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Transjugular intrahepatic portosystemic shunt (TIPS) can induce significant cardiovascular distress in patients with cirrhosis. Despite its therapeutic benefits, post-TIPS cardiac decompensation (CD) remains a serious concern, with early predictive factors still incompletely characterized. To identify reliable predictive factors of post-TIPS symptomatic CD (AHA stage C-D). We prospectively enrolled consecutive patients with cirrhosis undergoing TIPS between May 2022 and May 2024 at our tertiary referral center. Baseline clinical and biochemical parameters were recorded. Right-heart catheterization was performed at three time points: pre-TIPS, immediately post-TIPS, and one-month post-procedure. Liver stiffness measurement (LSM) by vibration-controlled transient elastography was performed at corresponding intervals. Among 53 patients treated with TIPS for secondary prophylaxis of variceal bleeding (59%) or refractory ascites (41%), with a median Child-Pugh score of 7 (IQR 3) and a MELD-Na score of 12 (IQR 6), CD developed in 20% of patients, with a median onset of 3.3 months (IQR 5.8). At univariable Cox regression analysis, factors associated with CD were advanced age (71 vs. 59 years; HR 1.10, p=0.010), presence of post-capillary pulmonary hypertension (pcPH) at one-month (82% vs. 26%; HR 6.33, p=0.018), and the evidence of increased LSM at one-month follow-up (73% vs. 19%; HR 6.42, p=0.006). The median LSM increased by +22% in patients who developed CD, in contrast to a -23% decrease observed in those who did not (p=0.012). Presence of pcPH and increase of LSM at one-month follow-up are strongly associated with the development of post-TIPS CD. This is the first demonstration that gold-standard diagnosis of pcPH few weeks after TIPS can predict evolution towards CD. Further studies are required to investigate the relationship between LSM changes and cardiac adaptation following TIPS. [ABSTRACT FROM AUTHOR]

Underdilated Transjugular Intrahepatic Portosystemic Shunt (udTIPS) effectively manages portal hypertension complications while minimizing shunt-related adverse events. Spleen Stiffness (SS) measured by vibration-controlled transient elastography has shown high accuracy in detecting clinically significant portal hypertension when compared to the gold standard hepato-venous pressure gradient. To evaluate SS as a non-invasive tool for identifying patients with Porto-Caval Pressure Gradient (PCPG) <12 mmHg after udTIPS. We prospectively enrolled patients with cirrhosis undergoing udTIPS at our referral center (January 2023–September 2024). Both invasive PCPG assessment and SS measurement with the spleen-dedicated 100Hz probe by FibroScan® were performed at three time-points: before TIPS, immediately post-TIPS, and one-month after the procedure. The study included 51 patients (mean age 62±12 years, 63% male) with preserved liver function [median Child-Pugh score 7 (IQR 3), MELD-Na 13 (IQR 6)]. TIPS indications were secondary prophylaxis for variceal bleeding (65%) and refractory ascites (35%). Median udTIPS dilation diameter was 6 (IQR 1) mm. PCPG progressively decreased from 22 (IQR 7) pre-TIPS to 15 (IQR 4) immediately post-TIPS and 11 (IQR 5) mmHg at one-month. Correspondingly, SS decreased from 74.5 (IQR 5) to 55.5 (IQR 21) and 41.6 (IQR 19) kPa. All SS measurements strongly correlated with PCPG values (ρ=0.72, p<0.0001). SS demonstrated an excellent diagnostic discrimination for PCPG <12 mmHg [AUC=0.90 (95% CI 0.84-0.96)]. The cut-off of <35 kPa accurately ruled in patients with post-TIPS PCPG <12 mmHg (97.8% specificity, 88.2% PPV, 21.3 positive likelihood ratio). SS measured with the spleen-dedicated 100Hz probe strongly correlates with PCPG over time and reliably identifies patients achieving PCPG <12 mmHg after udTIPS. If validated in larger cohorts, SS may become a non-invasive tool for tailoring invasive hemodynamic reassessments in post-TIPS monitoring protocols. [ABSTRACT FROM AUTHOR]

