Prospective Observational Study for the Comparison of Screening Methods Including Tongue Pressure and Repetitive Saliva Swallowing With Detailed Videofluoroscopic Swallowing Study Findings in Patients With Acute Stroke

BACKGROUND

Simple, noninvasive, and repeatable screening methods are essential for assessing swallowing disorders. We focused on patients with acute stroke and aimed to assess the characteristics of swallowing screening tests, including the modified Mann Assessment of Swallowing Ability score, tongue pressure, and repetitive saliva swallowing test (RSST), compared with detailed videofluoroscopic swallowing study (VFSS) findings to contribute as a helpful resource for their comprehensive and complementary use.

METHODS AND RESULTS

We enrolled first-ever patients with acute stroke conducting simultaneous assessments, including VFSS, modified Mann Assessment of Swallowing Ability score, tongue pressure measurement, and RSST. VFSS assessed aspiration, laryngeal penetration, oral cavity residue, vallecular residue, pharyngeal residue, and swallowing reflex delay. Screening tests were compared with VFSS findings, and multiple logistic analysis determined variable importance. Cutoff values for each abnormal VFSS finding were assessed using receiver operating characteristic analyses. We evaluated 346 patients (70.5±12.6 years of age, 143 women). The modified Mann Assessment of Swallowing Ability score was significantly associated with all findings except aspiration. Tongue pressure was significantly associated with oral cavity and pharyngeal residue. The RSST was significantly associated with all findings except oral cavity residue. Receiver operating characteristic analyses revealed that the minimum cutoff value for all VFSS abnormal findings was RSST ≤2.

CONCLUSIONS

The modified Mann Assessment of Swallowing Ability is useful for broadly detecting swallowing disorders but may miss mild issues and aspiration. The RSST, with a score of ≤2, is valuable for indicating abnormal VFSS findings. Tongue pressure, especially in oral and pharyngeal residues, is useful. Combining these tests might enhance accuracy of the swallowing evaluation.

Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders

Damage to the fascia can cause significant performance deficits in high-performance sports and recreational exercise and may contribute to the development of musculoskeletal disorders and persistent potential pain. The fascia is widely distributed from head to toe, encompassing muscles, bones, blood vessels, nerves, and internal organs and comprising various layers of different depths, indicating the complexity of its pathogenesis. It is a connective tissue composed of irregularly arranged collagen fibers, distinctly different from the regularly arranged collagen fibers found in tendons, ligaments, or periosteum, and mechanical changes in the fascia (stiffness or tension) can produce changes in its connective tissue that can cause pain. While these mechanical changes induce inflammation associated with mechanical loading, they are also affected by biochemical influences such as aging, sex hormones, and obesity. Therefore, this paper will review the current state of knowledge on the molecular level response to the mechanical properties of the fascia and its response to other physiological challenges, including mechanical changes, innervation, injury, and aging; imaging techniques available to study the fascial system; and therapeutic interventions targeting fascial tissue in sports medicine. This article aims to summarize contemporary views.

Fast-forward scaling theory

Speed is the key to further advances in technology. For example, quantum technologies, such as quantum computing, require fast manipulations of quantum systems in order to overcome the effect of decoherence. However, controlling the speed of quantum dynamics is often very difficult due to both the lack of a simple scaling property in the dynamics and the infinitely large parameter space to be explored. Therefore, protocols for speed control based on understanding of the dynamical properties of the system, such as non-trivial scaling property, are highly desirable. Fast-forward scaling theory (FFST) was originally developed to provide a way to accelerate, decelerate, stop and reverse the dynamics of quantum systems. FFST has been extended in order to accelerate quantum and classical adiabatic dynamics of various systems including cold atoms, internal state of molecules, spins and solid-state artificial atoms. This paper describes the basic concept of FFST and reviews the recent developments and its applications such as fast state-preparations, state protection and ion sorting. We introduce a method, called inter-trajectory travel, recently derived from FFST. We also point out the significance of deceleration in quantum technology. This article is part of the theme issue 'Shortcuts to adiabaticity: theoretical, experimental and interdisciplinary perspectives'.

Diagnostic performance of angiography-derived index of microvascular resistance: a systematic review and pooled meta-analysis

Background

The index of microvascular resistance (IMR) is an established measurement of coronary microcirculation status. However, it has not been widely incorporated into routine practice due to need for intracoronary instrumentation (pressure wire) and hyperaemic agents. Several angiography-derived quantitative flow ratio-based indexes of microvascular resistance (angio-IMR) have been proposed rekindling the interest for the assessment and management of microvascular disease.

Purpose

To review the overall diagnostic accuracy of angio-IMR against wire based IMR.

Methods

A systematic review of the literature was performed and studies comparing angio-IMR with wire based IMR were included. Individual data was extracted using semi-automatic digitalization. Correlation of angio-IMR with IMR and its diagnostic performance against IMR were analysed.

Results

Six studies directly comparing angio-IMR with IMR were included. Data extraction rate was 85.1% (582/684 vessels). There was a linear correlation between angio-IMR and IMR (β=0.483, R square=0.298) (Figure 1A). Pooled sensitivity was 77%, specificity was 66%, positive predictive value was 65%, negative predictive value was 78%, and accuracy was 71.0%. Pooled area under receiver operator curve of angio-IMR for predicting IMR diagnosed coronary microvascular disease was 0.754 (95% confidential interval 0.715 to 0.793) (Figure 1B). Similar diagnostic performance was observed in subgroups of patients with or without ST-segment elevation myocardial infarction.

Conclusions

Currently available angio-IMR showed a clearly useful discrimination and diagnostic performance against the standard of wire based IMR.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): China Scholarship Council

Prevalence and distribution of non-pulmonary vein atrial fibrillation triggers in real-world clinical settings

Background

Epidemiology of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) is not fully known.

Purpose

This study aimed to clarify the prevalence and distribution of non-PV triggers in real-world clinical settings of AF catheter ablation.

Methods

One-thousand and twenty patients undergoing AF ablations were retrospectively analyzed (mean age 65 years old, 702 males (69%), 506 paroxysmal and 514 non-paroxysmal). Induction and observation of AF triggers were attempted using intravenous isoproterenol/adenosine triphosphate and repeated direct current cardioversion during AF in each session. Documentable non-PV AF triggers were characterized in the studied population. Premature atrial contractions that did not initiate AF were excluded.

Results

A hundred and twenty-six non-PV triggers were documented in 108 patients (10.6%). Non-PV trigger was documented in 6.3% of 1st session cases, whereas 30.9% of recurrent cases undergoing multiple sessions (p<0.0001). Left atrial (LA) posterior wall was the most prevalent site (N=34), followed by 30 intra-atrial septum (IAS), 29 superior vena cava (SVC), 13 crista terminalis, 7 right atrial (RA) free wall, 6 LA anterior wall, 3 coronary sinus (CS), 3 left atrial appendage, and 1 persistent left superior vena cava (LSVC). We classified those non-PV triggers into 4 groups; 43 LA, 33 thoracic veins (SVC, CS and LSVC), 30 IAS and 20 RA. Thoracic vein/RA origins were more prevalently detected in paroxysmal AF cases (57%) compared to non-paroxysmal AF (28%) (p<0.01). Conversely, LA origin was more prevalently detected in non-paroxysmal AF cases (48%) compared to paroxysmal AF (20%) (p<0.01).

Conclusions

Prevalence of non-PV trigger in cases undergoing multiple sessions is extremely high, suggesting a particular importance of non-PV trigger targeting in patients with recurrent AF undergoing 2nd or 3rd ablation sessions. Progressive nature of AF with newly generated AF triggers should be under consideration. Distributions of non-PV triggers are largely different between paroxysmal and non-paroxysmal AF. These findings may help ablation strategy regarding non-PV trigger targeting in practice.

Funding Acknowledgement

Type of funding sources: None.

Impact of bifurcation lesion on 10-year mortality in the SYNTAX trial

Background

Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with higher rates of adverse events, and currently it is unclear whether PCI or coronary artery bypass grafting (CABG) is the safer treatment for these patients at very long-term follow up.

Objectives

To investigate the impact of bifurcation lesions on observed all-cause 10-year mortality in the SYNTAX trial.

Methods

In the SYNTAX Extended Survival study, 10-year observed mortality was compared among four groups: (a) presence of ≥1 bifurcation lesion and treatment with PCI (n=649), (b) no bifurcation lesion and treatment with PCI (n=248), (c) presence of ≥1 bifurcation lesion and treatment with CABG (n=651), and (d) no bifurcation lesion and treatment with CABG (n=239).

Results

Compared to patients without bifurcations, those with bifurcation lesion(s) treated with PCI had a significantly higher risk of all-cause death (19.8% vs 30.1%; HR: 1.55, 95% CI: 1.12 to 2.14; p=0.007), whereas following CABG, mortality was similar in patients with or without bifurcation lesion(s) (23.3% vs 23.0%; HR: 0.81, 95% CI: 0.59 to 1.12; p=0.207). (Figure1) There was a significant interaction between bifurcation lesion(s) and treatment arm (p for interaction=0.006).

In PCI patients, at 5-years there was no significant difference in mortality between 1- vs 2-stent techniques, whereas at 10-years, a 2-stent technique was associated with higher mortality (33.3% vs 25.9%; HR: 1.51, 95% CI: 1.06 to 2.14; p=0.021, Figure2).

