration into Heart Team workflows surrounding patient selection and procedure planning and thus potentially enhancing procedural outcomes and patient safety. Moreover, such a platform has the potential to be integrated with other transformative technologies further expanding its utility. Although promising, dynamic patient specific mitral modelling remains nascent and a considerable distance away from clinical translation. Indeed, studies in this arena are limited and only demonstrate feasibility, therefore larger studies are required for further validation prior to which caution must be applied to its application in clinical practice. Other practical limitations include the time taken to fabricate silicone based mitral replicas and that replica leaflet thickness is greater than native tissue. Moreover, any progress in this arena is contingent on advances in 3D printing technologies and the ability of MCS platforms to accurately model human haemodynamics.Surgical and transcatheter mitral interventions are technically complex and associated with significant intraprocedural neurocognitive demand thereby resulting in steep learning curves which are closely related to procedural volumes. Indeed, cardiac surgeons have been shown to require between 75–125 procedures to overcome the learning curve for minimal access mitral valve repair , 68. Imp. Moreover, given their complex nature, mitral interventions are typically undertaken in specialist centres with relatively low volumes further straitjacketing training opportunities. In the case of transcatheter mitral interventions many senior interventional cardiologists are still in the process of transitioning from coronary intervention and TAVI therefore further reducing the scope of technical training available for junior trainees.Currently surgical and transcatheter training is dependent on the apprentice model of supervised learning and the principle of ‘see one, do one, teach one’ , 71. TheSimulation training may offer junior trainees the opportunity become proficient in basic technical skills before graduating onto an apprentice style model whilst more senior operators can acquire the basic skills required for novel procedures. Simulation training is well established in the surgical domain and has been shown reduce the learning curve particularly in laparoscopic surgery . SignifiLow-fidelity, low-cost physical simulation platforms for surgical mitral valve interventions have been available for some time . Given tImportant progress has been achieved in this endeavour with direct or indirect 3D printing of patient-specific mitral replicas incorporated into either static  or a dynamic mock circulatory system. 3D printing has also been utilised to manufacture precision components for animal based ex-vivo simulators which can be adopted for training.Recent work by Nia et al. with the support of the European Association of Cardiothoracic Surgery is an apt example of how 3D printing and silicone based mitral modelling can facilitate efforts towards the systematic development of a validated mitral simulator which can be incorporated into a wider standardised training programme. The investigators conceived, manufactured, and validated a bench top static minimally invasive mitral simulator based on simulation requirements set out by a panel of experienced mitral surgeons. The simulator comprised of a model thoracic torso with robotic and endoscopic access ports. The torso housed a silicone casted generic mitral valve replica mounted within a 3D printed left ventricle and featured a real-time feedback system for suture depth and width Fig. . The autThe integration of 3D printing with other transformative technologies to derive hybrid patient-specific simulation platforms may harbour considerable future translational potential through offsetting limitations of individual technologies, conceivably resulting in a highly optimised platform. Engelhardt et al. demonstrated the feasibility of such a paradigm by first developing a standardised workflow incorporating 3D printing techniques to manufacture patient-specific silicone mitral valve phantoms which included the papillary muscles and chordae tendinae. The authors integrated these replicas within a non-dynamic commercial endoscopic mitral valve repair simulator and demonstrated it to be valuable for training junior surgeons and for patient-specific procedural rehearsal for senior surgeons . In furtThe increasing global volume of transcatheter mitral interventions (primarily edge-to-edge repair) has spurred the development of dedicated physical high-fidelity simulators in this arena with a view to training the next generation of interventional cardiologists and facilitating the transition of the current generation from TAVI to transcatheter mitral interventions. Operators undertaking TEER interventions not only require considerable dexterity but also simultaneously need to process and integrate real-time information from 3D TOE and fluoroscopy whilst maintaining close interaction with a multi-disciplinary catheterisation lab team to deploy repair devices safely and successfully within a beating heart. As such the development of effective high-fidelity physical simulators beyond ex-vivo animal models in this arena is fraught with challenges and in its nascency with 3D printing set to assume a pivotal role. Early work by Vukivecic et al. demonstrated the feasibility of successfully deploying and securing a Mitraclip onto a multi-material patient-specific 3D printed mitral replica- an important prerequisite for any substantive simulator .Meanwhile, Laing et al. validated the ability of a benchtop static simulator comprising of a patient-specific silicone-based heart model (manufactured using 3D printed moulds) mounted within a cylindrical container with port access to accurately display anatomical features and equipment on TOE and fluoroscopy to simulate septal puncture—a particularly demanding and crucial element of mitral TEER . More reBertolini et al. fabricated an alternative TEER simulation platform consisting of a stand mounted translucent 3D printed model of the inferior vena cava, atria, left ventricle (LV) with detachable mitral leaflets. The model was exposed for viewing at key points relevant to TEER to enable visualisation of equipment. Consideration was given to creating realistic haptics with the atria and LV fabricated to a shore hardness of 85A using a blend of Stratasys VeroClear (rigid) and Agilus30 (soft) whilst valve leaflets were printed with pure Agilus30. The blend hardness was selected qualitatively by clinicians following systematic behaviour evaluation of various compositions on cylindrical specimens. The investigators were able to perform four defined procedural steps on the static model  under fluoroscopic guidance. Important limitations include the absence of TOE guidance which is crucial to procedural success in TEER as well as the static nature of platform which therefore fails to emulate the challenges of deploying repair devices on a beating heart . These aImportant progress has been made towards high fidelity physical simulation in mitral interventions, however work in this area remains in its infancy with several prevailing barriers. There remains a lack of a standardised curriculum for technical skills training within interventional training programs, particularly in the transcatheter realm, thereby stifling simulator development due to lack of clarity regarding training requirements. Variable attention has been given to realistic haptics and feedback within simulators, this is partly due to limitations with materials technologies but also due to the absence of systematic quantitative evaluation of materials against native tissue and a limited understanding of cardiovascular biomechanics. Moreover, platforms thus far have largely offered static simulation therefore arguably not fully simulating the haemodynamic complexities of beating heart mitral interventions. Maintaining and employing simulation platforms for training is costly, time intensive and requires specialist infrastructure, which undoubtedly limits their widespread uptake within training programmes. Finally, there is also a lack of large-scale validation studies for platforms described in the literature.Cardiac surgery and transcatheter interventions are associated with significant periprocedural anxiety for patients and their families. Anxiety and distress often stem from a lack of understanding of their cardiac condition and the intervention proposed. Moreover, there is evidence to suggest that peri-procedural anxiety has an impact on outcomes in those undergoing cardiac surgery , 84.3D printed models have the potential to transform patient’s understanding of their pathology and proposed interventions and have been shown to help reduce periprocedural distress and anxiety. Conventional methods of counselling patients regarding their diagnosis and proposed interventions are through diagrams, information leaflets and verbal descriptions. Generic 3D anatomical heart models are now widely available and can be used for counselling patients however these are usually not patient or pathology specific. Hung et al. found the use of a 3D printed patient-specific mitral model in addition to standard patient educational materials to positively impact patient understanding of their condition and enhanced satisfaction compared a control group who were counselled using standard educational materials and a generic 3D printed heart model in a recent randomised questionnaire study . As suchDespite promising studies and the novelty associated with the application of transformative technologies such as 3D printing, the literature surrounding their use constitutes small studies and case series, often without significant quantitive data validating their efficacy, impact on patients’ outcome and cost-effectiveness. Therefore, the benefit of these interventions remains unclear and requires large scale clinical trials. However arguably, the scope for clinical studies in this arena is currently limited by nascency of the technologies involved and the rapid flux of multiple devices on various stages of the translational pathway. Indeed, there remains the prospect of clinical trial data being rendered obsolete by the sheer pace of multi-dimensional innovation and technological advancement in this arena. Further barriers stem from the absence of an overarching consensus framework guiding the standardisation of technical workflows  and the application of 3D printing technology in mitral interventions. The labour-intensive nature of 3D printing workflows which require considerable expertise and capital investment also preclude widespread translation particularly in the absence of uniform financing and reimbursement models in an era of strained health budgets.Clinical trial data could conceivably lay the foundation of governance frameworks for technical workflows, reimbursement, and quality control, ultimately fostering a wider cost-effective, evidence-based approach.In view of the significant technical challenges and the rapid pace of development in the realm of mitral valve interventions, disruptive technologies such as 3D-CAM are likely to see increasing uptake as adjuncts to procedural planning and training.Brisk development continues in materials and 3D printer technologies which will likely shift the paradigm closer to the fabrication of biomechanically realistic mitral valve replicas as demonstrated by the early work using metamaterials. The field of bioprinting continues to receive much attention and holds promise in the fabrication of physiologically and morphologically accurate cardiac tissue. Although of revolutionary potential, this area of research remains in its infancy and is some way from clinical translation, with challenges pertaining to maintaining cell viability and spatial control in the fabrication of complex biological structures as well as tissue functionality and the integration of biofabricated structures within native physiology , 86, 87.The heterogeneity and dynamic nature of mitral pathologies poses a formidable challenge to realistic dynamic biomechanical simulation, particularly as simulation of human cardiac haemodynamics currently relies on MCS which offer limited scope for adjusting physiological variables. Technologies such as computational flow dynamics may enable highly accurate simulation of human physiology and their integration with dynamic physical modelling may offer considerable future dividends in mitral modelling .Extended realities technologies harbour early promise in the arena of mitral valve modelling and intervention particularly in surgical training, virtual proctoring, and procedure planning. There is also the tantalising prospect of intraprocedural integration as demonstrated by Chu et al. where augmented reality optimised intraprocedural TOE guidance facilitated safer NeoChord implantation in a porcine model. Mixed r3D printing technologies carry considerable promise in aiding procedure planning, patient selection, operator training and ultimately delivering personalised care in the rapidly expanding domain of mitral valve interventions. They also appear amenable to synergistic integration with other rapidly evolving ‘transformative technologies’ such as extended realities, machine learning and computational modelling, thereby enhancing the potential clinical dividends particularly in the crucial remits of procedural outcomes and patient safety. However, it is important to appreciate the current limitations with this technology, and caution is required in its widespread application to the clinical decision-making process at this stage. Indeed, 3D printing technologies in the context of heart valve disease remain in their infancy with further advancements required, particularly in the realm of materials technologies to achieve high fidelity simulation of valvular tissue properties and biomechanics. Whilst the use of these technologies currently remains sporadic, there is no doubt about their potential to enhance personalised patient care and procedural outcomes in an area of rapidly expanding clinical need.