Transjugular intrahepatic portosystemic shunt (TIPS) has been demonstrated to be feasible in older adult patients (age ≥70 years), yet the selection criteria remain suboptimal. Sarcopenia, highly prevalent in elderly population, may be significantly associated with post-TIPS outcome. This study aimed at evaluating the impact of baseline sarcopenia on post-TIPS survival in older adults with cirrhosis. A retrospective analysis of the prospective Italian TIPS-Registry was conducted to identify patients ≥70 years who received TIPS from June 2015 to March 2023. The availability of baseline abdominal CT scan was a mandatory inclusion criterion. Skeletal muscle index (SMI) was evaluated at the L3-L4 level. Sarcopenia was defined as SMI <50 cm2/m2 for men and <39 cm2/m2 for women. Probability of liver-related death was evaluated by competing risks analysis. A prediction model for liver-related mortality was created. One-hundred and fifteen patients were included: median age 74 years (IQR 3.1), 62% male, median dry-BMI 25.7 (IQR 4.7), 60% prevalence of sarcopenia. The main etiologies were viral (40%), alcohol-associated cirrhosis (23%), and metabolic dysfunction-associated steatohepatitis (20%). Refractory ascites (57%) was the main indications for TIPS. During a mean follow up of 20 months (IQR 20), 40 (34.8%) patients died for liver-related causes and 16 (13.9%) for extrahepatic causes. Liver-related mortality was significantly higher in patients with sarcopenia than in those without (6-months: 25.0% vs. 2.2%; 1-year: 43.0% vs. 4.8%, respectively; p value <0.001). A predictive model including INR, creatinine, and sarcopenia was developed to estimate liver-related mortality. The model achieved good predictive performances with AUCs of 0.826, 0.788, and 0.712 at 6-month, 1-year, and 2-years, respectively. Due to its significant impact on survival, the evaluation of sarcopenia may improve the selection of older adults candidate to TIPS. The new predictive model for post-TIPS liver-related mortality deserves external validation. [ABSTRACT FROM AUTHOR]

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established treatment for refractory ascites (RA) in patients with cirrhosis. However, a major drawback is the development of post-procedural hepatic encephalopathy (HE), which results from the diversion of blood from the portal vein. According to the first-pass effect, this diversion reduces the liver's capacity to metabolize substances from the gut, leading to an accumulation of toxic compounds in the brain. Given that liver perfusion relies on arterial compensation (hepatic arterial buffer), it is plausible that effective compensation, which also depends on cardiac function, may reduce the risk of encephalopathy by detoxifying the blood during the second-pass metabolism. To evaluate by Dynamic Contrast Enhanced-Magnetic Resonance Imaging (DCE-MRI) the changes in liver perfusion induced by TIPS in patients with RA and their relationship with the risk of HE. Twenty-nine consecutive patients underwent DCE-MRI, cardiac and hepatic hemodynamic evaluation before and after TIPS. MRI images were processed by a homemade software using the Dual Input Dual Compartment (DIDC) model, focusing on perfusion parameters. The DIDC model showed that total hepatic perfusion decreased by 24% after TIPS (248 ml/min/100ml vs 189 ml/min/100ml, p 0.095). As expected, a significant reduction in portal perfusion (decreased by 67%; 128.6 ml/min/100ml vs 42.4 ml/min/100ml, p 0.004) and an increase in hepatic arterial fraction post-TIPS (48% vs 77%, p 0.001) was observed. Post-TIPS residual total hepatic perfusion inversely correlated with one-year HE risk: patients with perfusion ≤ 130 ml/min/100ml had a HE risk of 67.6% vs 36.4% for those > 130 ml/min/100ml (HR: 2.1, p 0.039). Perfusion MRI is able to elucidate the impact of TIPS on liver perfusion, quantifying the extent of hepatic perfusion and its correlation with the development of post-TIPS HE. [ABSTRACT FROM AUTHOR]

