Preoperative sarcopenia is a predictor of poor survival in cancer patients. We hypothesized that sarcopenia could progress as occult metastasis arose, especially after highly invasive surgery for highly aggressive malignancy. This study aimed to evaluate the associations of postoperative changes in skeletal muscle mass volume with survival outcomes in patients who underwent surgery for perihilar cholangiocarcinoma.Fifty-six patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar cholangiocarcinoma were studied. The skeletal muscle index (SMI) at the third lumbar vertebra was calculated from axial computed tomography images taken preoperatively and 3–6 months postoperatively (early postoperative period). The associations of clinicopathological variables, including changes of SMI after surgery, with overall survival and recurrence-free survival were evaluated. Moreover, the associations of decreased SMI and elevated serum carbohydrate antigen 19–9 level with early recurrence and poor survival was compared.P = 0.049) and a shorter recurrence-free survival , whereas elevated carbohydrate antigen 19–9 level was not.Among 56 patients, 26 (46%) had sarcopenia preoperatively and SMI decreased in 29 (52%) in the early postoperative period. During the median follow-up of 57.9 months, 35 patients (63%) developed recurrence and 29 (50%) died. Decreased SMI in the early postoperative period was independently associated with a shorter overall survival (hazard ratio, 2.39; 95% confidence interval, 1.00–6.18; Decreased SMI in the early postoperative period may be used as a predictor for recurrence and poor survival in patients undergoing surgery for perihilar cholangiocarcinoma. Perihilar cholangiocarcinoma is an aggressive malignancy arising from the biliary confluence, with the reported median overall survival of 4–6 months , 2. WhilSarcopenia was defined as a syndrome characterized by progressive and generalized loss of skeletal muscle mass volume (SMV) and strength . SMV is The medical records of 78 consecutive patients who underwent major hepatectomy with EBDR for perihilar cholangiocarcinoma between May 2006 and June 2017 at our institution were reviewed. Perihilar cholangiocarcinoma was defined as a tumor located in the extrahepatic biliary tree proximal to the origin of the cystic duct, consistent with the Union for International Cancer Control (UICC) Classification 8th Edition . In all Clinicopathological data, which could be affected survival or change of skeletal muscle mass, were retrieved from medical records. Those data included age, sex, body mass index (BMI), American Society of Anesthesiologists classification score, Charlson comorbidity index, preoperative biliary drainage, and portal vein embolization. Preoperative laboratory data included serum concentrations of total bilirubin, albumin, and carbohydrate antigen 19–9 (CA 19–9). Intraoperative factors included type of surgical procedure, operation time, blood loss, and blood transfusion. Postoperative complications included major complications consistent with Clavien-Dindo grade ≥ IIIa , surgicaThis study was approved by the ethics committee of the National Cancer Center (#2018–053).Computed tomography (CT), ultrasonography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography were routinely performed for the diagnosis of perihilar cholangiocarcinoma. Preoperative biliary drainage was performed in patients with obstructive jaundice. When the serum total bilirubin concentration decreased to < 2 mg/dL after biliary drainage, liver function was evaluated by testing indocyanine green retention at 15 min. Indocyanine green retention at 15 min and CT volumetry were routinely examined to evaluate the functional reserve of the future liver remnant. Preoperative portal vein embolization was performed in patients who were judged to have insufficient future liver remnant volume relative to liver function , 18.All patients underwent major hepatectomy with EBDR. In particular, regional lymph node dissection of the common hepatic artery and hepatoduodenal ligament were performed. Common bile duct was divided at the level of the pancreas and submitted for frozen section analysis to evaluate tumor negativity of the cut-end. Hemilateral hepatic artery and portal vein were divided. Hepatic parenchymal dissection was performed and caudate lobectomy was routinely performed. The proximal hemilateral bile duct was divided and a specimen was extracted. After confirmation of the tumor negativity of the proximal bile duct cut-end, hepaticojejunostomy with Roux-en-Y anastomosis were performed.Postoperative follow-up included medical examination, blood tests with serum CA 19–9 level, and CT examination every 3 months for the first 3 years, then every 6 months for the next 2 years, and then annually thereafter.2·m− 2) for each patient was calculated as follows: SMI =  / (height).2 Sarcopenia was defined as SMI < 43 cm2·m− 2 in men with a body mass index < 25 kg·m− 2, SMI < 53 cm2·m− 2 in men with a body mass index ≥25 kg·m− 2, or SMI < 41 cm2·m− 2 in women [As shown in Fig. in women . All stuCategorical variables are presented as n (%) and were analyzed using Fisher’s exact test. Continuous variables are presented as median [range] and were analyzed using the Mann-Whitney U-test. Cutoffs were determined as the upper limit of the normal range for laboratory data and as the median for other continuous variables. Correlations between the variables were evaluated using Spearman’s rank correlation coefficient. Overall survival (OS) was defined as the time from surgery to death or the date at last follow-up. Recurrence-free survival (RFS) was calculated as the time from surgery to recurrence, death, or the date at last follow-up. Recurrence was defined as the detection of a tumor on imaging or by pathological confirmation.s > 0.3. Variables in the early and late postoperative periods were evaluated separately because risk analysis for a shorter OS or RFS should be performed using the variables of each early and late postoperative period. The associations of decreased SMI and elevated serum CA 19–9 level in the early and late postoperative period with recurrence and poor survival was compared. All P-values were based on two-sided statistical tests, and the significance level was set at P <  0.05. All statistical analyses were performed using JMP version 13 .The study observation period was until December 2019. OS and RFS were determined by Kaplan-Meier survival analysis and the log-rank test. Clinicopathological findings and SMI were evaluated for the associations with a shorter OS or RFS by calculating hazard ratios (HRs) and 95% confidence intervals (95% CIs) using Cox regression analysis. Variables that were shown to be significant in univariable analysis were included in multivariable analysis, excluding the confounder with a lower hazard ratio if a correlation was shown between variables with Spearman’s rank analysis. The significant correlation coefficient was set at r Clinicopathological characteristics are shown in Table 2·m− 2 and 26 patients (46%) were categorized as having sarcopenia. In the early postoperative period (median of 137 days), median SMI was 45.1 [32.0–57.3] cm2·m− 2 and 23 patients (41%) had sarcopenia. In comparison between preoperative and early postoperative periods, the median percent change of SMI was − 0.16% [− 10.4 to 14.5], and SMI decreased in 29 patients (52%). In the late postoperative period (median of 372 days), median SMI was 43.7 [31.6–57.6] cm2·m− 2 and 28 patients (50%) had sarcopenia. In comparison between preoperative and late postoperative periods, the median percent change of SMI was − 0.59% [− 17.4 to 21.8], and SMI decreased in 29 patients (52%).In the preoperative period, median SMI was 44.4 [30.9–57.2] cmP = 0.049) was independently associated with a shorter OS. In the late postoperative period (multivariable model 2), decreased SMI  and elevated serum CA 19–9 level  were independently associated with a shorter OS. Of note, sarcopenia in the late postoperative period was excluded from multivariable model 2 because it was correlated with decreased SMI in the late postoperative period .As shown in Table P = 0.047) and decreased SMI  were independently associated with a shorter RFS. In the late postoperative period (multivariable model 2), only elevated serum CA 19–9 level  was independently associated with a shorter RFS.As shown in Table P = 0.002; Fig. P = 0.001; Fig. P = 0.136; Fig. P = 0.176; Fig. As shown in Fig. P = 0.003; Fig. P = 0.013; Fig. P <  0.001; Fig. P <  0.001; Fig. As shown in Fig. In this study, 46% of patients who underwent major hepatectomy with EBDR for perihilar cholangiocarcinoma had sarcopenia preoperatively; among the studied patients SMI decreased in 52% in the early postoperative period and also in 52% in the late postoperative period. Preoperative sarcopenia was not associated with a shorter OS or RFS. However, decreased SMI in the early postoperative period was independently associated with both shorter OS and RFS. Moreover, compared to elevated serum CA 19–9 level, decreased SMI in the early postoperative period was associated more strongly with recurrence and poor survival. On the other hand, decreased SMI in the late postoperative period was independently associated with a shorter OS but not with a shorter RFS.Tran et al. found that elevated preoperative serum CA 19–9 level, lymph node metastasis, and R1 resection were associated with poorer 5-year survival among 194 patients who underwent perihilar cholangiocarcinoma resection . Zhang eOne study evaluated the associations of the perioperative percent change in SMV with postoperative outcomes in patients who underwent major hepatectomy with EBDR for perihilar cholangiocarcinoma at a high-volume center in Japan . The autSeveral studies evaluated the mechanism for the poor prognosis of patients in whom SMV decreased in the clinical course of malignant disease , 21. LutSerum CA 19–9 is usually measured during follow-up after surgery for perihilar cholangiocarcinoma ; its eleThese results collectively suggest that decreased SMI is a more useful predictor for early recurrence and poor survival than elevated serum CA 19–9 level. Thus, measurement of SMI was considered to be useful for monitoring patients after surgery, and a decrease in SMI might be an early sign of tumor progression that precedes the elevation of tumor markers and appearance of tumor on CT. Accordingly, detecting recurrence before lesions on radiological examination enables clinicians to plan closer follow-up or additional examinations, or start secondary treatment. Moreover, the initiation of systemic chemotherapy at an earlier disease stage might improve survival.One limitation of this study was its retrospective design, which introduces a risk of selection bias mainly due to the exclusion of patients who were not surgical candidates. Second, this study included a small sample size from a single institution, as surgery for patients with perihilar cholangiocarcinoma is generally rare owing to its incidence, difficulty in diagnosis, and invasiveness and risks in surgery, even in a high-volume center. Further, multi-center investigations to analyze more cases would be recommended. Third, secondary treatments after recurrence were not considered in survival analysis. However, patients who were receiving pre- or postoperative adjuvant therapy as part of a clinical trial were excluded because the presence of adjuvant therapy might affect survival outcomes, regardless of the change of SMI. Clinical variables that were associated especially with early recurrence in condition with no other anti-cancer therapy than surgery were sought in this study.This study showed that a decreased SMI in the early postoperative period was independently associated with a shorter OS and RFS in patients who underwent major hepatectomy with EBDR for perihilar cholangiocarcinoma. During the early postoperative period in particular, decreased SMI appeared to be a better predictor for recurrence and poor survival than elevated serum CA 19–9 level. Hence, evaluating SMI on serial CTs was considered to be useful for monitoring patients after surgery.


