Effect of early hysterectomy on a risk of incident cardiovascular disease in women: a nationwide population-based cohort study

Aim

Women who inevitably underwent surgical hysterectomy before natural menopause may have an earlier increase in hematocrit and storage iron than women who continue menstruation, thereby increasing the risk of cardiovascular disease (CVD) early. We aimed to evaluate the association of women with hysterectomy vs. without hysterectomy before their 50s with the risk of incident CVD.

Methods

This was a retrospective-cohort study, 135,575 women aged 40 to 50 years in 2011–2014 were extracted from the Korean Health Insurance Review and Assessment Service data and after propensity score matching, 55,539 pairs were included in hysterectomy and non-hysterectomy group respectively. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of cardiovascular death, myocardial infarction (MI), stroke, and coronary artery revascularization.

Results

After adjustment for confounding factors, hysterectomy group had an increased risk of MACCE compared with non-hysterectomy group (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.09–1.44). Regarding individual outcomes, cardiovascular death, MI, and coronary revascularization were comparable between the groups, whereas, the risk of stroke was significantly higher in hysterectomy group than non-hysterectomy group (HR, 1.31; 95% CI, 1.12–1.53). Even after excluding women who underwent oophorectomy, hysterectomy group had a higher risk of MACCE than non-hysterectomy group (HR, 1.24; 95% CI 1.06–1.44).

Conclusions

Early surgical menopause due to hysterectomy, not hormonal menopause, was associated with an increased risk for a composite of CVD, especially stroke. This suggest that the role of “uterus” as well as sex hormones may be important for the sharp increase in the risk of CVD in women after menopause.

Funding Acknowledgement

Type of funding sources: None.

Optimal strategy for antiplatelet therapy after endovascular revascularization in patients with lower extremity artery disease

Background

The duration of antiplatelet therapy after endovascular revascularization in patients with lower extremity artery disease (LEAD) has not been well established. This study aimed to evaluate the clinical outcome according to the duration of dual antiplatelet therapy (DAPT) in real practice.

Methods

From April 2009 to June 2019, 376 patients with LEAD underwent successful endovascular revascularization. After the procedure, the received single antiplatelet therapy (SAPT) or DAPT of various durations were classified into two groups (SAPT or DAPT <6 months vs. DAPT ≥6 months). The primary outcomes were major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The safety outcome was moderate-to-severe bleeding according to the Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria.

Results

Over the 40-month follow-up period, MACE occurred less frequently in the DAPT ≥6 months group than that in the SAPT or DAPT <6 months group (12.4% vs. 23.8%; hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.35–0.89; p=0.014) after inverse probability-weighted adjustment and propensity-score matching analysis (HR: 0.55, 95% CI; 0.30–0.99, p=0.048). The incidence of MALE did not show significant difference between the two groups (DAPT ≥6 months group: 17.1% vs. SAPT or DAPT <6 months group: 13.1%; HR: 1.05; 95% CI: 0.62–1.78; p=0.846). A significant difference between the DAPT ≥6 months group and the SAPT or DAPT <6 months group was not observed regarding the incidence of moderate-to-severe GUSTO bleeding.

Conclusions

In patients with LEAD, DAPT for ≥6 months after endovascular revascularization was associated with a lower incidence of MACE.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Research Foundation of Korea (NRF) grant funded by the government of Korea (MSIT) (No. 2019R1G1A1100442).

The impact of statin treatment intensity after endovascular revascularization for lower extremity peripheral artery disease

Purpose

There are few Asian studies on the clinical impact of statin intensity on clinical outcomes in patients with peripheral artery disease (PAD). This study investigated the clinical impact of statin intensity in patients with PAD after endovascular revascularization.

Material and methods

From April 2009 to June 2019, 376 patients with lower extremity PAD treated with endovascular revascularization were enrolled. They were classified into three groups according to statin intensity: no-statin, low-to-moderate intensity (LMI), and high-intensity (HI) groups. The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE).