Abstract: In this work, a powder metallurgy procedure for the preparation of bulk hydrogen storage alloys based on MgH2 is presented. To meet the requirements of high specific surface area, high porosity and microstructural stability, all desirable features for this sort of material, a powder mixture with the following composition MgH2–15Nb–2B–1C has been ball-milled to reduce down to a few nanometers the average crystallite size of the main components. Another effect of milling, conducted under a static air atmosphere, was the in situ formation of a limited (5% approx.) amount of MgO, that, as shown by recent literature studies, may beneficially influence both the microstructural stability of the hydride alloy and the kinetics of adsorption and desorption of hydrogen. The powder was subsequently consolidated by spark plasma sintering, a process that, thanks to the limited working temperature and pressure, should not change to a significant extent the nanostructure of the ball-milled powder. The stability against recrystallisation of the consolidated specimens was verified by a number of heating and cooling cycles, up to 100, simulating the temperature conditions involved with the adsorption–desorption cycles. At the end, the crystallite size of the Mg-hydride phase was still in the nanometric range, although an unwanted oxidation, due to air contamination of the furnace atmosphere, reduced significantly the content of the hydrogen storing phase. [Copyright &y& Elsevier]

Background and Aims: In clinical practice, the reduction of portocaval pressure gradient (PCPG) following TIPS does not always meet the recommendation of current guidance. We evaluated the impact of different degrees of PCPG reduction, measured at the end of an elective TIPS, on ascites control, recurrence of portal hypertension-related bleeding (PHRB), and survival., Approach and Results: Patients with cirrhosis receiving TIPS for refractory ascites (RA) or for the secondary prophylaxis of PHRB were consecutively enrolled. Reduction in PCPG was defined as inadequate hemodynamic response (IHR) in patients not achieving a PCPG <12 mm Hg for both secondary prophylaxis of PHRB and RA, or a reduction of at least 50% only for PHRB. Four hundred fifteen patients were analyzed. An adequate hemodynamic response (AHR) was achieved in 66%. Fifty percent of patients received an under-dilated (≤7 mm) endoprosthesis. No significant differences between patients with IHR and AHR were observed in rebleeding rate and ascites control, while overt HE was higher in AHR. Regardless of TIPS indication, survival was not significantly different between IHR and AHR, while advanced age and liver function before TIPS were significantly associated with a higher cumulative incidence of liver-related death. Notably, in patients with RA the cumulative incidence of liver-related mortality was higher when AHR was defined as a post-TIPS PCPG <12 mm Hg or a reduction ≥50%., Conclusions: AHR measured at the end of an elective TIPS may not be essential to define the eventual outcome, while a marked drop in PCPG could negatively affect the prognosis of patients with RA., (Copyright © 2025 American Association for the Study of Liver Diseases.)

Background/Objectives : We evaluated the relationship between the neoangiogenic transcriptomic signature (nTS) and clinical symptoms, treatment outcomes, and survival in hepatocellular carcinoma (HCC) patients. Methods : This study prospectively followed 328 patients in the derivation and 256 in the validation cohort (with a median follow-up of 31 and 22 months, respectively). The nTS was associated with disease presentation, treatments administered, and overall survival rates. Additionally, this study investigated how multiple treatments influenced changes in nTS status and alterations in microRNA expression. Results : The nTS was identified in 27.4% of patients, linked to aggressive features like multifocality and elevated alpha-fetoprotein (AFP), a pattern consistent with that of the validation cohort. Most patients in both cohorts received treatment for HCC. nTS+ patients had limited access to, and benefited less from, liver transplantation or radiofrequency ablation (RFA) compared to nTS- patients. By the end, 78.9% had died, with nTS- patients showing better median survival and response to treatments than their nTS+ counterparts, who had lower survival across all treatment types. Among those who received transarterial chemoembolization (TACE), 31.2% (21/80 patients after the initial treatment and another four following a second TACE) transitioned from an nTS- to an nTS+ status. This shift was associated with lower survival and alterations in microRNA expressions related to oncogenic pathways. Conclusions : The nTS markedly influences treatment eligibility and survival in patients with HCC. Notably, the nTS can develop after repeated TACE procedures, significantly impacting patient survival and altering oncogenic microRNA expression patterns. These findings highlight the critical role of the nTS in guiding treatment decisions and prognostication in HCC management.

