Evaluation of the Significance of Persistent Remnant Filling and Enlargement After Flow Diversion for Intracranial Aneurysms

BACKGROUND

This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events.

METHODS

We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021.

RESULTS

The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling.

CONCLUSIONS

Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD.

The Feasibility of Fast, Four-Dimensional Computed Tomography-Based O-Ring Linac Plans for Stereotactic Body Radiotherapy in Patients with Poor Performance Status

PURPOSE/OBJECTIVE(S)

As patients with poor performance status cannot endure long treatment times, it can lead to unplanned and prolonged radiation treatment or discontinuation of treatment. Moreover, prolonged radiation treatment appears to negatively affect survival for patients. We aimed to verify the feasibility of fast 4DCT-based O-ring linear accelerator (LINAC) treatment in lung 4D stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

This study included data of 38 patients who received lung 4D-SBRT. Gating20-70% plans were based on 4DCT data obtained at phase values ranging from 20-70% using a C-arm LINAC. Non-GatingFB plans were retrospectively established based on 4DCT data obtained at phase values of 0-90% using an O-ring LINAC. The prescribed dose of 4,800 cGy was delivered to PTV in four fractions. The conformity index (CI), homogeneity index (HI), and gradient measurement (GM) of the PTV were analyzed to compare dosimetric data between Gating20-70% and Non-GatingFB plans. Organs at risks (OARs) were analyzed in accordance with the RTOG 0915 protocol. Treatment delivery time and total monitor units (MU) were analyzed to compare the efficiency of treatment delivery. Statistical comparisons were performed using the Wilcoxon signed-rank test (p<0.05).

RESULTS

For the PTV, there was no significant difference in the CI or HI between Gating20-70% and Non-GatingFB plans (CI: 1.337±0.137, 1.335±0.174, HI: 0.939±0.015, 0.939±0.016, all at p>0.05). However, there was a significant difference in GM between Gating20-70% and Non-GatingFB plan (1.528±0.206 cm, 1.381±0.222 cm, p<0.001). For OARs, all plans met the criteria for dose constraint. There was a significant difference between Gating20-70% and Non-GatingFB plans except in the spinal cord. In particular, D1000cc and D1500cc values for the ipsilateral lung for Gating20-70% plans were 31.6% and 59.9% lower than those for Non-GatingFB plans (D1000cc: 50.780±132.061 cGy, 34.755±102.480 cGy, p<0.001, D1500cc: 6.641±14.598 cGy, 2.666±7.926 cGy, p<0.001). Treatment delivery time was 92% longer for Gating20-70% plans than for Non-GatingFB plans (5.0±0.4 min, 9.6±3.3 min, p = 0.043). The total MU value for Gating20-70% plans was 9.6% higher than that for Non-GatingFB plans (3665.8±230.7, 4016±236.9, p = 0.039).

CONCLUSION

When compared to OARs both plans were acceptable per RTOG-0915 protocol, but significant differences were between Non-GatingFB and Gating20-70% plans. However, treatment delivery time of Non-GatingFB plans decreased by 47.9% than Gating20-70% plans. We verified the feasibility of fast 4DCT-based O-ring LINAC treatment for patients who cannot endure long treatment times due to poor performance status in lung 4D-SBRT. In further study, we will analyze dosimetric differences and treatment delivery efficiency considering tumor motion according to tumor location.

Mapping the Anatomical Distribution of MRI-Identified Locoregional Recurrence following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Adenocarcinoma

PURPOSE/OBJECTIVE(S)

The pattern of locoregional recurrence specifically after robotic-assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma is still unknown. In this study, we reviewed pelvic magnetic resonance images (MRI) after postoperative biochemical recurrence (BCR) and drew a map of locoregional recurrence to support evidence of determining the optimal target volume of salvage radiotherapy in a post-RALP BCR scenario.

MATERIALS/METHODS

We have retrospectively searched 7,583 prostate adenocarcinoma patients who have received RALP in our institution between January 2010 and December 2021, and found a pool of highly selected patients with gross tumor recurrence confirmed by post-BCR pelvic MRIs and did not have other histories of malignancy. BCR was defined as the serum PSA more or equal to 0.2 ng/mL, or three consecutive increases. Patients with serum PSA nadir more or equal to 0.2 ng/mL on the 90th postoperative day (POD 90) were excluded to guarantee successful tumor removal. We have reviewed serum PSA levels using R codes, MRI and pathological reports using Excel, and descriptive statistics using SPSS 25. The gross lesions were contoured on the correlating MRIs using MIM Maestro 7.1. The RT structure DICOM files were merged into a map using MATLAB 2022b. In addition, we have conducted Fisher exacted test, Mann-Whitney U test, and logistic regression to identify risk factors for regional recurrence.

RESULTS

A total of 173 patients were identified with locoregional recurrence from post-BCR pelvic MRIs, and 139 (80.3%) patients were in the high-risk group or very-high-risk group according to the NCCN guidelines: 57 (32.9%) patients with histological grade group 5, 50 (28.9%) patients with initial PSA over 20 ng/mL, 114 (65.9%) patients with extracapsular extension, 55 (31.8%) patients with seminal vesicle invasion, and 15 (9%) patients with pN1. The median follow-up was 4.7 (IQR 2.8-6.9) years for pelvic MRIs and 5.8 (IQR 4.0-8.6) years for serum PSA. The BCF survival was median of 10.7 (IQR 4.6-19.1) months, and the locoregional recurrence-free survival was median of 24.6 (IQR 9.7-49.4) months for this subgroup of patients. At first locoregional recurrence, 148 (85.5%) patients were local only, 20 (11.6%) patients were regional only, and 5 (2.9%) patients were both local and regional. Out of the 25 patients with regional recurrence, the incidence of gross tumor recurrence differed by nodal sites: 3 (12%) in perirectal space, 5 (20%) in internal iliac, 7 (28%) in obturator, 13 (52%) in external iliac, and 6 (24%) in common iliac lymph nodes.

CONCLUSION

We have found 173 patients and were able to map reliable gross tumor recurrence sites after RALP and confirmed by pelvic MRIs following BCR. The map supports evidence of using the existing consensus pelvic clinical target volume of salvage radiotherapy, in a post-RALP BCR scenario.

Prediction of Lymphopenia and Survival with Baseline Absolute Lymphocyte Count and Irradiated Dose to Immune Cells in Patients with Non-Small Cell Lung Cancer Treated with Concurrent Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

This study aimed to investigate the effect of effective dose to immune cell (EDIC) combined with pre-radiotherapy (RT) absolute lymphocyte count (ALC) on treatment-related lymphopenia during RT and treatment outcome in patients with locally advanced non-small cell lung cancer (NSCLC). A subgroup analysis in patients who received consolidation immunotherapy was also conducted.

MATERIALS/METHODS

Between August 2008 and December 2021, 517 patients with locally advanced NSCLC treated with definitive concurrent chemoradiotherapy (CRT) were retrospectively analyzed. All patients had serial complete-blood-count tests at pre-, and during-CRT. Severe lymphopenia was defined as ALC < 0.5x109cells/L during RT. EDIC was calculated according to mean doses of the lung, heart and the total body. The patients were grouped according to high and low EDIC and pre-RT ALC and was assessed for its correlation with radiation induced lymphopenia and survival outcomes.

RESULTS

Of 517 eligible patients, most of the patients received weekly paclitaxel with carboplatin (90.3%) and 195 patients (37.7%) received consolidation immunotherapy following CRT. A median radiation dose of 63 Gy (IQR, 60-64.5) was delivered in 30 fractions. The optimal cutoff value of EDIC and pre-RT ALC for predicting severe lymphopenia were 2.89 Gy and 2.03x109cells/L, respectively. High risk group was defined as EDIC ≥ 2.89 Gy and pre-RT ALC < 2.03x109cells/L, low risk group as EDIC <2.89 Gy and pre-RT ALC ≥ 2.03x109cells/L, and intermediate group as EDIC ≥ 2.89 Gy and pre-RT ALC ≥ 2.03x109cells/L or EDIC < 2.89 Gy and pre-RT ALC < 2.03x109cells/L. The incidence of severe lymphopenia during RT in high, intermediate, and low risk group was 90.1%, 77.1%, and 52.3%, respectively (p<0.001). The risk groups were independent predictors for both progression-free survival (PFS) (p<0.001) and overall survival (OS) (p<0.001). The high-risk group had higher incidence of locoregional and distant recurrences (p<0.001). In the subset of patients who were treated with consolidation immunotherapy, the risk groups were predictive of severe lymphopenia (p = 0.001), PFS (p = 0.004), and OS (p = 0.012).