Conclusions

Bifurcation lesion(s) require special attention from the heart team discussion, considering the higher 10-year all-cause mortality associated with PCI. Careful evaluation of bifurcation lesion complexity may be helpful in decision-making.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The SYNTAX Extended Survival study was supported by the German Foundation of Heart Research (Frankfurt am Main, Germany). The SYNTAX trial, during 0-5 years follow-up, was funded by Boston Scientific Corporation (Marlborough, MA, USA). Both sponsors had no role in the study design, data collection, data analyses, and interpretation of the study data, nor were involved in the decision to publish the final manuscript. The principal investigators and authors had complete scientific freedom.

Geographic disparity in 10-year mortality after coronary artery revascularization in the SYNTAXES trial

Aims

To investigate geographic disparity in long-term mortality following revascularization in patients with complex coronary artery disease (CAD).

Methods and results

The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and assessed their survival at 10-years. Patients were stratified according to the region of recruitment: North America (N-A, n=245), Eastern Europe (E-E: Poland, Hungary, Czech, n=189), Northern Europe (N-E: United Kingdom, Sweden, Norway, Latvia, Finland, and Denmark, n=425), Southern Europe (S-E: Spain, Portugal, and Italy, n=263), and Western Europe (W-E: Netherlands, Germany, France, Belgium, and Austria, n=678), which also served as the reference group. Compared to W-E, patients were younger in E-E (62 vs 65 years, p<0.001), and less frequently male in N-A (65.3% vs 79.6%, p<0.001). Diabetes (16.0% vs 25.4%, p<0.001) and peripheral vascular disease (6.8% vs 10.9%, p=0.025) were less frequent in N-E than W-E. Ejection fraction was highest in W-E (62% vs 56%, p<0.001). Compared to W-E, the mean anatomic SYNTAX score was higher in S-E (29 vs 31, p=0.008) and lower in N-A (26, p<0.001). Crude ten-year mortality was similar in N-A (31.6%), and W-E (30.7%), and significantly lower in E-E (22.5%, p=0.041), N-E (21.9%, p=0.003) and S-E (22.0%, p=0.014) as presented in left-middle lower of the graphical abstract. We adjusted the survival curves by following factors based on previous report; age, sex, medically treated diabetes, current smokers, peripheral vascular disease, chronic obstructive pulmonary disease, chronic kidney disease, left ventricular ejection fraction, disease type, and anatomical SYNTAX score [1]. When the differences in baseline characteristics were adjusted, mortality was still significantly lower in N-E (HR 0.85, 95% CI [0.74–0.97], p=0.019) and trended lower in S-E (HR 0.72 95% CI [0.52–0.99] p=0.043) compared to W-E (right middle-lower of the graphical abstract). However, no significant interaction (P interaction = 0.728) between region and modality of revascularization was seen.

Discussion and conclusions

The main findings of this study are:

1. Rates of crude 10-year mortality were significantly lower in E-E, N-E, and S-E compared to W-E and N-A.

2. The differences in 10-year mortality remained significantly lower with N-E and S-E even after adjustment for confounding factors.

3. However, when comparing PCI to CABG in the five geographic regions, there were no statistically significant interactions between the geographic disparity in pre- and peri-procedural characteristics and all-cause mortality.

In the era of globalization, knowledge and understanding of geographic disparity are of paramount importance for the correct interpretation of global studies.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The German Foundation of Heart Research (Frankfurt am Main, Germany)

Impact of left ventricular ejection fraction on 10-year mortality after percutaneous coronary intervention or coronary artery bypass grafting

Backgrounds

The impact on vital prognosis at very long-term of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with reduced ejection fraction (EF) remains to be elucidated.

Objective

To investigate the impact of left ventricular ejection fraction (LVEF) on 10-year mortality after PCI and CABG in the SYNTAX trial.

Methods

In the SYNTAXES study, 1,800 randomized patients were categorized into three groups according to the current guidelines; (1) reduced EF (rEF; LVEF ≤40%), (2) mildly reduced EF (mrEF; LVEF 41–49%), (3) preserved EF (pEF; LVEF ≥50%). The primary endpoint was 10-year all-cause mortality. Event rate up to 10 years was estimated according to the Kaplan-Meier method, and the log-rank test was performed to examine the differences among LVEF subgroups. The SYNTAX score 2020 (SS-2020) was compared between the patients with reduced (LVEF <50%) and preserved EF (LVEF ≥50%) in order to better refine their respective personalized vital prognosis and assess in cross-validation the value of the risk score.

Results

The population was stratified as rEF (n=168), mrEF (n=179), and pEF (n=1453). Ten-year all-cause mortality were 44.0% vs. 31.8% vs. 22.6% (P<0.001), in patients with rEF, mrEF and pEF, respectively. The significant interaction was not identified between LVEF classification and treatment (P interaction = 0.183). In patients with rEF, there was a tendency toward higher mortality in PCI group than CABG (52.9% vs 39.6%, P=0.054), and no significant differences in patients with mrEF (36.0% vs. 28.6%, P=0.273) and pEF (23.9% vs. 22.2%, P=0.275). According to the SS-2020, PCI was a relatively safe modality of revascularization in 37.8% of the patients with reduced EF (LVEF <50%). In the population with preserved EF (LVEF ≥50%), the proportion of patients eligible to PCI with predicted equipoise in mortality with CABG was 57.5%.

Conclusion

LVEF could an important factor for determining the revascularization treatment in patients presenting with complex coronary artery disease. Calculation of individualized 10-year prognosis using the SS-2020 may be a viable option in decision-making.

Funding Acknowledgement

Type of funding sources: None.

Catheter ablation of persistent atrial fibrillation with heart failure improves hemodynamic status without deteriorating renal function in the elderly

Background/Introduction

Atrial fibrillation (AF) and heart failure (HF) frequently coexist in the elderly people, leading to worse clinical outcomes. HF with preserved ejection fraction (HFpEF) is the most common form of HF in the elderly, particularly in women, associated with AF. Ablation of AF in younger patients with HF with reduced EF (HFrEF) has become an established treatment option. However, clinical impact of ablation for persistent AF accompanying with HF in the elderly remains unclear.

Purpose

This study aimed to evaluate the effect of catheter ablation of persistent AF with heart failure in the elderly.

Methods

Consecutive 70 patients who underwent catheter ablation of persistent AF accompanying with HF (NYHA class> II, mean LVEF 51.7%) in our institution were retrospectively analyzed with regards to their 1-year clinical outcomes, HF markers such as BNP, renal function and transthoracic echocardiographic findings. Patients were dichotomized by age of 75-year-old (31 elderly vs 39 younger subjects) and separately analyzed.

Results

Mean age of the studied population was 70.5 year-old; 79.6±3.8 in the elderly group and 63.2±8.5 in the younger group. The elderly patients were more frequently females (45% vs 21%). Longstanding persistent AF was observed in 32% in the elderly and 28% in the younger group. Circumferential pulmonary vein isolation (PVI) was performed in all patients, with additional ablations of liner lesions and/or non-PV foci as needed. PVI alone was observed in 54.8% in the elderly and 41% in the younger group. There were no serious complications associated with the procedure. During 1 year after ablation, recurrence of AF was observed in 15 patients [6/31 (19%) in the elderly, 9/39 (23%) in the younger]. Readmission due to HF was observed in only 1 patient in the elderly and 2 patients in the younger group (3% vs. 5%, respectively). Cardiovascular events were observed in 3 patients [2/31 (6%) in the elderly, 1/39 (3%) in the younger], but there was no death. The BNP level as well as the NYHA class significantly decreased at 1-year follow-up compared to baseline in the both groups (Figure A and B). There was no change in serum creatinine level in the both groups (Figure C). The left atrial dimension and the LA volume index decreased at 1-year follow-up in the both groups (Figure D and E). The LVEF improved only in the younger group (Figure F).

Conclusions

Ablation of persistent AF in the elderly with HF (mostly with preserved EF) was associated with hemodynamic and functional improvements without deteriorating renal function in a mid-term, which was mostly comparable to the results in the younger.

Funding Acknowledgement

Type of funding sources: None.

Appropriateness of the modality of revascularization according to the SYNTAX 2020 in the FASTTRACK CABG study

Objectives

To compare the modality of revascularization selected by the local heart team to the one recommended by the core laboratory according to the SYNTAX score 2020 amongst patients with three-vessel disease (3VD) with or without left main disease (LMCAD), who were allocated to CABG planned and solely guided by coronary computerized tomographic angiography in the FASTTRACK CABG trial.

Background

Personalized long term vital prognosis plays a key role in deciding between PCI and coronary artery bypass grafting (CABG) in patients with complex coronary artery disease.

Methods

In an interim analysis requested by the Data Safety Monitoring Board the treatment recommendations according to the SYNTAX 2020 were prospectively assessed in 57 consecutive patients (half of the planned population in this First in Man) by a core laboratory and compared to the decision of the “on site” heart team.