To investigate the independent risk factors of poor short‐term outcomes in patients with lung cancer‐associated acute ischemic stroke (LCAIS) and use them to develop an index of prognosis LCAIS (pLCAIS) which could help clinicians identify patients at high risk for poor short‐term outcomes.We retrospectively enrolled patients with lung cancer‐associated acute ischemic stroke and employed the 90D modified Rankin cale (mRS) to divide them into two groups: good outcomes (score 0–2) and poor outcomes (score 3–6). Propensity score matching (PSM) was used to remove confounding factors, and multivariable logistic regression analysis was used to analyze the independent risk factors of pLCAIS. The receiver operating characteristic (ROC) and area under the ROC curve (AUC) developed a multiple model combining the independent risk factors of pLCAIS.p = 0.048), CRP , and neutrophil count . The ROC curve, used to assess the diagnostic ability of binary classifiers, showed that the product of these three independent risk factors showed high sensitivity and specificity.A total of 172 patients were included: 67 (38.9%) with good outcomes and 105 (61.1%) with poor outcomes. After using PSM, there were 33 cases in each group. The results showed that patients with poor short‐term outcomes were significantly higher in D‐dimer  and area under the ROC curve (AUC) developed a multiple model incorporating independent risk factors for pLCAIS.To investigate independent risk factors of poor short‐term outcomes in patients with lung cancer‐associated acute ischemic stroke (LCAIS) and use them to develop an index of prognosis LCAIS (pLCAIS) which could help clinicians identify patients at high risk for poor short‐term outcomes. A total of 172 patients with lung cancer‐ associated acute ischemic stroke from 4 centers were retrospectively included and divided into two groups using the 90D modified Rankin scale (mRS): good outcomes (mRS score 0–2) and poor outcomes (mRS score 3–6). The two groups of data were matched with a 1:1 propensity score, the caliper value was set to 0.02, and a total of 33 cases were matched in each group. To identify independent risk factors, all baseline variables with a  Cancer and ischemic stroke are two major diseases that pose a significant threat to human health. Stroke and lung cancer are two of the five leading causes of disability adjusted life years (DALYs) associated with an aging population in China.Lung cancer is a known high‐risk factor for cancer‐associated ischemic stroke.At present, studies on patients with lung cancer‐associated acute ischemic stroke mainly focus on the pathogenesis, clinical manifestations, imaging characteristics, etc., and there have been few studies on the prognosis of patients. Based on this, our study analyzed the risk factors of poor short‐term outcomes in patients with lung cancer who experienced acute cerebral infarction, which we hope will help clinicians identify such patients and improve their outcomes.Data from patients with lung cancer‐associated acute ischemic stroke who were hospitalized in the Second Hospital of Tianjin Medical University, Tianjin Medical University Cancer Institute and Hospital, Qilu Hospital of Shandong University Dezhou Hospital and Shengli Oilfield Central Hospital from January 2012 to December 2021 were retrospectively collected. Inclusion criteria: (1) age > 18 years; (2) acute ischemic stroke patients met the diagnostic criteria of “China Guidelines for Diagnosis and Treatment of Acute Ischemic Stroke 2018,” confirmed by magnetic resonance imaging (MRI); (3) acute ischemic stroke occurred 3 months before diagnosis of non‐small cell lung cancer to 5 years after diagnosis; and (4) non‐small cell lung cancer patients had a complete history and pathological diagnosis. Exclusion criteria: (1) patients with intracranial cancers, including primary intracranial tumors or metastases; and (2) lung cancer patients who were not expected to survive for 3 months. A total of 172 patients were included: 85 males (49.4%) and 87 females (50.6%) with a mean age of 73.9 years. After propensity score matching, 66 patients were included in the study, with 33 patients in each group .All data were collected from paper medical records and the hospital information system, including lung cancer staging, treatment plan, comorbidities , laboratory markers: white blood cell count (WBC), neutrophil count (NC), red blood cell count (RBC), hemoglobin (HGB), platelets (PLT), D‐dimer (D‐D), fibrinogen (FIB), homocysteine (HCY), C‐reactive protein (CRP), carcinoembryonic antigen (CEA), carbohydrate antigen125 (CA125), cytokeratin fragment antigen 21–1(Cyfra21‐1), neuron‐specific enolase (NSE), whether antiplatelet therapy was received, whether anticoagulation therapy was received, and the location and number of cerebral infarction lesions in the diffusion‐weighted (DW) brain MRI images. The data related to acute ischemic stroke included the severity of neurological deficit using the National Institute of Health stroke scale (NIHSS) score and the etiological classification of cerebral infarction using Trial of Org10172 in Acute Stroke Treatment (TOAST) criteria. Follow‐up: after 90 days of discharge from the hospital, a neurologist conducted a face‐to‐face or telephone follow‐up in the cerebrovascular disease clinic and evaluated the patient's mRS score. The modified Rankin Scale (mRS) was used to evaluate the prognosis at 90 days after cerebral infarction. An mRS score of 0–2 was defined as a good outcome while an mRS score of 3–6 was defined as a poor outcome.t test was used to compare the continuous variables between the groups, and categorical variables were compared by Pearson's χ2 test or Fisher's exact test. The PSM method was used to reduce the effect of confounding factors and to make the comparison between two groups more reasonable. The two groups of data were matched with a 1:1 propensity score, the caliper value was set to 0.02, and a total of 33 cases were matched in each group. To determine the independent risk factors, all baseline variables with p < 0.05 compared between the two groups were included in the multivariate logistic regression analysis. The cutoffs with sensitivities and specificities were identified by ROC analysis. All p‐values were two‐sided and p < 0.05 was considered statistically significant.All statistical analyses were performed using SPSS version 25.0. The independent samples p < 0.05), but after PSM, there were no significant differences in stage, treatment and markers , carbohydrate antigen 125 (CA125), cytokeratin fragment 19 (Cyfra21‐1), neuron‐specific enolase (NSE) and squamous cell carcinoma (SCC) were measured. There were statistically significant differences in stages IV, chemotherapy and NSE (p < 0.05) were found between the good and poor outcome groups for age, hypertension, dyslipidemia, smoking, history of stroke, RBC, WBC, NC, FIB, D‐dimer, HCY, CRP, baseline NIHSS score, In‐hospital mortality, 90D mortality and ≥3 arterial ischemic territories. In acute ischemic stroke treatment, TOAST classification, number of acute cerebral infarction lesions in one or two arterial ischemic territories were not significant. After PSM, significant differences (p < 0.05) were only found in WBC, NC, FIB D‐dimer, CRP, baseline NIHSS score, 90D mortality and ≥3 arterial ischemic territories  had hypertension and 35 (20.3%) had diabetes. No mural thrombus and no valve structural problems were found in all cases by echocardiography. Before PSM, statistically significant differences (p = 0.048), CRP , and neutrophil count  were the significant three risk factors for poor short‐term outcomes in patients with lung cancer‐associated acute ischemic stroke , with a sensitivity of 90.9% and a specificity of 69.7%.The ROC curve showed that the cutoff value of D‐dimer was 2088 mg/l, the AUC value was 0.789 (95% CI: 0.680–0.898), the sensitivity was 54.5%, and the specificity was 97.0%; the cutoff value of CRP was 7.55 mg/l, AUC value was 0.839 (95% CI: 0.737–0.940), sensitivity was 87.9%, specificity was 75.8%; the cutoff value of NC was 3.25*10p) = In(p/[1 − p]) = β0 + β1X1 + β2X2 + β3X3, where p is the probability of poor short‐term outcomes of lung cancer‐associated acute ischemic stroke, X1 is the D‐D level, X2 is the CRP level, and X3 is the neutrophil count. ROC regression analysis showed that the product of the area under the curve (AUC) of the three risk factors was the largest, with an AUC value of 0.958 (95% CI: 0.907–0.997), a sensitivity of 93.9%, and a specificity of 93.9%, which was called this study pLCAIS index . After PSM, the above differences were not statistically significant. This may indicate that tumor staging and treatment methods do not have much influence on the short‐term prognosis of patients with lung cancer‐associated acute ischemic stroke, which may be related to the mRS as the evaluation standard.The outcomes of patients with cancer‐associated acute ischemic stroke are poor overall.The main treatment methods for acute cerebral infarction are thrombolytic, anticoagulation and antiplatelet aggregation therapies. Previous studies have shown that direct oral anticoagulants significantly decrease the risk of cancer‐associated thrombosis recurrence,p < 0.05). After PSM, only the WBC, NC, D‐D, FIB, CRP, baseline NIHSS score, ≥3 arterial ischemic territory and 90D mortality were significantly different between the two groups (p < 0.05). Multivariate logistic regression analysis showed D‐dimer , CRP , and neutrophil count  were risk factors for poor short‐term outcomes in patients with lung cancer‐associated acute ischemic stroke.Before PSM, the RBC, WBC, NC, FIB, D‐D, HCY, CRP, baseline NIHSS score, in‐hospital mortality, 90D mortality and ≥3 arterial ischemic territory were significantly different between the two groups ,Cancer cells can activate the coagulation system, and cancer patients often have elevated levels of D‐dimer, which is a risk factor for cancer‐associated cerebral infarctionThis study found that the elevation of D‐dimer, CRP, and NC may all play a role in the outcomes of patients with lung cancer‐associated acute ischemic stroke. While the three independent risk factors may each play their respective roles in the development of pLCAIS, they may also play a coordinated role. Their elevation can also be seen in other diseases or pathological states, and it is difficult to predict the prognosis of patients from any of these factors alone. We developed a multiple model of pLCAIS by combining three risk factors to predict the outcomes of patients with lung cancer‐associated acute ischemic stroke. We found that the multiple model of pLCAIS had the largest AUC ROC compared to each of the three individual risk factors, with high sensitivity and specificity, indicating that the multiple model of pLCAIS could be a specific biomarker of pLCAIS and may serve as a predictor of the development of pLCAIS.The role of the pLCAIS Index in pLCAIS patients will need to be confirmed in future studies with larger sample sizes and more biomarkers. Nevertheless, our study provided a meaningful method to further the investigation of the index of pLCAIS in future studies.The present study had some limitations. First, there is a potential risk of selection bias owing to the retrospective design, and differences in patient characteristics between the two groups were not completely overcome even after PSM, which could influence prognosis. Second, the relatively small sample size. Given the limitations of retrospective data, the relevant findings should be confirmed through prospective clinical studies with a large sample size.In conclusion, our findings suggest that the poor outcomes of pLCAIS may be induced by elevated D‐D, CRP and neutrophils. The pLCAIS index, which serves as a novel biomarker of pLCAIS, needs to be confirmed in future studies.Conceptualization: Ruixia Wang, Peijun Xu, Xin Li; Data collection: Ruixia Wang, Peijun Xu, Jun Zhou, yuanyuan Meng, Kum Men, Jinyuan Zhang; Data analysis: Ruixia Wang, Peijun Xu, Wei Lu, Juanjuan Xue; Writing‐original draft: Ruixia Wang; Writing‐review & editing: Xin Li.The authors declare there are no potential conflicts of interest.