CONCLUSION

This study demonstrated that the combination of EDIC and pre-RT ALC is a predictor for severe lymphopenia during RT, recurrence, and survival in patients with locally advanced NSCLC who received CRT. Moreover, the combination of EDIC and pre-RT ALC may serve as a potential biomarker for the benefit of maintenance immunotherapy.

Single-incision robotic colorectal surgery with the da Vinci SP® surgical system: initial results of 50 cases

PURPOSE

The da Vinci SP® (dVSP) surgical system (Intuitive Surgical, Sunnyvale, CA, USA), a robotic platform designed for single-incision surgery, overcame the need for multiple ports in traditional robotic surgery and issues including triangulation and retraction in single-incision laparoscopic surgery. However, previous studies only included case reports or series with small sample sizes. The aim of this study was to assess the safety and performance of the dVSP surgical system and its instruments and accessories for colorectal procedures.

METHODS

The medical records of patients who had surgery with the dVSP from March 2019 to September 2021 at Ewha Womans University Seoul Hospital were investigated. The pathologic and follow-up data of patients who had malignant tumors were analyzed separately to evaluate oncological safety.

RESULTS

Fifty patients (26 male and 24 female) with a median age of 59 years (interquartile range 52.5-63.0 years) were enrolled. The procedures included low anterior resection with total mesorectal excision (n = 16), sigmoid colectomy with complete mesocolic excision and central vessel ligation (CME + CVL) (n = 14), right colectomy with CME + CVL (n = 9), left colectomy with CME + CVL (n = 4), right colectomy (n = 6), and sigmoid colectomy (n = 1). Operative time significantly decreased after 25 cases (early phase vs. late phase; operative time 295.0 min vs. 250.0 min, p = 0.015; docking time 16.0 min vs. 12.0 min, p = 0.001; console time 212.0 min vs. 190.0 min, p = 0.019). Planned procedures were successfully completed in all patients. Postoperative outcomes were acceptable with only six cases of mild adverse events through a 3-month follow-up. No local recurrence and only one case of systemic recurrence occurred within 1 year postoperatively.

CONCLUSIONS

This study demonstrated the surgical and oncological safety and feasibility of dVSP, which may be a novel surgical platform for colorectal surgery.

SGO and the elephant that is still in the room: Wellness, burnout and gynecologic oncology

OBJECTIVE

To measure wellness and burnout among gynecologic oncology clinicians and identify trends and at-risk populations to inform future interventions.

METHODS

Gynecologic oncologist (GO) and advanced practice provider (APP) responses to the 2020 Society of Gynecologic Oncology State of the Society survey were analyzed. The Maslach Burnout Inventory criteria for burnout was used. Work-life balance was scored on a 5-point Likert scale. Chi-square tests were used to compare mental health factors and the prevalence of burnout. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between burnout and gender.

RESULTS

543 survey responses were included for analysis. Most GO (54%) and all APP respondents were female. Female GOs were disproportionately affected by burnout particularly in the Northeast (female(F): 40.9% vs male(M): 19.1%, p = 0.007) and South (F: 42.5% vs M:22.9%, p = 0.01). Burnout in female GOs over 40 was 1.79 (CI: 1.13-2.83; p-value 0.01) times higher than similarly aged males. Females in non-private practice experienced burnout 1.66 times that of males in similar positions (CI: 1.18-2.94; p < 0.0001). Female GOs reported the worst work-life balance across all 5 domains. APPs and female GOs experienced more stress and feeling overwhelmed compared to men. GOs were more reluctant to see a mental health professional (p = 0.0003) or take medication (p = 0.009) than APPs.

CONCLUSIONS

Burnout in gynecologic oncology persists in both genders and is felt most acutely by female GOs. APPs are not immune and would benefit from inclusion in future research to mitigate burnout in healthcare clinicians.

Genetic and clinical characteristics of transthyretin cardiac amyloidosis in Koreans

Background/Introduction

Transthyretin amyloidosis with mutations (aTTRv amyloidosis) have over 100 recognized pathogenic mutations of the TTR gene and its clinical manifestations are very heterogenous. Through the global THAOS (Transthyretin Amyloidosis Outcomes Survey) patient registry, different and several types of mutants and clinical differences have been identified. Awareness of aTTRv amyloidosis is now becoming somewhat significant amongst physicians all over the world. This is a detailed look at such efforts in Korea.

Purpose

We aimed to seek the geologic significance of aTTRv amyloidosis in South Korea.

Methods

This was an analysis of 638 Korean amyloidosis patients in a single center over a period of 16 years from 1995 to October 2021. 95 individuals were found with aTTR mutations.

Results

aTTRv amyloidosis constituted 14.8% (n=95) of amyloidosis patients, and the most commonly involved organ being the heart (61.7%, n=58). Unlike the rest of the world, the mixed phenotype was most common (51.0%, n=48) in Korea and the most universal mutation in Koreans were Asp38Ala, which only constitutes about 1.0% in the THAOS registry. Val30Met mutation, which comprises 76% of the mutation in the THAOS registry, was mostly associated the neurologic phenotypes. However, the same mutations in Korea mixed phenotypes with cardiac (38.4%) and neurologic (37%) symptoms.

Conclusion

aTTRv amyloidosis in Korea is different from other patients worldwide. The mixed phenotype was most common, emphasizing the need for heart failure management in the Korean population. Genotype wise, Koreans held a less common mutation of Asp38Ala. The most common mutation of Val30Met was more likely to be associated cardiac symptoms, which concurs with other studies that suggesting that geological features are more important than mutations itself.

Funding Acknowledgement

Type of funding sources: None.

Deep Learning-Based Prediction of the 3D Postorthodontic Facial Changes

With the increase of the adult orthodontic population, there is a need for an accurate and evidence-based prediction of the posttreatment face in 3 dimensions (3D). The objectives of this study are 1) to develop a 3D postorthodontic face prediction method based on a deep learning network using the patient-specific factors and orthodontic treatment conditions and 2) to validate the accuracy and clinical usability of the proposed method. Paired sets (n = 268) of pretreatment (T1) and posttreatment (T2) cone-beam computed tomography (CBCT) of adult patients were trained with a conditional generative adversarial network to generate 3D posttreatment facial data based on the patient's gender, age, and the changes of upper (ΔU1) and lower incisor position (ΔL1) as input. The accuracy was calculated with prediction error and mean absolute distances between real T2 (T2) and predicted T2 (PT2) near 6 perioral landmark regions, as well as percentage of prediction error less than 2 mm using test sets (n = 44). For qualitative evaluation, an online survey was conducted with experienced orthodontists as panels (n = 56). Overall, PT2 indicated similar 3D changes to the T2 face, with the most apparent changes simulated in the perioral regions. The mean prediction error was 1.2 ± 1.01 mm with 80.8% accuracy. More than 50% of the experienced orthodontists were unable to distinguish between real and predicted images. In this study, we proposed a valid 3D postorthodontic face prediction method by applying a deep learning algorithm trained with CBCT data sets.

Significance of D-Dimer in Acute Ischemic Stroke Patients With Large Vessel Occlusion Accompanied by Active Cancer

Background

This study aimed to investigate clinical outcome predictors of acute stroke patients with large vessel occlusion and active cancer and validate the significance of D-dimer levels for endovascular thrombectomy decisions.

Methods

We analyzed a prospectively collected hospital-based stroke registry to determine clinical EVT outcomes of acute stroke patients within 24 h with following criteria: age ≥18 years, NIHSS ≥6, and internal carotid artery or middle cerebral artery lesion. All patients were classified into EVT and non-EVT groups. Patients were divided into two groups by initial D-dimer level. We explored variables potentially associated with successful recanalization as well as 3-month functional outcomes and mortality rates.