Results

According to SS-2020, the predicted absolute risk difference (ARD) in mortality between the virtual PCI treatment population and the CABG treatment group, which can be considered a virtual surrogate for the average treatment effect, increased with the duration of follow up, from 4.8±3.5% at 5 years to 8.8±5.1% at 10 years (Table 1). The ARD of less than 0% in mortality at 5-year in favour of PCI was only documented in two patients while the 55 remaining patients had a predicted survival benefit over PCI if receiving CABG. However, based on a novel threshold of equipoise (ARD <4.5%) recently validated in a contemporary registry of 3VD and LMCAD, CABG was mandatory in 26 (45.6%) patients, whereas PCI or CABG could have been equally selected in 31 (54.4%) patients (Figure 1).

Conclusions

According to the SYNTAX Score 2020 there was a strict observance of the CABG treatment recommendation in the first 57 consecutive patients with 3VD or LMCAD, screened on site in the FAST TRACK CABG trial. The more lenient selection criteria derived from the contemporary regitry will have to be tested propectively. Application of artificial intelligence with expanded collection of baseline characteristics, scientific endorsement and regulatory enforcement as well as further prospective evaluation are the challenges of future decision-making scores, that should be ultimately shared with the patients.

Funding Acknowledgement

Type of funding sources: None.

Murray law-based quantitative flow ratio for assessment of left main bifurcation derived from a single fluoroscopic angiographic view as compared to FFRCT

Background

In patients with complex CAD, the presence of left main (LM) disease is an important prognostic factor in assessing the risk balance between PCI and CABG. Functional assessment has become standard of care to evaluate the significance of coronary stenosis and to justify the performance of PCI in the contemporary practice. FFRCT is a well-established method based on 3D reconstruction of coronary artery derived from CCTA. The Murray law-based quantitative flow reserve (μQFR) is a novel computational method of invasive angiography relying on a single angiographic view that takes into account side branches diameters to compute fractal flow division. The aim of the current analysis is to evaluate in patients with complex CAD the feasibility of μQFR in LM bifurcation and its diagnostic concordance with FFRCT. The impact of the optimal viewing angle defined by CCTA on the physiological assessment of the LM bifurcation using a single angiographic view was also evaluated.

Methods

In 299 consecutive patients with 3-vessel disease with or without LM coronary artery disease, up to 3 analyzable fluoroscopic projections per patient were analysed with μQFR retrospectively. FFRCT and μQFR were measured at 3 fiducial landmark points: i) point of LM bifurcation (POB); ii) proximal LAD 10 mm distal to POB; ii) proximal LCX 10 mm distal to POB. CCTA-based “optimal viewing angle” of LM bifurcation are computed by creating a 3-point closed spline involving the LM, LAD, and LCX at 5mm from the POB and subsequently by reconstructing the “en face” fluoroscopic viewing angle of the spline. The en face viewing angle provides an optimal assessment of the bifurcation geometry [1]. In terms of Rx gantry angulation, the closest angiographic projection to the optimal viewing angle derived from CCTA was defined as the “best fluoroscopic projection” for each patient.

Results

In 299 patients, 793 projections were analysed with μQFR and compared to FFRCT. Single view μQFR was analyzable in 100%. Correlation and agreement between μQFR and FFRCT for 793 projections in 299 patients are shown in Figure 1A, 2A. The Spearman's correlation coefficient showed moderate correlations at POB (r=0.481, p<0.001) and LCX (r=0.584, p<0.001), and strong correlation at LAD (r=0.642, p<0.001). Correlation and agreement between μQFR and FFRCT for best projections from each patient are shown in Figure 1B, 2B. Correlations were improved in the best projections with the following Spearman's correlation coefficient: at POB (r=0.522, p<0.001), LCX (r=0.622, p<0.001), and LAD (r=0.695, p<0.001).

Conclusion

Computation of μQFR from a single angiographic view has a high feasibility. Tailored optimal fluoroscopic view is essential for the physiological assessment of the LM bifurcation using a single angiographic view. Evaluation of diagnostic accuracy of μQFR warrants further analysis of the LMCAD after prospective planning of the optimal fluoroscopic view based on the selection of the best CCTA 3D view.

Funding Acknowledgement

Type of funding sources: None.

Angiographic derived physiological assessment after intervention for predicting 2-year vessel-oriented composite endpoints in Multivessel TALENT trial

Aims

The purpose of the study is to assess the treatment results in the first 200 patients in the ongoing Multivessel TALENT trial and to predict the vessel-oriented endpoint by assessing the quantitative flow ratio (QFR) post PCI in a central independent core laboratory.

Methods

In this prospective, randomized, 1:1 balanced, multi-centre, open-label trial, de novo multivessel coronary artery disease patients without left main disease are assigned to the sirolimus-eluting stent or everolimus-eluting stent arm. The percutaneous coronary intervention (PCI) is planned based on functional lesion evaluation by QFR provided by the Core laboratory and the PCI has to be optimized by intravascular imaging, optimal pharmacological treatment and prasugrel monotherapy.

Results

Mean age of the population was 66.6±14.7 years, and 78.1% of them were male. This population consists of 17.4% unstable angina and of 31.8% diabetic patients. Anatomical SYNTAX score was 18.8±9.1. Total 458 lesions were treated from September 2020 to December 2021. Left anterior descending artery accounts for 40.3%, bifurcation lesion was present in 40.8%, total occlusion in 4.2%. The average stent diameter and total stent length were 3.0±0.4mm and 38.7±22.4mm, respectively. Intravascular imaging was used in 92.8% of treated vessels (intravascular ultrasound 56.5%, optical coherent tomography 36.3%). Pre-PCI QFR was analysable in 435 vessels (0.59±0.21), and 5.5% of them were treated even though the pre-PCI QFR values were more than 0.8. Post-PCI QFR has been so far analysed in 303 vessels (0.93±0.11) and 79.5% of them achieved a post-PCI QFR equal or superior to 0.91. Based on the previous study [1], Two-year vessel-oriented composite endpoint (VOCE) was estimated to become 5.4% in the present study population (3.7% in the patient group that achieved post PCI QFR equal or superior to 0.91, while 12% in the patients who could not reach the threshold), which was almost equal to what is expected in the power calculation.

Conclusions

In the Multivessel TALENT trial, the large majority of the vessels treated (94.5%) complied with the hemodynamic criteria of recommended PCI as provided by the QFRs of the Core laboratory. Favourable post-PCI QFR (≥0.91) obtained in 80% of the patients let expected a favourable VOCE outcome of 5.4%.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The National University of Ireland Galway

Comparison of the SYNTAX score 2020 based on Coronary Artery Computed Tomography (CCTA) with Invasive Coronary Angiography (ICA)

Introduction

The SYNTAX III REVOLUTION trial demonstrated that clinical decision-making between coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) based on coronary artery computed tomography (CCTA) and predicting four years mortality according to the SYNTAX score II had a high agreement with the treatment decision derived from invasive coronary angiography (ICA). The agreement of the novel SYNTAX score 2020 (SS-2020) based on CCTA and ICA has not yet been evaluated in a prospective fashion.

Methods

This study included 54 consecutive patients in the ongoing FASTTRACK CABG trial that investigates decision making, planning and procedural CABG guidance based solely on CCTA and FFRct. All the patients underwent CCTA and ICA, and SS-2020 was calculated based on the results of anatomical SYNTAX score derived from either CCTA or ICA, and the respective scores were compared by using paired t-test.

Results

The mean age was 67.3±9.7, and 48 were men (88.9%). Anatomical SYNTAX score derived from CCTA was assessed in the 54 cases (analysability 100%). Anatomical SYNTAX scores based on CCTA and ICA were 34.3±9.3, and 35.5±11.3, respectively (P=0.480). As shown in the table predicted 5 years major adverse cardiac and cerebrovascular events (MACCE) following either PCI or CABG, as well as predicted 10 years mortality following CABG differed significantly. However the absolute risk differences (ARD) in 5 years MACCE and 10 years mortality following either PCI or CABG, were comparable.

Conclusions

High agreements were confirmed in the calculations of anatomical SYNTAX scores with CCTA and ICA. Despite significant differences in predicted MACCE rates at 5 years and mortalities at 10 years, the ARD in MACCE rates and mortality were comparable. In terms of treatment decision-making, SS-2020 calculations based on CCTA is a non-invasive predictive tool comparable to the one based on ICA.

Funding Acknowledgement

Type of funding sources: None.

Aggressive combined pharmacotherapy for heart failure reduces new onset atrial fibrillation

Backgrounds

Heart failure (HF) is a risk factor for new onset atrial fibrillation (AF), and the new onset AF is associated with a worse prognosis in HF patients. It has been reported that renin-angiotensin system inhibitor (RASi), β-blocker and mineral-corticoid receptor antagonist (MRA) prevent the new onset AF in HF patients. However, the effect of combined pharmacotherapy including angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitor (SGLT2i) on AF is unknown. We investigated the impact of contemporary regimen of combined pharmacotherapy for HF (RASi/ARNI+β-blocker+MRA+SGLT2i) on new onset AF.

