Impact of the COVID-19 pandemic on the incidence of surgical site infection after orthopaedic surgery: an interrupted time series analysis of the nationwide surveillance database in Japan

BACKGROUND

During the COVID-19 pandemic, hygiene awareness was increased in communities and hospitals. However, there is controversy regarding whether such circumstances affected the incidence of surgical site infections (SSIs) in the orthopaedic surgical field.

AIM

To examine the impact of the COVID-19 pandemic on the incidence of SSIs after orthopaedic surgery.

METHODS

The medical records of patients having undergone orthopaedic surgery were extracted from the nationwide surveillance database in Japan. The primary outcomes were the monthly incidences of total SSIs, deep or organ/space SSIs, and SSIs due to meticillin-resistant Staphylococcus aureus (MRSA). Interrupted time series analysis was conducted between pre-pandemic (January 2017 to March 2020) and pandemic (April 2020 to June 2021) periods.

RESULTS

A total of 309,341 operations were included. Interrupted time series analysis adjusted for seasonality showed no significant changes in the incidence of total SSIs (rate ratio 0.94 and 95% confidence interval 0.98-1.02), deep or organ/space SSIs (0.91, 0.72-1.15), or SSIs due to MRSA (1.07, 0.68-1.68) along with no remarkable slope changes in any parameter (1.00, 0.98-1.02; 1.00, 0.97-1.02; and 0.98, 0.93-1.03, respectively).

CONCLUSIONS

Awareness and measures against the COVID-19 pandemic did not markedly influence the incidence of total SSIs, deep or organ/space SSIs, or SSIs due to MRSA following orthopaedic surgery in Japan.

Native T1 mapping in early diffuse and limited systemic sclerosis, and its association with diastolic function

BACKGROUND

Systemic sclerosis (SSc) is divided into diffuse and limited cutaneous SSc (dcSSc and lcSSc). The dcSSc subtype has more severe internal organ damage. This study aimed to assess whether cardiovascular magnetic resonance (CMR) parametric mapping could detect early cardiac involvement and evaluate differences between these two subtypes.

METHODS

Eighty SSc patients (37 dcSSc and 43 lcSSc) underwent CMR at 3.0 T (Philips Healthcare, Best, The Netherlands) in our hospital between July 2018 and July 2021. We analyzed myocardial damage by CMR parametric mapping and compared it with clinical data.

RESULTS

The median duration of the disease was 10.2 months. The left ventricular ejection fraction was preserved in both groups. DcSSc had significantly higher native T1 (1333.4 ± 71.2 ms vs. 1295.0 ± 42.7 ms, p = 0.006) and extracellular volume fraction (32.6 ± 4.1 % vs. 30.3 ± 4.0 %, p = 0.018) in the mid-ventricular septum as compared to lcSSc, although there were no differences in T2 values. Native T1 values were positively correlated with the E/e' ratio and left atrial volume indices evaluated by transthoracic echocardiography in overall SSc and dcSSc, but not in lcSSc. Logistic regression analysis revealed that native T1 was an independent predictor of left ventricular diastolic dysfunction in SSc patients (odds ratio, 1.194; 95 % confidence interval, 1.021-1.396; p = 0.026). Native T1 was higher in SSc patients with progressive skin lesions. Additionally, there were positive correlations between brain natriuretic peptide, New York Heart Association functional classification, and native T1.

CONCLUSIONS

CMR parametric mapping is a useful tool for detecting myocardial changes. Native T1 was the most sensitive parameter for identifying diffuse myocardial changes in the early stages of SSc and was associated with left ventricular diastolic function. DcSSc had more severe myocardial involvement than lcSSc; therefore, the use of CMR parametric mapping may aid in its prediction.

A new assessment method for right ventricular diastolic function using right heart catheterization by pressure-volume loop

Diastolic stiffness coefficient (β) and end-diastolic elastance (Eed) are ventricular-specific diastolic parameters. However, the diastolic function of right ventricle had not been investigated sufficiently due to the lack of established evaluation method. We evaluated the validity of these parameters calculated using only data of right heart catheterization (RHC) and assessed it in patients with restrictive cardiomyopathy (RCM) and cardiac amyloidosis. We retrospectively analyzed 46 patients with heart failure who underwent RHC within 10 days of cardiac magnetic resonance (CMR). Right ventricular end-diastolic volume and end-systolic volume were calculated using only RHC data, which were found to be finely correlated with those obtained from CMR. β and Eed calculated by this method were also significantly correlated with those derived from conventional method using CMR. By this method, β and Eed were significantly higher in RCM with amyloidosis group than dilated cardiomyopathy group. In addition, the β and Eed calculated by our method were finely correlated with E/A ratio on echocardiography. We established an easy method to estimate β and Eed of right ventricle from only RHC. The method finely demonstrated right ventricular diastolic dysfunction in patients with RCM and amyloidosis.