Results

Among 68 patients, 36 were treated with EVT, with successful recanalization in 55.6%. The low D-dimer group showed a higher rate of successful recanalization and favorable outcome than the high D-dimer group. The mortality rate was higher in the high D-dimer group. No EVT and high D-dimer level were independent predictors of mortality, whereas lesion volume and low D-dimer level were independently associated with favorable outcomes.

Conclusions

D-dimer level is a prognostic factor in acute LVO stroke patients with active cancer, and its high value for EVT decisions provisionally supports its testing in this patient population.

Diffuse Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage in a 15-Year-Old Girl: A Case Report

Diffuse cerebral vasospasm after subarachnoid hemorrhage (SAH) is a complication resulting in an ischemic condition presenting with altered mentality and followed by motor or speech impairment. It is uncommon in pediatric population and requires differential diagnosis from Moyamoya disease, which is relatively common in Korea. We report a case of a 15-year-old girl who was presented with a seizure and subsequent headache, poor oral intake, and altered mentality, who was finally diagnosed with sporadic vasospasm followed by multiple aneurysm ruptures. The patient had recurrent seizures and persistent headache at the time of transfer. On the second day after transfer, she showed focal motor weakness and dysarthria, and her symptoms gradually progressed, showing paraplegia and aphasia on the third hospitalization day. Brain magnetic resonance imaging and magnetic resonance angiography demonstrated diffuse narrowing cerebral vasospasm of bilateral middle cerebral arteries, anterior cerebral arteries, and distal internal carotid arteries and three unruptured aneurysms. The patient was treated with intravenous hydration and nimodipine to expand the narrowed vessels. After confirming that the vessels were enlarged, we successfully executed the endovascular coil embolization. Her neurological deficits were improved through medical, interventional, and rehabilitation treatments and fully restored 11 months after discharge.

Percutaneous coronary intervention in patients with peripheral artery disease and adverse cardiovascular adverse event and bleeding

Background

Peripheral artery disease (PAD) increase the risk of comorbidity and mortality in coronary artery disease (CAD).

Objectives

We evaluate influence of PAD on prognosis in patients undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients included in our dedicated local registry for PCI between January 2011 and December 2016. Presence of PAD was defined by decreased ankle-brachial index (&lt;0.9). Major adverse cardiovascular event (MACE) was defined as a composite of cardiovascular death, non-fatal myocardial infarct, revascularization, and ischemic stroke. Major bleeding was defined as Bleeding Academic Research Consortium 3 or 5.

Results

Among the 4,747 patients who underwent the PCI, 12.9% (n=610) of PAD were identified. Old age (&gt;60 years), renal dysfunction, reduced ejection fraction, and presence of PAD were predictors with both MACE and major bleeding event. Among them, presence of PAD was an independent risk factor of MACE and major bleeding (MACE, HR 8.26, 95% CI 2.33- 29.41, p=0.036; major bleeding, HR 3.11, 95% CI 1.10–10.63, p=0.040, respectively). The MACE and major bleeding rate at 5-year was significantly increased in patients with PAD (MACE, 30.0% vs. 15.8%, log rank test p&lt;0.001; major bleeding, 6.7 vs. 3.6%, log rank test p=0.003, respectively) (Figure).

Conclusion

Presence of PAD was strongly associated with higher rate of long-term MACE and major bleeding. These findings could have a clinical relevance in requiring individualized pharmacologic strategies to reduce the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Impact of active and stable cancer on survival in patients undergoing percutaneous coronary intervention

Background

With advances in treatment of ischemic heart disease and cancer treatment, use of percutaneous coronary intervention (PCI) in cancer survivors and patients with active cancer (AC) is expanding.

Objectives

The purpose of this study was to determine the impact of cancer on survival and major cardiovascular events (MACE) in a long-term, single-center cohort of patients treated with PCI.

Methods

Patients treated with PCI between January 2010 and December 2017 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. AC was included patients with cancer diagnosed within the past 6 months, patients who had cancer-related therapy within the past 6 months, active metastatic disease, or active recurrence of the cancer. The primary endpoints were 5-year survival and a secondary endpoint was 5-year MACE.

Results

A total of 6,743 patients (age 66±12 years, 68.4% men) treated with PCI were included: 6,404 (95.0%) controls, 245 (3.6%) SC, and 94 (1.4%) AC. Predominant malignancies were gastrointestinal (37.4%), lung (22.7%), and genitourinary cancer (14.7%). No differences were observed between patients with AC, SC and controls regarding 5-year MACE (total MACE, 33.2% vs. 28.1% vs. 17.5%, p=0.072; cardiac death, 13.6% vs. 9.1% vs. 6.7%, p=0.066; non-fatal myocardial infarction, 2.9% vs. 7.5% vs. 7.8%, p=0.820; revascularization, 17.9% vs. 17.6% vs. 11.6%, p=0.794, respectively). Patients with AC and SC had reduced 5-year survival compared with controls (62.0% vs. 81.5% vs. 89.8%, p&lt;0.001) (Figure). AC was associated with a 1.76 (95% CI 1.22 to 2.54, p=0.002) fold increased risk of all-cause 5-year mortality in multivariable adjusted models.

Conclusions

Cumulative incidence of 5-year survival was discriminated by concurrent status of cancer following PCI. Individualized decision making is needed in the routine practice of PCI regarding concurrent cancer-specific treatment and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Pemetrexed plus cisplatin in patients with previously treated advanced sarcoma: a multicenter, single-arm, phase II trial

Background

Patients with advanced sarcomas have a poor prognosis and few treatment options that improve overall survival. We assessed the efficacy and tolerability of pemetrexed and cisplatin combination therapy in patients with refractory bone and soft tissue sarcoma (STS).

Patients and Methods

Patients were included in this multicenter, phase II study (ClinicalTrials.gov identifier NCT03809637) if they progressed after receiving one or more chemotherapy regimens containing an anthracycline and/or ifosfamide. Pemetrexed was first administered intravenously, followed by cisplatin, over a cycle of 21 days, for a maximum of six cycles. The primary endpoint was a progression-free rate (PFR) at 3 months (3-month PFR).

Results

From January 2017 to September 2019, we enrolled 37 patients; of these, 73% had previously undergone three or more rounds of chemotherapy. Five patients (13.5%) exhibited objective responses, including two patients (2/6, 33.3%) with malignant peripheral nerve sheath tumors, one patient (1/4, 25%) with synovial sarcoma, one patient (1/4, 25%) with undifferentiated pleomorphic sarcoma, and one patient (1/4, 25%) with angiosarcoma. The median progression-free survival was 2.6 months, and the 3-month PFR was 45.9% (n = 17). None of the four patients with osteosarcoma exhibited objective responses or were progression free at 3 months. The most frequent treatment-related grade 3-4 toxicities included neutropenia (16.2%), anemia (13.5%), thrombocytopenia (13.5%), and fatigue (8.1%). Among 26 patients (70.3%) available for immunohistochemical assessments, patients in the low-excision repair cross-complementation group 1 (ERCC1) and low-thymidylate synthase expression groups showed a tendency for longer overall survival.

Conclusions

Combination therapy with pemetrexed and cisplatin was associated with clinically meaningful and sustained responses among patients with advanced and refractory STS. The combination therapy met its predefined primary study endpoint.

•

Pemetrexed and cisplatin show promising efficacy for advanced sarcoma treatment, particularly as a salvage therapy option.

•

The combination therapy met its predefined primary endpoint, with a 3-month PFR of 45.9%.

•

Pemetrexed and cisplatin showed acceptable toxicity in heavily treated sarcoma patients.

Treatment Outcomes After Single-Device Flow Diversion for Large or Giant Aneurysms

OBJECTIVE

We aimed to evaluate the efficacy and safety of single-device flow diversion in patients with aneurysms measuring ≥15 mm in diameter.

