Search Results (9,935)

Polyethylene terephthalate (PET) has become the predominant material for single-use packaging owing to its cost and performance advantages. However, massive post-consumer waste leads to environmental concerns, and recycled PET from thermomechanical processing followed by chain extension often suffers from low toughness and poor processability, restricting its use to low-value applications. In this study, halloysite nanotubes (HNTs) and ethylene–methyl acrylate–glycidyl methacrylate random terpolymer (E-MA-GMA) were melt-blended with recycled PET to examine their synergistic modification effects. The DSC results show that HNTs retain a nucleating effect on recycled PET even with the co-addition of E-MA-GMA, albeit with a substantial reduction compared with their effect when used alone. Nevertheless, rheological measurements indicate that the combined introduction of E-MA-GMA and HNTs imposes a significantly stronger restriction on the relaxation behavior of recycled PET molecular chains than the individual addition of either HNTs or E-MA-GMA. This is attributed to the interfacial reactions between E-MA-GMA and the recycled PET matrix, as well as between E-MA-GMA and HNTs, leading to the formation of branching and hybrid structures. This synergistic restraint markedly reduces the crystallization growth rate of PET. As a result, the recycled PET/E-MA-GMA/HNTs composites maintain relatively lower crystallinity compared with the recycled PET/E-MA-GMA composite after high-temperature injection molding or annealing treatment, leading to superior impact resistance. The impact strength of the recycled PET/E-MA-GMA/HNTs composites is 2.28 and 2.14 times that of the recycled PET/E-MA-GMA composite under high-mold-temperature injection molding and annealing conditions, respectively. The approach presented here facilitates the substitution of virgin plastics with recycled PET in demanding applications. Full article

Caudal type homeobox 2 (CDX2) is an intestine-specific transcription factor that serves as a diagnostic marker of enteric differentiation and may also reflect tumor behavior and therapeutic susceptibility. Emerging evidence suggests that CDX2 expression may predict sensitivity to fluoropyrimidine-based therapy independent of tissue of origin. We report a retrospective case series of three patients with metastatic adenocarcinoma (aggressive variant prostate, minor salivary gland, and intestinal-type sinonasal tract) exhibiting strong CDX2 nuclear expression. In all cases, tumors were refractory to or lacked established standard systemic therapy. Treatment decisions were informed by the CDX2-positive enteric phenotype, leading to the initiation of fluoropyrimidine-based regimens. Response was assessed using PET-CT and MRI. All three patients achieved marked metabolic and clinical responses, including a sustained complete metabolic response in the prostate cancer case and durable disease control in the salivary gland and sinonasal tumors. These findings highlight CDX2 as a potential biomarker requiring validation, which may identify tumors intrinsically susceptible to fluoropyrimidines regardless of anatomical origin. CDX2 immunohistochemistry is widely available and inexpensive, and may complement genomic profiling in rare malignancies or in settings where standard treatment algorithms are limited. This report is hypothesis-generating and not intended to estimate response rates or treatment efficacy. Full article

Background/Objectives: Robotic-assisted radical prostatectomy (RARP) is a standard treatment for localized and locally advanced prostate cancer; however, optimizing oncologic control while preserving urinary continence and erectile function remains challenging. Advances in preoperative imaging, molecular diagnostics, artificial intelligence (AI), and intraoperative assessment have the potential to refine surgical planning and execution. This review summarizes contemporary evidence on advanced imaging and intraoperative technologies used to optimize RARP outcomes. Methods: A narrative literature review was conducted of English-language studies published between 2015 and 2025 using PubMed/MEDLINE, Scopus, and Google Scholar. Studies evaluating multi-parametric and bi-parametric MRI, prostate-specific membrane antigen-based positron emission tomography/computed tomography (PSMA PET/CT), AI-assisted tumor modeling, and intraoperative histologic or molecular imaging techniques in the context of robotic-assisted radical prostatectomy were included. Evidence from randomized controlled trials, prospective and retrospective studies, technical feasibility reports, and expert consensus statements was reviewed. Results: MRI remains central to anatomic mapping and local staging but consistently underestimates true tumor extent, with implications for margin control. AI-assisted platforms improve tumor contouring accuracy and may meaningfully influence surgical decision-making. PSMA-based imaging enhances detection of extra-prostatic extension and nodal disease and shows early promise for ex vivo and intraoperative guidance. Intraoperative margin assessment techniques are supported by randomized evidence demonstrating improved functional outcomes without compromising short-term oncologic safety and emerging digital histologic technologies offer scalable alternatives for real-time margin evaluation. Conclusions: Integration of advanced anatomic, molecular, and intraoperative imaging technologies represents an evolving multimodal paradigm in RARP. Combined use of MRI, PSMA-based imaging, AI-assisted modeling, and rapid histologic assessment may enable more precise, individualized surgery that balances oncologic control with functional preservation. Further validation is required to define optimal implementation in routine clinical practice. Full article