The effect of immunosuppressive therapy on cardiac involvements in anti-mitochondrial antibody-positive myositis

AIMS

Anti-mitochondrial antibody (AMA)-positive myositis is frequently associated with various cardiac involvements, such as arrhythmia and left ventricular (LV) dysfunction. However, the efficacy of immunosuppressive therapy in these complications remains unknown. This study aimed to investigate the cardiac response to immunosuppressive therapy in patients with AMA-positive myositis.

METHODS AND RESULTS

The clinical data of 15 AMA-positive myositis patients with cardiac involvement were retrospectively collected at our centre. To evaluate the effects of immunosuppressive therapy, echocardiographic and laboratory data of patients who received glucocorticoid therapy with additional immunosuppressants (n = 6) and those who did not (n = 6) were compared. Also, the characteristics of patients with or without >5% LV ejection fraction (LVEF) decline during the follow-up period (n = 5 vs. n = 7) were compared. Thirteen patients (87%) had arrhythmias, and eight patients (53%) had LV wall motion abnormalities. Although arrhythmias decreased after treatment, reduced LVEF and LV wall motion abnormalities persisted. Further investigation revealed an increased LV end-systolic dimension and reduced LVEF in patients without additional immunosuppressive therapy, while those in patients with additional immunosuppressive therapy were maintained. Six of seven patients (86%) without LVEF decline received additional immunosuppressive therapy, whereas no patients with LVEF decline had additional immunosuppressive therapy.

CONCLUSIONS

Cardiac involvement in AMA-positive myositis may worsen even with glucocorticoid monotherapy, and there might be some associations between the change of LV function and additional immunosuppressive therapy.

Successful treatment of recurrent cardiac sarcoidosis with the combination of corticosteroid and methotrexate monitored by 18F-fluoro-2-deoxyglucose positron emission tomography: case series

Background

The standard treatment for cardiac sarcoidosis (CS) is corticosteroids, including prednisolone (PSL). Previous studies have shown that the addition of methotrexate (MTX) to PSL is effective for steroid-refractory and recurrent cases. ¹⁸F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) is an essential tool for the diagnosis of CS. However, it is unclear whether FDG-PET is useful for detecting recurrence of CS and monitoring the effectiveness of PSL and MTX combination therapy.

Case summary

We detected CS recurrence during PSL treatment using FDG-PET. Patient 1 was accompanied by increased FDG uptake in other organs, Patient 2 was complicated with a decrease in left ventricular ejection fraction, and Patient 3 showed enlargement of the late gadolinium enhancement area, which was compatible with the recurrence of CS. We successfully monitored the inflammation activity by FDG-PET and treated recurrent CS by increasing the PSL dose and adding MTX to suppress inflammation.

Discussion

FDG-PET is useful for detecting CS recurrence and monitoring the effectiveness of PSL and MTX combination therapy. Serial FDG-PET scans indicated that it might be more difficult to suppress inflammation in recurrent CS than in the initial treatment. The use of FDG-PET is necessary to monitor long-term disease activity.

Outcomes by Severity of Obesity During Extracorporeal Membrane Oxygenation Support for COVID-19

Purpose

Obesity adversely impacts outcomes during COVID-19 but its relation to mortality in those receiving extracorporeal membrane oxygenation (ECMO) is uncertain.

Methods

A retrospective multicenter study was conducted. Adult patients (≥18 years old) with severe COVID-19 infection placed on ECMO between March 1, 2020 to April 30, 2021, across the United States were included. A web-based database application, REDCap, was utilized to capture clinical characteristics and outcomes. Patients were grouped into tertiles of body mass index (BMI). The primary outcome was in-hospital mortality after ECMO placement assessed by a time-to-event analysis.

Results

Overall 444 patients (age 49, IQR: 38-57 years, 29% female, BMI: 33, IQR: 29-39 kg/m2) from 17 centers comprised the study cohort. Patients that expired during hospitalization had a similar BMI in comparison to those that were discharged (33, IQR: 29-38 vs. 34, IQR: 30-40 kg/m2, p=0.13). BMI across groups was 27, IQR: 25-29 (lowest tertile), 33, IQR: 32-34 (middle tertile), 41, IQR: 38-45 kg/m2 (highest tertile). At 90 days, in-hospital mortality between BMI tertiles was 53%, 59%, and 53%, p=0.99 (figure). After adjustment for clinical covariates including age, sex, presence of preexisting co-morbidities, cardiopulmonary arrest prior to ECMO, serum creatinine and arterial partial pressure of oxygen (PaO2) to inspired oxygen concentration (FiO2) ratio, there was no difference in hospital mortality in the middle (aHR:1.13, CI: 0.79-1.63, p=0.5) and highest (aHR: 1.38, CI: 0.95-2.01, p=0.09) tertiles in comparison to the lowest BMI tertile.