Methods and results

We retrospectively studied rEF and mrEF patients without AF admitted to our hospital due to decompensated HF between 2015 and 2021 (n=366). Long-term (The mean follow-up was 635±421 days) incidence of new onset AF was investigated with regard to medical therapies. Patients were divided into 2 groups; patients with ≤2 HF drugs (n=181) and patients with ≥3 HF drugs (n=185). Patients with ≤2 HF drugs group were older (77.3 vs 67.0 years old, P<0.001), had a poorer renal function (Cre: 1.66 vs 1.09 mg/dl, P<0.001), and had a higher rate of ischemic heart disease (52 vs 38%, P=0.009), whereas left ventricular systolic function was better (EF: 31.9 vs 27.3%, P<0.001). There were 19 (10.5%) new onsets AF in the ≤2 HF drugs group, whereas only 7 (3.8%) had new onsets AF in the ≥3 HF drugs group (HR 0.36, 95% CI 0.15–0.85, P=0.01). All-cause death and hospitalization for HF were fewer in the ≥3 HF drugs group. A multivariate analysis revealed that ≥3 HF drugs use was an independent negative predictor of new onset AF (HR 0.37, 95% CI 0.15–0.93, P=0.03). Even after a propensity score matching of the clinical variables, the incidence of new onset AF was consistently fewer in the ≥3 HF drugs group (HR 0.36, 95% CI 0.13–0.99, P=0.04). Finally, patients with new onset AF had a higher rate of hospitalization for HF in the studied population (HR 9.68, 95% CI 5.67–16.5, P<0.01).

Conclusion

Aggressive combined pharmacotherapy for HF may be associated with fewer new onset AF in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Applying patient characteristics, stent-graft selection, and pre-operative computed tomographic angiography data to a machine learning algorithm: Is endoleak prediction possible?

INTRODUCTION

This study aims to predict endoleak after endovascular aneurysm repair (EVAR) using machine learning (ML) integration of patient characteristics, stent-graft configuration, and a selection of vessel lengths, diameters and angles measured using pre-operative computed tomography angiography (CTA).

METHODS

We evaluated 1-year follow-up CT scans (arterial and delayed phases) in patients who underwent EVAR for the presence or absence of an endoleak. We also obtained data on the patient characteristics, stent-graft selection, and preoperative CT vessel morphology (diameter, length, and angle). The extreme gradient boosting (XGBoost) for the ML system was trained on 30 patients with endoleaks and 81 patients without. We evaluated 5217 items in 111 patients with abdominal aortic aneurysms, including the patient characteristics, stent-graft configuration and vascular morphology acquired using pre-EVAR abdominal CTA. We calculated the area under the curve (AUC) of our receiver operating characteristic analysis using the ML method.

RESULTS

The AUC, accuracy, 95% confidence interval (CI), sensitivity, and specificity were 0.88, 0.88, 0.79-0.97, 0.85, and 0.91 for ML applying XGBoost, respectively.

CONCLUSIONS

The diagnostic performance of the ML method was useful when factors such as the patient characteristics, stent-graft configuration and vessel length, diameter and angle of the vessels were considered from pre-EVAR CTA.

IMPLICATIONS FOR PRACTICE

Based on our findings, we suggest that this is a potential application of ML for the interpretation of abdominal CTA scans in patients with abdominal aortic aneurysms scheduled for EVAR.

AB0971 Relationship between walking speed and lower limb skeletal muscle mass in patients with knee joint disorders

Background

Knee joint disorder is one of the factors causing frailty in the elderly, which is associated with a decrease in walking speed.

Objectives

We measured the walking speed of patients scheduled to undergo primary total knee arthroplasty (TKA) and examined factors correlated with walking speed.

Methods

The patients with knee disorders scheduled to undergo knee arthroplasty at our hospital between July 2020 and May 2021 were included. They were assessed for basic attributes, clinical assessment including Kness Society Score (KSS), degree of pain on walking by visual analogue scale (VAS), range of motion (ROM), and also leg skeletal muscle mass index (SMI; whole-body mode DXA), quadriceps strength by dynamometer with written consent (UMIN ID: 000040940). And Japanese Cardiovascular Health Study criteria for frailty, and sarcopenia by Asian Working Group for Sarcopenia 2019 criteria were evaluated.

Results

Demographic data of 83 patients (65 women, mean age 74.9 years) included in this study was shown in Table 1. The distribution in frailty is 36.2% and that in sarcopenia is 7.3%. Most of the patients with frailty with knee disorder did not suffer from sarcopenia. A multivariate analysis was conducted with walking speed as the objective variable and the dependent variables as age, gender, pain VAS on walking, KSS, leg SMI, quadriceps strength, and ROM. The results showed that age and ROM in flexion were significantly and independently associated with walking speed (P=0.01, 0.03). Gender, pain VAS on walking, KSS, leg SMI, quadriceps strength, and ROM in extension were not significantly associated with walking speed (P=0.92, 0.11, 0.11, 0.52, 0.85, 0.52).

Conclusion

Among the patients with knee disorders immediately before arthroplasty, frailty was not caused by sarcopenia. Age was found to be the most correlated factor with walking speed, and walking speed became slower with age. In addition, poor flexion angle was also the factor for delayed walking speed, but it did not correlate with lower limb skeletal muscle mass or quadriceps strength. In this study pain on walking was not significant factor for walking speed, because it was observed in most of all cases.

FactorGroup　disease (n)osteoarthritis78 (94%)　rheumatoid arthritis5 (6.0%)body mass index (kg/m2)　25.54 (4.11)pain VAS on walking　37.08 (26.35)total Knee Society Score　77.66 (27.85)range of motion (degree)flexion119.46 (12.88)　extension-9.58 (6.59)quadriceps power (N)　122.00 [53.00, 350.00]waling speed (m/sec)　0.95 (0.33)grip power (kg)　20.24 (6.97)skeletal muscle mass index (kg/m2)appendicular6.50 [4.92, 9.85]　lower limb5.06 [3.76, 7.56]Frailty (n)none10 (12.5%)Pre-frail41 (51.2%)　frail29 (36.2%)Sarcopenia (n)none76 (92.7%)sarcopenia4 (4.9%)　severe sarcopenia2 (2.4%)

mean (standard deviation)

; median [min max]

Disclosure of Interests

None declared

OP0090 PRECLINICAL STUDIES OF A NOVEL CATHEPSIN C INHIBITOR IN MPO-ANCA-ASSOCIATED VASCULITIS MODEL

Background

MPO-ANCA-associated vasculitis (MPO-AAV) is a systemic small vessel vasculitis with the production of MPO-ANCA in the serum. This disease develops necrotizing and crescent glomerulonephritis (NCGN) and peritubular capillaritis-mediated interstitial damages in the kidneys, and pulmonary hemorrhage due to capillaritis in the lungs. Recent studies have revealed that neutrophil extracellular traps (NETs) induced by MPO-ANCA are critically involved in its pathogenesis,1 and neutrophil elastase (NE) plays an essential role in the formation of NETs.2 Cathepsin C (CatC) functions as a key enzyme in the activation process of several neutrophil serine proteases (NSPs) such as NE, proteinase 3 and cathepthin G by converting the inactive forms of the NSPs to the active forms by digesting dipeptides at the N-terminus of the enzymes.3

Objectives

Although glucocorticoids and immunosuppressive drugs used as the standard of cares can lead remission in MPO-AAV patients, there are remaining unmet medical needs such as severe side effects, resistance to the treatment and relapse. Therefore, development of new therapeutic strategies is awaited. The aim of this study is to demonstrate the efficacy of MOD06051, a novel CatC inhibitor, against MPO-AAV, using an MPO-AAV rat model established previously.4

Methods

In vitro studies: Cathpsins and NE inhibitory activity was measured using recombinant enzymes and fluorescent substrates. Cellular NE activity in the granulocytes differentiated from the primary human bone marrow-derived hematopietic stem cells under the presence or absence of MOD06051 was determined using fluorescent substrates.

In vivo studies: 4-week-old Wistar Kyoto (WKY) rats were immunized with human MPO according to Little’s protocol.4 The rats were divided into three groups (n=8 in each group), and vehicle (0.5% methylcellulose) or MOD06051 (0.3 or 3 mg/kg bid) was orally administered every day for 42 days. All rats were euthanized at the end of the study for serological and histological evaluations.

Results

In vitro studies: MOD06051 inhibited the enzymatic activity of human recombinant CatC with an IC50 value of 1.5 nM, and no other cathepsins nor NE inhibition was observed at 10 μM. The NE activity in primary human granulocytes was suppressed by MOD06051 with an IC50 value of 18 nM.

In vivo studies: MPO-ANCA was induced in all groups at the same level. The percentage of affected glomeruli including those with NCGN, NET-forming neutrophils in the peripheral blood and glomeruli, and glomerular neutrophil counts were significantly suppressed by MOD06051 treatment in a dose-dependent manner. Furthermore, hematuria score, urinary NGAL (Neutrophil Gelatinase-Associated Lipocalin), tubular erythrocyte cast counts, and pulmonary hemorrhage foci were significantly decreased in the 3 mg/kg of MOD06051 treated group with the similar trends in 0.3 mg/kg group.

Conclusion

MOD06051 showed sepcific inhibition of CatC activity. This compound suppressed the serine proteases activation in primary human neutrophils and NET formation in the MPO-AAV model rats, resulting in amelioration of MPO-ANCA-induced tissue destruction, including NCGN and tubular interstitial damages in the kidneys, and disorder of alveolar septal capillaries in the lungs. MOD06051 appears to be a promising agent for treatment of MPO-AAV patients.