METHODS

For this retrospective study, we extracted medical record data for patients with unruptured intracranial aneurysms, who underwent flow diversion, at the authors' institution between July 2014 and August 2019. The primary effectiveness outcome was defined as angiographic occlusion of the target aneurysm within 18 months without major (>50%) parent artery stenosis, major adverse events, or additional treatment.

RESULTS

Thirty-five aneurysms in 35 patients were analyzed. Most aneurysms (n = 29, 82.9%) involved the anterior circulation. The median aneurysmal diameter was 18.3 mm, and the median neck size was 7.6 mm. Eleven (31.4%) aneurysms were considered giant (≥25 mm). The primary effectiveness outcome was achieved in 20 (57.1%) patients at a median of 10 months (interquartile range, 4.3-12.5) after flow diversion. Major adverse events occurred in 6 (17.1%) patients, including remote intraparenchymal hemorrhages (n = 2), a major ischemic stroke (n = 1), a delayed rupture of the target aneurysm (n = 1), and clinical deterioration caused by aggravated mass effect (n = 2). Multivariate logistic regression analysis found 2 independent predictors of the primary effectiveness outcome: the aneurysmal diameter (odds ratio, 0.71; 95% confidence interval, 0.54-0.86; P = 0.004) and the parent-vessel angle (odds ratio, 0.97; 95% confidence interval, 0.93-0.99; P = 0.017).

CONCLUSIONS

Single-device flow diversion was shown to be ineffective for large or giant intracranial aneurysms with a high parent vessel angle.

Vibration reduction during milling of highly flexible workpieces using active workpiece holder system

The milling of highly flexible workpieces, such as thin-walled structures used in turbine blades, aerospace equipment, and jet engine compressors, requires vibration compensation to improve the quality of the workpiece surface. Vibration can be reduced by selecting appropriate cutting parameters. However, this approach reduces system productivity. This paper presents an active workpiece holder that controls the vibration of general computer numerical control machine tools. The proposed holder, which comprises a flexible guide mechanism, driver, and sensor, measures vibration and actively controls it using piezoactuators. A high-rigidity flexure mechanism was designed for the holder, and finite element method simulation and modal analysis were performed. Finally, the proposed system was fabricated, and experimental verification indicated that the system reduced vibration. The surface quality obtained using the controlled system was ∼50% better than that obtained using the uncontrolled system.

Characteristics of silicon nitride deposited by very high frequency (162 MHz)-plasma enhanced atomic layer deposition using bis(diethylamino)silane

Silicon nitrides, deposited by capacitively coupled plasma (CCP)-type plasma enhanced atomic layer deposition (PEALD), are generally applied to today's nanoscale semiconductor devices, and are currently being investigated in terms of their potential applications in the context of flexible displays, etc. During the PEALD process, 13.56 MHz rf power is generally employed for the generation of reactive gas plasma. In this study, the effects of a higher plasma generation frequency of 162 MHz on both plasma and silicon nitride film characteristics are investigated for the purpose of silicon nitride PEALD, using bis(diethylamino)silane (BDEAS) as the silicon precursor, and N₂ plasma as the reactant gas. The PEALD silicon nitride film deposited using the 162 MHz CCP exhibited improved film characteristics, such as reduced surface roughness, a lower carbon percentage, a higher N/Si ratio, a lower wet etch rate in a diluted HF solution, lower leakage current, and higher electric breakdown field, and more uniform step coverage of the silicon nitride film deposited in a high aspect ratio trench, as compared to silicon nitride PEALD using 13.56 MHz CCP. These improved PEALD silicon nitride film characteristics are believed to be related to the higher ion density, higher reactive gas dissociation, and lower ion bombardment energy to the substrate observed in N₂ plasma with a 162 MHz CCP.

Perfusion recovery on TTP maps after endovascular stroke treatment might predict favorable neurological outcomes

OBJECTIVES

Early recanalization and adequate collateral blood flow are surrogates for functional recovery in endovascular stroke treatment (EVT). We evaluated the prognostic value of pre- and immediate post-thrombectomy perfusion-weighted magnetic resonance imaging (PWI) parameters.

METHODS

Consecutive patients with acute ischemic stroke who underwent EVT were enrolled. Lesion volumes and their corresponding changes on diffusion-weighted (DWI) and PWI were assessed. Outcome was measured with modified Rankin Scale (mRS) at 90 days, and early neurological improvement (> 8 points improvement on National Institutes of Health Stroke Scale [NIHSS] or 0 to 1) at 7 days.

RESULTS

Fifty-two patients were enrolled. After control of initial NIHSS and recanalization status, post-thrombectomy time-to-peak (TTP) hypoperfused volume and TTP hypoperfused volume change remained independent predictors of favorable functional outcome (odds ratio [OR] = 0.13, 95% confidence interval [CI] = 0.03-0.54, p = 0.005; OR = 1.018, 95% CI = 1.00-1.03, p = 0.017), and early neurological improvement (OR = 0.20, 95% CI 0.07-0.58, p = 0.003; OR = 1.02, 95% CI = 1.00-1.03, p = 0.010). The areas under the curve of post-thrombectomy TTP hypoperfused volume and TTP hypoperfused volume change were 0.90 and 0.82 (cutoff 68 mL and 56 mL) for favorable outcome and 0.86 and 0.82 (cutoff 76 mL and 58 mL) for early neurological improvement, which had better prognostic values than other MR parameters and recanalization grades.

CONCLUSIONS

These results suggest a large amount of perfusion recovery on TTP is associated with favorable outcome as well as early neurological improvement after EVT, and may be a useful prognostic marker.

KEY POINTS

• A large amount of perfusion recovery on TTP map is associated with favorable outcome and early neurological improvement after EVT. • The best cutoff value for favorable functional outcome was 68 mL for post-EVT TTP hypoperfused volume and 56 mL decrease for TTP hypoperfused volume. • Amount of perfusion recovery on TTP map has better performance on the prediction of favorable functional recovery and early neurological improvement than other diffusion- and perfusion-weighted MRI parameters and recanalization grades.

The Association with rhegmatogenous retinal detachment and paediatric atopic dermatitis: a 12-year Nationwide Cohort Study

PURPOSE

Historically, atopic dermatitis (AD) is associated with an increased risk of rhegmatogenous retinal detachment (RRD). However, uncertainty remained regarding the effect of AD itself and comorbidities (e.g., allergic diseases, cataract surgery) on RRD occurrence in a large, population-based paediatric population.

PATIENTS AND METHODS

We analysed the 12-year National Health Insurance Service database (2002-2013) covering the entire Korean population to estimate the association between AD and RRD in people aged under 20 years.

RESULTS

We identified 3142 RRD patients, and matched 18,852 controls (six controls to each RRD patient); therefore, we included 21,994 peoples under aged 20 years in the analyses. AD was more prevalent in the RRD group (329 patients, 10.47%) than the control group (1043 patients, 5.53%; P < 0.001), and so were severe AD (153 patients [4.87%] and 223 patients [1.18%], respectively; P < 0.001). In conditional logistic regression analysis, AD was associated with RRD (OR, 1.61; 95% CI, 1.93-1.87) even after adjusting for allergic conditions, connective tissue disease, uveitis, and cataract surgery. In addition, severity of AD was associated with an increased risk of RRD (OR for non-severe AD and severe AD, 1.26 [95% CI, 1.05-1.51] and 2.88 [95% CI, 2.25-3.68]).

CONCLUSION

This study suggests that AD itself is a risk factor of RRD in children by showing the association between AD and RRD occurrence and the biologic gradient even after adjustment for known confounders including allergic conditions, uveitis, and cataract surgery.

Development and control of a hybrid active mount module for precision stages

In recent years, precision stages, which are widely used in many industrial fields, have been required to have a higher speed, larger size, and higher precision to help realize higher productivity and product quality. High-performance positioning techniques for inspection and production equipment are classified as one of the most challenging technologies. Vibration control is crucial to realize high-precision positioning technologies. In a precision system, various vibrations exist, which act as disturbances and can degrade the system performance. Minimizing the vibrations generated by the system can, thus, help improve the accuracy of system positioning. This paper proposes a hybrid active mount module for a precision stage. The developed module improves stage performance by reducing the base vibration arising from the floor, minimizing the vibration caused by the driving linear motors of the precision stage, and reducing the settling time by compensating the offset displacement due to the nonlinearity of the passive mount during stage driving. The prototype design is presented herein, and the experimental results demonstrate the potential of the developed device. The developed system is expected to effectively improve the stage performance by controlling the various causes of vibration.