Conclusion

Severity of obesity is not associated with death during hospitalization in patients placed on ECMO for COVID-19

Clinical Outcome of Closure of a Small Atrial Septal Defect in a Patient with Pulmonary Arterial Hypertension

The closure of small/coincidental atrial septal defects (ASDs) in patients with pulmonary arterial hypertension (PAH) has been described in recent major guidelines as useless or even contraindicated. We confirm the effectiveness of "Treat and Repair" for ASD closure through one patient diagnosed with idiopathic PAH with small ASD, under careful observation with right heart catheterization and cardiac magnetic resonance imaging. The clinical decision concerning the closure of ASD with PAH should be made not only by referring to the guidelines but also by evaluating the benefits and risks specific to that case.

Detection of Profound Myocardial Damage by Cardiac MRI in a Patient with Severe Cardiotoxicity Induced by Anti-HER2 Therapy

Anti-HER2 therapy has greatly improved the long-term prognosis of patients with HER2-positive breast cancer. Meanwhile, by interfering with the protective effects of neuregulin-1/HER2 signaling on stressed cardiomyocytes, anti-HER2 therapy occasionally induces reversible cancer therapeutics-related cardiac dysfunction (CTRCD). Cardiac magnetic resonance (CMR) parametric mapping or myocardial feature-tracking, in combination with late gadolinium enhancement (LGE) imaging, has the potential to detect changes in the myocardium in anti-HER2 therapy-related cardiac dysfunction. Here we report a breast cancer patient who experienced life-threatening CTRCD after treatment with trastuzumab plus pertuzumab. This case showed multiple transmural LGE-positive myocardial lesions in CMR imaging and high native T1 and T2 values in CMR parametric mapping, which was apparently more extensive than those observed in most patients with anti-HER2 therapy-related cardiac dysfunction. Consistent with profound myocardial damage indicated by CMR, her cardiac function was not fully restored despite intensive care and cardioprotective drug therapy. These findings suggest the potential usefulness of LGE imaging and parametric mapping by CMR for the assessment of myocardial injury to determine the clinical severity of anti-HER2 therapy-related cardiac dysfunction.

The therapeutic dilemma of immunosuppressive drugs for refractory cardiac sarcoidosis in COVID-19 infection

Patients with refractory cardiac sarcoidosis (CS) take a high dose of corticosteroid and immunosuppressive agents. During the pandemic outbreak of severe acute respiratory syndrome coronavirus 2, appropriate treatment of corticosteroids or immunosuppressive agents in CS patients with coronavirus disease 2019 (COVID‐19) is unknown. Here, the woman with refractory CS receiving maintenance therapy with 15 mg of prednisolone daily and 10 mg of methotrexate weekly was emergently admitted to our hospital because of COVID‐19. This case was successfully treated by the intravenous administration of dexamethasone 6 mg/day instead of prednisolone and interruption of methotrexate without resulting in recurrent life‐threatening ventricular lethal arrhythmias or obvious sarcoidosis flare‐ups. She started taking prednisolone and methotrexate at the maintenance dose immediately and at 2 weeks after discharge, respectively. Although the optimal regimen of immunosuppressive agents during COVID‐19 is under intense debate, this report might provide an effective treatment strategy for CS patients with COVID‐19.

Cardiac magnetic resonance parametric mapping can detect early cardiac involvement of patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is divided into two subtypes, diffuse and limited cutaneous SSc (dcSSc and lcSSc). The dcSSc subtype has more severe internal organ fibrosis than lcSSc. It is unclear whether cardiovascular magnetic resonance (CMR) parametric mapping can detect early cardiac involvement in these two subtypes.

Purpose

To detect cardiac involvement and evaluate differences between the two subtypes, we examined CMR parametric mapping.

Methods

57 consecutive SSc patients (27 dcSSc and 30 lcSSc) who visited our hospital from July 2018 to February 2021 and underwent CMR at 3.0T (Philips) were included. We analyzed myocardial damage using CMR parametric mapping and compared it with clinical data.