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.

Background: To achieve an optimal clinical outcome in reverse total shoulder arthroplasty (RSA), accurate placement of the components is essential. The recently introduced navigation technology of augmented reality (AR) through head-mounted displays (HMD) offers a promising new approach to visualize the anatomy and navigate component positioning in various orthopedic surgeries. We hypothesized that AR through HMD is feasible, reliable, and accurate for guidewire placement in RSA baseplate positioning., Methods: Twelve human cadaver shoulders were scanned with computed tomography (CT) and RSA baseplate positioning was 3-D planned using dedicated software. The shoulders were prepared through a deltopectoral approach and an augmented reality hologram was superimposed using the HMD Microsoft HoloLense. The central guidewire was then navigated through the HMD to achieve the planned entry point and trajectory. Postoperatively, the shoulders were CT-scanned a second time and the deviation from the planning was calculated., Results: The mean deviation of the entry point was 3.5 mm  ± 1.7 mm (95% CI 2.4 mm; 4.6 mm). The mean deviation of the planned trajectory was 3.8°  ± 1.7° (95% CI 2.6°; 4.9°)., Conclusion: Augmented reality seems feasible and reliable for baseplate guidewire positioning in reverse total shoulder arthroplasty. The achieved values were accurate., (© 2021. The Author(s).)

Objective: To determine potential predictive associations between patient-/lesion-specific factors, clinical outcome and anterior ankle impingement in patients that underwent isolated autologous matrix-induced chondrogenesis (AMIC) for an osteochondral lesion of the talus (OLT)., Design: Thirty-five patients with a mean age of 34.7 ± 15 years who underwent isolated cartilage repair with AMIC for OLTs were evaluated at a mean follow-up of 4.5 ± 1.9 years. Patients completed AOFAS (American Orthopaedic Foot and Ankle Society) scores at final follow-up, as well as Tegner scores at final follow-up and retrospectively for preinjury and presurgery time points. Pearson correlation and multivariate regression models were used to distinguish associations between patient-/lesion-specific factors, the need for subsequent surgery due to anterior ankle impingement and patient-reported outcomes., Results: At final follow-up, AOFAS and Tegner scores averaged 92.6 ± 8.3 and 5.1 ± 1.8, respectively. Both body mass index (BMI) and duration of symptoms were independent predictors for postoperative AOFAS and Δ preinjury to postsurgery Tegner with positive smoking status showing a trend toward worse AOFAS scores, but this did not reach statistical significance ( P = 0.054). Nine patients (25.7%) required subsequent surgery due to anterior ankle impingement. Smoking was the only factor that showed significant correlation with postoperative anterior ankle impingement with an odds ratio of 10.61 when adjusted for BMI and duration of symptoms (95% CI, 1.04-108.57; P = 0.047)., Conclusion: In particular, patients with normal BMI and chronic symptoms benefit from AMIC for the treatment of OLTs. Conversely, smoking cessation should be considered before AMIC due to the increased risk of subsequent surgery and possibly worse clinical outcome seen in active smokers.