References

[1]Nakazawa D, et al. Nat Rev Rheumatol 15: 91-101, 2019.

[2]Papayannopoulos V, et al. J Cell Biol 191: 677-691, 2010.

[3]Korkmaz B, et al. Pharmacol Ther 190: 202-236, 2018.

[4]Little MA, et al. Am J Pathol 174: 1212-1220, 2009.

Disclosure of Interests

Akihiro Ishizu Grant/research support from: Modulus Discovery, Inc., Mai Taniguchi: None declared, Suishin Arai: None declared, Yuka Nishibata Grant/research support from: Modulus Discovery, Inc., Sakiko Masuda Grant/research support from: Modulus Discovery, Inc., Utano Tomaru: None declared, Takafumi Shimizu Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., William Sinko Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., Tadashi Nagakura Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., Yoh Terada Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc.

Revision for cage migration after transforaminal/posterior lumbar interbody fusion: how to perform revision surgery?

Background

Symptomatic pseudarthrosis and cage migration/protrusion are difficult complications of transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). If the patient experiences severe radicular symptoms due to cage protrusion, removal of the migrated cage is necessary. However, this procedure is sometimes very challenging because epidural adhesions and fibrous union can be present between the cage and vertebrae. We describe a novel classification and technique utilizing a navigated osteotome and the oblique lumbar interbody fusion at L5/S1 (OLIF51) technique to address this problem.

Methods

This retrospective study investigated consecutive patients with degenerative lumbar diseases who underwent TLIF/PLIF. Symptomatic cage migration was evaluated by direct examination, radiography, and/or computed tomography (CT) at 1, 3, 6, 12, and 24 months of follow-up. Cage migration/protrusion was defined as symptomatic cage protrusion > 5 mm from the posterior border of the over and underlying vertebral body compared with initial CT. We evaluated patient characteristics including body mass index, smoking history, fusion level, and cage type. A total of 113 patients underwent PLIF/TLIF (PLIF n = 30, TLIF n = 83), with a mean age of 71.1 years (range, 28–87 years). Mean duration of follow-up was 25 months (range, 12–47 months).

Results

Cage migration was identified in 5 of 113 patients (4.4%). All cases of symptomatic cage migration involved the L5/S1 level and the TLIF procedure. Risk factors for cage protrusion were age (younger), sex (male), and level (L5/S1). The mean duration to onset of cage protrusion was 3.2 months (range, 2–6 months). We applied a new classification for cage protrusion: type 1, only low back pain without new radicular symptoms; type 2, low back pain with minor radicular symptoms; or type 3, cauda equina syndrome and/or severe radicular symptoms. According to our classification, one patient was in type 1, three patients were in type 2, and one patient was in type 3. For all cases of cage migration, revision surgery was performed using a navigated high-speed burr and osteotome, and the patient in group 1 underwent additional PLIF without removal of the protruding cage. Three revision surgeries (group 2) involved removal of the protruding cage and PLIF, and one revision surgery (group 3) involved anterior removal of the cage and OLIF51 fusion.

Conclusions

The navigated high-speed burr, navigated osteotome, and OLIF51 technique appear very useful for removing a cage with fibrous union from the disc in patients with pseudarthrosis. This new technique makes revision surgery after cage migration much safer, and more effective. This technique also reduces the need for fluoroscopy.

Comparison of two simple stitches and modified Mason-Allen suture for medial meniscus posterior root tear based on the progression of meniscal posterior extrusion: A retrospective cohort study

Purpose: Medial meniscus (MM) posterior root (PR) tear leads to severe MM posterior extrusion (PE), resulting in rapid knee cartilage degeneration. MMPR repairs are recommended to reduce MMPE, especially during knee flexion. However, the difference in MMPE between different repair techniques remains unknown. This study aimed to investigate preoperative and postoperative MMPE following several pullout repair techniques. We hypothesized that a technique using two simple stitches (TSS) would be more useful than FasT-Fix-dependent modified Mason-Allen suture (F-MMA) to prevent the progression of MMPE in knee extension. Methods: This retrospective study included 35 patients who underwent MMPR repair. To compare MMPE, patients were divided into two groups according to the use of F-MMA while grasping the posterior capsule and TSS without grasping it. Open magnetic resonance imaging was performed at 10° and 90° knee flexion preoperatively, and at 3 and 12 months postoperatively, and the MMPE of both groups was evaluated. Results: A significant difference was observed between preoperative and 3-month postoperative MMPE at 90° knee flexion in both groups (p < .01). A significant difference was observed in 3- and 12-month postoperative MMPE at 10° knee flexion between both groups (p = .04/.02), whereas no significant difference in the preoperative MMPE at 10° knee flexion was observed between them (p = .45). Conclusions: Both repairs were found to be useful to reduce MMPE in knee flexion. Further, F-MMA repair increased MMPE in knee extension, unlike TSS repair. These findings suggest that TSS might have more advantages for load distribution when standing or walking.

Large flexion contracture angle predicts tight extension gap during navigational posterior stabilized-type total knee arthroplasty with the pre-cut technique: a retrospective study

Background

This study aimed to determine the predictors of tight extension gap (EG) compared with the flexion gap (FG) during navigational posterior stabilized-type total knee arthroplasty using the pre-cut technique.

Methods

Nineteen patients with tight EG (defined as FG-EG ≥2 mm after pre-cut; group T) and 84 patients with an approximately equal gap (defined as FG-EG = 0–1 mm after pre-cut; group E) were enrolled. Medial tibial slope angle, hip knee ankle angle, flexion contracture angle, and active maximum flexion angle were compared between the two groups.

Results

The multivariate logistic regression model indicated that the probability of tight EG increased with flexion contracture angle (odds ratio, 1.13; 95% confidence interval 1.05–1.20; P ≤ 0.001). According to the receiver operating characteristic analysis, the flexion contracture angle cut-off value associated with tight EG was 15.0° (sensitivity, 85%; specificity, 78%).

Conclusion

This study demonstrated that a large flexion contracture angle (cut-off 15.0°) was associated with tight EG after pre-cut osteotomy during posterior stabilized-type total knee arthroplasty. Awareness of this risk factor may help improve preoperative predictability of tight EGs and preparedness for additional procedures, such as soft tissue release or capsulotomy, to correct them.

Level of evidence

Level III.

Effect of injection duration on contrast enhancement during cardiac computed tomography angiography in newborns and infants

INTRODUCTION

To investigate how changing the injection duration at cardiac computed tomography angiography (CCTA) affects contrast enhancement in newborns and infants.

METHODS

Included were 142 newborns and infants with confirmed congenital heart disease who underwent CCTA between January 2015 and December 2018. In group 1 (n = 71 patients), the injection duration was 8 s; in group 2 (n = 71) it was 16 s. Our findings were assessed by one-to-one matching analysis to estimate the propensity score of each patient. We compare the CT number for the pulmonary artery (PA), ascending aorta (AAO), left superior vena cava (SVC), AAO and PA enhancement ratio, and the scores for visualization between the two groups.

RESULTS

In group 1, median CT number and ranges was 345 (211-591) HU in the AAO, 324 (213-567) HU in the PA, and 62 (1-70) HU in the SVC. These values were 465 (308-669) HU, 467 (295-638) HU, and 234 (67-443) HU, respectively, in group 2 (p < 0.05). The median score for volume-rendering visualization on 3D images of the CCTA was 2 in group 1 and 3 in group 2; the score for visualization of the left SVC of the maximum intensity projection images was 2 in group 1 and 3 in group 2 (p < 0.05). The CT number for the AAO and PA enhancement ratio was 15.2 in group 1 and 9.2 in group 2 (p < 0.05).

CONCLUSION

The 16-sec injection protocol yielded significantly higher CT numbers for the AAO, PA, and the SVC than the 8-sec injection protocol; the visualization scores were also significantly higher in group 2.

IMPLICATIONS FOR PRACTICE

In newborns and infants, the longer injection time for CCTA yields stable and higher contrast enhancement at identical CM concentrations.

Enhancement rate of venous phase to portal venous phase computed tomography and its correlation with ultrasound elastography determination of liver fibrosis

INTRODUCTION

This study aimed to compare the correlation between the computed tomography (CT) enhancement rate of the venous to portal venous phase (VP-ER) and the extracellular volume (ECV) fraction with shear-wave ultrasound elastography (USE) findings in patients with liver fibrosis.

METHODS

We included 450 patients with clinically suspected liver cirrhosis who underwent triphasic dynamic CT studies and USE. We compared the USE results with the unenhanced CT phase, with enhancement in the hepatic artery phase (HAP), portal venous phase (PVP), and venous phase (VP), and with the ECV fraction and the VP-ER. We also compared the area under the curve (AUC) of the receiver operating characteristic (ROC) curve of the ECV fraction and VP-ER with that of the values obtained with USE.

RESULTS

The VP-ER was the most highly correlated with the liver stiffness value determined with USE (Pearson's correlation coefficient: r = 0.37), followed by enhancement in the PVP (r = -0.25), CT number on unenhanced CT scans (r = -0.22), the ECV fraction (r = 0.19), enhancement in the VP (r = 0.059), and enhancement in the HAP (r = -0.023) (all p < 0.01). The VP-ER showed a significantly higher AUC than the ECV fraction (0.75 vs 0.62) when the liver stiffness was >15 kPa in USE studies (p = 0.04).