Results

During the 40-month follow-up, MACE occurred less in the HI and LMI groups than the no-statin group (11.4% vs. 16.0% vs. 39%, p<0.001). In the adjusted Cox models, the HI group had the lowest MACE (hazard ratio [HR]: 0.347; 95% confidence interval [CI] 0.144–0.834; p=0.018) and MALE (HR: 0.344; 95% CI 0.120–0.989, p=0.048), while the LMI group had fewer MACE (HR: 0.319; 95% CI 0.169–0.604, p=0.048) than the no-statin group. HI therapy was associated with better outcomes in terms of MALE (HR: 0.377; 95% CI: 0.208–0.684; p=0.001) and repeat revascularization (HR: 0.449; 95% CI: 0.243–0.830; p=0.011) than the LMI group after the inverse probability treatment weighting analysis.

Conclusions

HI and LMI statin use is associated with a significant reduction of MACE than no statin use. Regarding MALE, HI statin use was associated with better outcomes than no statin or LMI statin use.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2019R1G1A1100442).

Clinical significance of serum YKL-40 in Behçet disease

BACKGROUND

Serum YKL-40 is an inflammatory biomarker of endothelial dysfunction and may play a role in the inflammatory process of Behçet disease (BD).

OBJECTIVES

Serum YKL-40 levels were evaluated in patients with BD in order to identify associations with other inflammatory cytokines and establish laboratory parameters. Serum YKL-40 levels were also compared with BD clinical features and disease activity.

METHODS

In total, 112 patients with BD and 45 age- and sex-matched healthy volunteers were included. Disease activity was assessed with BD Current Activity Form score and Electronic Medical Record-based Activity Index (EMRAI) score.

RESULTS

Serum YKL-40 levels were significantly higher in patients with BD (median 41·88, range 12·52-171·30 ng mL(-1) ) than in healthy volunteers (median 20·92, range 5·01-64·20 ng mL(-1) ; P < 0·01). The cut-off value for YKL-40 (30·005 ng mL(-1) ) was determined from the receiver operating characteristic curve. EMRAI scores and the proportion of patients in the active phase of BD presenting with two or more major criteria were significantly higher in patients with elevated YKL-40 levels (P = 0·04 and P = 0·04, respectively). A statistically significant elevation in YKL-40 levels was observed in patients with active BD compared with patients with inactive BD (P = 0·05). Serum YKL-40 values were positively correlated with interleukin-6 and EMRAI scores (both P = 0·04), indicating that serum YKL-40 levels are increased in patients with BD and positively correlate with disease activity.

CONCLUSIONS

YKL-40 may play a role in the pathophysiology of BD and provide a useful marker for monitoring patients with BD.

Aortic dissection: percutaneous management with a separating stent-graft--preliminary results

The authors used a separating stent-graft to treat Stanford type B aortic dissection. The separating stent-graft consists of two stents: a stent-graft and an inner bare stent. The separating stent-graft has three parts: a proximal stent, a graft made of synthetic polyester textile fiber, and a distal stent. A 12-F introducing sheath was used. After the separating stent-graft was placed, false-lumen thrombosis was evident in all six patients during a follow-up period of 206 days. The major advantages of this technique are that a cutdown and blood pressure control are not required.

Isolation and characterization of cultured human periodental ligament fibroblast-specific cDNAs

The molecular mechanisms that control the function of periodontal ligament (PDL) fibroblasts remain unclear. We speculated that the character of differentiating PDL fibroblasts is defined by the altered expansion of specific genes not found in neighboring gingival fibroblasts in the periodontium. To expand this set, subtractive hybridization was applied between cultured human PDL and gingival fibroblasts to identify genes differentially expressed in PDL. Consequently five candidate clones, PDLs (periodontal ligament specific) 5, -17, -22, -25, and -31 were identified and characterized by homology search, Northern analysis, and in situ hybridization. Although the mRNAs of these clones were expressed by bone marrow cells and rarely by gingival fibroblasts, the highest expression was detected in the PDL cells, which were uniformly distributed throughout the whole PDL. Amongst the five candidate clones, we focused on PDLs17, because it is a hypothetical protein whose biological function has not been reported yet in the database. Polyclonal antiserum raised against PDLs17 peptide was made, and stained the PDL fibroblasts, osteoblast-like cells and stromal cells in the bone marrow, but not gingival fibroblasts. The results suggest that clones, PDLs5, -17, -22, -25, and -31 may be used as PDL fibroblast-specific markers, and that PDLs17 could act as an important factor in the differentiation process of PDL fibroblasts.