Squamous cell carcinoma predominates as the most common malignant lesion of the oropharynx with human papilloma virus-associated disease now predominant over tobacco-related oropharynx cancer. Other rare malignant pathologies can manifest as visible neoplasms in these anatomic sites with varying degrees of symptoms such as dysphagia, odynophagia, otalgia, aspiration, hemorrhage, weight loss and dyspnea. We present a case of a rarely encountered primary oropharyngeal sarcoma managed by single-port transoral robotic resection and a selective cervical lymph node dissection followed by adjuvant radiotherapy.  Awareness of head and neck address neoplasms has vastly increased in the age of human papilloma virus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). HPV-related OPSCC now accounts for the majority share of oropharynx malignancy as opposed to HPV negative OPSCC with an incidence of ~4.6 cases per 100 000 individuals in the United States . This shHowever, other malignant pathologies do manifest in the lymphatic-rich environment of the oropharynx including salivary carcinomas, lymphomas and sarcomas. Clinicians must be vigilant to recognize less commonly encountered malignant pathologies in these anatomic sites. This surgical case report describes a rare primary tonsillar malignancy managed by primary transoral robotic surgery (TORS).A 37-year-old Latino male presented with a 1-month history of an enlarging, painless right tonsillar mass noticed during routine oral self-care. He self-referred to our tertiary care academic otolaryngology-head and neck surgery clinic with a clearly visible right tonsillar 1 cm violaceous exophytic mass arising from the tonsil tissue into the oropharyngeal lumen. An in-office transoral biopsy was performed.His social history was notable for active vaporized nicotine use and prior polysubstance abuse. He identifies as a homosexual male in a monogamous relationship with multiple prior sexual partners. He started pre-exposure prophylaxis (PREP) for human immunodeficiency virus (HIV) with a combination of pharmacologic emtricitabine/tenofovir 2 months prior to the onset of the lesion. As part of initiating this PREP regimen, he received screening testing which was negative for HIV by serology and polymerase chain reaction (PCR) testing.Staging imaging by positron emission tomography-computed tomography (PET-CT) showed right tonsil avidity and a suspicious level IIb ipsilateral node  and B. RThe initial in-office transoral biopsy specimen returned as Kaposi’s sarcoma with immunohistochemical positivity for CD31, CD34, Vimentin and Human Herpes Virus 8. The case was discussed in our multi-disciplinary head and neck oncology tumor board, which recommended locoregional control by transoral robotic resection and selective neck dissection, given his HIV negativity and lack of immunocompromising risk factors.He declined an elective neck dissection despite the avid ipsilateral level II node out of concern for the transcervical incision necessary to perform the lymphadenectomy portion of the procedure. We counseled the patient that in addition to gaining accurate staging and even therapeutic lymph node resection, the transcervical approach allows for ligation of the external carotid arterial system to mitigate postoperative catastrophic hemorrhage risks , 4. UltiHe underwent transoral robotic-assisted right radical tonsillectomy by a single-port technique  in conjunction with an ultrasound-guided needle biopsy of the right level II suspicious node. He tolerated the procedure well and was discharged home once demonstrating an adequate oral intake and achieving oral pain control.He presented to the hospital emergency department on postoperative Day 2 with an episode of small volume hemoptysis while at home. He was hemostatic and hemodynamically stable on arrival. His nodal fine needle aspirate also returned that day, showing suspicion for malignancy and identifying spindle cells. The patient was counseled and readily consented to a selective therapeutic neck dissection and external carotid supply ligation to address his nodal disease burden and hemorrhage risk. He was taken to the operating room that evening and underwent an ipsilateral right selective neck dissection of levels II–IV, as well as ligation of the ipsilateral linguofacial trunk of the external carotid system.His final pathology revealed a 1.2 cm right tonsil Kaposi’s sarcoma primary with clear margins but perivascular lymphoplasmacytic infiltration identified. The nodal dissection revealed Kaposi’s sarcoma in 3 of 42 lymph nodes examined. All nodal deposits were contained within the node and sub-centimeter in volume  and B.He was again presented in review at our institutional multidisciplinary head and neck oncology tumor board with recommendation for adjuvant radiotherapy for additive locoregional control. After completion of adjuvant therapy, he has been followed closely by the head and neck surgical oncology, radiation oncology and medical oncology teams according to the National Comprehensive Cancer Network recommended schedule for a minimum of 5 years post-treatment. He remains to be in a state of disease-free survival at the time of this article, 14 months post-treatment.Kaposi’s sarcoma is a disease entity typically associated with immunocompromised states, most notably of individuals with HIV/AIDS. Endemic forms of the disease are also well described and characterized in certain ethnic populations. Perhaps the least known at-risk population are HIV seronegative men having sex with men with limited cases reported to date . Limited