CONCLUSION

Compared to the ECV fraction, the VP-ER is more useful for predicting all degrees of liver fibrosis on routine triphasic dynamic CT images.

IMPLICATIONS FOR PRACTICE

Although improvement is needed, the VP-ER has a higher diagnostic ability for liver fibrosis than the ECV fraction in clinical practice.

Efficacy of the spiral flow generating extended tube during paediatric CCTA

INTRODUCTION

To compare the computed tomography (CT) number for paediatric cardiac computed tomography angiography (CCTA) and visualisation score of the three-dimensional (3D) images using the conventional T-shaped extended tube (T-tube) and spiral flow-generating extended tube (spiral-tube) connected between the contrast injector and cannula.

METHODS

In total, 108 patients suspected to have congenital heart disease (CHD) were considered for inclusion. We utilised the T-tube for intravenous contrast and spiral-tube in 54 patients each. Observers individually inspected randomized volume rendering images of the internal thoracic artery, each acquired from the with or without spiral-tube groups, using a four-point scale. We compared the mean CT number of the ascending aorta (AAO) and pulmonary artery (PA), contrast noise ratio (CNR), CT number for the AAO and PA enhancement ratio, and the visualisation scores between the groups.

RESULTS

There were no significant differences in patient characteristics between the with or without spiral-tube groups (p > 0.05). The mean CT number ±standard deviation for the AAO and PA, and the CNR without or with spiral-tube groups were 441.2 ± 89.2 and 489.8 ± 86.1 HU for the AAO, 436.3 ± 100.6 and 475.3 ± 85.2 HU for the PA, and 9.5 ± 2.2 and 10.8 ± 2.4 for the CNR, respectively (p < 0.05). In the spiral-tube group, the CT number, CNR, and visualisations score of the 3D images were significantly higher for the AAO and PA than those in the T-tube group (p < 0.05).

CONCLUSION

The spiral-tube proved to be beneficial in improving the CT number for the AAO and PA, CNR, and visualisation score compared with the conventional T-tube during paediatric CCTA.

IMPLICATIONS FOR PRACTICE

The spiral-tube may allow the visualisation of smaller blood vessels than those visualised by the conventional T-tube for paediatric patients in CCTA.

Diagnostic performance of computed tomography digital subtraction angiography of the lower extremities during haemodialysis in patients with suspected peripheral artery disease

INTRODUCTION

With intra-arterial digital subtraction angiography (DSA) considered as the gold standard, we compared the diagnostic value of computed tomography angiography (CTA) and computed tomography-digital subtraction angiography (CT-DSA in hemodialysis (HD) patients suspected of having lower limb peripheral artery disease (PAD).

METHODS

In this retrospective study, we enrolled 220 HD patients with suspected PAD. CT-DSA images were obtained by subtracting unenhanced images from enhanced images. The research team calculated the area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV, NPV), and recorded the diagnostic accuracy between the CTA and CT-DSA images using the DSA as gold standard. Visual evaluation of calcifications in the peripheral arteries were also compared between CTA and CT-DSA images.

RESULTS

At the above-knee level, the CTA AUC [95% confidence interval (CI)] was 0.68 (CI 0.64-0.72), sensitivity and specificity were 60 and 81%, PPV and NPV were 85 and 53%, and accuracy was 67%. Below the knee, these values were 0.66 (CI 0.62-0.70), 71 and 79%, 79 and 47%, and 66%. For CT-DSA, above-knee, the AUC [95% CI] was 0.88 (CI 0.85-0.91), sensitivity and specificity were 84 and 92%, PPV and NPV were 89 and 97%, and accuracy was 93%. Below the knee, these values were 0.95 (CI 0.93-0.97), 95 and 93%, 96 and 83%, and 93%. The scores for the visualization of calcification in the peripheral arteries was significantly higher for CT-DSA than CTA (p < 0.05).

CONCLUSIONS

CT-DSA helps to assess stenotic PAD with high calcification in the lower extremities of HD patients.

IMPLICATIONS FOR PRACTICE

On CT-DSA images, the severity of vascular calcification can be assessed for HD patients suspected of PAD of the lower extremities.

Placement of an anatomic tibial tunnel significantly improves the medial meniscus posterior extrusion at 90° of knee flexion following medial meniscus posterior root pullout repair

PURPOSE

The purpose of this study was to evaluate the influence of tibial tunnel position in pullout repair for a medial meniscus (MM) posterior root tear (MMPRT) on postoperative MM extrusion.

METHODS

Thirty patients (median age 63 years, range 35-72 years) who underwent transtibial pullout repairs for MMPRTs were included. Three-dimensional computed tomography images of the tibial surface were evaluated using a rectangular measurement grid for assessment of tibial tunnel position and MM posterior root attachment. Preoperative and postoperative MM medial extrusion (MMME) and posterior extrusion (MMPE) at 10° and 90° knee flexion were measured using open magnetic resonance imaging.

RESULTS

Tibial tunnel centers were located more anteriorly and more medially than the anatomic center (median distance 5.8 mm, range 0-9.3 mm). The postoperative MMPE at 90° knee flexion was significantly reduced after pullout repair, although there was no significant reduction in MMME or MMPE at 10° knee flexion after surgery. In the correlation analysis of the displacement between the anatomic center to the tibial tunnel center and improvements in MMME, and MMPE at 10° and 90° knee flexion, there was a significant positive correlation between percentage distance and improvement of MMPE at 90° knee flexion.

CONCLUSION

This study demonstrated that the nearer the tibial tunnel position to the anatomic attachment of the MM posterior root, the more effective the reduction in MMPE at 90° knee flexion. Our results emphasize that an anatomic tibial tunnel should be created in the MM posterior root to improve the postoperative MMPE and protect the articular cartilage in a knee flexion position. Placement of an anatomic tibial tunnel significantly improves the MMPE at 90° of knee flexion after MM posterior root pullout repair.

LEVEL OF EVIDENCE

IV.

The combined application of the contrast-to-noise index and 80 kVp for cardiac CTA scanning before atrial fibrillation ablation reduces radiation dose exposure

INTRODUCTION

To compare the radiation dose, diagnostic accuracy, and the resultant ablation procedures using 80 and 120-kVp cardiac computed tomography angiography (CCTA) protocols with the same contrast-to-noise ratio in patients scheduled for atrial fibrillation (AF) ablation.

METHODS

This retrospective study was performed following institutional review board approval. We divided 140 consecutive patients who had undergone CCTA using a 64-MDCT scanner into two equal groups. Standard deviation (SD) of the CT number was set at 25 Hounsfield units (HU) for the 120-kVp protocol. To facilitate a reduction in radiation dose it was set at 40 HU for the 80 kVp protocol. We compared the two protocols with respect to the radiation dose, the diagnostic accuracy for detecting left atrial appendage (LAA) thrombi, matching for surface registration, and the resultant ablation procedures.

RESULTS

At 120 kVp, the dose length product (DLP) was 2.2 times that at 80 kVp (1269.0 vs 559.0 mGy cm, p < 0.01). The diagnostic accuracy for thrombus detection was 100% using both protocols. There was no difference between the two protocols with respect to matching for surface registration. The protocols did not differ with respect to the subsequent time required for the ablation procedures and the ablation fluoroscopy time, and the radiation dose (p = 0.54, 0.33, and 0.32, respectively).

CONCLUSION

For the same CNR, the DLP at 80 kVp (559.0 mGy cm) was 56% of that delivered at 120 kVp (1269.0 mGy cm). There was no reduction in diagnostic accuracy.

IMPLICATIONS FOR PRACTICE

Maintaining CNR allows for a reduction in the radiation dose without reducing the image quality.

Presence of low voltage area predicts atrial tachyarrhythmia inducibility with atrial burst pacing after pulmonary vein isolation

Background

Induction of atrial fibrillation (AF)/atrial tachycardia (AT) by atrial burst pacing following ablation procedure may reflect the presence of residual substrates in the atria that maintain AF. However, the relation between the inducibility and left atrial low voltage area (LVA) has not been established.

Methods

Fifty-nine patients (65 years old, 43 males) with persistent AF who underwent pulmonary vein isolation (PVI)-based ablation were studied. All patients underwent left atrial voltage mapping during sinus rhythm and atrial burst pacing after PVI. Atrial burst pacing was performed with 30-beat at an amplitude of 10V from the ostium of the coronary sinus; increasing from 240 to 320 ppm in steps of 20 ppm or failure to 1:1 atrial capture. Inducibility was defined as AF/AT lasting more than 5 minutes following burst pacing. Left atrial LVA and other co-variates were analyzed with regard to burst pacing positivity.

Results

AF/AT was induced by burst pacing in 23 patients (39%). Univariate analysis revealed that past history of stroke, CHADS2 score and presence of left atrial LVA were significantly associated with the inducibility of AF/AT. Multivariate analysis revealed that only the presence of LVA was associated with the inducibility (OR 1.5: per 10% increase; p=0.04). We focused on the relationship between the extent of LVA and burst positivity. AF/AT inducibility increased as low voltage area increased, and it was as high as 72.7% when low voltage area was more than 20% (P&lt;0.05). Interestingly, induced arrhythmia type was AT rather than AF when low voltage area was more than 20%.