Nephrotic syndrome is the one of the commonest renal disorders in children. Children with nephrotic syndrome (NS) are at a high risk of atherosclerosis due to hyperlipidemia, hypertension. Carotid intima media thickness (CIMT) is a surrogate marker for atherosclerosis. This study aimed to evaluate the carotid intima media thickness in children with nephrotic syndrome and its relation to different risk factors.2. CIMT was assessed by ultrasound. Lipid profile, protein/creatinine ratio in urine and kidney function tests were done.This is an observational case control study that included forty children with nephrotic syndrome and thirty healthy children as controls. The inclusion criteria were: age of 2 years or more with disease duration of minimum of 1 year and glomerular filtration rate > 90 mL/min/1.73mP < 0.001) even when compared across different age groups. 60% of patients had received non-steroid immunosuppressive therapy. CIMT was significantly higher in patients receiving non-steroid immunosuppressive therapy than those receiving steroids alone. Subsequently, CIMT had significant positive correlation to duration of the disease (p = 0.05), body mass index (BMI) (p = 0.03), number of relapses (p = 0.01) and diastolic blood pressures (p = 0.003).The mean CIMT (mm) was significantly higher in patients with NS (0.477 ± 0.04) compared to controls (0.39 ± 0.03) (Children with NS had significantly higher CIMT than control group. CIMT was positively correlated to disease duration, number of relapses and BMI. It was significantly higher among patients receiving non-steroid immunosuppressive therapy than those receiving steroids alone. Carotid intima media thickness (CIMT) is a reliable marker of atherosclerosis and its complications in adults, such as myocardial infarction and stroke , 2. Its Nephrotic syndrome (NS) is one of the commonest renal disorders in children . The cliDisturbances of lipid metabolism in NS might be persistent even during remission periods –10 and mThere are only few studies that evaluated CIMT in children with idiopathic nephrotic syndrome. This study was designed to evaluate the CIMT in children with idiopathic nephrotic syndrome as an atherosclerosis surrogate marker in children with nephrotic syndrome and assess different risk factors that could affect CIMT.This observational case control study was carried out in the period from November 2021 till July 2022. Forty children with idiopathic NS following up at the pediatric-nephrology outpatient clinic of Fayoum university hospital were included in the study. Patients were categorized according to their response to steroid treatment into 3 groups; steroid-sensitive (SSNS), steroid-dependent (SDNS) and steroid-resistant (SRNS). Thirty children with history of minor non-renal illness who attended the general outpatient clinic were included as a control group. Children of both groups were age and sex-matched.2. The exclusion criteria were: patients having history of familial hypercholesterolemia, known case of essential hypertension, children with type-1 diabetes mellitus or obesity, presence of edema at time of examination.The Inclusion criteria were: Age is 2 to 18 years old at time of enrollment in the study, being on continuous or interrupted treatment for at least 1 year before enrollment and glomerular filtration rate more than 90 mL/min/1.73mAll children were subjected to full history taking and complete physical examination stressing on age at diagnosis, duration of the disease, response to steroid therapy, number of relapses, immunosuppressive drugs, anthropometric measurements including weight, height, body mass index (BMI) and arterial blood pressure measurement. Laboratory investigations were done including serum albumin, urea and creatinine level, spot albumin/creatinine ratio in urine (ACR), total serum cholesterol, and triglycerides (TG) levels. Hypercholesterolemia was defined as serum cholesterol level at or above 200 mg/dL, hypertriglyceridemia as serum triglyceride level at or above 100 mg/dL (children aged < 9 years) or above 130 mg/dL (children aged 10–18 years). glomerular filtration rate (GFR) was calculated using Schwartz formula .Patients were classified according to the following definitions of nephrotic syndrome:Remission: 24 hours’ urinary proteins less than 4 mg/m2/h, nil or trace by dipstick for at least three consecutive days.Relapse: 24 hours urinary proteins more than 40 mg/m2/h or urinary proteins more than 3+ by dipstick in for at least three consecutive days.Infrequent relapse nephrotic syndrome (IFRNS): 3 or less relapses within one year,Frequent relapse nephrotic syndrome (FRNS): Two or more relapses within 6 months of steroid-induced remission; 4 or more relapses in any 12 months period.Steroid dependent nephrotic syndrome (SDNS): Occurrence of two consecutive relapses during alternate day steroid therapy or within 2 weeks of its discontinuation;Steroid resistant nephrotic syndrome (SRNS): Failure to achieve remission after 4–6 weeks of daily oral prednisolone therapy at a dose of 2 mg/kg/day.Both infrequently and frequently relapsing patients were grouped into “steroid sensitive nephrotic syndrome (SSNS)” in this study.e) with a linear high-frequency transducer (7.5 MHz). The CIMT is defined as the distance between the first echogenic line (lumen–intima interface) and the second echogenic line (media–adventitia interface) of the far wall, using a manual cursor placement measurement technique. This double-line pattern is seen by 2D- echo on both walls of the common carotid artery (CCA) in the longitudinal view.Measurement of CIMT was performed according to Mannheim’s Consensus Guideline 2011  by an exThe examination was performed after 10 minutes of rest with the patient at supine position with a slightly overextended neck and head turned slightly to the contralateral side. Measurements are obtained from the far wall of the common carotid artery on both sides at 10–20 mm proximal to the bifurcation. On the Images of the thickest CIMT, measurements were taken with calipers positioned on a zoomed image of the common carotid artery. CIMT was measured at end diastole. The Mean value of the 3 measurements on each side was used  software version 22 in windows 7 . For qualitative data, Chi-square test was used to compare between two or more qualitative groups. For quantitative data, Independent samples This study included 40 children with idiopathic nephrotic syndrome and 30 age-and sex-matched healthy children as controls. Children were stratified according to their age at time of the study into 3 groups: G1; ≤5 years (9 patients and 10 controls), G2; 6–10 years , and G3; > 10 years (14 patients and 7 controls). The clinical and laboratory data of the study groups are shown in Table In the patients’ group, 10 (25%) patients were steroid-sensitive nephrotic syndrome (SSNS) which included frequently and infrequently relapsing patients, 20 (50%) were steroid-dependent nephrotic syndrome (SDNS) and 10 (25%) were steroid-resistant nephrotic syndrome (SRNS). The mean age at disease onset was 5.4 ± 2.9 years (range 1.3–16 years). The mean disease duration was 3.2 ± 2.5 years (range 1–10 years) and the mean number of relapses was 3 ± 2 (range 0–8 relapses) among cases.p-value = 0.01 and 0.001 respectively). On the other hand, there was no statistically significant difference as regards the height.There was no statistically significant difference between cases and controls as regards the age and sex. The weight and BMI were significantly higher in nephrotic patients as compared to the healthy controls  as compared to controls. However, there was no statistically significant difference as regards the mean diastolic blood pressure. Also significantly higher percentage of stage 1 and 2 hypertension was found among cases as compared to controls . Among the nephrotic patients, 35% were found to have hypertension .There was a significantly higher mean systolic blood pressure in the cases group . In this study, 17 out of 40 patients (42.5%) had hypercholesterolemia but none of controls had (p < 0.001). Similarly, 17 patients (42.5%) had hypertriglyceridemia compared to 3 children (10%) in the control group (p = 0.003).The mean total serum cholesterol and triglyceride levels were significantly higher among cases than controls with Among our patients, 60% had received non steroid-immunosuppressive agent. 30% of patients had received calcineurin inhibitors (CNI), 15% received mycophenolate mofetil (MMF), 2.5% received cyclophosphamide (CYP), 12.5% received combined therapy .Among patients with SRNS and SDNS, 11 patients had underwent renal biopsy; 4 patients had minimal change disease (MCD), 4 patients had focal segmental glomerulosclerosis (FSGS), 2 patients had mesangiocapillary glomerulonephritis and 1 patient had membranous glomerulonephritis (GN).p-value = 0.01), number of relapses  and mean CIMT  than the other groups. However, patients with SRNS had significantly higher mean ACR . On the other hand, there was no statistically significant difference between the 3 groups of nephrotic syndrome  as regards other clinical and laboratory data.The clinical and laboratory data of the three nephrotic groups are shown in Table p value< 0.001  as compared to controls (mean of 0.391 mm) with 01 Table .Table 3Cn = 24) than those not receiving therapy (n = 16)  as shown in Table p-value = 0.04). However, there was no significant difference in CIMT between patients treated with CNI (n = 17) and those that were not treated with CNI (n = 23) .We found that the CIMT was significantly higher among patients with nephrotic syndrome receiving non-steroid immunosuppressive therapy , patients’ weight , height , BMI , age at disease onset , duration of the disease , number of relapses  and diastolic blood pressure . However, there were no significant correlations between CIMT and systolic blood pressure, total cholesterol, triglycerides, serum urea, serum creatinine or GFR. A negative, but statistically insignificant correlation was noted between CIMT and serum albumin  and albumin/creatinine ratio in urine .Correlations between CIMT and other clinical and laboratory data are shown in Table This study was designed to evaluate the CIMT in children with idiopathic nephrotic syndrome and its correlation with dyslipidemia and other risk factors.p-value = 0.01 and 0.001 respectively). Similar results were reported by other studies [In this study, the body weight and BMI were significantly higher in NS patients as compared to the healthy controls  had high total serum cholesterol > 200 mg/dL) and TG levels. Paripović et al. 0 mg/dL a high totp-value = 0.01), number of relapses . However, Ahmed et al. [p-value = 0.009) which is in agreement with the findings by Ahmed et al. [On stratification of the patients according to their response to steroids, patients with SDNS had significantly higher mean duration of the disease . However, unlike our results, Paripović et al. [In the current study, the mean CIMT was significantly higher among patients receiving