Cognitive (dys)function after ECT is often considered as a homogeneous phenomenon across patients. However, there are important inter-individual differences, with some patients experiencing residual invalidating cognitive deficits. We present the results of a study combining both group-level and individual-level analyses of cognitive function using an extensive cognitive test battery that was assessed in 73 patients at 5 time points during their ECT care pathway. Furthermore, we explored the presence of distinct subgroups of patients with a similar cognitive trajectory over time after treatment with ECT using Latent Class Growth Analysis.None Declared


This is a peer-review report submitted for the paper “Exercise-Induced Hypoalgesia Following Proprioceptive Neuromuscular Facilitation and Resistance Training Among Individuals With Shoulder Myofascial Pain: Randomized Controlled Trial”This paper  aims to 1. Methods: In the procedures section, please add information about possible blinding of the evaluators .2. Discussion: Please try to address the important improvements in the proprioceptive neuromuscular facilitation exercise group in relation to personal interaction with the researcher .


A 42-year-old man presented to our emergency department with a history of having swallowed several sewing needles an hour previously. Physical examination showed mild hyperemia of the pharynx and slight abdominal tenderness. Cervical thoracoabdominal computed tomography detected several high density shadows in the stomach and duodenum, without any signs of perforation . GastroGiven that the needles are metal, a magnet grasped by forceps was subsequently used to retrieve them . The fiMagnet-assisted endoscopic removal of ingested sewing needles from the stomach and descending duodenum.Video 1The ingestion of sharp-pointed foreign bodies such as sewing needles is an urgent situation, with an increased risk of perforation. Commonly used retrieval devices for sharp-pointed foreign bodies are forceps or snaresEndoscopy_UCTN_Code_TTT_1AO_2AL


Peliosis hepatis remains a rare focal liver lesion with inconclusive imaging features. The unknown pathogenesis represents a wide possible range of etiologies including the breakdown of the sinusoidal borders, a potential hepatic outflow obstruction or dilatation of the central vein of a hepatic lobule. In histopathology, a blood-filled cystlike appearance with sinusoidal dilatation was reported. On ultrasound, B-mode features are not specific demonstrating a irregular, moreover hypoechogenic focal liver lesions. Postcontrast imaging features on Contrast-Enhanced-Ultrasound may mimic a malignant lesion with irregular contrast inflow and washout during late phase. Our case demonstrates a peliosis hepatis with malignant image features on contrast-enhanced ultrasound, ruled out by PET-CT and core needle biopsy with corresponding histopathological workup. Peliosis hepatis is known as a rare disease showing multiple blood-filled parenchymal cysts in parenchymal organs, which may be associated with a wide range of conditions varying from medication or infectious diseases and autoimmune diseases We demonstrate the case of a 79-year old female patient with conjunctival melanoma diagnosed in 2001. The patient was referred to the Department of Cardiology due to dyspnea under cardiac decompensation and subacute pulmonary embolism. Afterwards, the patient was referred to head and neck surgery to further perform imaging for tumor staging. Magnetic resonance imaging was avoided due to an implanted pacemaker.Positron emission tomography / computed tomography (PET/CT) revealed a 4 × 3 cm mass in the so-called Riedel-lobe, which is described as a normally absent, tongue-shaped process at the anterior margin of the right liver lobe overhanging the right kidney. The focal liver lesion (FLL) was slightly hypodense compared to the surrounding liver tissue on nonenhanced CT (Hounsfield units: 39 HU vs 59 HU in the surrounding liver tissue of the right lobe) and showed no sufficient contrast enhancement  after injection of 80 ml iodine-based contrast agent A and B. To further characterize the FLL, CEUS was performed by an expert in the field with more than 20 years of experience in this field (EFSUMB Level III). The ultrasound (US) protocol using a high-end US system with 1–6 MHz convex array transducer  included color-coded duplex sonography (CCDS) and superb microvascular imaging (SMI) to determine vessel structure. Afterwards, the liver lesion was examined in modified longitudinal and transversal planes with an up-to-date CEUS-specific protocol available at the time of the examination. On B-Mode US, the lesion was inhomogenous and hyperechogenic compared to the surrounding liver tissue A and B. A percutaneous US-guided core biopsy (16 Gauge needle) was performed due to the discordance between CEUS findings and PET/CT findings after an internal discussion of several disciplines. The histopathological report revealed no atypical cells suspicious for malignancy. The hepatic parenchymal specimen showed peliosis-like dilatation of the sinusoids and edematous widened portal fields with a mixed cell inflammatory .Fig. 4HiPeliosis hepatis is known as a rare disease with several underlying conditions, which is a challenge for diagnosis on established imaging modalities. Our case report shows a patient with suspicion of malignancy receiving a PET/CT scan and CEUS with discrepant findings on both modalities.Perfusion pattern of peliosis hepatis in CEUS are quite variable including a variety of B-mode findings with hyper-, iso- and hypoechogenicity In comparison to the results of the study by Dong et al., the lesion we present is in congruence with the described arterial hyperenhancement—but our case showed early progressive washout, whereas the authors concluded washout in the very late portal venous phase (after 1 minute) to be characteristic in peliosis hepatis Several contrast pattern findings for peliosis hepatis are known through the literature, including centripetal contrast enhancement mimicking hemangiomas or atypical enhancement patterns not suggestible for any typical FLL •Peliosis hepatis showed strong enhancement with irregular enhancement pattern•Early washout starting after 40 seconds post injection was present•CCDS depicted no macrovascularization, while microvascular imaging revealed some tiny vesselsCatchword phrases:Our patient demonstrated in the case report signed a written informed consent for publication/research purpose.