Results

Mean disease durations of dcSSc and lcSSc were 4.0±6.5 years and 4.4±8.3 years, respectively. Although there were no significant differences in LVEF (56.8±8.8 vs 59.6±7.2), the left and right atrial volume index were significantly larger in dcSSc compared with lcSSc (all p<0.05). Focal fibrosis as evaluated by late gadolinium enhancement was found in 9 SSc patients (15.7%) and 4 patients had pulmonary hypertension. DcSSc patients had significantly higher mid-ventricular native T1 (1350.8±73.2 vs 1312.9±52.1, p=0.029) and postcontrast T1 values (640.4±59.4 vs 604.6±42.5, p=0.015) as compared to lcSSc, although there were no significant differences in ECV and T2 values. Native T1 values in mid-ventricular septum were positively correlated with E/e' ratio of echocardiography in overall SSc patients and dcSSc patients but not in lcSSc patients (r=0.320, p=0.021; r=0.505, p=0.010; r=0.195, p=0.329). Native T1 values in mid-ventricular septum were also positively correlated with plasma levels of brain natriuretic peptide (BNP) in overall SSc patients and dcSSc patients but not in lcSSc patients (r=0.353, p=0.008; r=0.484, p=0.011; r=0.113, p=0.559).The multiple regression analysis considering age and sex revealed that mid-ventricular septum native T1 was the independent predictor of E/e' in SSc patients (β=0.306, p=0.026), and dcSSc patients (β=0.553, p=0.007) but not in lcSSc patients (β=−0.282, p=0.105). The ROC curve for predicting E/e'≥14, cut-off value of native T1 in mid-ventricular septum was ≥1348.5msec (AUC 0.762; 95% CI 0.571–0.953; sensitivity 80.0%; specificity 68.1%). BNP was significantly higher in patients with native T1≥1348.5 msec compared with native T1<1348.5 (102.8±112.8 vs 45.7±55.7; p=0.014). The interobserver variability of CMR parametric mapping values was excellent in this study.

Conclusion

DcSSc patients showed higher native T1 and larger left and right atrial volume index of CMR than lcSSc patients, suggesting that DcSSc patients had more severe myocardial involvement and left ventricular diastolic dysfunction than lcSSc patients. Early detection of the high native T1 may predict the occurrence of cardiovascular events in the future.

Funding Acknowledgement

Type of funding sources: None. Correlation between native T1 and BNPCorrelation between native T1 and E/e'

Deep Learning Algorithm to Detect Cardiac Sarcoidosis From Echocardiographic Movies

BACKGROUND

Because the early diagnosis of subclinical cardiac sarcoidosis (CS) remains difficult, we developed a deep learning algorithm to distinguish CS patients from healthy subjects using echocardiographic movies.Methods and Results:Among the patients who underwent echocardiography from January 2015 to December 2019, we chose 151 echocardiographic movies from 50 CS patients and 151 from 149 healthy subjects. We trained two 3D convolutional neural networks (3D-CNN) to identify CS patients using a dataset of 212 echocardiographic movies with and without a transfer learning method (Pretrained algorithm and Non-pretrained algorithm). On an independent set of 41 echocardiographic movies, the area under the receiver-operating characteristic curve (AUC) of the Pretrained algorithm was greater than that of Non-pretrained algorithm (0.842, 95% confidence interval (CI): 0.722-0.962 vs. 0.724, 95% CI: 0.566-0.882, P=0.253). The AUC from the interpretation of the same set of 41 echocardiographic movies by 5 cardiologists was not significantly different from that of the Pretrained algorithm (0.855, 95% CI: 0.735-0.975 vs. 0.842, 95% CI: 0.722-0.962, P=0.885). A sensitivity map demonstrated that the Pretrained algorithm focused on the area of the mitral valve.

CONCLUSIONS

A 3D-CNN with a transfer learning method may be a promising tool for detecting CS using an echocardiographic movie.

Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement for Aortic Stenosis in Japan - Analysis of a Nationwide Inpatient Database

Background: Nationwide data on transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in Japan are scarce. Methods and Results: Using a nationwide inpatient database, we analyzed patients undergoing TAVI (n=8,338) or SAVR (n=16,298) due to aortic stenosis between 2014 and 2017. The annual number of TAVI increased rapidly from 2014 to 2017, particularly in older patients. In-hospital deaths were lower and the length of hospital stay was shorter for patients undergoing TAVI than SAVR. Conclusions: TAVI has been penetrating in Japan as an alternative therapeutic option for aortic stenosis and is associated with acceptable clinical outcomes.