non-steroid immunosuppressive therapy at the time of evaluation than those receiving steroids alone . It appears from our data that the mean CIMT becomes progressively higher with combination of immunosuppressive therapy. However, more number of cases have to be included in further studies to confirm this assumption.There was also a statistically significant higher mean CIMT among cases who received combined or serially immunosuppressive agents of CYP, CNI & MMF (n = 17) and those not receiving CNI (n = 23) . In consonance with our results, other studies [We didn’t find significant difference in CIMT between patients with nephrotic syndrome receiving CNI  which is in consonance with Mehta et al. [In our study, CIMT was also positively correlated to advancing patients’ age a et al.  study. Aa et al.  found tha et al.  and Paria et al.  reporteda et al.  study.Development of early atherosclerosis in children with nephrotic syndrome could be attributed to long periods of dyslipidemia even during remission of nephrotic syndrome . When CISystemic hypertension is a risk factor for the development of renal injury and cardiovascular disease . In the Paripović et al.  reportedThe main limitation of this study is the lack of long-term follow up to see the changes in CIMT over a period of time and lack of studying the effect of cumulative dose of steroids on CIMT. We did not investigate carotid function including distensibility, stiffness and elasticity.In conclusion, CIMT was significantly increased in children with NS. There was significant positive correlation between CIMT and duration of the disease, number of relapses, body mass index, diastolic hypertension and advancing age. However, it’s not correlated to total serum cholesterol or triglycerides level. CIMT was significantly higher among patients receiving non-steroid immunosuppressive therapy than those receiving steroids alone. As increased CIMT is a surrogate marker of atherosclerosis in children, the assessment of CIMT can be of benefit on the long term care of patients with NS.


Gemcitabine has shown clinical activity against angiosarcoma in small series, alone, or combined with taxanes. We aimed to evaluate its activity as a single‐agent in a larger series of patients with advanced angiosarcoma. We retrospectively reviewed the electronic medical records of consecutive adult patients with advanced angiosarcoma treated with single‐agent gemcitabine at our institutions from January 2010 to January 2021. Response was evaluated according to RECIST 1.1, and toxicity was graded according to NCI‐CTC v5.0. 42 patients were identified. 38 patients (90%) had received prior anthracyclines and weekly paclitaxel, and 9 (21%) had received pazopanib. The best tumor response was partial response (PR) in 16 patients (38%), or stable disease . All 8 patients with cardiac angiosarcoma experienced a PR. Median PFS was 5.4 months (95%CI: 3.1–6.5), and median OS was 9.9 months (95%CI: 6.6–13.4). Single‐agent gemcitabine has clinically meaningful activity in advanced, heavily pre‐treated angiosarcoma. We aimed to evaluate the activity of single‐agent gemcitabine in the largest series of 42 patients with advanced angiosarcoma. The best tumor response was partial response (PR) in 16 patients (38%), or stable disease , median PFS was 5.4 months, and median OS was 9.9 months. Single‐agent gemcitabine has clinically meaningful activity in advanced, heavily pre‐treated angiosarcoma. Informed consent was obtained from all patients or relatives.Eligible patients were adults with progressive, metastatic angiosarcoma neither eligible for surgical resection nor for a clinical trial, or having exhausted other conventional chemotherapy regimens. All cases were confirmed by a pathologist from the French network of expert sarcoma pathologists (RRePS). Imaging data were centrally reviewed, and only patients with confirmed tumor progression according to RECIST 1.1Exclusion criteria included bone angiosarcoma and treatment with gemcitabine in combination with other drugs.2.12 on days 1, 8, and 15 of a 28‐day cycle. Treatment was pursued until tumor progression or major toxicity. Standard laboratory tests were performed weekly. G‐CSF was administered in case of clinically meaningful neutropenia. Tumor evaluation using CT or MRI was performed every 2 cycles or earlier if clinically required.Patients received intravenous gemcitabine at a dose of 1000 mg/m2.2The primary endpoint was the best tumor response according to RECIST 1.1. Secondary endpoints were: progression‐free survival (PFS), overall survival (OS), and toxicity. PFS was defined as the time from gemcitabine initiation to disease progression, death, or last follow‐up. OS was defined as the time from gemcitabine initiation to death or last follow‐up. Gemcitabine‐related clinical and biological toxicities were retrospectively collected and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI‐CTCAE) version 5.0.2.3https://www.ncss.com/) was used for data analysis. The Kaplan–Meier methodMedian, ranges, and 95% confidence intervals (95% CI) were used to describe patients' characteristics. The NCSS 2020™ software (33.1n = 41), or patient's preference for oral treatments (n = 12). Out of the remaining 53 patients, 11 were excluded .Between January 1, 2010, and January 31, 2021, a total of 126 patients with metastatic angiosarcoma were treated at our institutions. Among them, 73 did not receive gemcitabine due to altered PS, progression, or death after weekly paclitaxel and/or doxorubicin  had received prior anthracyclines (either peri‐operatively or in the metastatic setting) and weekly paclitaxel, and nine (21%) had received pazopanib. Hence, gemcitabine was given as second, third, and fourth line in seven (17%), 20 (47%), and 15 (36%) patients, respectively.Overall, 42 patients were eligible for the present analysis. Median age was 52 years (range: 25–90), median PS: 1 (range: 0–2), 36 were women. Patients' baseline characteristics are summarized in Table 3.2The median duration of treatment was 5.2 months (range: 0.4–18.7). All patients but 9 (who rapidly progressed) received at least two cycles of treatment. One patient with metastatic cardiac angiosarcoma died of a non‐tumor‐related cause (head trauma) while she had an ongoing partial response.2) were needed in three patients (7%) due to cumulative hematological grade 2–3 toxicities after four cycles. Twenty patients (48%) were able to receive one or more subsequent treatment lines after progression under gemcitabine.Dose reductions (down to 800 mg/m3.3The median follow‐up was 8.5 months (95% CI: 4.7–12.3). The best tumor response was partial response (PR) in 16 patients (38%), or stable disease . All patients with cardiac angiosarcoma experienced a PR, as well as four of 10 patients with angiosarcoma arising in irradiated field, as well as three of the four patients with brain metastases. Median PFS was 5.4 months , we observed evidence of significant anti‐tumor activity, along with an acceptable toxicity profile.n = 25) from the Italian Rare Cancer Network.The primary aim of this study was to evaluate the anti‐tumor efficacy of single‐agent gemcitabine in second, third, or fourth metastatic line. We were not able to replicate the response rate of 68% reported in a previous series  were lower than those observed in less heavily pre‐treated patients in the Italian series . Hence, our results are not contradictory with those previously reported in a smaller series, and add evidence to the activity of gemcitabine in patients with angiosarcoma pre‐treated with the current standard of care for advanced disease. Notably, the treatment line did not seem to affect PFS, suggesting that gemcitabine might be active even in some multi‐drug resistant tumors, possibly due to its activity in ABCB1‐expressing tumor cells.In this context, single‐agent gemcitabine appears an attractive option in advanced angiosarcoma, among other options. Currently approved systemic treatment options beyond anthracyclines and weekly paclitaxel are limited to pazopanibKDR (a gene encoding for VEGFR2) activating mutations in up to 26% of cases.KDR mutations). We have also reported dramatic responses to pazopanib  following treatment with the NOTCH inhibitor crenigacestat,Anti‐VEGF agents seem a coherent approach given the vascular phenotype of angiosarcoma and the identification of Investigational approaches include PD‐1/PD‐L1 inhibition, with several responses reported in small series of patients.Another critical finding of the present series is the activity of gemcitabine in patients with advanced cardiac angiosarcoma, with all eight patients having an objective response. Cardiac angiosarcoma represent a difficult‐to‐treat disease since the primary tumor is often unresectable, metastatic spread (to lungs and brain) is frequent at diagnosis, and the use of cardiotoxic drugs such as anthracyclines might be limited due to altered cardiac function.KDR mutational status, TLS status, and expression of hENT1. However, we believe that our clinical data strengthen existing recommendations on the role of gemcitabine in the treatment of advanced angiosarcoma.Overall, our study is limited by its retrospective nature and the lack of translational data on 4.1Gemcitabine is an attractive option in advanced, pre‐treated angiosarcoma due to its schedule of administration  and a favorable toxicity profile. Single‐agent gemcitabine represents an additional therapeutic option in advanced angiosarcoma adult patients pre‐treated with doxorubicin and/or weekly paclitaxel.5In our experience, single‐agent gemcitabine demonstrated effective palliation along with acceptable toxicity in patients with progressive, advanced angiosarcoma. Our findings confirm that it represents an additional therapeutic option in this population, and its use should be further investigated in specific subpopulations (including cardiac angiosarcoma).All authors have made substantial contributions to acquisition, analysis, and interpretation of data; all authors have been involved in revising the manuscript critically for important intellectual content; all authors have given final approval of the version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Dr. Mir has received consultancy fees from Astra‐Zeneca, Blueprint Medicines, Boehringer‐Ingelheim, Bristol‐Myers Squibb, Eli Lilly, Ipsen, Merck Sharpe & Dohme, Pfizer, Roche, Servier, and Vifor Pharma. Dr. Mir is an employee and shareholder of Amgen since February 1, 2022. Dr. Watson has received consultancy fees from Deciphera and Amgen. Dr. Faron has received consultancy fees from HRA Pharma. Dr. Le Péchoux has received consultancy fees from Amgen, Astra‐Zeneca, Eli‐Lilly, Nanobiotix, and Roche. Prof. Court has received consultancy fees from Medtronics and Safeorthopaedic. He is a shareholder of NeuroFrance and SpineGuard. Dr. Le Cesne has received consultancy fees from Amgen, Bayer, Eli‐Lilly, Novartis, Pfizer, and PharmaMar. Other authors have no conflict of interest to disclose.Table S1Click here for additional data file.