Complete obstruction of the bile duct after hepatic resection is rare and extremely difficult to treat. We report recanalization using magnetic compression anastomosis and retrieval of a magnet that migrated into the intrahepatic bile duct.A 77-year-old man developed complete obstruction of the bile duct due to a biliary fistula following hepatic resection for hepatocellular carcinoma . BreaktA thick sheath was inserted into the PTBD route, and one magnet was inserted through the sheath to the site of bile duct obstruction . A 10-mVideo 1 Recanalization by magnetic compression anastomosis for complete bile duct obstruction and retrieval of the migrated magnet.There have been several reports of magnetic compression anastomosisEndoscopy_UCTN_Code_CPL_1AK_2AZ


Colorectal endoscopic submucosal dissection (ESD) is now widely used for the treatment of colorectal tumors using several strategies. The effectiveness of the pocket-creation method combined with saline immersion has been reported with an improved endoscopic visual field and submucosal approach due to the buoyancy of the lesion and reduced the amount of submucosal injection. Its disadvantages include a poor visual field during bleeding and dissipation of coagulation ability with monopolar devicesHerein, we report a combination of gel immersion ESD and tunneling in a colorectal tumor . A 71-yVideo 1 Successful gel immersion colorectal endoscopic submucosal dissection using the tunneling method.Endoscopy_UCTN_Code_TTT_1AQ_2AD


An 11-year-old Japanese boy presented to our hospital with intrahepatic biliary duct stones and regional cholangitis. He had undergone cholecystectomy, complete excision of the extrahepatic biliary duct, and Roux-en-Y hepaticojejunostomy for choledochal cysts (Todani classification IVa) at the age of 8 years. Abdominal magnetic resonance imaging confirmed cystic dilatation of the left hepatic duct and the presence of left intrahepatic biliary duct stones .During long school vacations, three separate endoscopic procedures using balloon enteroscopy  were performed to improve the long-term prognosis following the choledochal cyst surgery. During the first session, endoscopic biliary drainage with multiple plastic stents was performed to reduce the size of the stones by abrasion between the plastic stents and the stones, while also avoiding recurrence of the cholangitis . The seVideo 1 Three separate endoscopic procedures were performed using balloon enteroscopy to improve the long-term prognosis after choledochal cyst surgery.Postoperative complications of choledochal cysts generally worsen the outcome and represent a major challengeEndoscopy_UCTN_Code_TTT_1AR_2AH


Background: Attention-deficit hyperactivity disorder (ADHD) is a condition which has been consistently documented to impact educational outcomes. Children with ADHD are regularly found to have lower educational attainment and increased likelihood of dropping out of school compared to children without ADHD.Objectives: To project the long-term societal economic consequences of reduced educational attainment, as measured by total lifetime earnings, in an untreated cohort of individuals diagnosed with ADHD in childhood, in Germany. In addition, this research aims at illustrating a cost-benefit analysis framework which could be applied to economically appraise the rate of return from investments in hypothetical health interventions targeting ADHD.Methods: Observational ADHD evidence was collated with demographic and human capital economics methods to quantify ADHD’s impact on educational attainment and long-term labour outcome in Germany. The theoretical benefits deriving from effective interventions targeting ADHD were also quantified.Results: It was estimated that the average per capita lifetime earning loss associated with ADHD was €92,000 suggesting a societal loss of €2.93 billion from a single cohort . The benefit-cost analysis suggested that reasonably effective intervention may justify considerable investment in ADHD targeted intervention.Conclusions: Considering the broad economic consequences of the condition might suggest that interventions which change the life course of individuals with ADHD could offer cost-savings and influence future economic outputs.


We investigated thumb joint stability and patient-reported and functional outcomes a minimum of 1 year after flexor digitorum superficialis opponensplasty and ligament reconstruction in 23 thumbs of 20 consecutive children with radial longitudinal deficiency. In total, 15 thumbs had preoperative multidirectional instability in the metacarpophalangeal joint. We reconstructed 22 ulnar and 16 radial collateral ligaments. At follow-up, all the metacarpophalangeal joints were stable ulnarly. Seven metacarpophalangeal joints were unstable radially despite ligament reconstruction but had no related complaints. We recommend the flexor digitorum superficialis opponensplasty as a safe and reliable procedure in hypoplastic thumbs to create stability and augment thumb strength.Level of evidence: IV All patients with a congenital radial longitudinal deficiency (RLD) have thumb hypoplasia , rangingWe began reconstructing type II and IIIa hypoplastic thumbs at Oslo University Hospital in 2009. We used the FDS-ring for the opponensplasty and MCPJ ligament reconstruction in all our patients. The primary aim of this study was to investigate whether we achieved adequate stability for uni- and multidirectionally unstable MCPJs. The secondary aim was to explore patient-reported and functional outcomes.We conducted the study according to the Helsinki declaration and have reported it according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement . Our insTwo surgeons (MW and INS) carried out all except two of the earliest procedures. We constructed a palmar aponeurosis  or flexoWe checked the patient records for intra- and postoperative complications  and included any adverse events reported by the children or their caregivers.At the study follow-up, a congenital hand surgeon (INS or MW) assessed whether the thumb joints were unstable (yes or no?) or if the first web space was tight (yes or no?). We defined MCPJ and IPJ instability as a lack of a definite endpoint at ligament testing, indicating the need for surgical stabilization. The CMCJ was defined as unstable if we found a positive dorsal shift . The firThe children performed the Thumb Grasp and Pinch Assessment (T-GAP), and a senior paediatric occupational therapist (OT) (ABS) scored the video clips . There aWe used the Pollexograph  to measu2, mobility) and strength . We used our measurements of radial abduction, Kapandji score, MCPJ stability, ROM in the MCPJ and IPJ according to normative paediatric data  populations from the PROMIS website.All the children and caregivers completed together five Patient-Reported Outcomes Measurement Information System (PROMIS) domains validated from the age of 5 years: Parent Proxy Item Bank v2.0 Upper Extremity – Short Form 8a; Depressive Symptoms – Short Form 6a; Anxiety – Short Form 8a; Peer Relationships – Short Form 7a; and Parent Proxy Scale v1.0 – Global Health 7 + 2 . PROMIS n = 9) and all caregivers assessed the following statements or questions on a visual analogue scale : the thumb works like a thumb; the thumb looks like a thumb; ‘How often do you (or does the child) use the thumb to pinch versus scissor pinch for small objects?’; ‘How often do you (or does the child) incorporate the thumb when holding larger objects like a bottle?’ . Only the caregivers were asked ‘Has the child used the thumb more after surgery?’. The OT and surgeon also rated statements 1 and 2.The children aged >8 years  had a modified Bayne type N/0-1 RLD  in the 2Two children had had secondary bilateral first web releases for recurring tightness before follow-up. We found no complications in the medical records or adverse events reported by the patients or their caregivers.At follow-up, all the MCPJs were stable on the ulnar side, whereas nine were unstable radially ; Table 3The surgeon judged eight first webs to be tight , but onlt-score of 37 (IQR: 28 to 42) in type II thumbs and 35 (IQR: 32 to 50) in type IIIa thumbs, indicating a moderately reduced function. t-scores were normal for the other PROMIS domains . The VAS assessments are presented in Supplementary Table S3 (available online).We found a median PROMIS upper extremity We found satisfactory MCPJ stability after ligament reconstruction with FDS-ring tendon slips in both type II and IIIa hypoplastic thumbs, including those that were multidirectionally unstable before operation. The patient-reported and assessor-measured outcomes were also good after FDS opponensplasty.The main strengths of our study were the consecutive cohort, preventing selection bias and a low attrition bias. As in earlier studies, the main limitations were the cohort size and the lack of preoperative outcome measures. We cannot rule out performance bias, as the assessors had treated most patients.The successful stabilization of the ulnar side but with remaining radial instability in almost half of the multidirectionally unstable MCPJs might be because we routinely reconstructed the UCLs first and thus did not obtain correct tension in the RCLs. We have chosen this reconstruction sequence because the UCL is the most important MCPJ ligament for grip stability. Our proportion of stable joints after ligament reconstruction was comparable to the findings in two studies with an identical ligament insertion technique , and oneA postoperative positive dorsal shift of the CMCJ has also been reported previously . In two We found no detailed reports on the clinical assessment of the first web. There is no agreement on a clinical definition of a tight first web in children, and again we decided to use the surgeon’s subjective assessment. We did not note web tightness at follow-up as a surgical complication, as not all webs can be completely corrected with primary surgery, and recurrence is common in growing children as scar tissue is less flexible.The T-GAP scores we report were predictably better than those reported after index finger pollicization . The ROMOur study indicates that FDS tendon slips are adequate to stabilize most MCPJs, but we cannot rule out an occasional need for primary or secondary joint fusion. The earlier treatment in our unit of mildly affected hypoplastic thumbs with instability and partial thenar aplasia was a ligament reconstruction with free tendon grafts. Palmar abduction and opposition are present in these thumbs, but strength is lacking. Based on the good outcomes in our study, we have expanded our indications of FDS opponensplasties to include these thumbs to strengthen them.Click here for additional data file.Supplemental material, sj-pdf-1-jhs-10.1177_17531934231187813 for Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency by Ida Neergård Sletten, Jarkko Jokihaara, Anne Birgit Stavenes and Mona Irene Winge in Journal of Hand Surgery (European Volume)Click here for additional data file.Supplemental material, sj-pdf-2-jhs-10.1177_17531934231187813 for Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency by Ida Neergård Sletten, Jarkko Jokihaara, Anne Birgit Stavenes and Mona Irene Winge in Journal of Hand Surgery (European Volume)Click here for additional data file.Supplemental material, sj-pdf-3-jhs-10.1177_17531934231187813 for Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency by Ida Neergård Sletten, Jarkko Jokihaara, Anne Birgit Stavenes and Mona Irene Winge in Journal of Hand Surgery (European Volume)