Ultrafast Transient Spectroscopy of Trans-Polyacetylene in the Midinfrared Spectral Range

Trans-polyacetylene [t-(CH)_{x}] possesses twofold ground state degeneracy. Using the Su-Schrieffer-Heeger Hamiltonian, scientists predicted charged solitons to be the primary photoexcitations in t-(CH)_{x}; this prediction, however, has led to sharp debate. To resolve this saga, we use subpicosecond transient photomodulation spectroscopy in the mid-IR spectral range (0.1-1.5 eV) in neat t-(CH)_{x} thin films. We show that odd-parity singlet excitons are the primary photoexcitations in t-(CH)_{x}, similar to many other nondegenerate π-conjugated polymers. The exciton transitions are characterized by two photoinduced absorption (PA) bands at 0.38 and 0.6 eV, and an associated photoluminescence band at ∼1.5  eV having similar polarization memory. The primary excitons undergo internal conversion within ∼100  fs to an even-parity (dark) singlet exciton with a PA band at ∼1.4  eV. We also find ultrafast photogeneration of charge polarons when pumping deep into the polymer continuum band, which are characterized by two other PA bands in the mid-IR and associated photoinduced IR vibrational modes.

Intracranial Aneurysms in Young Adult Patients: Surgical and Endovascular Treatment Outcomes

BACKGROUND

Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients.

METHODS

A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed.

RESULTS

Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome.

CONCLUSIONS

Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients.

P1443 Sex differences of coronary physiology can be justified by fractional myocardial mass

Purpose

We hypothesized that the gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease.

Background Women has lower prevalence of coronary artery disease but has higher mortality from acute myocardial infarction. The gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease.

Methods In this multicenter registry, 482 patients who underwent coronary CT angiography and fractional flow reserve (FFR) measurement were enrolled. Fractional myocardial mass (FMM, a vessel-specific amount of myocardium) and %FMM (fraction of FMM to whole myocardial mass) was measured in major coronary arteries and branches. FFR and quantitative coronary angiography (QCA) were interrogated in the subset of 772 vessels. The severity of physiological or anatomical stenosis was assessed by FFR and diameter stenosis (DS), respectively.

Results In the analysis of all major epicardial arteries (N = 3,833), FMM was lower in women compared to men (p &lt; 0.01, all), but %FMM was similar between women and men (p = NS, all). Among physiologically assessed 772 vessels, compared to men (N = 587), vessels of women (N = 185) showed smaller dimension (reference diameter (RD) = 2.90 ± 0.65 vs 3.14 ± 0.69 mm, minimal luminal diameter (MLD) = 1.30±.0.57 vs 1.40 ± 0.57 mm (p &lt; 0.05, all), similar severity of stenosis (DS = 55% vs 55% p = NS), and higher FFR (0.81 ± 0.13 vs 0.78 ± 0.15, p &lt; 0.001). In subgroup analysis according to the tertiary categories of DS, RD, and MLD, vessels of women showed higher FFR and lower FMM. Generalized estimating equations modeling demonstrated that gender, DS, RD, MLD, and location in left anterior descending artery were not (p = NS, all) but FMM/MLD were significant predictors for FFR ≤ 0.80 (p = 0.021).

Conclusions

Compared to men, coronary arteries of women are smaller and supply smaller amount of myocardium even after adjusting for vessel size, which may explain overall higher FFR value of women. This gender difference in anatomical-physiological relationship may explain the gender difference in the clinical coronary artery disease.

Abstract P1443 Figure.

1175 Comparison of fractional myocardial mass, a vessel-specific myocardial mass-at-risk, with coronary angiographic scoring systems for predicting myocardial ischemia

Aims The burden of coronary artery disease has been assessed by various semi-quantitative angiographic scores, which are frequently different each other. A non-invasive and quantitative modality may substitute angiographic sores for prognostic implication and decision of revascularization strategy. We compared fractional myocardial mass (FMM) with angiographic scores for predicting myocardial ischemia.

Methods In this multicenter registry, 411 patients who underwent coronary computed tomography angiography (CCTA) were followed by invasive coronary angiography and FFR measurement. CCTA–derived %FMM with diameter stenosis ≥70% (%FMM-70) or ≥50% (%FMM-50) were compared with 9 angiographic scores (APPROACH, Duke Jeopardy, BARI, CASS, SYNTAX, Jenkins, BCIS-1, Leaman, Modified Duke) and were tested regarding their performance for predicting FFR ≤ 0.80. Predictive performance of %FMM or angiographic scores for FFR ≤ 0.80 established in derivation cohort (N = 250) and tested in validation cohort (N = 161).

Results The performance of %FMM-70 and %FMM-50 were similar to most angiographic scores (%FMM-70, c-statistics = 0.76; %FMM-50, 0.71; angiographic scores, 0.68 – 0.79). The frequency of FFR ≤ 0.80 increased consistently according to %FMM-70, %FMM-50, and all angiographic scores (p &lt; 0.001, all). The optimal cutoff of %FMM-50 and %FMM-70 for FFR ≤ 0.80 were ≥34.5% and ≥9.8%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of %FMM-50 were 83%, 56%, 73%, 70%, 72%, and of %FMM-70 were 72%, 78%, 75%, 75%, and 75% using these cutoffs. Validation cohort showed consistent results.

Conclusion %FMM correlated well with angiographic scores and had a potential to be used as a non-invasive alternative to the angiographic scores. The integration of the severity of stenosis and the amount of subtended myocardium may improve the detection of clinically significant coronary artery stenosis.

Abstract 1175 Figure. FMM vs angiographic score

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

P1526Pre-dialysis left atrial function assessed by two-dimensional speckle tracking echocardiography as a predictor of upcoming heart failure in hemodialysis patients

Background

Left atrial global longitudinal strain (LA GLS) by 2-dimensional speckle tracking echocardiography is a useful tool to assess LA function and left ventricular (LV) diastolic function. The authors assessed prognostic value of LA GLS, and other diastolic functional parameters in patients undergoing hemodialysis.

Methods

A total of 78 (49 male) patients undergoing hemodialysis who checked echocardiography due to heart failure (HF) symptoms were included for this analysis. Echocardiography wasperformed at the same day of, and before hemodialysis session. Besides conventional echocardiographic measurements, GLS of the LA and the LV were checked and compared. Incidence of rehospitalization due to HF symptoms during mean follow up duration of 381.4±197.5 days was investigated and echocardiographic parameters were compared between patients who experienced rehospitalization and who did not.

Results

16 (20.1%) patients experienced rehospitalization due to HF. HF rehospitalization group had significantly low baseline LV ejection fraction (55.7±7.2 vs. 61.3±7.1%, p=0.006) and LV GLS (14.7±3.4 vs. 18.2±3.9%, p=0.002), while LV geometry (LV end-diastolic volume index and LV wall thickness) did not show significant differences. In HF rehospitalization group, baseline LA function and diastolic function were significantly impaired as reflected by LA GLS (18.8±2.6 vs. 23.8±3.6%, p<0.001), E/E' ratio (20.8±3.3 vs. 15.8±4.6%, p<0.001), and right ventricular systolic pressure (61.4±9.6 vs. 53.4±12.8%, p=0.022). LA end-systolic volume index was not significantly different between the 2 groups. Among various echocardiographic parameters, receiver operation characteristic curve analysis revealed that LA GLS had the strongest power (cutoff value 20.6%, sensitivity 0.813 and specificity 0.790, area under curve 0.849) in prediction of future rehospitalization due to HF.

Predictor of future HF: ROC analysis

Conclusions

The present study demonstrated that functional changes of the LA as measured by LA GLS before hemodialysis session can be used as an echocardiographic parameter to predict future rehospitalization due to HF. Further studies are required to evaluate prognostic value of LA function in predicting other cardiovascular events in hemodialysis patients.