Improved Diagnostic Performance of New-generation 320-slice Computed Tomography with Forward-projected Model-based Iterative Reconstruction SoluTion for the Assessment of Late Enhancement in Left Ventricular Myocardium

Objective Forward-projected Model-based Iterative Reconstruction SoluTion (FIRST) is a novel reconstruction method. We investigated the improvement in the diagnostic performance for the detection of abnormal late enhancement (LE) in left ventricular myocardium (LVM) using a new-generation 320-slice computed tomography (CT) device with FIRST. Methods This is a retrospective study that included 100 adult patients who underwent cardiac CT including a late phase scan and magnetic resonance imaging (MRI) within 3 months. The first 50 consecutive patients (first-generation group) underwent first-generation 320-slice CT without FIRST, and the next 50 consecutive patients (second-generation group) underwent second-generation 320-slice CT with FIRST. We compared the diagnostic performance of the first- and second-generation 320-slice CT with FIRST with MRI as a reference standard to detect LE in LVM. Results In the patient-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of detection of LE on CT were 79%, 90%, 92%, 76%, and 84%, respectively, in the first-generation group and 97%, 84%, 91%, 94%, and 92%, respectively, in the second-generation group. The sensitivity was significantly higher in the second-generation group than in the first-generation group (p=0.049). In the segment-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of detection of LE on CT were 69%, 96%, 83%, 92%, and 90%, respectively, in the first-generation group and 87%, 94%, 84%, 95%, and 92%, respectively, in the second-generation group. The sensitivity and negative predictive value were significantly higher in the second-generation group than in the first-generation group (p<0.001 and p=0.016). The contrast-noise ratio was significantly higher in the second-generation group than in the first-generation group (5.6±1.7 vs. 2.8±1.1, p<0.001), and the radiation dose for the assessment of LE on CT was significantly higher in the first-generation group than in the second-generation group (4.7±2.7 mSv vs. 2.3±0.1 mSv, p<0.001). Conclusion The diagnostic performance for the detection of LE in LVM significantly improved with the use of second-generation 320-slice CT and FIRST.

Improved Diagnosis of Detection of Late Enhancement in Left Ventricular Myocardium Using 2nd Generation 320-Slice CT Reconstructed with FIRST in Non-Ischemic Cardiomyopathy

Forward Projected Model-based Iterative Reconstruction SoluTion (FIRST) is a new reconstruction technique using CT, which provides successful reconstruction of high-quality CT images, especially in low contrast imaging. To evaluate improvements in the diagnostic accuracy of the detection of abnormal late enhancement (LE) in left-ventricular myocardium (LVM) using 320-slice CT with FIRST, we compared this modality with previous CT methods in patients with non-ischemic cardiomyopathy or a cardiac tumor.This was a retrospective study of 88 patients (56 males; 57 ± 15 years) suspected of having non-ischemic myocardial disease or a cardiac tumor. The first 52 consecutive patients (Group 1) underwent 16-slice CT at 140 kV tube voltage and an average tube current of 337 ± 20 mA, and 1.5 T MRI. The next 18 patients (Group 2) underwent 1st generation 320-slice CT at 120 kV tube voltage and an average tube current of 255 ± 106 mA, and 1.5T MRI; the remaining 18 patients (Group 3) underwent 2nd generation 320-slice CT with FIRST, at 80 kV tube voltage and a tube current of 800 mA, and 1.5T or 3T MRI.On patient-based analysis, no significant differences were observed between the 3 groups. For segment-based analysis, the specificity and overall accuracy were significantly higher (both P < 0.05) in Group 3 than in Group 1. Positive predictive value (PPV) was significantly higher in Group 3 than in Groups 1 and 2.The diagnostic accuracy of LE on CT for detecting myocardial fibrosis determined by late gadolinium-enhanced MRI was improved with the use of 2nd generation 320-slice CT with FIRST, in particular regarding specificity, PPV, and overall accuracy.

Thoracic aortic aneurysm is an independent factor associated with diffuse idiopathic skeletal hyperostosis

Aims

Although we often encounter patients with an aortic aneurysm who also have diffuse idiopathic skeletal hyperostosis (DISH), there are no reports to date of an association between these two conditions and the pathogenesis of DISH remains unknown. This study therefore evaluated the prevalence of DISH in patients with a thoracic aortic aneurysm (AA).

Patients and Methods

The medical records of 298 patients who underwent CT scans for a diagnosis of an AA or following high-energy trauma were retrospectively examined. A total of 204 patients underwent surgery for an AA and 94 had a high-energy injury and formed the non-AA group. The prevalence of DISH was assessed on CT scans of the chest and abdomen and the relationship between DISH and AA by comparison between the AA and non-AA groups.

Results

The prevalence of DISH in the AA group (114/204; 55.9%) was higher than that in the non-AA group (31/94; 33.0%). On multivariate analysis, the factors of AA, male gender, and ageing were independent predictors of the existence of DISH, with odds ratios of 2.9, 1.9, and 1.03, respectively.

Conclusion

This study revealed that the prevalence of DISH is higher in patients with an AA than in those without an AA, and that the presence of an AA significantly influenced the prevalence of DISH. Cite this article: Bone Joint J 2018;100-B:617-21.