Alzheimer’s disease (AD) is traditionally defined by Amyloid-β (Aβ) plaques and tau neurofibrillary tangles, yet these proteinopathies alone fail to explain disease heterogeneity, progression, and cognitive decline. Emerging evidence identifies chronic neuroinflammation as a central integrator that converts molecular pathology into synaptic failure and neurodegeneration. In this context, Aβ acts as a danger-associated molecular pattern that activates microglial and astrocytic immune programs through receptors such as TREM2, TLRs, and RAGE, leading to inflammasome activation, cytokine release, and oxidative stress. These responses pathologically re-engage developmental complement pathways (C1q–C3–CR3), driving excessive synaptic pruning that correlates more closely with cognitive impairment than neuronal loss. Reactive astrocytes further amplify dysfunction by impairing glutamate and potassium homeostasis, promoting excitotoxic and metabolic stress, while inflammatory glia facilitate prion-like tau propagation via extracellular vesicles. Concurrent neurovascular inflammation disrupts blood–brain barrier integrity and cerebral perfusion, reinforcing immune-metabolic failure. Importantly, neuroinflammatory biomarkers (GFAP, sTREM2, YKL-40, cytokines, complement, and TSPO-PET) provide dynamic readouts of disease activity and therapeutic response. Together, these findings position AD as a disorder of failed immune resolution and support precision immunomodulatory and pro-resolving therapies aimed at restoring neuroimmune homeostasis rather than merely removing protein aggregates. Full article

Background/Objectives: Estrogen receptor (ER) expression is a key biomarker in breast cancer (BC) and guides endocrine therapy selection. Estrogen receptor-targeted imaging with 16ɑ-[¹⁸F]-fluoro-17β-estradiol (¹⁸F-FES) PET is recommended in several clinical guidelines for noninvasive assessment of ER status. In clinical practice, ¹⁸F-FES PET may also identify ER-negative malignancies or benign breast lesions with variable uptake patterns. This study aimed to systematically characterize ¹⁸F-FES PET/MRI uptake patterns in benign breast lesions and across breast cancer subtypes defined by receptor status, histology, and molecular phenotype. Methods: This retrospective single-center study included 41 women with 50 breast lesions who underwent simultaneous ¹⁸F-FES PET/MRI prior to any treatment. Histopathology or long-term follow-up served as the standard of reference. Maximum and mean standardized uptake values (SUVmax and SUVmean) were derived using MRI-based lesion delineation. Results: Both benign and malignant breast lesions measuring < 10 mm demonstrated low ¹⁸F-FES uptake (SUVmax < 1.00). ¹⁸F-FES uptake among benign breast lesions was variable, with SUVmax ranging from 0.44 to 1.57. In contrast, ER-positive lesions ≥ 10 mm exhibited substantially higher ¹⁸F-FES uptake (median SUVmax 2.76; range 1.23–9.74) compared with ER-negative tumors of similar size (SUVmax 0.30–0.94). ¹⁸F-FES uptake was consistent across histologic BC subtypes and did not differ significantly among ER-positive molecular subtypes. No significant associations were observed with HER2 status or tumor grade. Conclusions: Awareness of the heterogeneous ¹⁸F-FES uptake patterns in benign breast lesions, as well as the limited sensitivity for detecting ER-positive tumors < 10 mm, is essential for accurate image interpretation. ¹⁸F-FES PET/MRI enables reliable assessment of ER expression in BC lesions ≥ 10 mm, with uptake patterns remaining consistent across molecular and histologic subtypes. Full article