P3520Admission hyperglycemia is a predictor of mortality of acute heart failure: comparison between patients with and without diabetes mellitus

Background

Regardless of diabetes mellitus (DM), admission hyperglycemia is not uncommon in patients with acute heart failure (AHF). Although DM is a well-known predictor of mortality in AHF, the impacts of admission hyperglycemia on clinical outcomes in non-DM patients with AHF have been poorly studied. The aim of this study, therefore, was to compare the impact of admission hyperglycemia on long-term clinical outcomes in AHF patients with or without DM.

Methods

Among 5,625 AHF patients enrolled in a nationwide registry, a total of 5,541 patients were enrolled and divided into 2 groups; DM group (n=2,125, 70.4±11.4 years) vs. non-DM group (n=3,416, 67.3±16.0 years). Each group were further divided into 2 groups according to the presence of admission hyperglycemia (admission serum glucose level >200mg/dl); admission hyperglycemia (n=248) and no hyperglycemia (n=3,168) in non-DM; admission hyperglycemia (n=799) and no hyperglycemia (n=1,326) in DM. All-cause death and hospitalization due to HF (HHF) during 1-year follow-up were compared.

Results

Death was developed in 1,220 patients (22.2%) including 269 inhospital deaths (4.9%) during 1-year of follow-up. Death rate were significantly higher in DM than in non-DM group (24.8% vs 20.5%, p<0.001), however there was no difference in inhospital death (5.1% vs 4.7%, p=0.534). Both inhospital death (7.6% vs. 4.2%, p<0.001) and 1-year death (26.2% vs. 21.3%, p=0.001) were more frequent in AHF patients with hyperglycemia. On Kaplan-Meier survival curve analysis, however, admission hyperglycemia was associated with significantly higher death (p<0.001 by log-rank test) and rehospitalization (p=0.006 by log-rank test) in non-DM group, but not in DM group. In non-DM group, admission hyperglycemia was an independent predictor of 1-year mortality (HR 1.46, 95% CI 1.10–1.93, p=0.009).

Conclusion

DM was a significant predictor of long-term mortality in patients with AHF. Admission hyperglycemia was associated with both higher inhospital and 1-year mortality. The present study also demonstrated that admission hyperglycemia is an independent predictor of mortality in non-DM patients with AHF, but not in DM patients. In addition to the presence of DM, admission hyperglycemia would be a useful marker in the risk stratification of AHF, especially in non-DM patients.

P688Cardiac dysfunction as a predictor of hepatic sinusoidal obstruction syndrome after hematopoietic cell transplantation

Background

Hepatic sinusoidal obstruction syndrome (HSOS) is a well-known fatal complication of hematopoietic cell transplantation (HCT), but the impact of cardiac abnormalities on the occurrence of HSOS has been poorly evaluated. Therefore, the authors investigated whether the structural changes or dysfunction of the heart before HCT is associated with the future occurrence of HSOS.

Methods

A total of 92 patients who underwent HCT were divided into 2 groups; HSOS group (n=11, 6 males, 53.8±15.9 years) vs no HSOS group (n=81, 51 males, 48.6±14.7 years). According to the modified Seattle criteria, HSOS was defined as otherwise unexplained occurrence of 2 or more of the following events within 20 days of HCT; serum total bilirubin >2 mg/dL, hepatomegaly or right upper quadrant pain, sudden weight gain due to fluid accumulation (>2% of baseline body weight). Echocardiography examinations were performed 1 month before HCT, and echocardiographic findings were compared between the groups.

Results

HSOS was developed in 11 patients (12.0%). HSOS group had significantly larger left ventricular end-diastolic volume index (LVEDVI) (65.2±4.9 vs 53.2±6.9 ml/m2, p<0.001) and relatively worse systolic function than no HSOS group (LV ejection fraction: 56.4±3.4 vs 65.1±5.9%, p<0.001, LV global longitudinal strain: −17.9±1.4 vs −20.1±2.0%, p=0.001). LV diastolic functional parameters were also significantly worse in HSOS group than in no HSOS group (E/E' ratio: 11.3±1.8 vs 9.1±2.0, p=0.002, left atrial global longitudinal strain: 27.7±3.3 vs 34.9±5.9%, p<0.001). However, left atrial volume index was not different between the groups (30.8±2.8 vs 29.0±3.3 ml/m2, p=0.078). By receiver operation characteristic curve analysis, among significantly different variables, LVEDVI was the most powerful predictor for HSOS, and the optimal cutoff value was 59.25 mL/m2. (81.8% sensitivity and 77.8% specificity, AUC 0.909).

Predictor of HSOS: ROC analysis

Conclusions

The present study demonstrated that structural changes or dysfunction of the heart are more prevalent in patients with HSOS after HCT and larger LVEDVI, among them, can be a useful predictor of upcoming HSOS. Routine echocardiographic study before HCT would be useful to identify high risk group for HSOS, and the development of HSOS should be carefully monitored in HCT patients with cardiac structural changes or dysfunction on echocardiography.

P671Impacts of echocardiography-defined pulmonary hypertension on clinical outcome in patients with multiple myeloma

Background

Pulmonary hypertension (PH) is a rarely reported complication of multiple myeloma (MM). PH of MM is usually mild to moderate and can be secondary to a variety of conditions, including left ventricular dysfunction, diastolic dysfunction, chronic heart failure, treatment-related toxicity, thrombophilic condition and precapillary involvement. However, only few reports regarding PH in MM incidence and prognosis exist up to now.

Purpose

The purpose of this study was to investigate the risk factors of transthoracic echocardiography-defined PH and its impact on clinical outcome in patients with MM.

Methods

A total of 277 MM patients was included and divided into 2 groups–those non-pulmonary hypertension (PH) or those with PH, based on the results of the transthoracic echocardiography (TTE); PH group (n=143, 60.9±9.2 years, 68 males) versus non-PH group (n=134, 55.9±11.5 years, 72 males). We analyzed propensity score matching and multiple imputation method were used to deal with the missing data in echocardiographic characteristics.

Results

During the follow-up period (median 618 days), all-cause death occurred in 79 (28.5%) patients and 41 patients (14.8%) died from cardiovascular causes (including acute decompensated heart failure, fatal MI, sudden cardiac arrest). In the Kaplan-Meier survival analysis of crude population and propensity-matched population, cumulative overall survival and cardiovascular death (CVD)-free survival were significantly lower in the PH group than in the non-PH group (p<0.001). In propensity-matched population, estimated pulmonary artery pressure >35mmHg in TTE, congestive heart failure, and DM were significant independent predictors of all-cause death.

KM curves in MM stratified by PH

Conclusion

This study demonstrates that the presence of PH, congestive heart failure, and DM is an independent prognostic factor for all-cause death in MM patients with MM. These results highlight the risk associated cardiovascular disease in MM patients and emphasize that management strategies that prevent deterioration of cardiac function are essential.

Cav-1 (Caveolin-1) and Arterial Remodeling in Adult Moyamoya Disease

Background and Purpose- Moyamoya disease (MMD) is a unique cerebrovascular occlusive disease characterized by progressive stenosis and negative remodeling of the distal internal carotid artery (ICA). We hypothesized that cav-1 (caveolin-1)-a protein that controls the regulation of endothelial vesicular trafficking and signal transduction-is associated with negative remodeling in MMD. Methods- We prospectively recruited 77 consecutive patients with MMD diagnosed via conventional angiography. Seventeen patients with intracranial atherosclerotic stroke and no RNF213 mutation served as controls. The outer distal ICA diameters were examined using high-resolution magnetic resonance imaging. We evaluated whether the degree of negative remodeling in the patients with MMD was associated with RNF213 polymorphism, cav-1 levels, or various clinical and vascular risk factors. We also investigated whether the derived factor was associated with negative remodeling at the cellular level using the tube formation and apoptosis assays. Results- The serum cav-1 level was lower in the patients with MMD than in the controls (0.47±0.29 versus 0.86±0.68 ng/mL; P=0.034). The mean ICA diameter was 2.48±0.98 mm for the 126 affected distal ICAs in patients with MMD and 3.84±0.42 mm for the asymptomatic ICAs in the controls ( P<0.001). After adjusting for confounders, cav-1 levels (coefficient, 1.018; P<0.001) were independently associated with the distal ICA diameter in patients with MMD. In vitro analysis showed that cav-1 downregulation suppressed angiogenesis in the endothelial cells and induced apoptosis in the smooth muscle cells. Conclusions- Our findings suggest that cav-1 may play a major role in negative arterial remodeling in MMD.