Peroral immunization with Helicobacter pylori adhesin protein genetically linked to cholera toxin A2B subunits

Helicobacter pylori is a major cause of gastric-associated diseases. To evaluate the efficacy of a possible vaccine antigen against H. pylori infection, the chimaeric construct adhesin--CTXA2B, derived from H. pylori adhesin genetically coupled to cholera toxin (CTX) subunits A2 and B (CTXA2B), was expressed in Escherichia coli as an insoluble recombinant chimaeric protein. The protein was then purified by denaturation, renaturation and size-exclusion chromatography. The composition of purified adhesin--CTXA2B was verified by SDS/PAGE and Western blotting with antibodies to antigenic components of adhesin and CTXB, and confirmed as a chimaeric protein with G(M1)-ganglioside binding activity and adhesin epitopes by a G(M1)-ELISA developed using antibodies to adhesin. Oral immunization of mice with adhesin--CTXA2B induced higher levels of mucosal IgA and serum IgG antibodies to H. pylori adhesin and to CTXB than in mice immunized with adhesin or CTXA2B alone. Adhesin--CTXA2B was also demonstrated to be a potential protective antigen in a mouse model of H. pylori infection. The immunization of mice with adhesin--CTXA2B protected 62.5% of mice infected with H. pylori SS1 strain, whereas adhesin immunization was not able to confer protection to mice. This protection may be correlated with high levels of mucosal IgA and serum IgG antibodies against H. pylori adhesin. Taken together, the results indicate that the genetically linked CTXA2B acts as a useful mucosal adjuvant, and that the adhesin-CTXA2B chimaeric protein could be a potential component in future H. pylori vaccine development.

Activation of murine peritoneal macrophages by Streptococcus pneumoniae type II capsular polysaccharide: involvement of CD14-dependent pathway

In this study we examined the ability of capsular polysaccharide type 2 (PS) from Streptococcus pnemoniae to induce secretory and cellular responses in peritoneal macrophages. Tumour cytotoxicity induced by preincubation with PS was demonstrated to be concentration-dependent. PS-induced tumouricidal activity was partially abrogated by anti-tumour necrosis factor (TNF)-alpha and inhibitor of nitric oxide, whereas anti-interferon (IFN)-alpha/beta antibody and the scavengers of reactive oxygen intermediates had no effect. In addition, supernatants from macrophages treated with PS contained TNF-alpha, and their iNOS-enzymatic activity was significantly increased. Thus, the tumouricidal activity induced by PS appeared to be mediated by the production of TNF-alpha and nitrite. Treatment of macrophages with PS increased the expression of CD14, the receptor for lipolysaccharide (LPS)/LPS-binding protein. Moreover, blocking antibody to CD14 abrogated partially TNF-alpha and nitrite induction by PS, suggesting that the PS-induced CD14 upregulation was correlated with secretion of TNF-alpha and nitrite. Taken together, these results demonstrate that PS may induce macrophage-secretory and cellular activities, in part, possibly via CD14-dependent pathway.

Microinjection of opiates into the periaqueductal gray matter attenuates neuropathic pain symptoms in rats

We have previously demonstrated that electrical stimulation of the ventral periaqueductal gray matter (PAG) produced analgesia in neuropathic pain in rats. Opioids were also shown to be involved in analgesic effects. This study sought to determine whether opiates microinjected into the ventral PAG produce analgesia. Male Sprague-Dawley rats were chronically implanted with a guide cannula in the PAG under pentobarbital anesthesia and both the tibial and sural nerves were completely cut. Pain sensitivity was postoperatively measured with a von Frey filament and acetone applied to the sensitive area for 1 week. Opioids such as [D-Ala2,N-MePhe4,Gly(ol)5]-enkephalin (DAMGO) and [D-Pen ,D-Pen5]-enkephalin (DPDPE) were injected into the PAG. DAMGO, a mu-opioid agonist, and DPDPE, a delta-opioid agonist, were highly effective in reducing neuropathic pain. These effects were reversed by naloxone. These results suggest that the neurons in the ventral PAG are activated by opioids to produce analgesia and that specific opioid receptors are involved in the descending pain inhibition system from the PAG.

Association between periodontitis and hyperlipidemia: cause or effect?