Background: In triple-negative breast cancer (TNBC), the addition of immunotherapy has significantly improved outcomes. Immune-related adverse events (irAEs) can be accelerated in patients with pre-existing autoimmune (AI) conditions. The treatment-response standardized protocol used in clinical care raises concerns about the need for right-sizing strategies. As the use of immunotherapy expands, recognizing toxicity from recurrence and optimizing response-adapted approaches are essential to balance cure with quality of survival. Case Presentation: A 38-year-old pregnant woman with a distant history of uveitis and psoriasis was discovered to have pregnancy-associated TNBC. Postnatally, she was treated with neoadjuvant chemotherapy and pembrolizumab, followed by wire-guided left breast wide local excision and sentinel lymph node biopsy of the left axilla. After surgery, residual cancer was noted. She continued adjuvant pembrolizumab and adjuvant radiotherapy 40.05 Gy/15 fr to the breast and nodes, followed by a 13.35 Gy/5 fr boost to the tumour bed (breast). Despite a persistent residual tumour, pembrolizumab was continued as per protocol in a response-agnostic manner. At the end of one year of adjuvant pembrolizumab, she developed progressive numbness and weakness in the ipsilateral arm, initially raising suspicion for local recurrence. Comprehensive MRI and PET-CT imaging did not identify recurrent tumour or new metastatic disease. Electromyography confirmed a lower-trunk brachial plexopathy without a structural cause. An immune-mediated process was diagnosed by a process of elimination. Despite treatment with 1st-line high-dose corticosteroids and 2nd-line intravenous immunoglobulin (IVIG), improvement was limited. Therapeutic plasmapheresis led to marked functional recovery and symptom resolution 20 months later. Discussion: Four main challenges are identified: (1) the diagnostic difficulty in identifying local recurrence or radiation injury from immune-related neuropathy; (2) the emerging therapeutic role of plasmapheresis in steroid-refractory irAEs; (3) the possible inconsistencies between rare toxicities observed in clinical trials vs. clinical practice; and (4) the limitations in response in adjuvant therapy, particularly in patients with coexisting AI conditions. Conclusions: Early recognition and accurate distinction from tumour recurrence, as well as support for plasmapheresis as a potential option in steroid-refractory presentations, have been shown to improve patient survival and symptom reduction. With increasing use of immunotherapy, real-world toxicity data, predictive biomarkers, and personalized treatment strategies are urgently needed to balance cure with long-term functional outcomes. Full article

Introduction: Rapid and reliable neurovascular imaging is critical for time-sensitive diagnosis in acute cerebrovascular disorders, yet conventional magnetic resonance imaging (MRI) workflows remain constrained by acquisition speed, motion sensitivity, and limited integration of physiological context. We introduce the Intelligent Neurovascular Imaging Engine (INIE), a sensor-informed, topology-aware framework that jointly optimizes accelerated data acquisition, physics-grounded reconstruction, and cross-scale physiological consistency. Methods: INIE combines adaptive sampling, structured low-rank (Hankel) priors, and topology-preserving objectives with multimodal physiological sensors and scanner telemetry, enabling phase-consistent gating and confidence-weighted reconstruction under realistic operating conditions. The framework was evaluated using synthetic phantoms, a translational porcine stroke recanalization model with repeated measures, and retrospective human datasets. Across $N_{\mathrm{runs}}=120$ acquisition–reconstruction runs derived from $N_{\mathrm{animals}}=18$ pigs with animal-level train/validation/test separation, performance was assessed using image quality, topological fidelity, and cross-modal consistency metrics. Multiple-comparison control was performed using Bonferroni/Holm–Bonferroni procedures. Results: INIE achieved acquisition acceleration exceeding 70% while maintaining high reconstruction fidelity (PSNR $\approx 35$–36 dB, SSIM $\approx 0.90$–0.92). Topology-aware analysis showed an approximately twofold reduction in Betti number deviation relative to baseline accelerated methods. Cross-modal validation in a PET subset demonstrated strong agreement between MRI-derived perfusion parameters and metabolic markers (Pearson $r\approx 0.9$). INIE improved large-vessel occlusion detection accuracy to approximately 93% and reduced automated time-to-decision to under three minutes. Conclusions: These results indicate that sensor-informed, topology-aware, closed-loop imaging improves the reliability and physiological consistency of accelerated neurovascular MRI and supports faster, more robust decision-making in acute cerebrovascular imaging workflows. Full article