Identification of High Risk Carotid Artery Stenosis: A Multimodal Vascular and Perfusion Imaging Study

Background: Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization. We sought to identify factors associated with symptomatic carotid artery stenosis (SCAS) using multimodal imaging techniques.

Methods: We retrospectively collected data on patients who underwent carotid artery revascularization. Results from duplex sonography, computerized tomography angiography, brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), perfusion-weighted imaging, and demographic profiles were compared between ACAS and SCAS patients. Differences in baseline characteristics between the two groups were balanced by the propensity matching score method. Multivariable regression analysis was performed to identify factors associated with symptomaticity of carotid artery stenosis. We compared the strength of associations between significant imaging factors and symptomatic carotid stenosis using C statistics.

Results: A total of 259 patients (asymptomatic 57.1%, symptomatic 42.9%) with carotid stenosis were included. After 1:1 propensity score matching, the multivariable regression analysis revealed that the absence of plaque calcification [Odds ratio 0.41, 95% confidence interval (CI) 0.182–0.870, p = 0.023], deep white matter hyperintensity (DWMH; Odds ratio 3.46, 95% CI 1.842–6.682, p < 0.001), susceptibility vessel sign seen on gradient-echo MRI (Odds ratio 2.35, 95% CI 1.113–5.107, p = 0.027), and increased cerebral blood volume (CBV) seen on perfusion-weighted MRI (CBV; Odds ratio 2.17, 95% CI 1.075–4.454, p = 0.032) were associated with SCAS. The combination of these variables had a fair accuracy to classify SCAS (Area under the curve 0.733, 95% CI 0.662–0.803).

Conclusions: We identified several multimodal imaging markers independently associated with SCAS. These markers may provide information to identify ACAS patients with high risk of ischemic stroke. Future studies are needed to predict SCAS using our findings in other independent cohorts.

Hyperprogressive disease during PD-1/PD-L1 blockade in patients with non-small-cell lung cancer

BACKGROUND

Immune checkpoint blockade with Programmed cell death 1 (PD-1)/PD-L1 inhibitors has been effective in various malignancies and is considered as a standard treatment modality for patients with non-small-cell lung cancer (NSCLC). However, emerging evidence show that PD-1/PD-L1 blockade can lead to hyperprogressive disease (HPD), a flair-up of tumor growth linked to dismal prognosis. This study aimed to evaluate the incidence of HPD and identify the determinants associated with HPD in patients with NSCLC treated with PD-1/PD-L1 blockade.

PATIENTS AND METHODS

We enrolled patients with recurrent and/or metastatic NSCLC treated with PD-1/PD-L1 inhibitors between April 2014 and November 2018. Clinicopathologic variables, dynamics of tumor growth, and treatment outcomes were analyzed in patients with NSCLC who received PD-1/PD-L1 blockade. HPD was defined according to tumor growth kinetics (TGK), tumor growth rate (TGR), and time to treatment failure (TTF). Immunophenotyping of peripheral blood CD8+ T lymphocytes was conducted to explore the potential predictive biomarkers of HPD.

RESULTS

A total of 263 patients were analyzed. HPD was observed in 55 (20.9%), 54 (20.5%), and 98 (37.3%) patients according to the TGK, TGR, and TTF. HPD meeting both TGK and TGR criteria was associated with worse progression-free survival [hazard ratio (HR) 4.619; 95% confidence interval (CI) 2.868-7.440] and overall survival (HR, 5.079; 95% CI, 3.136-8.226) than progressive disease without HPD. There were no clinicopathologic variables specific for HPD. In the exploratory biomarker analysis with peripheral blood CD8+ T lymphocytes, a lower frequency of effector/memory subsets (CCR7-CD45RA- T cells among the total CD8+ T cells) and a higher frequency of severely exhausted populations (TIGIT+ T cells among PD-1+CD8+ T cells) were associated with HPD and inferior survival rate.

CONCLUSION

HPD is common in NSCLC patients treated with PD-1/PD-L1 inhibitors. Biomarkers derived from rationally designed analysis may successfully predict HPD and worse outcomes, meriting further investigation of HPD.

Comparison of Clopidogrel and Ticlopidine/Ginkgo Biloba in Patients With Clopidogrel Resistance and Carotid Stenting

Background and Purpose: Patients undergoing carotid artery stenting (CAS) who show low responsiveness to clopidogrel may have a higher risk of peri-procedural embolic events. This study aimed to compare the effectiveness and safety of clopidogrel and ticlopidine plus Ginkgo biloba in clopidogrel-resistant patients undergoing CAS.

Methods: In this multi-center, randomized, controlled trial, we used platelet reactivity test to select patients undergoing CAS who showed clopidogrel resistance, and compared treatments using clopidogrel and ticlopidine plus ginkgo. The primary outcome was the incidence of new ischemic lesion in the ipsilateral hemisphere of CAS. Detection of microembolic signal on transcranial Doppler was the secondary outcome. The clinical outcomes were also monitored.

Results: This trial was discontinued after 42 patients were randomized after preplanned interim sample size re-estimation indicated an impractical sample size. The primary endpoint occurred in 12/22 patients (54.5%) in the clopidogrel group and 13/20 patients (65.0%) in the ticlopidine–ginkgo group (P = 0.610). No significant differences in the presence of microembolic signal (15.0 vs. 11.8%, P = 0.580), clinical outcomes (ischemic stroke or transient ischemic attack, 0.0 vs. 5.5%; acute myocardial infarction 0.0 vs. 0.0%; all-cause death, 4.5 vs. 0.0%), or incidence of adverse events were found in the two groups. In terms of resistance to clopidogrel, treatment with ticlopidine–ginkgo significantly increased the P2Y12 Reaction Units (difference, 0.0 [−0.3–3.0] vs. 21.0 [6.0–35.0], P < 0.001).

Conclusions: In patients who showed clopidogrel resistance, ticlopidine–ginkgo treatment was safe and increased P2Y12 Reaction Units; however, compared to clopidogrel, it failed to improve surrogate and clinical endpoints in patients undergoing CAS. This multimodal biomarker-based clinical trial is feasible in neurointerventional research.

Clinical Trial Registration:http://www.clinicaltrials.gov. Unique identifier: NCT02133989.

Intra- and Extra-pericardial Lengths of the Superior Vena Cava in Vivo: Implication for the Positioning of Central Venous Catheters

To reduce the possibility of cardiac tamponade, a rare but lethal complication of central venous catheters, the tip of the central venous catheter should be located above the cephalic limit of the pericardial reflection, not only above the superior vena cava-right atrium junction. This study was performed to measure the superior vena cava lengths above and below the pericardial reflection in cardiac surgical patients. Cardiac surgical patients (n=61; 27 male), whose age [mean±SD (range)] was 47±15 (15–75) years, were studied. The intrapericardial and extrapericardial lengths, and the length of the medial duplicated part were measured separately. The whole vertical lengths of the superior vena cava on either side were calculated respectively by adding the intra-and extrapericardial and medial duplication lengths. The lateral extrapericardial was 29.1±6.5 (Mean±SD) (9–49) mm (range), and lateral extrapericardial length was 32.6±6.9 (20–53) mm. The medial extrapericardial length was 23.3±5.0 (11–39) mm, medical duplicated length was 7.2±3.3 (4–20) mm, and medial intrapericardial was 28.3±7.0 (20–52) mm. The averaged superior vena cava length of both sides was 60.3±9.0 (44.5–90) mm. Almost half of the superior vena cava was found to be within the pericardium and half out. This information may be helpful in deciding how far a central venous catheter should be withdrawn beyond the superior vena cava-right atrial junction during right atrial electrocardiographic guided insertion, and in the prediction of optimal central venous catheter insertion depth.