Background: Accurate glenoid positioning in reverse total shoulder arthroplasty (RSA) is important to achieve satisfying functional outcome and prosthesis longevity. Optimal component placement can be challenging, especially in severe glenoid deformities. The use of patient-specific instruments (PSI) and 3D computer-assisted optical tracking navigation (NAV) are already established methods to improve surgical precision. Augmented reality technology (AR) promises similar results at low cost and ease of use. With AR, the planned component placement can be superimposed to the surgical situs and shown directly in the operating field using a head mounted display. We introduce a new navigation technique using AR via head mounted display for surgical navigation in this feasibility study, aiming to improve and enhance the surgical planning., Methods: 3D surface models of ten human scapulae were printed from computed tomography (CT) data of cadaver scapulae. Guidewire positioning of the central back of the glenoid baseplate was planned with a dedicated computer software. A hologram of the planned guidewire with dynamic navigation was then projected onto the 3D-created models of the cadaver shoulders. The registration of the plan to the anatomy was realized by digitizing the glenoid surface and the base of the coracoid with optical tracking using a fiducial marker. After navigated placement of the central guidewires, another CT imaging was recorded, and the 3D model was superimposed with the preoperative planning to analyze the deviation from the planned and executed central guides trajectory and entry point., Results: The mean deviation of the ten placed guidewires from the planned trajectory was 2.7° ± 1.3° (95% CI 1.9°; 3.6°). The mean deviation to the planned entry point of the ten placed guidewires measured 2.3 mm ± 1.1 mm (95% CI 1.5 mm; 3.1 mm)., Conclusion: AR may be a promising new technology for highly precise surgical execution of 3D preoperative planning in RSA., (© 2020. The Author(s).)

This study examined the association between dynamic angiopoietin-2 assessment and COVID-19 short- and long-term clinical course. We included consecutive hospitalized patients from 1 February to 31 May 2020 with laboratory-confirmed COVID-19 from 2 Italian tertiary referral centers (derivation cohort, n = 187 patients; validation cohort, n = 62 patients). Serum biomarker levels were measured by sandwich enzyme-linked immunosorbent assay. Lung tissue from 9 patients was stained for angiopoietin-2, Tie2, CD68, and CD34. Cox model was used to identify risk factors for mortality and nonresolving pulmonary condition. Area under the receiver operating characteristic curve (AUROC) was used to assess the accuracy of 3- and 10-day angiopoietin-2 for in-hospital mortality and nonresolving pulmonary condition, respectively. Three-day angiopoietin-2 increase of at least twofold from baseline was significantly associated with in-hospital mortality by multivariate analysis (hazard ratio [HR], 6.69; 95% confidence interval [CI], 1.85-24.19; P = .004) with AUROC = 0.845 (95% CI, 0.725-0.940). Ten-day angiopoietin-2 of at least twofold from baseline was instead significantly associated with nonresolving pulmonary condition by multivariate analysis (HR, 5.33; 95% CI, 1.34-11.77; P ≤ .0001) with AUROC = 0.969 (95% CI, 0.919-1.000). Patients with persistent elevation of 10-day angiopoietin-2 levels showed severe reticular interstitial thickening and fibrous changes on follow-up computed tomography scans. Angiopoietin-2 and Tie2 were diffusely colocalized in small-vessel endothelia and alveolar new vessels and macrophages. Angiopoietin-2 course is strongly associated with COVID-19 in-hospital mortality and nonresolving pulmonary condition. Angiopoietin-2 may be an early and useful predictor of COVID-19 clinical course, and it could be a relevant part of disease pathogenesis. Angiopoietin-2 blockade may be a COVID-19 treatment option., (© 2021 by The American Society of Hematology.)

Objective: To assess accuracy and reproducibility of MRI diagnosis of invasive placentation (IP) in high-risk patients and to evaluate reliability of MRI features. Secondary aim was to evaluate impact of interventional radiology (IR) on delivery outcomes in patients with IP at MRI., Methods: 26 patients (mean age 36.24 y/o,SD 6.16) with clinical risk-factors and echographic suspicion of IP underwent 1.5 T-MRI. Two readers reviewed images. Gold-standard was histology in hysterectomised patients and obstetric evaluation at delivery for patients with preserved uterus. Accuracy and reproducibility of MRI findings were calculated., Results: Incidence of IP was 50% (13/26) and of PP was 11.54% (3/26). MRI showed 100% sensitivity (95% CI = 75.3-100%) and 92.3% specificity (95% CI = 64.0-100%) in the diagnosis of IP. Gold-standard was histology in 10 cases and obstetric evaluation in 16. MRI findings with higher sensitivity were placental heterogeneity, uterine bulging and black intraplacental bands. Uterine scarring, placental heterogeneity, myometrial interruption and tenting of the bladder showed better specificity. MRI inter-rater agreement with Cohen's K was 1. 11 patients among 14 with MRI diagnosis of IP received IR assistance with positive impact on delivery outcomes in terms of blood loss, red cells count, intense care unit length of stay, days of hospitalisation and risk of being transfused., Conclusion: MRI is an accurate and reproducible technique in prenatal diagnosis of IP. MRI helps planning a safe and appropriate delivery eventually assisted by IR, which positively affects foetal and maternal outcomes., Advances in Knowledge: The adoption of MRI evaluation in patients with high risk of invasive placentation allows a more accurate diagnosis in terms of both presence of the disease and its extension to or through or even beyond the myometrium. This led to a better dedicated delivery management with eventual adoption of interventional radiology with a global positive effect on foetal and maternal outcomes.