Microplastic (MP) pollution poses a significant and emerging threat to global marine ecosystems; however, regional data for the Caribbean remain limited. This study presents a spatial and temporal characterization of MPs in surface and mid-waters of the Colombian Caribbean (Atlántico and Magdalena departments), which were analyzed as independent compartments due to methodological differences in sampling strategies. Sixteen sampling stations were established across two anthropogenic influence zones: Zone 1 (nearshore/bather zone) and Zone 2 (offshore). MPs were quantified and characterized according to shape, color, size, and polymer composition using attenuated total reflectance Fourier transform infrared microspectroscopy (µATR-FTIR) and multivariate techniques. MPs were detected in 100% of samples. Surface water MP abundance was higher in Magdalena (4.5 MPs m⁻³) than in Atlántico (1.7 MPs m⁻³). Mid-water MP concentrations reached maximum values during the high rainfall season in Atlántico, reflecting localized hydrological and anthropogenic influences rather than vertical gradients. Higher concentrations were generally observed in the nearshore Zone 1 compared to offshore Zone 2, although these differences were not consistently statistically significant. Fibers and fragments were the predominant shapes, and synthetic–natural polymer blends, polyethylene terephthalate (PET), polypropylene (PP), and polyacrylic acid (PAA) were the most prevalent. Generalized Additive Models (GAM) indicated that strong fluvial inputs and proximity to urban and riverine sources were factors driving MP distribution. Additionally, the detection of polymers reported in the literature as rare and high-risk, such as acrylonitrile butadiene styrene (ABS), acrylonitrile styrene acrylate (ASA), styrene–ethylene–butylene–styrene (SEBS), and polyvinyl stearate (PVS), highlights the complexity of MP sources in the region. Overall, these results provide the first spatial and temporal characterization of MPs in the surface and mid-water of the Colombian Caribbean and identify critical contamination hotspots that warrant targeted mitigation strategies. Full article

Objective: This study aimed to evaluate and compare the diagnostic performance of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) in detecting metastatic cervical lymph nodes in patients with oral squamous cell carcinoma (OSCC), with a particular focus on radiologically indeterminate lymph nodes. Materials and Methods: A retrospective analysis was conducted on OSCC patients who underwent CT, MRI, and PET-CT imaging prior to surgery, followed by histopathologic confirmation. Lymph nodes were categorized as metastatic, indeterminate, or benign based on imaging criteria specific to each modality. Diagnostic accuracy, sensitivity, and specificity were calculated using histopathology as the reference standard. Results: After excluding lymph nodes classified as indeterminate on preoperative imaging, CT demonstrated an accuracy of 83.6%, sensitivity of 51.9%, and specificity of 92.4% for metastatic lymph node detection. MRI and PET-CT showed comparable accuracies (81.6% and 80.8%, respectively) and identical sensitivities (53.9%). In contrast, among radiologically indeterminate lymph nodes, most lesions identified on CT and MRI were histopathologically benign, whereas PET-CT yielded very few indeterminate nodes, all of which were benign. For benign node identification, PET-CT exhibited the highest sensitivity (86.8%) but lower specificity (55.8%), while CT and MRI demonstrated more balanced specificity (73.1%) with lower sensitivity. Logistic regression confirmed SUVmax as a significant predictor of malignancy (p < 0.001; odds ratio 1.71, 95% CI: 1.48–2.35), and ROC analysis demonstrated strong discriminative performance (AUC = 0.88), with an optimal SUVmax cutoff of 3.6. Conclusion: While CT remains highly specific, PET-CT offers greater sensitivity in detecting benign and indeterminate lymph nodes, making it a valuable adjunct in preoperative assessment. SUVmax serves as a strong quantitative indicator for metastatic involvement. A multimodal imaging approach may enhance diagnostic accuracy, particularly in cases where lymph nodes lack definitive radiologic features. Full article