Quantitative Differentiation of LV Myocardium with and without Layer-Specific Fibrosis Using MRI in Hypertrophic Cardiomyopathy and Layer-Specific Strain TTE Analysis

To achieve further risk stratification in hypertrophic cardiomyopathy (HCM) patients, we localized and quantified layer-specific LVM fibrosis on MRI in HCM patients using regional layer-specific peak longitudinal strain (PLS) and peak circumferential strain (PCS) in LV myocardium (LVM) on speckle tracking transthoracic echocardiography (TTE). A total of 18 HCM patients (14 males; 58 ± 17 years) underwent 1.5T-MRI and TTE. PLS and PCS in each layer of the LVM (endocardium, epicardium, and whole-layer myocardium) were calculated for 17 AHA-defined lesions. MRI assessment showed that fibrosis was classified as endocardial, epicardial, or whole-layer (= either or both of these). Regional PLS was smaller in fibrotic endocardial lesions than in non-fibrotic endocardial lesions (P = 0.004). To detect LV endocardial lesions with fibrosis, ROC curves of regional PLS revealed an area under the curve (AUC) of 0.609 and a best cut-off point of 13.5%, with sensitivity of 65.3% and specificity of 54.3%. Regional PLS was also smaller in fibrotic epicardial lesions than in non-fibrotic epicardial lesions (P < 0.001). To detect LV epicardial lesions with fibrosis, ROC curves of PLS revealed an AUC of 0.684 and a best cut-off point of 9.5%, with sensitivity of 73.5% and specificity of 55.5%. Using whole-layer myocardium analysis, PLS was smaller in fibrotic lesions than in non-fibrotic lesions (P < 0.001). To detect whole-layer LV lesions with fibrosis, ROC curves of regional PLS revealed an AUC of 0.674 and a best cut-off point of 12.5%, with sensitivity of 79.0% and specificity of 50.7%. There were no significant differences in PCS of LV myocardium (endocardium, epicardium, and whole-layer) between fibrotic and non-fibrotic lesions. Quantitative regional PLS but not PCS in LV endocardium, epicardium, and whole-layer myocardium provides useful non-invasive information for layer-specific localization of fibrosis in HCM patients.

2D speckle-tracking TTE-based quantitative classification of left ventricular myocardium in patients with hypertrophic cardiomyopathy by the presence or the absence of fibrosis and/or hypertrophy

We used peak longitudinal strain (PLS) on TTE in HCM patients to differentiate LV myocardium (LVM) into the following 4 groups: group 1-no fibrosis or hypertrophy (≥ 13 mm), group 2-no fibrosis but hypertrophy evident, group 3-fibrosis present but without hypertrophy, and group 4-both fibrosis and hypertrophy. Seventeen HCM patients (13 males, 56 ± 16 years) underwent both 1.5 T CMR and TTE. On TTE, PLS (absolute values) for each LVM segment from 17 AHA-defined lesions was calculated. Of 289 LVM lesions, the numbers in each group, 1-4, were 156, 53, 39, and 41, respectively. PLS for LVM segments in group 1 (13.6 ± 6.4%) were significantly greater than those in group 2 (8.5 ±  4.9%, P < 0.001), group 3 (10.4 ± 5.0%, P = 0.006), and group 4 (7.1 ± 4.4%, P < 0.001). PLS for LVM segments in group 3 was significantly greater than those in group 4 (P = 0.016). However, significant differences in PLS in LVM between groups 2 and 3, and between 2 and 4 were not observed. Using regional PLS, we demonstrate successful differentiation of LVM in HCM patients for group 1 (LVM with zero fibrosis or hypertrophy) from LVM belonging to groups 2-4 and we also demonstrate successful differentiation of LVM with fibrosis present but without hypertrophy from LVM with both fibrosis and hypertrophy. However, it is not possible to differentiate between LVM with no fibrosis but hypertrophy evident and those with fibrosis present but without hypertrophy and also between LVM with no fibrosis but hypertrophy evident and those with both fibrosis and hypertrophy. Our findings have significant implications for the management of HCM patients.

A spinner magnetometer for large Apollo lunar samples

We developed a spinner magnetometer to measure the natural remanent magnetization of large Apollo lunar rocks in the storage vault of the Lunar Sample Laboratory Facility (LSLF) of NASA. The magnetometer mainly consists of a commercially available three-axial fluxgate sensor and a hand-rotating sample table with an optical encoder recording the rotation angles. The distance between the sample and the sensor is adjustable according to the sample size and magnetization intensity. The sensor and the sample are placed in a two-layer mu-metal shield to measure the sample natural remanent magnetization. The magnetic signals are acquired together with the rotation angle to obtain stacking of the measured signals over multiple revolutions. The developed magnetometer has a sensitivity of 5 × 10^-7 Am² at the standard sensor-to-sample distance of 15 cm. This sensitivity is sufficient to measure the natural remanent magnetization of almost all the lunar basalt and breccia samples with mass above 10 g in the LSLF vault.