Conclusions

Presence of left atrial LVA is an independent predictor of atrial tachyarrhythmia inducibility after PVI in patients with persistent AF. A large amount of low voltage area is related to AT inducibility rather than AF.

Extent of LVA and burst positivity

Funding Acknowledgement

Type of funding source: None

Medial meniscus posterior root tear causes swelling of the medial meniscus and expansion of the extruded meniscus: a comparative analysis between 2D and 3D MRI

PURPOSE

This study aimed to clarify the advantages of three-dimensional (3D) magnetic resonance imaging (MRI) over two-dimensional (2D) MRI in measuring the size of the medial meniscus (MM) and to analyse the volumes of MM and the extruded meniscus in patients with MM posterior root tear (MMPRT), at 10° and 90° knee flexion.

METHODS

This study included 17 patients with MMPRTs and 15 volunteers with uninjured knees. The MMs were manually segmented for 3D reconstruction; thereafter, the extruded part separated from the tibial edge was determined. The length, width, height, and extrusion of MM were measured by the 2D and 3D methods, and compared. The MM volume, extruded meniscus volume, and their ratio were also calculated using 3D analysis software in the two groups.

RESULTS

The estimated length and posterior height of MM were larger with 3D MRI than with 2D MRI measurements. The MM volume was significantly greater in MMPRT knees than in normal knees, with increasing MM height. In MMPRT knees, the mean volume of the extruded meniscus and its ratio significantly increased by 304 mm³ (p = 0.02) and 9.1% (p < 0.01), respectively, during knee flexion.

CONCLUSIONS

This study demonstrated that 3D MRI could estimate the precise MM size and that MMPRT caused swelling of the meniscus due to the increased thickness in the posteromedial part. The clinical significance of this study lies in its 3D evaluation of MM volume, which should help the surgeon understand the biomechanical failure of MM function and improve MMPRT repair technique.

LEVEL OF EVIDENCE

III.

Early follow-up visit at outpatient care after discharge improves 2-year heart failure readmission rate and long-term prognosis in patients with decompensated heart failure

Background/Introduction

It has been reported that heart failure (HF) readmission has not declined even with current cardiology practice in the last 10 years. It has been also reported that HF readmission tends to occur shortly after discharge. This may be due to overwork and excessive salt intake after discharge. In other words, it is conceivable that patient factors are largely attributable, which should be intervene for better clinical outcomes.

Purpose

We hypothesized and investigated whether an early follow-up visit at outpatient care within 2 weeks after discharge affects the re-admission rate and prognosis in patients with decompensated HF.

Methods

We retrospectively investigated consecutive 407 hospitalized patients due to decompensated HF. After exclusion of 99 patients with in-hospital death, transfer to another hospital and readmission within 2 weeks after discharge, consecutive 308 out of 407 patients were investigated. Two-year clinical outcomes after discharge were collected and analyzed. An early follow-up was defined as an outpatient care visit within 2 weeks after discharge with the adjustment of drugs and/or the lifestyle guidance, if necessary. A setting of early follow-up in each patient was according to a physician's discretion.

Results

One hundred-twenty eight patients underwent early follow-up visits and other 180 patients were without it. An univariate analysis showed that the early follow-up was significantly associated with a lower HF readmission rate during 2 years (17.1% in the early follow-up group, 34.4% in the control group, p≤0.001, OR=0.397, 95% CI=0.230–0.685, Figure) and a 2-year composite adverse outcome (all cause death and HF readmission; 18.7% vs. 40.5%, p&lt;0.001, OR=0.332, 95% CI=0.196–0.563, Figure). To exclude possible relationships of other co-variable factors, we performed a multivariate analysis about the association with HF readmission rate and the 2-year composite adverse outcome (co-variate factors as follows are included; factors of which p-value was less than 0.1 and general confounding factors). The multivariate analysis showed that the early follow-up was independently associated with HF readmission during 2 years (p=0.002, OR=0.376, 95% CI=0.197–0.716) and the 2-year composite outcome (p&lt;0.001, OR=0.343, 95% CI=0.182–0.648). Finally, we characterized the practical interventions at outpatient care after discharge. Lifestyle guidance was done in all patients. However, medication adjustments were done in only 36.7% patients. Interestingly, whether or not a medication adjustment was done at the early follow-up visit was not associated with the HF readmissions (p=0.781).

Conclusions

The present study suggests that an early follow-up approach after discharge in decompensated HF patients may improve the long-term prognosis. These results were not dependent on whether a medication adjustment was performed or not. An early follow-up may help improve patient factors of HF worsening.

Main results

Funding Acknowledgement

Type of funding source: None

A histological study of the medial meniscus posterior root tibial insertion

Purpose/Aim of the study: Posterior root injury of the medial meniscus often leads to articular cartilage degeneration due to altered biomechanics. To avoid dysfunction, the attachment must be repaired using the transtibial pullout technique. To guide appropriate placement of the tibial tunnel, additional details on the normal anatomy of the meniscus insertion are needed. Therefore, we performed a histological analysis of a tibial bone slice with the medial meniscus posterior insertion obtained during total knee arthroplasty surgery. Materials and methods: Horizontal slices of the proximal tibia were obtained from 7 patients with osteoarthritis who underwent total knee arthroplasty. After decalcification, the region of the posterior horn was cut out and segmented into four pieces (2.0 mm thickness; medial to lateral). Sagittal sections were evaluated by safranin O staining or immunohistochemistry with anti-type collagen antibody. Results: Safranin O staining showed that the insertion of the posterior root consisted primarily of fibrocartilaginous layers in segment 2. Anatomically, segment 2 corresponded to the sagittal plane passing through the peak of the medial intercondylar tubercle. In this section, safranin O staining and immunohistochemistry revealed that the anterior one-third of the posterior root insertion was richer in proteoglycans and type II collagen than the central and posterior one-third. Conclusions: Anatomical insertion of the posterior root of the medial meniscus was located at the sagittal plane passing through the peak of the medial intercondylar tubercle. The structure of the medial meniscus posterior insertion was mainly localized in the anterior one-third.

Delayed Swallowing Reflex is Overlooked in Swallowing Screening Among Acute Stroke Patients

BACKGROUND AND PURPOSE

Dysphagia in the acute phase of stroke contributes significantly to poor outcomes and is associated with the development of aspiration pneumonia and malnutrition. Therefore, an accurate evaluation of swallowing is necessary before initiating oral food intake. The modified water swallow test (MWST) and the repetitive saliva swallow test (RSST) are commonly used as bedside screening methods for swallowing dysfunction, but it is unclear whether other factors contribute to dysphagia and consequent aspiration. The purpose of this study was to identify characteristics that might be overlooked in screening tests.

METHODS

Participants were prospectively selected from patients hospitalized for stroke at the Suiseikai Kajikawa Hospital between August 1, 2016 and June 30, 2018. Inclusion criteria were conscious and stable medical condition, and patients who were diagnosed with dementia were excluded. A videofluoroscopic (VF) swallowing study was carried out on all patients who met the inclusion/exclusion criteria and who passed both the MWST and the RSST.

RESULTS

Aspiration was observed in 16 of 172 patients (9.3%) when swallowing 3 ml of water. These aspirated patients showed significantly delayed swallowing reflex on VF.

CONCLUSIONS

Swallowing evaluation using a combination of the MWST and the RSST is reasonably effective. However, patients who show a delayed swallowing reflex might be overlooked by this screening procedure.

Comparison of the clinical outcomes of transtibial pull-out repair for medial meniscus posterior root tear: Two simple stitches versus modified Mason-Allen suture

BACKGROUND

Transtibial pullout repair of a medial meniscus posterior root tear (MMPRT) is a commonly used procedure, and several techniques have been reported. We hypothesised that pull-out repairs using two simple stitches (TSS) would have similar postoperative outcomes as those using the modified Mason-Allen suture with FasT-Fix (F-MMA). We aimed to investigate the clinical outcomes of these techniques, including the meniscal healing status and osteoarthritic change.

METHODS

The data of 68 patients who underwent transtibial pull-out repair were retrospectively investigated. The patients were divided into two groups of 41 and 27 patients using F-MMA and TSS, respectively. The clinical outcomes were assessed preoperatively and at second-look arthroscopy (the mean period from surgery was one year) using the Knee injury and Osteoarthritis Outcome Score. The meniscal healing status, evaluated at second-look arthroscopy, was compared between the two groups. The cartilage damage was graded as per the classification of the International Cartilage Repair Society and compared at the primary surgery and second-look arthroscopy.

RESULTS

Both groups showed significant improvement in each clinical score. No significant difference was seen in the clinical outcome scores and the meniscal healing status between the two groups at second-look arthroscopy. Moreover, no significant progression of cartilage damage was observed in both groups. Fourteen patients in the F-MMA group developed a complication of suture bar failures postoperatively; however, there were no complications in the TSS group.

CONCLUSIONS

The TSS and F-MMA techniques showed favourable clinical outcomes and would be established as clinically useful techniques for the MMPRT treatment.