At 8 years of age, this patient with cavernous transformation of the portal vein presented with variceal hemorrhage and underwent successful creation of a transjugular intrahepatic portosystemic shunt (TIPS) Fig. A, B. SheHPS complicates a small proportion of pediatric liver disease patients. Potential mechanisms include increased production of vasoactive metabolites due to portal hypertension or decreased hepatic clearance due to liver disease or portal bypass. These metabolites lead to pulmonary vasodilation and the formation of intrapulmonary right-to-left shunts . The dia


Scientific Reports 10.1038/s41598-023-45753-5, published online 30 October 2023Correction to: The Acknowledgements section in the original version of this Article was incomplete.“This work is part of a project funded by the Independent Research Fund Denmark (grant number: 0135 00351B). The authors gratefully acknowledge Marcos Moreno for his insights and discussions, which contributed to the improvement of this manuscript. JMB acknowledges Valentina Espinoza for her invaluable inputs in multiple aspects of this study.”now reads:“This work is part of a project funded by the Independent Research Fund Denmark (grant number: 0135 00351B). AT and DM acknowledge support from the Chilean ANID Milenio Grant NCN19_167—Millennium Nucleus CYCLO. The authors gratefully acknowledge Marcos Moreno for his insights and discussions, which contributed to the improvement of this manuscript. JMB acknowledges Valentina Espinoza for her invaluable inputs in multiple aspects of this study.”The original Article has been corrected.


A 57-year-old man was presented with severe headache that had persisted for 1 week. He was diagnosed with diabetes mellitus (DM) and was followed up in the internal medicine clinic because of diabetic ketoacidosis, and he had a history of tooth extraction in the right upper jaw 10 days ago. The patient was administered with antibiotics for being diagnosed with orbital cellulitis. A paranasal computed tomography (CT) scan performed before treatment revealed mucosal thickening in the maxillary sinus . Neurolo


Diagnostic esophagogastric endoscopy has recently been performed using new sterile single-use disposable endoscopes   due to N-butyl cyanoacrylate (NBCA) is used for emergency endoscopic hemostasis in cases of gastric and ectopic varicesWe report two cases in which sclerotherapy was performed using the Ambu aScope Gastro for treating gastric and jejunal varices .Gastric and jejunal variceal sclerotherapy using the Ambu aScope Gastro.Video 1Case 1 is of a 65-year-old man who was referred for the treatment of gastric varices due to alcoholic cirrhosis. The gastric varices were punctured using a 23-G esophageal varices puncture needle  . Under Case 2 is of a 76-year-old man  who wasThese cases demonstrate the successful use of sclerotherapy with NBCA using the Ambu aScope Gastro. This single-use disposable endoscope prevents the need for costly endoscope repair following NBCA adhesion and provides excellent visibility on fluoroscopic images.Endoscopy_UCTN_Code_TTT_1AO_2AD


Invasive fungal infections (IFIs) can cause high morbidity and mortality in immunocompromised patients. Posaconazole is a commonly used triazole antifungal agent for prophylaxis against IFIs in high-risk populations. However, the effectiveness of Posaconazole as antifungal prophylaxis in Allogeneic Stem Cell Transplantation  in Latin-America has not been well described. The aim of this study is to describe the clinical experience with the use of Posaconazole as antifungal prophylaxis in allo-SCT in a high complexity medical center in Latin-America.A retrospective descriptive study was conducted to evaluate the experience of using Fluconazole or Posaconazole as antifungal prophylaxis in patients undergoing Allogeneic Stem Cell Transplant at the Fundación Valle de Lili in Cali, Colombia between 2012 and 2020. . The primary outcome variable was the incidence of IFI in the first 100 days of prophylaxis.Allogenic Stem Cell Transplant: Methods selectionA Retrospective descriptive study involving the selection of 194 patients who underwent Allogeneic Stem Cell Transplantation, of which 179 patients met the selection criteria for the study.This study analyzed 179 individuals with hematologic malignancies who received prophylaxis with either Posaconazole (n=164) or Fluconazole (n=15). The occurrence of IFI was lower in the Posaconazole group compared to the fluconazole group during the initial 100 days of prophylaxis  . Aspergillus spp were the most frequent microorganisms observed in 3 cases (1.67%). The Number Needed to Treat (NNT) was 8.25, indicating that 8 patients treated with Posaconazole can prevent one IFI that would have occurred with Fluconazole treatment.Comparative analysis of Posaconazole and Fluconazole as antifungal prophylaxis in Allogeneic Stem Cell TransplantationPercentage of Invasive Fungal Infections found in Allogeneic Stem Cell Transplantation during the first 100 days post-transplantation in patients who received prophylaxis with Posaconazole or Fluconazole.This study suggests that using Posaconazole as antifungal prophylaxis reduces the incidence of invasive fungal infections (IFI) in patients undergoing Allogenic Stem Cell Transplantation under real-world conditions and is a safe alternative to be used in low-income settings. Further clinical studies with larger sample sizes are required to confirm these findings.All Authors: No reported disclosures


Augmented renal clearance (ARC) has been reported to occur across many critical illnesses but has not been evaluated in critically ill burn patients. The impact of ARC on clinical outcomes within this population remains unknown. We hypothesize that ARC is prevalent in critically ill burn patients and is associated with improved survival.2. Clinical outcomes were compared between patients with and without ARC.We retrospectively reviewed a prospectively-maintained registry of Burn ICU patients from July 2021 – September 2022 at an academic burn center. We included patients in whom 24-hour urine creatinine collection was performed on admission and excluded patients in whom accurate collection was not performed within 48 hours of admission. Creatinine clearance was calculated for all patients who met inclusion criteria. ARC was determined to occur when creatine clearance exceeded 130 mL/min/1.73m2 (range 37-313), and 7 patients (29%) had creatinine clearance greater than 200. Complication rates were low and were similar between patients with and without ARC .The analysis included 24 patients . The median percentage of total body surface area (TBSA) burned was 25 [10-38]. ARC was present in 17 patients (71%). Mean creatinine clearance was 162 ml/min/1.73mARC appears to be a common phenomenon among critically injured burn patients. While the presence of ARC could be particularly meaningful in this population of patients that often receives massive volumes of resuscitative fluids, the sample size of our study did not permit the detection of statistically significant differences in outcomes between burn patients with and without ARC. Further work must be undertaken to assess the impact of ARC on fluid resuscitation strategies and medication dosing including that of antibiotics and thromboprophylaxis agents.Augmented renal clearance (ARC) has never before been characterized in the population of critically injured burn patients. This topic merits further research, as it could have far-reaching clinical impact relating to fluid resuscitation practices and dosing of renally-cleared medications .