Rapid Improvement of thyroid storm-related hemodynamic collapse by aggressive anti-thyroid therapy including steroid pulse: A case report

RATIONALE

Heart failure is relatively common in patients with hyperthyroidism, but thyrotoxic cardiomyopathy with poor left ventricular (LV) systolic function is very rare.

PATIENT CONCERNS

We experienced a representative case of a patient who presented with severe LV dysfunction related to thyroid storm and needed extracorporeal membrane oxygenation (ECMO) temporally.

DIAGNOSIS

Thyrotoxic cardiomyopathy.

INTERVENTIONS AND OUTCOMES

Aggressive antithyroid therapy, including steroid pulse to hyperthyroidism, leads to the dramatic improvement of cardiac function and she was successfully weaned from ECMO.

LESSONS

The most outstanding feature of the current case was the rapid decrease of cardiac injury and improvement of cardiac function by strengthening antithyroid therapy, including steroid pulse, without thyroid hormone level normalization. In thyroid storm, various systemic inflammatory reactions have different time courses and among them, the cardiac phenotype emerges in most striking and critical ways.

Feasibility of Extracorporeal Shock Wave Myocardial Revascularization Therapy for Post-Acute Myocardial Infarction Patients and Refractory Angina Pectoris Patients

Extracorporeal shockwave myocardial revascularization (ESMR) is one of the new treatment options for refractory angina pectoris (RAP), and some studies have indicated its effectiveness. A single-arm prospective trial to assess the feasibility of ESMR using Cardiospec for patients with post-acute myocardial infarction (AMI) and RAP was designed and performed. The patients were treated with 9 sessions of ESMR to the ischemic areas for 9 weeks. The feasibility measures included echocardiography; cardiac magnetic resonance imaging; troponin T, creatine kinase-MB (CK-MB), and brain natriuretic peptide testing; and a Seattle Angina Questionnaire (SAQ) survey. Three post-AMI patients and 3 RAP patients were enrolled. The post-AMI patients had already undergone revascularization with percutaneous coronary intervention (PCI) in the acute phase. In two patients, adverse events requiring admission occurred: one a lumbar disc hernia in a post-AMI patient and the other congestive heart failure resulting in death in an RAP patient. No apparent elevations in CK-MB and troponin T levels during the trial were observed. Echocardiography revealed no remarkable changes of ejection fraction; however, septal E/E' tended to decrease after treatments (11.6 ± 4.8 versus 9.2 ± 2.8, P = 0.08). Concerning the available SAQ scores for two RAP patients, one patient reported improvements in angina frequency and treatment satisfaction and the other reported improvements in physical limitations and angina stability. In this feasibility study, ESMR seems to be a safe treatment for both post-AMI patients and RAP patients. The efficacy of ESMR for post-AMI patients remains to be evaluated with additional studies.

Rotatable Offner imaging system for ellipsometric measurement

To realize high spatial resolution imaging ellipsometric measurement with large field of view, we developed a rotatable Offner system with unit magnification. When the conventional Offner imaging system is tilted relative to the sample plane for the ellipsometric measurement, only a small region of plane is in focus. The rotatable Offner system developed here renders the entire object in focus through all rotations. The performance of the prototype of the Offner system and imaging ellipsometer is tested by generating maps of the ellipsometric parameters Δ and Ψ for samples such as a silicon wafer and a resolution target made of chromium film evaporated on a glass substrate.

Measurement of effect of electron cyclotron heating in a tandem mirror plasma using a semiconductor detector array and an electrostatic energy analyzer

Temporally and spatially resolved soft x-ray and end-loss-electron analyses of the electron cyclotron heated plasmas are carried out by using a semiconductor detector array and an electrostatic energy analyzer in the GAMMA 10 tandem mirror. The flux and the energy spectrum of the end loss electrons are measured by a multi-grid energy analyzer. Recently, the electron cyclotron heating power modulation experiments have been started in order to generate and control the high heat flux and to make the edge localized mode-like intermittent heat load pattern for the divertor simulation studies by the use of these detectors for electron properties.