Background: Indeterminate renal masses (IRMs) frequently require biopsy for characterization and often lead to unnecessary surgical interventions. ⁸⁹Zr-girentuximab is a positron emission tomography (PET) radiopharmaceutical targeting carbonic anhydrase IX, a biomarker overexpressed in clear-cell renal cell carcinoma (ccRCC). This real-world experience demonstrates the impact of ⁸⁹Zr-girentuximab PET on the clinical management of patients with IRM and its role in differentiating primary and metastatic ccRCC from other etiologies. Methods: This prospective single-center study, part of an expanded access program (NCT06090331), investigated patients with IRM on conventional imaging who underwent ⁸⁹Zr-girentuximab PET/computed tomography (PET/CT). Qualitative and quantitative PET/CT features of each lesion were assessed. Pathologic or clinical diagnosis was determined for all lesions. Referring physicians were surveyed to evaluate the impact of PET on patient management. Results: Seven male patients (age range, 57–78 years) were included; four had ccRCC (including two with metastatic disease) and three had oncocytoma (including one with Birt-Hogg-Dubé syndrome). Across all 32 lesions identified, ⁸⁹Zr-girentuximab PET/CT accurately characterized each lesion based on pathologic or clinical diagnosis. ⁸⁹Zr-girentuximab PET/CT identified ccRCC tumor thrombi in the inferior vena cava and renal vein branches (SUV_max 12.0–13.0), a perinephric deposit (SUV_max 36.4), and intramuscular (SUV_max 103.0), pulmonary (SUV_max 4.0–10.5), and osseous (SUV_max 10.2) metastases. ⁸⁹Zr-girentuximab PET/CT enabled the diagnosis of oncocytomatosis in one patient and detected a renal lesion with positive uptake that was occult on MRI. According to referring physicians, ⁸⁹Zr-girentuximab PET/CT changed clinical management in six of seven patients and improved patient care in all cases. Conclusions: ⁸⁹Zr-girentuximab PET/CT provides a noninvasive tool for characterizing indeterminate renal masses and metastatic ccRCC and may improve clinical problem-solving in complex scenarios. Full article

Purpose: To develop prognostic models integrating delta radiomics from prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) and dosiomics with clinical variables to predict metastasis-free survival (MFS) in patients with localized prostate adenocarcinoma treated with androgen deprivation therapy and external-beam radiotherapy. Materials/Methods: Delta-radiomics analysis included 43 patients. Radiomics features were extracted from the primary tumor on pre- and post-treatment PSMA-PET/CT, and delta features were calculated as relative changes. Eight high-variance features were selected and combined with clinical variables (age, Gleason score, initial PSA, and a binary variable, indicating the occurrence of PSA relapse). Data was split 70:30 with training-set imbalance correction. Predictors that were significant in univariate Cox regression (p < 0.05) were entered into multivariate Cox models, and five-year MFS was classified using a quadratic support vector machine. Dosiomics analysis included 48 patients. Dosiomics features were extracted from the planning target volume receiving 86 Gy and combined with pre-treatment radiomics and clinical variables using the same framework. Results: For delta radiomics, Model 1 (delta radiomics + pre-treatment radiomics + clinical) achieved the best performance (test c-score 0.58; AUC 0.70), exceeding Model 2 (pre-treatment radiomics + clinical; c-score 0.56; AUC 0.65) and Model 3 (clinical only; c-score 0.51; AUC 0.56). For dosiomics, Model 1 showed the highest performance (test c-score 0.56; AUC 0.67) compared with Model 2 (c-score 0.55; AUC 0.62) and Model 3 (c-score 0.50; AUC 0.54). Conclusions: Integrating delta radiomics or dosiomics with pre-treatment imaging and clinical variables improves MFS prediction and supports their role as non-invasive biomarkers for individualized radiotherapy in localized prostate cancer. Full article

Background: Cardiac sarcoidosis (CS) is associated with potentially serious complications, including heart failure and life-threatening arrhythmias. The diagnosis and management of CS is multifaceted, requiring a multi-disciplinary team (MDT)-based approach. A new regional CS clinical service was established in Sussex County (UK) in January 2025. This service is based on a core of cardiologists working with a wider MDT, including specialists in pulmonary sarcoidosis, nuclear medicine and cardiac electrophysiology. This study assessed the clinical performance of this new service. Methods: Patients with suspected CS referred to the Sussex CS Service between January and December 2025 were included, as compared to a control cohort of patients referred for CS assessment before the service was conceived. Results: Of the 51 CS service referrals, 13 patients fulfilled the Heart Rhythm Society (HRS) criteria, all of whom were correctly diagnosed with CS, whilst only two out of seven HRS-positive control patients were correctly diagnosed. In the 38 HRS-negative CS service referrals, 8 patients (21%) were still given a clinical CS diagnosis compared to none in the HRS-negative controls. Of the 21 patients diagnosed with CS, 7 (33%) had active myocardial inflammation and 8 (38%) had LV systolic dysfunction. Where indicated, immunosuppressive and heart failure therapies were initiated in all patients. Eight CS patients (38%) underwent implantable cardioverter defibrillator implantation. No deaths or heart failure hospitalisations occurred within the first 11 months. Conclusions: An MDT-based CS service model can provide multi-faceted care to patients, without major short-term adverse outcomes. The service model replicability and long-term outcomes require further assessment. Full article