Background: Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis. This study aimed to identify factors associated with functional outcomes and quality of life after subtalar fusion for posttraumatic subtalar arthritis after calcaneal fracture., Methods: This is a retrospective study with follow-up by questionnaire in two level 1 trauma centers. Patients who underwent subtalar arthrodesis for posttraumatic arthritis after a calcaneal fracture between 2001 and 2016 were identified and contacted for completion of a survey consisting of the Foot and Ankle Ability Measure (FAAM), Maryland Foot Score (MFS), Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire, EuroQol 5-dimensional (EQ-5D) questionnaire, and EuroQol visual analog scale (EQ-VAS). Exclusion criteria were initial subtalar arthrodesis at an outside facility, primary arthrodesis for fracture, initial arthrodesis earlier than 2001, amputation of the fused foot or leg, younger than 18 years at time of fusion, and inability to communicate in English. A total of 159 patients met our inclusion criteria. Eighty-four patients completed the questionnaires, resulting in a response rate of 59%., Results: Median FAAM score was 79 (interquartile range [IQR], 48-90), median MFS was 74 (IQR, 56-86), and median PROMIS PF was 45 (IQR, 38-51). Quality of life was significantly lower when compared to a reference population ( P = .001). Smoking was independently associated with worse outcomes. Complications after fusion (such as nonunion, implant failure, and infectious complications), high-energy trauma, and ipsilateral injury were also predictors for poorer outcomes., Conclusion: Acceptable functional outcomes and quality of life were observed after subtalar fusion. Smoking, complications after subtalar fusion, high-energy trauma, and presence of ipsilateral injuries were independently associated with worse functionality and quality of life., Level of Evidence: Prognostic level III, comparative series.

Introduction: This report describes the challenges of treating a pregnant woman who had a rare case of critical placenta accreta with concurrent Cromer system anti-Tc(a) and anti-Kidd A alloantibodies. No previous case of such alloimmunization in a patient with placenta accreta has been reported., Case Presentation: A 28-year-old African woman with anti-Cromer Tc(a) antibodies, anti-Kidd A antibodies and placenta accreta was admitted to the obstetric emergency department at our university hospital with persistent vaginal bleeding. Her rare Cromer blood group system antibodies had been diagnosed 1 month earlier; no compatible blood had been found despite a worldwide search. We performed a cesarean section after placement of Fogarty balloons in her uterine arteries with preoperative endovascular interventional radiology. Other therapeutic interventions included preoperative iron administration to raise hemoglobin and the scheduled predeposit of autologous blood. Intraoperative therapeutic management was aimed at preventing coagulopathy and massive bleeding. With the use of alternative medical techniques determined during perioperative planning, her intraoperative blood loss was only 1000 mL, despite the placenta accreta. She was discharged from the hospital 4 days after cesarean section., Conclusions: To the best of our knowledge, this is the first report of an alloimmunized patient with two different alloantibodies and concurrent high risk of bleeding because of placenta accreta. The close collaboration among obstetricians, anesthesiologists, interventional radiologists, blood bank pathologists and intensive care doctors prevented serious consequences in this patient. The exceptional feature of this case is the patient's double risk: the placenta accreta and the inability to transfuse compatible blood. These two extreme situations challenged the multidisciplinary medical team.