Alterations in 18F-FDG accumulation into neck-related muscles after neck dissection for patients with oral cancers

BACKGROUND

18F-fluoro-2-deoxy-D-glucose (18F-FDG) accumulations are commonly seen in the neck-related muscles of the surgical and non-surgical sides after surgery with neck dissection (ND) for oral cancers, which leads to radiologists having difficulty in diagnosing the lesions. To examine the alterations in 18F-FDG accumulation in neck-related muscles of patients after ND for oral cancer.

MATERIAL AND METHODS

18F-FDG accumulations on positron emission tomography (PET)-computed tomography (CT) in neck-related muscles were retrospectively analyzed after surgical dissection of cervical lymph nodes in oral cancers.

RESULTS

According to the extent of ND of cervical lymph nodes, the rate of patients with 18F-FDG-PET-positive areas increased in the trapezius, sternocleidomastoid, and posterior neck muscles of the surgical and/or non-surgical sides. In addition, SUVmax of 18F-FDG-PET-positive areas in the trapezius and sternocleidomastoid muscles were increased according to the extent of the ND.

CONCLUSIONS

In evaluating 18F-FDG accumulations after ND for oral cancers, we should pay attention to the 18F-FDG distributions in neck-related muscles including the non-surgical side as false-positive findings.

Optimized heart rate for 320-row cardiac CT can be feasibly predicted from prescan parameters

To evaluate the degree of heart rate (HR) changes at rest (HRrest), during breath hold (HRtest), and during cardiac CT examinations (HRscan) in a large group of patients , and to derive and asses the feasibility of a predictive formula for HRscan. HRrest, HRtest, and HRscan were retrospectively compared in a total of 563 consecutive patients who underwent 320-row cardiac CT. Multiple regression analysis was performed to derive predictive formulae for HRscan in the entire study population and, in each group of patients with decreased (Dec) or increased (Inc) HR during breath hold. The predictive formula was evaluated as accurate when less than 5 % of the actual HRscan exceeded the predicted HRscan by ±5 beats per minute (bpm). The average values of the HRtest (65.3 ± 12.0 bpm) and HRscan (63.7 ± 11.9 bpm) significantly decreased from those of the HRrest (68.4 ± 11.9 bpm) (p < 0.0001). The predictive formula (HRscan = 3.601 + 0.113HRrest + 0.8HRtest) was determined to be accurate only in Group Dec. The HRtest significantly decreased from the HRrest, and the HRscan significantly decreased from the HRtest. An accurate predictive formula for HRscan could be built only for Group Dec.

Serine protease inhibitor-6 differentially affects the survival of effector and memory alloreactive CD8-T cells

The clonal expansion of effector T cells and subsequent generation of memory T cells are critical in determining the outcome of transplantation. While cytotoxic T lymphocytes induce direct cytolysis of target cells through secretion of Granzyme-B (GrB), they also express cytoplasmic serine protease inhibitor-6 (Spi6) to protect themselves from GrB that has leaked from granules. Here, we studied the role of GrB/Spi6 axis in determining clonal expansion of alloreactive CD8-T cells and subsequent generation of memory CD8-T cells in transplantation. CD8-T cells from Spi6(-/-) mice underwent more GrB mediated apoptosis upon alloantigen stimulation in vitro and in vivo following adoptive transfer into an allogeneic host. Interestingly, while OT1.Spi6(-/-) CD8 T cells showed significantly lower clonal expansion following skin transplants from OVA mice, there was no difference in the size of the effector memory CD8-T cells long after transplantation. Furthermore, lack of Spi6 resulted in a decrease of short-lived-effector-CD8-cells but did not impact the pool of memory-precursor-effector-CD8-cells. Similar results were found in heart transplant models. Our findings suggest that the final alloreactive CD8-memory-pool-size is independent from the initial clonal-proliferation as memory precursors express low levels of GrB and therefore are independent of Spi6 for survival. These data advance our understanding of memory T cells generation in transplantation and provide basis for Spi6 based strategies to target effector T cells.

Soft x-ray intensity profile measurements of electron cyclotron heated plasmas using semiconductor detector arrays in GAMMA 10 tandem mirror

Temporally and spatially resolved soft x-ray analyses of electron cyclotron heated plasmas are carried out by using semiconductor detector arrays in the GAMMA 10 tandem mirror. The detector array has 16-channel for the measurements of plasma x-ray profiles so as to make x-ray tomographic reconstructions. The characteristics of the detector array make it possible to obtain spatially resolved plasma electron temperatures down to a few tens eV and investigate various magnetohydrodynamic activities. High power electron cyclotron heating experiment for the central-cell region in GAMMA 10 has been started in order to reduce the electron drag by increasing the electron temperature.

A prospective study of the incidence and outcomes of incidental dural tears in microendoscopic lumbar decompressive surgery

Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery.

Cite this article: Bone Joint J 2014;96-B:641–5.