Studies on the electrocardiogram findings in African pregnant women are limited. There is no information available in the literature on the electrocardiographic parameters of pregnant Angolan women.The aim of this study was to describe electrocardiographic findings in women with normal pregnancies in Bengo Province, Angola.This is a community‐based study with a cross‐sectional design conducted between September 2013 and March 2014 in Bengo. The study involved 114 black pregnant women, compared with a paired control group comprising of 120 black non‐pregnant women, aged 15 to 42 years. A 12‐lead electrocardiogram and a rhythm strip were recorded for all participants.p < .001), PR interval , QT interval , QTIc Fridericia , QTIc Framingham  and T‐wave axis .The main electrocardiographic changes found were: Sinus tachycardia (4.4% vs. 2.5%), T‐wave inversion (14.9% vs. 1.7%), Minor ST segment depression (4.5% vs. 0%) and left ventricular hypertrophy .In this study, the mean age was 26.2 ± 7.3 years. Comparing pregnant women vs. non‐pregnant, we found the following mean values: Heart rate (83 bpm vs. 74 bpm, Pregnant Angolan women compared with controls, had several significantly higher values for heart rate, and significantly lower values of systolic blood pressure and diastolic blood pressure, PR interval, QT interval, QTc interval by Fridericia and Framingham and T‐wave axis. Sinus tachycardia, T‐wave inversion, and left ventricular hypertrophy, were the main electrocardiographic changes found. higher values for heart rate,significantly lower levels of systolic blood pressure and diastolic blood pressure, PR intervals, QT intervals and QTc intervals according to Fridericia and Framingham and the T‐wave axis.The main electrocardiographic changes found are:Sinus tachycardia, T‐wave inversion, minor ST segment depression and left ventricular hipertrophy.Angolan women, compared with their non‐pregnant peer controls, displayed: Akinwusi et al. , in a crThere is no information available in the literature on the parameters of electrocardiograms in Angolan women with normal pregnancies. Although there are some data in some African populations, local studies are needed, given the variation in genetics, environmental and behavioral conditions of the different population groups.Using the data collected in the CardioBengo Study , based on the Surveillance Manual (STEPS) for Risk Factors for Chronic Diseases  WHO, . We meas2 were considered obese; with participants who currently smoked classified as smokers.The following risk factors for CVD were considered: participants who reported being on some antihypertensive medication or who presented mean values of systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg were classified as hypertensive; participants with a defined diagnosis or treatment for Diabetes or fasting glycemia >126 mg/dl or postprandial glycemia >200 mg/dl) were considered diabetic; participants with total cholesterol levels >240 mg/dl (6.2 mmoL/L) or undergoing statins were considered with Hypercholesterolemia; participants with body mass index ≥30 kg/mFor the analyzes described in the present work, an exclusion criteria was previous or current heart failure, history suggestive of congenital or valvular heart disease, diabetes mellitus, hypertension, stroke, thyrotoxicosis, sickle cell disease and anemia.2.1A 12‐lead electrocardiogram and a rhythm strip were recorded for all participants using a 12‐channel AsCARD Mr.Gray V 201 electrocardiograph . The examination was performed in a private way behind closed curtains, with the individual at rest, in supine position, respecting the participant's rights to privacy. The exam was digitally recorded using cardio TEKA v001 database software , and subsequently transferred to the Central Electrocardiography Laboratory at the University of Glasgow, where they were analyzed and processed by the University of Glasgow software and coded by the Minnesota Code  index (SV1 or SV2+RV5 or V6) was calculated, and left ventricular hypertrophy (LVH) was considered when the index ≥3.5 mV or 35 mm was determined  was obtained for skewed data. Data were analyzed considering pregnant and non‐pregnant groups and it was also compared some parameters by the trimester pregnancy.t‐test, proportions test for two independent populations, and Chi square (χ2) tests or, one‐way ANOVA and non‐parametric Kruskal‐Wallis tests were used for comparison between groups as appropriate. Bonferroni adjustments were used for multiple testing. The significance level was set at .05 and all statistical analysis was carried out using the software IBM SPSS®  version 26.Student's 3Table p = .034), QT interval , QTIc Fridericia , QTIc Framinghan  and T‐wave axis , while pregnant women had a significantly high value only for heart rate (HR) . Differences in other comparisons were not statistically significant.The ECG parameters for pregnant and non‐pregnant participants are presented in Table p = .010), while differences in other comparisons were not statistically significant.Table p = .726).Table 4In the present study we analyze the electrocardiographic findings in Angolans with normal pregnancies in comparison with a paired control group of non‐pregnant women. These data came from the population of the municipality of Dande, province of Bengo, in northern Angola. The electrocardiographic changes found can be explained by the physiological adaptations that occur during normal pregnancy.Our study has shown that pregnant women had significantly higher values for heart rate, and significantly lower SBP, DBP, PR interval, QT interval, and QTc interval by Fridericia and Framingham and T‐wave axis.It was found that pregnant women had significantly lower values of systolic and diastolic blood pressure. These results agree with the results of several studies , DII, DIII, and aVF (2.6%). Minor ST segment depression were observed in 4.5% of pregnant women. An observational study revealed that inverted T‐waves were seen in 8.2% of cases during the second and third trimesters, and the inversion was predominantly observed in lead III and chest leads V1–V3 . Written informed consent was obtained from all participants prior to data collection, following all human research standards according to the Helsinki declaration on the ethical principles for medical research involving human subjects.