Cervical dystonia with concurrent cervical myelopathy is a challenging pathology that requires thoughtful management. A 46-year-old female was referred to our center with this presentation. We elected to perform bilateral globus pallidus internus deep brain stimulation (DBS-GPi) prior to C5 to C7 anterior cervical discectomy and fusion (ACDF) to avoid the potential for dystonic movements to negatively impact cervical fusion. The patient was followed up at three months post C5 to C7 ACDF and nine months post DBS-GPi with complete control of tremor and no radiographic evidence of hardware loosening or malalignment. Though this strategy was successful in treating both our patient’s cervical myelopathy and cervical dystonia, larger studies need to be conducted to optimize the treatment of patients presenting with these concurrent pathologies. Dystonic movement disorders such as cervical dystonia may present with cervical myelopathy. Epidemiologic evidence has revealed that degenerative disorders of the spine associated with dystonia occur earlier in life than normal physiological aging, and disease is often seen at higher cervical levels . This prA 46-year-old female with a primary complaint of neck pain, bilateral upper extremity radiculopathy, paresthesia, and myelopathic gait was referred to our center. She had also been diagnosed with cervical dystonia 15 years prior. She had trialed various medications for her dystonia over many years with no relief. She also received botulinum toxin injections, which resulted in the worsening of her symptoms. The patient also had significant cervical myelopathy due to disc herniations at C5-C6 and C6-C7 with myelomalacia on cervical MRI seen in Figure There is a small but growing body of evidence that suggests the use of DBS and surgical fixation of the spine may provide long-lasting symptom resolution for carefully selected patients. Bilateral DBS-GPi has been shown to improve symptoms of cervical dystonia for over a decade after implantation . It may The co-occurrence of both a dystonic movement disorder and cervical myelopathy presents a unique challenge in terms of surgical management. This case presents a viable surgical strategy for managing this challenging pathology in patients whose symptoms are refractory to medical management for cervical dystonia with concurrent myelopathy. Larger clinical trials could help further establish this paradigm as an effective treatment for these patients while also elucidating the finer details of managing specific deformities in the cervical spine in this concurrent pathology.


Glioblastoma (formerly named glioblastoma multiforme) is the most common primary central nervous system tumor, representing 45% of all cases and 15% of all intracranial neoplasms [1]. Its typical radiologic findings and localization make it often a lesion easy to diagnose. In MRI it usually appears as an irregularly shaped cystic lesion with ring contrast enhancement in T1-weighted images, localized in subcortical white matter and deep gray matter nuclei of the cerebral hemispheres. It involves more frequently the frontotemporal region followed by parietal lobes [1]. Few articles in literature described cases of intraventricular glioblastomas, defining those as secondary ventricular tumors because of their probable origin primarily from cerebral tissue with consequent transependymal development . Atypical presentations of these tumors make it more difficult to clearly differentiate them from other lesions more commonly located in the ventricular system. We describe a case with a unique radiological presentation: an intraventricular glioblastoma lying entirely within the ventricular walls, involving all the ventricular system, without mass effect or nodular parenchymal lesions. A 56-year-old woman with history of ankylosing spondylitis presented with a 2-month drug-resistant headache and short-term memory loss. Brain MRI showed an enhancing multinodular lesion with dissemination along the walls of all the ventricular system Fig. . Total bThe integrated histological diagnosis with molecular analysis was compatible with glioblastoma IDH-wildtype, grade 4 according to CNS WHO 2021 criteria  is the most common primary central nervous system tumor representing 45% of all cases and 15% of all intracranial neoplasms [The peculiar distribution following only the ependymal lining instead of white matter tracts is anecdotic, but it may support the hypothesis that the glioblastomas’ cell of origin (COO) is a neural precursor cell located in the subventricular zone (SVZ) along the lateral ventricular walls. Lee and Manzano stated that possible alternative origins of intraventricular glioblastomas could be the septum pellucidum or the fornix, both components of the limbic system : the invWe here present this case because of its uniqueness: to our knowledge no such cases with subependymal distribution in all ventricular walls, without nodular appearance or mass effect on brain parenchyma, has been described in literature.


Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in patients with surgically altered anatomy; in these cases, balloon-enteroscope-assisted ERCP can be performedVideo 1Advantages of a dual-channel multi-bending endoscope for endoscopic retrograde cholangiopancreatography in patients with Billroth II reconstruction.The M-scope can overcome even acute angles by bending in two places sequentially . On reaBiliary cannulation can be challenging in patients with Billroth II anatomy because of high papillary mobility or its angle relative to the scope. The dual channel of the M-scope facilitates simultaneous holding and pulling of the papilla and biliary cannulation . This sPerforming sphincterotomy is often difficult in cases of altered anatomy because scope position adjustments are not straightforward. These adjustments are made easier by utilizing both bending sites . FurtheIf these features were incorporated into the balloon endoscope, it could further facilitate ERCP in cases with altered surgical anatomy.Endoscopy_UCTN_Code_TTT_1AR_2AK


To optimize the process to obtain bacterial DNA directly from human urine and blood samples to produce high-quality genomic data using long-read Nanopore sequencer.Escherichia coli or Klebsiella pneumoniae and corresponding isolates were collected from the microbiology diagnostics laboratory. DNA isolation optimization was performed testing three different sample volumes and seven DNA extraction kits. DNA concentration was quantified with Qubit fluorometer. Nanopore sequencing was performed on a MinION Mk1C device in R9.4.1 flow cells using the Rapid Barcoding Kit. Bacterial species and antimicrobial resistance (AMR) genes were determined with EPI2ME ARMA pipeline. Genomes were assembled with Flye, polished with Medaka and remaining human contigs removed with Krakentools. Bacterial isolates from the same samples were also sequenced using Illumina technology. Illumina and Nanopore assemblies were quality checked with Quast, Kraken was used to identify bacterial species, MLST for multilocus sequence typing and ABRicate with ResFinder database to detect AMR genes.A total of 22 blood cultures and 24 urine samples positive for E. coli). A variety of clinically relevant AMR genes were detected, such as dfrA and bla CTX-M genes, which matched the phenotypic antimicrobial susceptibility testing results. Comparison of genomic assemblies obtained through Nanopore sequencing of 10 urine samples and Illumina sequencing of the corresponding clinical isolates showed a high degree of matching, validating Nanopore sequencing as an alternative option to support diagnosis and treatment choice.A total of 72 DNA extractions from 24 urine and 22 blood samples with different kits were performed to find the optimal extraction protocol for each sample type. DNA from urine samples was isolated from 5 mL, while 1 mL was best for blood cultures. We found that the host depletion step prior to DNA extraction using MolYsis basic 5 Kit (VH-Bio) was essential. DNA from urine samples was extracted with GenElute Bacterial Genomic DNA Kit (Merck) and QIAamp Biostic bacteremia Kit (Qiagen) was best to allow successful bacterial genome sequencing for blood samples. Bacterial isolates from 11 urine and 1 blood sample (out of 54 sequenced) were successfully sequenced. In all 12 cases, the highest percentage of bacterial reads matched with the causative organism found during routine microbiology diagnostics (We have successfully optimized the protocols to extract and sequence pathogenic bacterial DNA directly from blood and urine samples. Short-read sequencing confirmed results acquired by Nanopore sequencer, endorsing long-read sequencing in clinical settings to support timely diagnosis and treatment.