Surface reconstruction and charge modulation in BaFe2As2 superconducting film

Whether or not epitaxially grown superconducting films have the same bulk-like superconducting properties is an important concern. We report the structure and the electronic properties of epitaxially grown Ba(Fe_1-x Co _x )₂As₂ films using scanning tunneling microscopy and scanning tunneling spectroscopy (STS). This film showed a different surface structure, [Formula: see text]R45° reconstruction, from those of as-cleaved surfaces from bulk crystals. The electronic structure of the grown film is different from that in bulk, and it is notable that the film exhibits the same superconducting transport properties. We found that the superconducting gap at the surface is screened at the Ba layer surface in STS measurements, and the charge density wave was observed at the surface in sample in the superconducting state.

Local myogenic pulp-derived cell injection enhances craniofacial muscle regeneration in vivo

OBJECTIVES

To enhance myogenic differentiation in pulp cells isolated from extracted premolars by epigenetic modification using a DNA demethylation agent, 5-aza-2'-deoxycytidine (5-Aza), and to evaluate the potent stimulatory effect of 5-Aza-treated pulp cell injection for craniofacial muscle regeneration in vivo.

SETTING AND SAMPLE POPULATION

Pulp cells were isolated from premolars extracted for orthodontic purposes from four adults (age range, 18-22.1 years).

MATERIAL AND METHODS

Levels of myogenic differentiation and functional contraction response in vitro were compared between pulp cells with or without pre-treatment of 5-Aza. Changes in muscle regeneration in response to green fluorescent protein (GFP)-labelled myogenic pulp cell injection in vivo were evaluated using a cardiotoxin (CTX)-induced muscle injury model of the gastrocnemius as well as the masseter muscle in mice.

RESULTS

Pre-treatment of 5-Aza in pulp cells stimulated myotube formation, myogenic differentiation in terms of desmin and myogenin expression, and the level of collagen gel contraction. The local injection of 5-Aza pre-treated myogenic pulp cells was engrafted into the host tissue and indicated signs of enhanced muscle regeneration in both the gastrocnemius and the masseter muscles.

CONCLUSION

The epigenetic modification of pulp cells from extracted premolars and the local injection of myogenic pulp cells may stimulate craniofacial muscles regeneration in vivo.

The relationship between clinical characteristics including presence of exposed lesions and health-related quality of life (HRQoL) in patients with psoriasis: analysis from the nationwide epidemiologic study for psoriasis in Korea (EPI-PSODE study)

BACKGROUND

Psychological aspect and quality of life should be considered in treating patients with psoriasis.

OBJECTIVE

We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis.

METHODS

The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ).

RESULTS

Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental).

CONCLUSION

The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

Predicting hypertension among Korean cancer survivors: A nationwide population-based study

Hypertension is the most common comorbidity among cancer survivors, although there is no model for predicting hypertension in this population. Therefore, we developed a model for predicting hypertension using data from 6,480 Korean cancer survivors who were ≥20 years old. The odds ratios (ORs) for hypertension were calculated using stepwise logistic regression analyses, and a nomogram was generated to predict hypertension. Hypertension was independently associated with an age of ≥65 years (OR: 3.058), male gender (OR: 1.195), obesity (OR: 1.998), prehypertension (OR: 2.06), dyslipidaemia (OR: 2.011) and diabetes mellitus (OR: 2.297). Each variable in the nomogram was assigned a specific number of points, and the total score (range: 0-400) was used to obtain a value for predicting hypertension. The estimated prevalence of hypertension increased when the total nomogram score exceeded the sixth decile (total points: 128; p for trend <.001). Therefore, among Korean cancer survivors, hypertension was significantly associated with an age of >65 years, male gender, obesity, and having various comorbidities (e.g., prehypertension, dyslipidaemia and diabetes mellitus). Furthermore, our nomogram could predict the incidence of hypertension, and the sixth decile of the total nomogram score predicted an increased risk of hypertension.

Dual-graft adult living donor liver transplantation with ABO-incompatible graft: short-term and long-term outcomes

ABO-incompatible (ABOi) dual-graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short- and long-term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end-stage liver disease score was 12.2 ± 4.6. The 1-, 3-, and 5-year patient survival rate was 96.4% during the mean follow-up period of 57.0 ± 22.4 months. The 1-, 3-, and 5-year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO-compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.

Abstract TP47: Prediction of Stroke Outcome With Immediate Post-Thrombolysis Magnetic Resonance Imaging

Background: Early recanalization and adequate collateral blood flow are strong surrogates for functional recovery in endovascular stroke treatment. We sought to evaluate the prognostic value of immediate post-thrombolysis magnetic resonance imaging (MRI).

Methods: Consecutive patients with acute ischemic stroke who underwent endovascular treatment were enrolled. We measured diffusion-weighted MRI (DWI) and perfusion-weighted MRI (PWI) lesion volume, mismatch ratio, and DWI and PWI lesion volume change before and immediate after treatment. Outcome was measured with modified Rankin Scale (mRS) at 90 days, early neurological improvement (NIHSS ≥ 8) within 7 days, and any intracerebral hemorrhage. Multivariate analysis and c -statistics were used to identify prognostic value of MR parameters.

Results: A total of 65 patients with a complete pre- and post-thrombolysis MRI were included. Mean age was 65±18 years, median baseline NIHSS score was 14, and median time from symptom onset to endovascular treatment was 192 minutes. Median time from endovascular treatment to post-treatment MRI was 20 minutes. After control of initial stroke severity and complete recanalization on angiography, post-thrombolysis PWI lesion volume remained an independent predictor of favorable outcome ( p = 0.017, odds ratio [OR] = 0.970, 95% confidence interval [CI] = 0.946-0.995), and early neurological improvement ( p = 0.014, OR = 0.957, 95% CI = 0.923-0.991), whereas DWI lesion volume, mismatch ratio, and DWI and PWI lesion volume changes did not show statistical significance. None of the measured variables predicts intracerebral hemorrhage. Post-thrombolysis PWI lesion volume revealed area under the curve of 0.821 (p < 0.001, 95% CI = 0.722-0.920) for favorable outcome and 0.878 (p < 0.001, 95% CI = 0.799-0.957) for early neurological improvement.

Conclusions: Perfusion lesion volume on immediate post-thrombolysis MRI more accurately predicts functional recovery and early neurological improvement than pre-treatment DWI and PWI parameters.

Contrast-Induced Acute Kidney Injury after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage

PURPOSE

Contrast-induced acute kidney injury (CI-AKI) is associated with poor outcomes after percutaneous coronary intervention. However, CI-AKI has rarely been evaluated within the neurovascular field. The aim of this study was to investigate the incidence and clinical implication of CI-AKI after coil embolization in patients with an aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Between January 2005 and March 2016, 192 patients who underwent coil embolization were enrolled in this study. CI-AKI was defined as an increase from baseline serum creatinine concentration of >25% or >0.5 mg/dL within 72 hours after coil embolization. A poor clinical outcome was defined as a score of ≥3 on the modified Rankin Scale at one-year post-treatment.

RESULTS

A total of 16 patients (8.3%) died as a result of medical problems within one year. CI-AKI was identified in 14 patients (7.3%). Prominent risk factors for one-year mortality included CI-AKI [odds ratio (OR): 16.856; 95% confidence interval (CI): 3.437-82.664] and an initial Glasgow Coma Scale (GCS) score ≤8 (OR: 5.565; 95% CI: 1.703-18.184). A poor clinical outcome was associated with old age (≥65 years) (OR: 7.921; 95% CI: 2.977-21.076), CI-AKI (OR: 11.281; 95% CI: 2.138-59.525), an initial GCS score ≤8 (OR 31.02; 95% CI, 10.669-90.187), and a ruptured aneurysm (p=0.016, OR: 4.278) in posterior circulation.

CONCLUSION

CI-AKI seems to be an independent predictor of the overall outcomes of aSAH after endovascular treatment.