Postoperative cardiac outcomes after intracardiac repair (ICR) are determined by numerous factors whereas right ventricle (RV) dysfunction is considered essential for them, as only few studies attempted to evaluate it postsurgically. RV's function is supposed to be the strong prognostic factor for patients diagnosed with congenital heart defects; therefore, assessing it is the main objective of the study.This is a prospective single‐centered cohort study performed on 50 pediatric patients with congenital heart disease (CHD) who underwent ICR between January 2019 and January 2022. All patients underwent echocardiographic assessment of RV function via tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC) at 1, 24, and 48 h. After surgery, where pre‐ and postoperative RV pressure, cardiopulmonary bypass (CPB), and aortic cross‐clamp (ACC) time were assessed. Similarly ventilation intensive care unit (ICU) and hospital stay times and mediastinal drainage were also monitored.p value of <0.002 and <0.001, respectively. The mean ± standard deviation of CPB and ACC times was 120.92 ± 74.17 and 78.44 ± 50.5 min accordingly, while those for mean ± standard deviation of ventilation time, mediastinum chest drainage, ICU and hospital stays were 30.36 ± 54.04, 43.78 ± 46.7 min, 5.9 ± 4.01 h, were 30.36 ± 54.0, 43.78 ± 46.7 min, 5.9 ± 4.01 and 10.3 ± 4.83 h, respectively.The mean ± standard deviation for pre‐ and postoperative RV pressure was 49.1 ± 16.12 and 42.7 ± 2.9 mmHg, respectively, whereas that for pre‐ and postoperative pulmonary artery pressure was 30.4 ± 2.6 and 24.2 ± 12.9 mmHg, with RV dysfunction plays the important role in longer recovery and intraoperative time, while its effect is mostly transient. The use of TAPSE and FAC methods is valuable in the evaluation of postoperative outcomes, and the former proved to be more effective. One of the most serious complications associated with it is right ventricle (RV) dysfunction that can lead to profound ischemia and myocardial infarction.CPB guarantees a motionless and bloodless surgical field by involving an extracorporeal circuit to provide physiological support. Typically, blood is drained by gravity out of the heart and lungs to a reservoir by venous cannulation and tubing. Later, a pump and artificial lung (oxygenator or gas exchanger) facilitate the return of the oxygenated blood to the arterial system.CPB is a surgical intervention that significantly affects systemic metabolism and endocrine function. Many trials have attempted and tried to assess the predictive value of fatty acid‐binding protein compared with other biomedical markers to predict perioperative myocardial injury and early ventricular dysfunction.Conversely, on the other hand, most interventions with CPB with cardioplegic arrest lead to ischemic–reperfusion injury resulting in myocardial dysfunction. This dysfunction may be temporary (up to 24 h), stunning, and even persistent in profound ischemia and myocardial infarction cases. However, there are many contributing factors such as preoperative myocardial dysfunction, degree of myocardial protection, systemic inflammatory responses, and alterations in signaling transduction systems.RV dysfunction pathology includes high RV preload or afterload, impaired right coronary artery perfusion, and decreased contractility. In contrast to the left coronary artery, perfusion of the right coronary artery occurs during the whole heart cycle. Moreover, high RV pressure due to pathological causes such as pulmonary hypertension leads to lower coronary artery perfusion, highlighting the importance of preserving the normal pressure inside the two ventricles. Additionally, the RV normally provides low‐pressure perfusion for the pulmonary vasculature, making it highly sensitive to even moderate increases in pulmonary arterial pressure. However, RV dysfunction is usually a result of different mechanisms, and that is why RV failure is associated with many underlining conditions. Contractility impairment as one of the major causes of RV dysfunction is mainly caused by perioperative RV ischemia and infarction. Volume overload, on the other hand, is commonly developed as a result of tricuspid or pulmonic regurgitation leads. However, the causes of pressure overload include left‐sided valvular disease, cardiomyopathy, pulmonary hypertension, embolism, acute respiratory distress syndrome (ARDS), and high positive‐pressure ventilation. Pulmonary hypertension or contractile impairment may lead to RV failure associated with rapid progression to RV dilation, resulting in higher end‐diastolic pressure. That can push the ventricular septum toward the already underfilled left ventricle (LV) chamber, which, in its turn, reduces LV preload and decreases CO.The physiopathological process of RV failure after cardiac surgery is more complex than what we have described above in the traditional model. More than one mechanism is involved in the process, including pulmonary hypertension primarily associated with CPB, pre‐existing pulmonary hypertension, and ventricular interdependency. Inflammatory mediators after CPB may mediate the increase in pulmonary resistance and vasoconstriction after CPB. These mediators may result from endothelial damage or ischemic and reperfusion mechanisms due to inadequate blood flow through the bronchial arteries. As a result, nitric oxide and prostacyclin go down, while thromboxane A2 and endothelin level up. This represents the imbalance between vasoconstriction and vasodilation factors. Additional factors disturb the hemodynamic status of RV and increase pulmonary hypertension, such as administration of heparin and/or protamine, pulmonary microembolism phenomena, ischemia of the RV, metabolic acidosis, hypercapnia, hypothermia, hydric overload, poor myocardial protection, extended extracorporeal circulation time, obstruction of vascular grafts, and loss of auricular–ventricular synchrony.The relevant diagnostic methods are used to prevent these complications, and one of them is echocardiography.The echocardiographic machine uses ultrasound waves, and it must have some features to perform standard pediatric echocardiograms. These features must include two‐dimensional (2D) imaging, M‐mode, pulsed‐wave and continuous‐wave Doppler, color flow Doppler mapping, electrocardiogram 2D gating, Doppler velocities, and a color monitor. Additionally, it must have the ability to measure cardiac structures and store moving images. A hard‐copy paper printout is desirable but not required.Although evaluating ventricular function is an essential part of every echocardiographic study on children with congenital or acquired heart disease, it is still challenging to evaluate the systolic function. That is because of the confounding effect of different factors, such as ventricular structure and the difference in loading conditions.Evaluating contractility, on the other hand, is also difficult because of the complex structure physiology of RV. Many indices have been described as surrogate parameters of RV global systolic function. According to the latest guidelines for cardiac chamber quantification, sonographers recommended observing the right heart from various perspectives using multiple acoustic windows. Additionally, including multiple parameters is strongly needed to give the best result.During cardiac anesthesia and in the intensive care unit (ICU), clinicians use echocardiography to make the right decisions regarding surgical procedures and perioperative management.Thus, considering the prevalence of heart diseases in children, the use of echocardiography to assess RV performance during the heart cycle is crucial to determine the long‐term outcomes of surgery and to take the appropriate intervention in case of poor RV performance, especially if there are congenital diseases present. Therefore, RV evaluation using the appropriate measurements should be performed routinely using various parameters according to the main diagnosis.In modern clinical practice, the evaluation of RV systolic function is routinely implemented via Doppler tissue imaging, tricuspid annular plane systolic excursion (TAPSE), derived tricuspid lateral annular systolic velocity (S wave), and fractional area change (FAC).2The FAC is a 2D measure of RV global systolic function where the normal value is >35% in adults.3TAPSE is another 2D measuring procedure that evaluates systolic RV function in the M‐mode apical four‐chamber view by placing the cursor on the lateral section of the tricuspid valve annulus. It assesses the tricuspid valve's excursion by calculating the difference in distance between the annulus and the apex at the end‐diastole and end‐systole phases. This distance can also be easily quantified with 2D imaging techniques,Electrocardiogram (ECG) tracing can be used to determine the optimal frame to measure the longitudinal shortening of the RV. The normal value in adults is greater than 1.6 cm, which is different from that of children. TAPSE, conversely on the other hand, can assess RV function effectively in patients with pulmonary hypertension or those with nonoperated hearts. Despite the reproducibility of the measure, it correlates poorly with EF compared with MRI measures. Therefore, it should be cautiously used in congenital heart defects that involve RV, such as single and systemic RVs, and Tetralogy of Fallot.As RV function plays a crucial role in the outcomes of patients who undergo cardiac surgery, our study aims to compare the efficacy of TAPSE and FAC in the postoperative measurement of RV function. This also includes an investigation of the influence of the surgical approach and its correlation with CPB.4This is a prospective observational study on pediatric patients with CHD who underwent cardiac surgery at Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India, between January 2019 and January 2020.A total of 50 patients were enrolled, and the following inclusion criteria were applied: age between 1 month and 18 years and the presence of CHD. Exclusion criteria comprised consisted of preoperative moderate‐to‐severe RV dysfunction, single ventricle physiology, an abnormal left coronary artery from the PA (ALCAPA), and LV dysfunction besides moderate‐to‐severe RV dysfunction Table .4.1The study was approved by the institutional ethics committee, and all the participants provided written informed consent. All the operations, including the aorta‐bicaval cannulation, were performed under traditional CPB through median sternotomy. All the surgical procedures were provided access through the right atrium where we cross‐clamped the aorta, all patients were cooled to 28°C, and cold‐blood cardioplegia (CP) was supplied through the aortic root to stop the heart.4.2Anesthesia was induced and maintained by the weight‐related doses of thiopental, fentanyl, midazolam, and pancuronium.After shifting patients to the operation theater, standard monitoring viz. ECG, pulse oximetry, and invasive blood pressure monitoring, temperature monitoring with the nasopharyngeal probe was done for all the patients enrolled in the study.Anesthesia induction was done by injecting ketamine 1 mg/kg, fentanyl 2 mcg/kg, and midazolam 0.02–0.05 mg/kg, and orotracheal intubation was facilitated by injecting vecuronium 0.08–0.1 mg/kg.Routine airway and ventilator management was done. Anesthesia was maintained with oxygen, sevoflurane, and top‐up doses of injected fentanyl, vecuronium, and midazolam.4.3In the postoperative period, analgesia and sedation were achieved via dexmedetomidine infusion at a rate of 0.2–0.7 mcg/kg/h. It is titrated as per the pain score. In patients with relative bradycardia, fentanyl/midazolam infusion was used. The dose of fentanyl infusion is at a rate of 0.5–2 mcg/kg/h and the dose of midazolam