Blunt trauma predominantly affects the right adrenal gland (3) owing to its proximity to vertebrae and drainage through the inferior vena cava (4); the patient’s left-sided injury could be attributed to situs inversus. As with other reports (4), this case was nonoperative and successfully managed in the primary care setting. Our incidental discovery of situs inversus highlights one potentially disastrous consequence of estimating injury severity based on conventional anatomical features and eschewing diagnostic imaging.A 43-year-old man presented to our primary care clinic with back pain and contusions following a motorcycle accident. Contrast-enhanced computed tomography revealed complete situs inversus, left upper rib fractures, left adrenal enlargement, and no evidence of extravasation or other organ damage. The left adrenal gland measured 3.1 cm along the major axis : arrow aNoneAll authors contributed to patient care. YH conceived the idea for the study and wrote the manuscript. NH contributed to the editing of the manuscript.An IRB approval is not required because this is a case report.Written informed consent was obtained from the patient for publication.


Cytomegalovirus (CMV) infection in renal transplant recipients (RTR) impacts morbidity, mortality, and graft survival. Patients are risk-stratified based on their CMV serostatus as low risk (D-/R-), moderate risk (R+), and high risk (D+/R-). Most transplant centers conduct surveillance for CMV reactivation using quantitative nucleic acid testing (qNAT) at regular intervals for a fixed duration after transplantation. Antiviral treatment decisions are often guided by quantitative DNAemia. We hypothesize that the change in the qNAT platform to a newer, more sensitive assay lead to earlier CMV detection, longer antiviral treatment durations, and no difference in one-year all-cause mortality in moderate and high CMV risk RTR.We conducted a cohort study comparing RTRs monitored with the historical higher lower limit of quantification (LLOQ) qNAT  to the newer lower LLOQ qNAT assay . Patients were stratified by CMV serostatus for direct comparisons among moderate and high CMV risk patients. CMV viral load monitoring occurred at least monthly post-transplantation. Primary outcomes were antiviral treatment duration and time to detection of CMV DNAemia.Both the moderate and high CMV risk groups tested with the lower LLOQ qNAT assay exhibited lower peak viral loads and lower first detected viral loads (Table 1). Comparing moderate risk groups, lower LLOQ patients experienced longer CMV DNAemia and corresponding antiviral treatment durations. All-cause mortality risks were not significantly different between the lower LLOQ and higher LLOQ moderate risk patients. In Kaplan Meier analyses, moderate risk patients tested using the lower LLOQ qNAT assay had CMV reactivation detected earlier following cessation of antiviral prophylaxis compared with patients tested using the higher LLOQ assay.Table 1Lower LLOQ and higher LLOQ moderate and high-risk group comparisons for follow up time, CMV DNAemia incidence rate, peak CMV DNAemia, first CMV viral load detected, CMV DNAemia duration, and duration of antiviral treatment. Means, standard deviations, and t-tests are reported where applicable.Moderate Risk KM ComparisonKaplan Meier curve analysis comparing time to first episode of CMV DNAemia for higher LLOQ moderate risk patients (n=523) with lower LLOQ moderate risk patients (n=505) over a one year follow up period after transplantation. A log-rank test was performed and shows a statistically significant difference  in time to CMV DNAemia between the two groups. The median survival for the lower LLOQ group was 300 days and could not be calculated for the higher LLOQ group given that the survival probability was greater than 50% at the end of the study period.High Risk KM ComparisonKaplan Meier curve analysis comparing time to first episode of CMV DNAemia for higher LLOQ high risk patients (n=103) with lower LLOQ high risk patients (n=90) over a one year follow up period after transplantation. A log-rank test was performed and showed no significant difference  in time to CMV DNAemia between the two groups. The median survival for the lower LLOQ group was 335 days and could not be calculated for the higher LLOQ group given that the survival probability was greater than 50% at the end of the study period.qNAT assays with a lower LLOQ result in earlier CMV DNAemia detection and longer antiviral treatment durations in moderate-risk RTRs without affecting all-cause mortality. These findings have important implications for healthcare associated costs and antiviral stewardship.All Authors: No reported disclosures


Biliary access in patients with altered anatomy represents a limitation of endoscopic retrograde cholangiopancreatography (ERCP), with Roux-en-Y reconstruction being one of the most challenging postoperative variantsA 64-year-old woman with a history of a choledochal cyst treated with bile duct resection and hepaticojejunostomy 25 years previously was referred with recurrent cholangitis due to an anastomotic stricture and large intrahepatic stones. Previous anastomotic stricture dilation had not prevented further stone formation, and surgical revision was not considered an optimal option. Percutaneous transhepatic drainage (PTD) was performed, with an 11-Fr sheath placed, which was followed by cholangioscopy  . A signVideo 1 Percutaneous cholangioscopy with placement of a biodegradable stent for stone disease on a background of a postanastomotic biliary stricture.Remodeling of the anastomotic stricture was attempted using an endoscopic balloon-expandable biodegradable stent system . A cholangiogram confirmed the presence of residual stone burden above the anastomotic stricture . An extPercutaneous cholangioscopy combined with biodegradable stent placement represents a novel approach in the management of stones above biliary strictures in patients with surgically altered anatomy.Endoscopy_UCTN_Code_TTT_1AR_2AG