BACKGROUND

Epidemiological studies suggest a relationship between periodontitis and coronary artery disease, but the mechanism has not been established. Recent studies in animals indicate that low dose endotoxin, as in a gram-negative infection, can induce hyperlipidemia and myeloid cell hyperactivity. The association between periodontitis, systemic exposure to Porphyromonas gingivalis, lipopolysaccharides (LPS), and hyperlipidemia has not been examined in humans.

METHODS

Sera were obtained from 26 adult periodontitis patients and 25 healthy control (C) subjects selected from patients and staff. Serum antibodies against Porphyromonas gingivalis and its LPS were analyzed by enzyme-linked immunosorbent assay (ELISA) and Western blotting, respectively. Serum triglycerides (TG) and cholesterol (CHOL) were assayed by a commercial laboratory. The associations between AP and blood levels of TG, CHOL, and anti-P. gingivalis whole cells and LPS were examined by logistic regression analysis. Peripheral blood polymorphonuclear leukocytes (PMNs) from 6 healthy fasted donors were incubated with purified TG (0.1 mg/ml) for 2 hours at 37 degrees C, stimulated with 100 ng/ml P. gingivalis LPS, and the release of IL-1beta measured by ELISA.

RESULTS

The presence of periodontitis was significantly associated with age (odds ratio = 3.5, P = 0.04), elevated TG levels (odds ratio = 8.6, P = 0.0009), elevated CHOL levels (odds ratio = 7, P = 0.004), elevated ELISA titer (odds ratio = 35, P = 0.003) and reactivity with P. gingivalis LPS (odds ratio = 41, P = 0.001). PMNs from all 6 healthy patients released modest levels of IL-1beta (10 to 60 pg/ml) when stimulated with 100 ng/ml P. gingivalis LPS. Addition of TG resulted in a significant increase (P <0.05) in IL- 1beta secreted that ranged from 7 to 150% over LPS alone. No IL-1beta was elicited by TG or vehicle alone.

CONCLUSIONS

The results of this study indicate the presence of a significant relationship between periodontitis, hyperlipidemia, and serum antibodies against P. gingivalis LPS that warrants further examination in a larger patient population. Furthermore, these studies indicate that elevated triglycerides are able to modulate IL-1beta production by PMNs stimulated with P. gingivalis LPS.

Pulsed wave and color Doppler echocardiography and cardiac catheterization findings in bilateral pulmonary vein stenosis

Pulmonary vein stenosis is a rare condition that usually is congenital in origin; it is almost invariably fatal in its bilateral and severe forms. It is often overlooked, however, during clinical examination, routine echocardiography, and even at cardiac catheterization. This report describes the pulsed Doppler, color flow echocardiography, and hemodynamic findings of bilateral pulmonary vein stenosis that accompany ventricular septal defect and atrial septal defect corrected by surgery.

Clinical and immunologic evaluations of reactive dye-exposed workers

To evaluate type 1 hypersensitivity to reactive dyes, its prevalence, and its relationship to respiratory dysfunction, we studied clinical and immunologic features, including skin prick tests. RAST, and bronchoprovocation tests, of 309 employees working in a reactive-dye industry. Our survey revealed that 78 (25.2%) employees had work-related lower respiratory symptoms associated with or without nasal, skin, or eye symptoms. Among these employees, 38 (48.7%) had nonspecific bronchial reactivity. Thirteen demonstrated immediate (6), dual (6), or late only (1) asthmatic responses after inhalation of four kinds of reactive-dye solutions. Twenty-five employees demonstrated immediate skin responses to black GR dye, and 21 reacted to orange 3R. Fifty-three employees (17%) had specific serum IgE antibody against black GR and orange 3R-human serum albumin conjugate. Specific IgE was detected more frequently in symptomatic employees (30%) and smokers (100%). No association was found between atopy and specific IgE binding. The RAST-inhibition tests of black GR revealed significant inhibitions by black GR-human serum albumin conjugate and minimal inhibitions by unconjugated black GR. Orange 3R RAST-inhibition tests revealed significant inhibitions by conjugated forms of black GR and orange 3R and some inhibitions by two unconjugated dyes, suggesting an immunologic cross-reactivity between these dyes. These findings suggested that reactive dyes could induce immunologic responses, most likely IgE-mediated.