infusion is at a rate of 1–5 mcg/kg/h.In all cases, CPB was performed in the standard manner using a nonpulsatile roller pump, membrane oxygenators, and standard (uncoated) extracorporeal circuits under mild hypothermia (28°C). The circuit was primed with appropriate amounts of Plasmalyte‑A solution, mannitol, and sodium bicarbonate. Blood was added as required.Through the right atrium, the surgeon performed aorto‐bicaval cannulation, cold‐blood root CP (with del Nido solution), and ventricular septal defect repair with a glutaraldehyde‐treated pericardial patch. The right atrium was used to close the ventricular septal defect. Then, a restricted ventriculotomy was done in the RV outflow tract, beginning 0.5 cm below the annulus and extending for 1–2 cm, through which infundibular resection and pulmonary valvotomy were performed. Commisssurotomy  or release of tethering was used to treat pulmonary valve stenosis, as well as dilating the pulmonary valve with an appropriately sized Hegar dilator. The ventriculotomy was subsequently closed by a primary RV outflow tract patch using autologous glutaraldehyde‑fixed pericardium along with a bovine pericardial patch. From either route, the pulmonary annulus was assessed by passing a Hegar dilator expected for that weight if the pulmonary annulus was stenotic and of small size, followed by an incision of the RV outflow tract that extended across the annulus with resection of parietal and septal bands in the RV outflow tract.4.4Perioperative data were collected for CPB and aortic cross‑clamp (ACC) times, mean arterial pressure, and RV pressure. After the repair was completed, the pressure in the right ventricle/pressure in the left ventricle was measured in all patients. If there was no gradient between the RV and the PA and the hemodynamics was as steady, the value of 0.8 was accepted. All patients had intraoperative transesophageal echocardiography to assess the repair's adequacy and biventricular function. Hemodynamic status, particularly central venous pressure, cardiac rhythm stability, time to peripheral warming, and attainment of negative fluid balance were all measured postoperatively. We assessed the need for inotropes by calculating the inotropic score using the following formula:Inotropicscore = dopaminedose(μg/kg/min) +dobutaminedose(μg/kg/min)+100×epinephrinedose(μg/kg/min)+10 × milrinone dose(μg/kg/min)+10,000×vasopressin.4.5A single echocardiographer assessed the patients (using an ACUSON X300™ ultrasound machine with a frequency range of 1.2–13 MHz). As a reference for RV performance, TAPSE was estimated in the apical four‐chamber view using M‐mode echocardiography. The longitudinal excursion of the TAPSE's lateral annulus was found to have a high association with RVEF calculated from isotopic data. FAC was defined as (end‐diastolic area − end‐systolic area)/end‐diastolic area × 10. The values were obtained postoperatively by tracing the RV endocardium both in end‐diastole and end‐systole from the annulus, along the free wall to the apex, and then back to the annulus, along the interventricular septum. We recorded the values preoperatively and in the postoperative period after 1, 24, and 48 h.4.6t‐test. A p value of <0.05 was considered statistically significant.All the patients' data were entered into Microsoft Excel, and the analysis while it was carried out by STATA 14.2. Descriptive statistics (mean (SD), frequency [%]), where the characteristics of the study participants were described and analyzed with the paired 5The demographic data and male:female ratios are represented in Table According, to the postoperative echocardiographic data, the mean ± SD of TAPSE and FAC was 35.62 ± 3.59 and 14.4 ± 1.5 at baseline as compared with 8.80 ± 2.2 and 26.5 ± 2.40 at 1 h postoperatively respectively. However, the difference was statistically significant. The mean ± SD of TAPSE and FAC was 8.82 ± 2.21 and 26.5 ± 2.40 at 1 h postoperatively and 9.8 ± 1.9 and 28.5 ± 2.19 at 24 h postoperatively, respectively; the difference was statistically significant. The mean ± SD of TAPSE and FAC was 9.8 ± 1.9 and 28.5 ± 2.19 at 24 h postoperatively as compared with 11.7 ± 2.02 and 25.1 ± 12.6 at 48 h postoperatively, respectively. This comparison was statistically significant. The mean ± SD of TAPSE and FAC was 35.62 ± 3.59 and 14.4 ± 1.5 at baseline as compared with 25.1 ± 12.6 and 11.7 ± 2.1 at 48 h postoperatively, respectively, which was a statistically significant difference. From the echocardiographic data, the difference in CPB time between 1, 24, and 48 h postoperatively was statistically significant. The difference in ACC time at these same time was also significant.At 1 h after the operation, all 50 patients had RV dysfunction, and after 48 h, RV function was poor and additionally increased. In addition, TAPSE was a more accurate echocardiographic parameter than FAC.6The primary goal of this study was to use recognized deformational RV techniques to characterize and predict the acute intraoperative change in RV function. Improvements in surgical procedures and advances in sedation and critical care have increased postoperative cardiac endurance. Many factors have been attributed to the poor postoperative cardiac outcome, including underlying defect with a small primary PA annulus, extreme hypoplasia or insufficient right or left PA, ventriculotomy and RV outflow patch, myocardial hypoxia during CPB, or ARDS.6.1In the early postoperative period, RV dysfunction is described by elements of prohibitive physiology on Doppler echocardiography .Multiple processes such as increased RV afterload due to pulmonary hypertension affect RV contractility in cases of idiopathic dilated cardiomyopathy (DCM). RV is also affected by cardiomyopathic activity such as ventricular interdependence caused by septal dysfunction and myocardial ischemia due to lessened coronary perfusion. However, RV systolic dysfunction is believed to be a conventional final pathway in heart failure, which may lead to a poor prognosis.Tricuspid regurgitation forth and indications of foundational venous blockage, like raised jugular venous tensions, foresee higher mortality in patients with cardiovascular breakdown.CMRI is recommended as the gold standard approach for RV evaluation in guidelines; however, it is not readily available, which is seen as a serious limitation to its use.n = 13/24) of patients demonstrated RV dysfunction. After 12 weeks, only 15.3% (n = 2/13) still present the dysfunction. The presence of cyanotic spell (p = 0.006), recurrent chest infection (p = 0.002), increased hematocrit (p = 0.02), and increase in serum iron level (p = 0.002) were considerably correlated with postoperative RV dysfunction, resulting in extended ICU stay and slower recovery. Preoperative RV dysfunction was related to difficult weaning from bypass and poor postoperative outcomes (p < 0.001). Singh et al. concluded that RV dysfunction is frequently present even after adequate ICR. However, in this setting, its etiology remains to be established. In this study, the preoperative clinical profile and fluctuations in serum iron levels were important contributing factors to postoperative outcomes.Singh et al.p = 0.41). Though, only RV dysfunction patients had an iron overload. The myocardium of the tetralogy of Fallot lacks antioxidants, making it susceptible to free radical‐mediated injury and leading to impaired RV functions. The CK‐MB levels were significantly higher in patients who acquired postoperative RV dysfunction. That indicates that myocardial impairment in patients after ICR is significantly greater in patients with RV dysfunction than in those patients with a normal postoperative course.Chaturvedi et al.B = 0.56, p < 0.0001, and B = 0.35, p = 0.0002 per mm, respectively) and nonischemic etiology of heart failure  were independent predictors of TAPSE . TAPSE's predictive value was not related to the cause of heart failure or any of the other clinical parameters studied. The authors thought that TAPSE might have diminished in heart failure individuals with heart failure with LV dysfunction, especially those who have reduced longitudinal septal motion. TAPSE levels were also lower in patients with ischemic heart failure. However, the absolute decrease in TAPSE was minimal. It appears to have no major impact on TAPSE's clinical use, whether as a marker of RV systolic function or as a predictive factor.In heart failure, Kjaegaard et al.6.26.2.1Repair at a young age has been shown to minimize postoperative RV dysfunction caused by persistent hypoxia and stress loading, which causes the substrate in the myocardium that is liable for arrhythmias and diastolic brokenness in patients going through late repair. Significant RV remodeling has been predicted if repairs are carried out before the age of 6 months. It has been suggested that irreversible changes are set in by 4 years of age, based on microscopic analysis; consequently, repair before the age of 3 years is optimal. According to the research above, repairs performed before 3 years of age may cause myocardial changes to recur. Still, the best functional outcome is attained before 1 year of age when changes are just starting to emerge. Therefore, at 3 years of age, the foundation of irreversible changes, “age” may have decreased the effect on postoperative outcomes.6.3According to the literature, more than 18 g% hemoglobin level has been linked to serious disease. RV physiology can be unreliable preoperatively or postoperatively. It is unclear whether this is part of the same pattern or if the same functional substrate is involved. Diastolic dysfunction may indicate greater ischemia myocardium, hence a higher risk of reperfusion injury or ischemic offense.p values of <0.002 and <0.001, respectively.In this prospective observational study, we examined the demographic attributes and other factors of 50 patients. The difference between preoperative and postoperative RV and PA pressure was statistically significant with The management of the CPB machine and the CP emulsion directly influence postoperative states. Davidson et al.7After ICR, RV dysfunction causes a long recovery time and a delayed postoperative course. Preoperative RV diastolic dysfunction could be another marker for distinguishing populations with a higher risk of postoperative mortality or requiring vasoactive support and those with difficulty weaning from bypass.CPB time is directly proportional to RV dysfunction that commonly occurs after ICR and is transient and resolves in the maximum number of patients after 48 h. The application of TAPSE and FAC pre‐ and postoperatively enables the evaluation of to evaluate postoperative outcomes  effectively, whereas TAPSE proved to provide a more accurate estimate of RV function when compared than FAC.8This study has limitations, such as the small sample size from a single center and the lack of follow‐up data to evaluate the effect of RV systolic dysfunction on survival. The patients enrolled in the study were assessed by a pediatric cardiologist and designated echocardiographer who were coauthors in the study. Further studies involving a greater sample size, and long‐term follow‐up data will be required to better understand the effect of RV systolic dysfunction on survival rate.Vishal V. Bhende: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing–original draft; writing–review and editing. Tanishq S. Sharma: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing–original draft; writing–review and editing. Bhadra Y. Trivedi: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Amit Kumar: Data curation; formal analysis; investigation; methodology; project administration; software; supervision; validation; visualization. Dushyant M. Parmar: Data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Paresh Nerurkar: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Prachi M. Shah: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Naresh J. Fumakiya: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Hardil P. Majmudar: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Sohilkhan R. Pathan: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization.The authors declare no conflict of interest.The lead author Vishal V. Bhende affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