Dear Editor, on the prognostic role of platelet-leukocyte indices incongenital cardiac surgical subset with pulmonary hypertension (PH) is indeedinteresting, and the authors should be congratulated for their admirable endeavors.However, I wish to bring forth few additional insights into the topic that could bebeneficial to the readers of the BJCVS.The recently published “Retrospective Evaluation of Platelet-Leukocyte Indices andCardiac Surgical Outcomes in Acyanotic Heart Disease Patients with PulmonaryHypertension (REPLICA-PH)” study by Walian et al.,3. While Walian et al. have evaluated neutrophil-lymphocyte ratio (NLR),platelet-lymphocyte ratio, and systemic immune-inflammation index (SII = neutrophil× platelet/lymphocyte) in their retrospective analysis, Fois et al. recently described other hematologicalinflammatory indices such as the systemic inflammation response index (SIRI = NLR× monocyte) and the aggregate index of systemic inflammation (AISI = NLR ×platelet × monocyte or SII × monocyte) in the setting of coronavirusdisease 2019 (or COVID-19).Inflammatory prognostication using hematological cell lines is an evolving field with thenovel composite indices being increasingly studied across diverse clinicalscenarios. Hence, a comparative account of SIRI and AISI in the favorable andpoor-outcome groups in the Walian et al. analysis could have added an incremental value.Recent research outlines monocyte corpuscular lineage as an important contributor to anongoing systemic inflammatory process“err on either side of the pulmonarycapillary”. The provision of the PVR data could have substantiated theauthors’ proposition of inflammatory links of proliferative remodeling of pulmonaryvasculature in the congenital cardiac surgical subset with an underlying increasedpulmonary blood flow.Moreover, the lack of data on pulmonary vascular resistance (PVR) in the index of theretrospective study also deserves equal attention. The research group circumspectlylabels the study cohort to be suffering from preoperative PH and not pulmonary arteryhypertension, refraining to , future researchendeavors exploring haematological inflammatory prognostication in a dedicated syndromicsubset can yield potentially interesting results.Although the authors excluded multisystem syndromic association from theiranalysis


Cognitive (dys)function after ECT is often considered as a homogeneous phenomenon across patients. However, there are important inter-individual differences, with some patients experiencing residual invalidating cognitive deficits. We present the results of a study combining both group-level and individual-level analyses of cognitive function using an extensive cognitive test battery that was assessed in 73 patients at 5 time points during their ECT care pathway. Furthermore, we explored the presence of distinct subgroups of patients with a similar cognitive trajectory over time after treatment with ECT using Latent Class Growth Analysis.None Declared


Ankylosing spondylitis (AS) is a chronic inflammatory disease involving the sacroiliac joint and axial spine. AS may render the ankylosed spine prone to trauma and cause an increased frequency of associated epidural hematomas in spine fractures. Herein, we report a rare case of L5 chance fracture and epidural hematoma in a 27-year-old female patient with AS. She was treated surgically but without bone fusion or decompressive laminectomy due to the neurologically intact status despite significant neural compression by the spinal epidural hematoma (SEH). We believe that conservative treatment with close observation of neurological status may be effective in SEH presenting with mild neurological symptoms despite significant neural compression. Ankylosing spondylitis (AS) is a chronic inflammatory disease of the sacroiliac joint and axial spine that is closely linked to human leukocyte antigen (HLA)-B27 . ChronicA 27-year-old female patient with a 5-year history of AS was admitted to the emergency room (ER) with severe low back pain (LBP) radiating to both lower extremities. She had a history of accidental fall from chair on the same day. She had been treated with selective Cox-2 inhibitor and TNF-α antagonist to alleviate pain and to recover physical functions for 2 years before accident. Medical treatment was continued through consultation with rheumatologist. Despite severe LBP and radiating pain, neurological examination revealed no bilateral motor or sensory deficits in the legs. The deep tendon reflexes were normoreactive, and there were no neurological abnormalities related to cauda equina syndrome such as bladder or bowel dysfunction. Simple radiography and computed tomography (CT) revealed a discontinued ossified paraspinal ligament and Chance fracture of the L5 vertebra extending into the posterior elements Fig. . MagnetiAS is an inflammatory rheumatic disease involving the bones and ligaments of the spine. The most characteristic features of AS are syndesmophytes and ankylosis, resulting in ossification of the entire spine. Another important feature is low bone mineral density as a result of chronic inflammation and diffuse atrophy . These tLower lumbar fractures accompanying SEH are extremely rare, even in patients with AS. We believe that close observation and medical management can be an effective way to cause spontaneous regression of SEH in patients presenting with mild neurological symptoms.


These processes are crucial for the proper function of excitable and non-excitable cells. Keeping plasma K+ within such a narrow range is a constant challenge because the extracellular [K+] can be easily disturbed either by potassium intake as daily intake can be equal to the overall amount of extracellular [K+], or by intra-to-extracellular K+ shift given the intracellular [K+] is much higher than the extracellular [K+]. Hence, dyskalemia is common and occurs in many conditions . In thisure see . The Chosure see . Further+ secretion takes place in the distal nephron and is mediated by K+-secreting channels of small and big conductance . ROMK and BK are exquisitely regulated by dietary K+ intake, a regulation that also involves the potassium counteranion  is essential in regulating BK protein levels. The authors found that the knockdown of SPAK decreased, whereas SPAK overexpression increased BK protein abundance. The stimulatory effect of SPAK requires inhibiting BK lysosomal degradation, mediated by ERK1/2 signaling. They showed that SPAK-KO mice exhibit decreased BK channel abundance and a total absence of BK current in the cortical CD’s principal cells (PCs). Their study expands a previously suggested model in which WNK1 activates BK by inhibiting its ERK1/2-mediated lysosomal degradation   , indicat


We present findings on cine magnetic resonance imaging (MRI) using steady-state free precession (SSFP) pulse sequences in a patient with pulmonary arteriovenous malformation (PAVM). The technique has the advantage of demonstrating the pulsation of lesions during the cardiac cycle on cine images. It may not replace but may complement other MRI sequences in the characterization of pulmonary lesions in selected cases. To our knowledge, no prior video of cine images of PAVM has been provided in the literature. Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary arteries and pulmonary veins, creating a right-to-left shunt. PAVMs are usually associated with hereditary hemorrhagic telangiectasia (HHT), inherited in an autosomal dominant pattern There is an estimated cerebral abscess risk of 5%-19% and a 9%-18% risk of ischemic stroke in those who manifest PAVM [Transthoracic contrast echocardiography (TTCE) is the preferred initial screening test. This test allows for potential shunt identification in suspected PAVM cases. TTCE has a high sensitivity and negative predictive value of 97% and 99%, respectively. Unfortunately, it has a high false positive rate and cannot localize lesions . ContrasA 53-year-old female with a history of acute ischemic stroke had an extensive workup, including transesophageal echocardiogram (TEE), which suggested a patent foramen ovale (PFO). However, there was no PFO demonstrated on intracardiac echocardiography (ICE) imaging during attempted closure. A bubble study performed during ICE showed a late crossing of bubbles suggesting a pulmonary shunt. CTPA demonstrated a simple PAVM in the right middle lobe Figures , 2A-2D.Incidentally, this PAVM appeared as a pulsating lesion on cine cardiac MRI images using steady-state free precession (SSFP) sequences Video .Classification of PAVMs is based on the number of feeding arteries. The simple type has one segmental feeding artery, whereas the complex type has two or more segmental feeding arteries . This clCT techniques, without and with contrast, are most commonly used in the initial evaluation and follow-up of patients with PAVM or risk of developing PAVM. Cumulative radiation dose may be substantial in patients with HHT secondary to repeated diagnostic and therapeutic interventions .SSFP cine MRI sequence may not replace currently used MRI sequences since this sequence type and protocol is typically used for a small field of view rather than the entire lungs. It may complement currently used MRI sequences by demonstrating pulsation of the lesions on cine images.The unique feature of the technique may help the characterization of pulmonary lesions since certain vascular and non-vascular abnormalities may mimic PAVM . Non-vasSSFP cine MRI demonstrates potential in aiding initial diagnosis and follow-up of PAVM in conjunction with other MRI sequences. Optimization of the technique and comparative studies are required to determine the value of this technique to complement established MRI sequences in selected cases.