Fluorine-18 fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) is widely used to evaluate patients with cancer and to detect various inflammatory processes. Here, we report a rare case of a 53-year-old woman with breast cancer who developed generalized pain, weakness, rash, and edema over the trunk after the first cycle of neoadjuvant pembrolizumab and cytotoxic chemotherapeutic agents. ¹⁸F-FDG PET revealed diffusely increased uptake in the muscles without skeletal or visceral metastasis, aiding in the diagnosis of paraneoplastic and pembrolizumab-associated myositis and subsequent monitoring. This case underscores the value of ¹⁸F-FDG PET in differentiating myositis from tumor progression and monitoring treatment response in such cases. Full article

Rabies remains a fatal yet preventable zoonotic disease, and understanding population-level knowledge, attitudes, and practices (KAP) is essential to guide national elimination strategies. This nationwide cross-sectional study assessed rabies-related KAP among 2116 residents across all major regions of Saudi Arabia. An online validated questionnaire measured sociodemographic characteristics and KAP indicators. Descriptive and inferential statistics, including logistic regression, were used to identify predictors of good KAP outcomes. Overall, more than half of participants demonstrated poor knowledge (54.9%), particularly regarding rabies etiology, transmission, and essential post-exposure wound care, while attitudes toward prevention were overwhelmingly positive (92%). Despite this, several unsafe practices persisted, including interaction with stray animals and use of traditional remedies. Good knowledge was significantly associated with higher income, pet ownership, and residency in the Central region, whereas younger age and Northern residency predicted poorer practices. Mediation analysis suggested that knowledge may partly explain (mediate) the association between sociodemographic characteristics and reported preventive practices; however, causal inference is limited by the cross-sectional design. These findings demonstrate substantial knowledge and behavioral gaps despite favorable attitudes and highlight the need for culturally tailored educational interventions, improved access to post-exposure prophylaxis, and strengthened One Health strategies to support rabies elimination in Saudi Arabia. Full article

Paravalvular leak (PVL) remains a clinically important complication after surgical or transcatheter valve implantation, presenting predominantly with heart failure (HF) and/or high-shear hemolysis. While redo surgery can be definitive, contemporary candidates frequently carry prohibitive operative risk, positioning transcatheter PVL closure as a key therapeutic alternative. However, available outcome data are largely derived from observational series and registries with heterogeneity in PVL mechanisms, prosthesis types, imaging protocols, and endpoint definitions. Standardized frameworks—such as those proposed by the PVL Academic Research Consortium—support harmonized PVL grading and clinically meaningful composite endpoints that integrate imaging/hemodynamic results with patient-centered outcomes. Across datasets, the most consistent determinant of benefit is residual PVL severity: procedural efficacy is most commonly defined as achieving ≤ mild residual regurgitation without prosthetic leaflet interference, device embolization, or major complications. This review provides a step-by-step, phenotype-driven approach to transcatheter PVL closure, emphasizing multimodality imaging (TEE and cardiac CT, with adjunct CMR and PET when appropriate), access and support planning tailored to valve position, and morphology-matched device selection—often requiring modular multi-device strategies for elongated crescentic channels, particularly in hemolysis-predominant presentations. We also synthesize evidence on complications and bailout management, with a focus on preventable high-severity events (leaflet impingement, embolization, stroke/air, vascular injury, tamponade) and standardized pre-release safety checks. Collectively, contemporary practice supports high implant success in experienced programs, with clinical improvement tightly coupled to procedural endpoint quality and careful Heart Team selection. Full article