To evaluate the role of in‐bore MRI‐guided biopsy (IB‐MRGB) in the diagnosis of clinically significant prostate cancer (csPCa).In this tertiary single centre study, a total of 125 consecutive patients receiving IB‐MRGB over a three‐year period were evaluated, including 73 patients who had prior biopsies and 52 biopsy‐naïve patients. We assessed cancer detection rate of patients according to the degree of suspicion based on mpMRI findings. Histopathological data were reviewed by experienced uropathologists.The mpMRI was suspicious for PCa (PI‐RADS 4/5) in 77% (96/125) and equivocal (PI‐RADS 3) in 23% (29/125). The detection rate for csPCa was 54.2% (52/96) and 20.7% (6/29) for suspicious lesions (PI‐RADS 4/5) and equivocal lesions (PI‐RADS 3), respectively. In subgroup analysis, patients with previous negative biopsy, overall positive biopsy rate and csPCa detection rate were 48.3% (19/35) and 34.5% (13/35), respectively. In patients on AS, 36/44 (81.8%) and 21/44 (47.8%) had PCa and csPCa respectively. In biopsy‐naïve patients 34/52 (65.4%) and 27/52 (51.92%) had PCa and csPCa respectively. Of the patients on AS, 18/44 (41.6%) upgraded from ISUP 1 to ISUP 2 PCa, and 4/44 (9.1%) upgraded from ISUP 1 to ISUP 3 PCa on IB‐MRGB. A total of 14 Clavien‐Dindo≤2 complications occurred in 14 patients (11.2%) that were directly related to the biopsy. No Clavien‐Dindo≥3 complications occurred.MRI‐targeted biopsy is suitable for assessment of csPCa. Given the favourable complications profile, its use may be considered in both the initial biopsy and re‐biopsy settings. In‐bore MRI guided biopsy of the prostate gland provides accurate is safe and feasible method to investigate suspicions of prostate cancer. Prostate cancer (PCa) is the second most common cancer amongst men.mpMRI with standardized Prostate Imaging‐Reporting and Data System (PI‐RADS) has improved diagnostic accuracy of PCa, and is incorporated into the pathways for diagnosis of PCa as well as active surveillance (AS).The present study protocol was approved by the local ethics committee , and the study was conducted in accordance with the principles of the Helsinki Declaration.In this analysis of a prospectively collected database from a tertiary single centre study, we examined 125 patients who underwent IB‐MRGB between June 2016 and August 2019. Patient details collected include age at IB‐MRGB, serum PSA prior to IB‐MRGB, DRE findings, previous biopsy method (TRUS or TP) and histology.Patients underwent mpMRI either at our institution or at an external service. The indication for IB‐MRGB was presence of PI‐RADS≥3 in patients on AS, biopsy‐naïve with clinical suspicion of PCa, or those with prior negative biopsy but ongoing suspicion of csPCa. Lesions amenable to biopsy are those within 4 cm of the rectum, limited by the reach of our biopsy needle. Lesions deemed not amendable include anterior lesions, lesions in the extreme apex,Our centre utilized only the in‐bore method of biopsies. Two radiologists experienced in prostate imaging and transrectal biopsy technique were involved (SH and PS). Initial mpMRIs were reviewed . The two radiologists performed all IB‐MRGBs in a subsequent session and both utilized the same technique on a 3 T machine. Pre‐procedure enema and oral ciprofloxacin were given on the day of procedure. If the patient had proven extended spectrum beta‐lactamase (ESBL) producing bacteria on previous urine culture, then intravenous ertapenem was also given for prophylaxis. Full details of the biopsy procedure are in Appendix Patient tolerance of the IB‐MRGB is not formally assessed in this study. However, as patients already had an mpMRI prior to the biopsy, this selects for patients who have sufficient tolerance of the MRI to also tolerate an IB‐MRGB.Histopathological data were reviewed by experienced uropathologists. Gleason scoring was then verified by a senior uropathologist and followed the recommendations of the 2005 consensus conference of the International Society of Urological Pathology (ISUP). csPCa was defined as ISUP≥2.Separate results were collected for patients with high volume ISUP 1. Maximal cancer core length (MCCL) was used as a surrogate measure of tumour volume in the biopsy specimen, and is defined as ≥6 mm of cancer.Complications (≤90 days) were assessed during the admission and follow‐up at 1 week and 3 months. All patients were either reviewed in clinics or by phone call. For patients undergoing active treatment, complications were assessed at the commencement of this. The definition of sepsis was according to the ‘Third International Consensus Definitions for Sepsis and Septic Shock’.The primary endpoint was csPCa detection. Secondary endpoints included overall PCa detection, positive biopsy stratified by PI‐RADS score and complications.Descriptive statistics were performed. Statistical significance was calculated using the either the Pearson‐Chi‐squared test or the Fisher's exact test. Statistical analysis was performed using SPSS v. 26 .Of 125 patients, 52/125 patients were biopsy naïve, 35/125 patients had prior negative biopsy and 38/125 patients were on AS (Table Median age was 65 years (IQR: 59.0–70.1) and mean serum PSA prior to biopsy was 6.3 ng/dL (IQR: 4.6–8.4). mpMRI was suspicious for PCa (PI‐RADS 4/5) in 96/125 (76.8%) patients and equivocal (PI‐RADS 3) in 29/125 (23.2%) patients.The median size of targeted lesions was 11 mm (range: 4–34 mm). PCa was detected in 84/125 (67.2%) of IB‐MRGB. Detection rate of csPCa was 58/84 (69.0%). Detection rate for csPCa in suspicious lesions (PI‐RADS 4/5) was 52/96 (54.1%) and 6/29 (20.7%) for equivocal (PI‐RADS 3) lesions  had MCCL of 6 mm or more. All of these patients underwent AS.A total of 14 minor complications (Clavien–Dindo ≤2) occurred in 14/125 patients (11.2%): five cases of urinary tract infections (UTI)  (Clavien–Dindo 2), one vasovagal episode needing intravenous fluids (Clavien–Dindo 1), four cases of haematospermia not needing treatment (Clavien–Dindo 1), three cases of macroscopic haematuria including two needing catheterisation and bladder washout (Clavien–Dindo 2) and one not needing intervention (Clavien–Dindo 1) and one episode of urinary retention needing catheterisation. No Clavien–Dindo≥3 complications occurred.With increasing utility of pre‐biopsy mpMRI,More recently, TP‐biopsies have increasingly replaced TRUS‐biopsies in certain institutions given the favourable infectious complications profile.In our study, we found that of the patients who have previously underwent a biopsy with either negative or insignificant results, 42.4% of those who underwent an IB‐MRGB demonstrated csPCa. This highlights that IB‐MRGB may be particularly useful for repeat biopsies. Comparatively, 28% of patients can avoid a biopsy with negative mpMRI results.We chose the in‐bore technique for our biopsy as it allowed direct visualization of the lesion of interest within the same system. This aimed to reduce sampling error and false negatives, which is particularly significant for targeting smaller lesions as the needle can be visualized piercing the target lesion Appendix . A more et al. found 4.3% of PI‐RADS 3 lesions contained csPCa according to Epstein's criteria.We observed that higher rates of csPCa are associated with higher PI‐RADSv2 rating, a finding seen in prior studies.et al. also demonstrated 31 of 46 tumours were anterior in a series of men with repeated negative biopsies,As expected, detection rate for both PCa and csPCa increased with PI‐RADS score, where 67.6% of PI‐RADS 4 lesion showed PCa and 92% of PI‐RADS 5 lesions showed PCa. csPCa detection rate for PI‐RADS 5 lesions was 64.0%. This is low comparing to a recent review where 72% of PI‐RADS 5 lesions represented csPCa.et al. reported rates of upgrading on systematic biopsies were 38.8% versus 16.7% for targeted biopsies.Several prior studies examined the concordance between systematic prostate biopsy Gleason grades and RP Gleason grades. Specifically, De Luca et al. found that mpMRI had a sensitivity of 72% for tumours with ISUP≥2et al. demonstrated a false positive rate of 40–42%,Given that IB‐MRGB relies on the mpMRI, our study relies on the accuracy of mpMRI to detect suspicious lesions. Le We performed IB‐MRGB via the transrectal route. This was chosen as patients required only sedation and is also the route of IB‐MRGB with the most experience.Our antibiotic regimen included oral ciprofloxacin given on the day of procedure, with additional ertapenam if there was proof of ESBL bacterium. We observed five (4.0%) cases of UTIs, with two patients requiring intravenous antibiotics. This was comparable to the rates of infectious complications from TRUS‐biopsies.Vast majority of studies on IB‐MRGB have been done via the transrectal route, with one study examining TP‐biopsy and one study examining transgluteal biopsy.We observed 2.4% patients experiencing haematuria, which is lower than the 50% reported risk.Our study was not without limitations, and some have been discussed above. Given our IB‐MRGB is via the transrectal route, it is also not suitable for lesions in inaccessible areas of the prostate. We relied on mpMRI technology, which has inherent shortcomings discussed above.Another limitation of this study was selection bias. It was designed to assess the detection of csPCa in patients who have undergone IB‐MRGB, hence only patients who underwent IB‐MRGB were included. It also comprised a small cohort of patients.Finally, the diagnostic mpMRIs are not all performed in our institution and as such, we were not able to control this process. We aim to reduce the potential confounding by reviewing PI‐RADS 3 or above lesions at the MDTM where there are three experienced radiologists present to form a consensus. Furthermore, using external mpMRIs are a closer representation of real‐world scenarios, thus improves applicability of our data. These shortcomings notwithstanding, our study add to the growing body of literature supporting the judicious use of mpMRI and IB‐MRGB in selected patients.Our study contributes to evidence that mpMRI and MRI‐targeted biopsy provide valuable additions to the diagnostic evaluation of csPCa. With changes to our antibiotic regime and potential improvements to our infectious complications profile it may be appropriate as the biopsy technique of choice prior to systematic biopsy in Australia. Despite the limitations of our study, it supports the use of mpMRI and MRI‐targeted biopsy as part of the diagnostic algorithm for csPCa.None declared.Preliminary results of this study was presented as a poster at the 40th Congress of the Société Internationale d'Urologie held on 10–11th October 2020.Marc Furrer:Data curation; formal analysis; writing – review and editing. Anne Hong: Data curation; formal analysis; writing – original draft. David Wetherell: Data curation; formal analysis; methodology; project administration. Stefan Heinze: Investigation; writing – review and editing. Paul Simkin: Investigation; writing – review and editing. Ken Chow: Formal analysis. Nathan Lawrentschuk: Writing – review and editing. Homayoun Zargar: Conceptualization; investigation; project administration; supervision; writing – review and editing.Appendix S1:Supporting InformationClick here for additional data file.