The distance between the tibial tunnel aperture and meniscal root attachment is correlated with meniscal healing status following transtibial pullout repair for medial meniscus posterior root tear

BACKGROUND

To investigate the relationship between tibial tunnel aperture location and postoperative meniscal healing.

METHODS

We enrolled 25 patients (20 women and five men, mean age: 62.5 years) who underwent transtibial pullout repair for medial meniscus (MM) posterior root repair. The expected MM posterior root attachment center (AC) and tibial tunnel center (TC) were identified using three-dimensional computed tomography, and the minimum AC-TC distance was calculated. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period: 15 months) using a previously reported scoring system (meniscal healing score; range: 0-10). The association between AC-TC distance and meniscal healing score was investigated using univariate linear regression models. The optimal AC-TC distance cut-off for improved MM healing score (≥7) was determined using receiver operating characteristic analysis.

RESULTS

The AC-TC distance and meniscal healing score were significantly associated (y = -0.42x + 9.48, R² = 0.342; P = 0.002), with the optimum AC-TC distance being 5.8 mm. This cut-off had a sensitivity of 100% and specificity of 53%.

CONCLUSIONS

This study demonstrates that AC-TC distance is significantly correlated with postoperative meniscal healing. Anatomical repair within 5.8 mm of the AC may result in improved meniscal healing.

The Early Arthroscopic Pullout Repair of Medial Meniscus Posterior Root Tear Is More Effective for Reducing Medial Meniscus Extrusion

Clinical studies have demonstrated that transtibial pullout repair led to favorable midterm outcomes in patients with medial meniscus posterior root tears (MMPRTs) although medial meniscal extrusion (MME) continued to be present. It has been unclear whether these residual postoperative MMEs existed after the pullout repair or had progressed at the very short-term evaluation after surgery. We sought to determine which characteristics of patients with MMPRTs influence the incidence of postoperative MME. The cases of 23 patients whose date of injury was known were analyzed. All patients underwent MMPRT pullout fixation. Preoperative and 3-month postoperative magnetic resonance imaging (MRI) examinations were performed. MME was retrospectively assessed on the mid-coronal plane of MRI scans. The preoperative and postoperative MME values were 4.2±1.2 mm and 4.3±1.5 mm, respectively (p=0.559). Pullout repair surgery was performed significantly earlier after the MMPRT-specific injury in patients whose postoperative MME improved compared to the patients whose MME did not improve (p<0.001). Our findings demonstrated that an early transtibial pullout repair of an MMPRT was more effective in reducing MME than a late repair. Surgeons should not miss the optimal timing for the pullout repair of an MMPRT, considering the period from the injury and the preoperative MME.

Bilateral Anterior Cruciate Ligament Tear Combined with Medial Meniscus Posterior Root Tear

The case of an individual with a bilateral anterior cruciate ligament (ACL) tear combined with a medial meniscus (MM) posterior root tear is described. A 34-year-old Japanese man with bilateral ACL rupture that occurred > 10 years earlier was diagnosed with bilateral ACL tear combined with MM posterior root tear (MMPRT). We performed a transtibial pullout repair of the MMPRT with ACL reconstruction. The tibial tunnels for the MM posterior root repair and ACL reconstruction were created separately. Postoperatively, a good clinical outcome and meniscal healing were obtained. Our surgical technique may thus contribute to anatomical MM posterior root repair and ACL reconstruction.

Transtibial Pullout Repair Reduces Posterior Extrusion of the Medial Meniscus

Medial meniscus posterior root tear causes rapid knee cartilage degradation by inducing posteromedial displacement of the medial meniscus. We evaluated medial meniscus posterior extrusion before and after pullout repair for medial meniscus posterior root tear using magnetic resonance images. Twenty-eight patients with symptomatic medial meniscus posterior root tear were included. The inclusion criteria were: acute (< 3 months) or chronic (≥3 months) medial meniscus posterior root tear after painful popping events. The exclusion criteria were: other meniscus and anterior cruciate ligament injuries. We measured medial meniscus posterior extrusion and medial meniscus anteroposterior interval at knee flexion angles of 10° and 90° preoperatively and at 3 months postoperatively. The posterior extrusion at 90° knee flexion decreased from 4.42±1.38 mm preoperatively to 3.09±1.06 mm (p<0.001) postoperatively, while at 10° knee flexion it was -4.17±1.63 mm preoperatively and -3.77±1.72mm postoperatively, showing no significant change. The anteroposterior interval at 10° knee flexion increased from 19.74±4.27 mm preoperatively to 22.15±5.10 mm postoperatively (p<0.001); at 90° knee flexion, it increased from 16.81±4.51 mm preoperatively to 19.20±4.30 mm postoperatively (p<0.001). Medial meniscus posterior extrusion and movement decreased after pullout repair. Pullout repair for medial meniscus posterior root tear improves medial meniscus posterior extrusion, especially at 90° knee flexion.

Posteromedial vertical capsulotomy selectively increases the extension gap in posterior stabilized total knee arthroplasty

PURPOSE

In total knee arthroplasty (TKA), it is important to obtain an appropriate flexion-extension gap. The extension gap is expanded by posteromedial vertical capsulotomy (PMVC). This study aimed to evaluate the increase in the extension gap by PMVC using a navigation system.

METHODS

In posterior stabilized (PS)-type TKA, PMVC was performed in 37 knees. The medial extension gap at 0° and flexion gap at 90° flexion of the knee joint using the navigation system before and after PMVC were measured.

RESULTS

The extension gap before the PMVC was 5.3 ± 2.9 mm. After PMVC, the extension gap had significantly increased to 8.0 ± 2.8 mm (p < 0.001). In addition, the flexion gap was 8.1 ± 2.7 mm before the PMVC, but it was 8.7 ± 2.8 mm after the PMVC, and the flexion gap was not enlarged (n.s.).

CONCLUSION

In PS-type TKA, it is possible to obtain selective expansion of about 2.7 mm of the extension gap by PMVC. Therefore, gap balance can be acquired by soft-tissue treatment while preserving the bone. The PMVC was a useful method for acquiring gap balance and preserving the bone stock.

LEVEL OF EVIDENCE

IV.

Transtibial pullout repair of the lateral meniscus posterior root tear combined with anterior cruciate ligament reconstruction reduces lateral meniscus extrusion: A retrospective study

BACKGROUND

Lateral meniscus (LM) posterior root tear (PRT) is often associated with anterior cruciate ligament (ACL) injury and can result in rotational instability, joint overloading, and degenerative changes in the knee. Improved rotational stability and kinematics have been reported after LMPRT repair. However, it is unclear what repair technique can achieve the greatest reduction in LM extrusion (LME).

HYPOTHESIS

We hypothesized that transtibial pullout repair would decrease LME to a greater extent than other repair techniques.

PATIENTS AND METHODS

Seventeen patients with ACL injury and complete LMPRT were evaluated. Nine underwent ACL reconstruction (ACLR) and transtibial pullout repair, and eight underwent ACLR and other repairs such as inside-out suturing. Double-bundle ACLR was performed using hamstring tendons, and LMPRT pullout repair was performed through the bone tunnel for the posterolateral bundle. Magnetic resonance imaging was performed immediately preoperatively and at>6 months postoperatively, and LME was measured from coronal images only.

RESULTS

A significantly greater decrease in the value of LME from pre- to postoperative measurement was observed in the transtibial pullout repair group (-0.5±0.7mm) than in the other-repair group (1.0±0.9mm, p<0.01). Pre- and postoperative LME measurements were not significantly different between the two groups.

DISCUSSION

The most important finding of this study was that transtibial pullout repair resulted in a greater decrease in LME than other repair techniques in patients with ACL injury and LMPRT. This technique might be useful for restoring hoop tension by decreasing LME.

LEVEL OF EVIDENCE

III, comparative retrospective study.

Prevalence and clinical features of hearing loss caused by EYA4 variants

Variants in the EYA4 gene are known to lead to autosomal dominant non-syndromic hereditary hearing loss, DFNA10. To date, 30 variants have been shown to be responsible for hearing loss in a diverse set of nationalities. To better understand the clinical characteristics and prevalence of DFNA10, we performed genetic screening for EYA4 mutations in a large cohort of Japanese hearing loss patients. We selected 1,336 autosomal dominant hearing loss patients among 7,408 unrelated Japanese hearing loss probands and performed targeted genome enrichment and massively parallel sequencing of 68 target genes for all patients. Clinical information of cases with mutations in EYA4 was gathered and analyzed from medical charts. Eleven novel EYA4 variants (three frameshift variants, three missense variants, two nonsense variants, one splicing variant, and two single-copy number losses) and two previously reported variants were found in 12 probands (0.90%) among the 1,336 autosomal dominant hearing loss families. The audiometric configuration of truncating variants tends to deteriorate for all frequencies, whereas that of non-truncating variants tends to show high-frequency hearing loss, suggesting a new correlation between genotype and phenotype in DFNA10. The rate of hearing loss progression caused by EYA4 variants was considered to be 0.63 dB/year, as found in this study and previous reports.

Early chondral damage following meniscus repairs with anterior cruciate ligament reconstruction

Background

Meniscal tears are commonly observed in patients with anterior cruciate ligament (ACL) injuries. Meniscal repair has become a common procedure for the injured meniscus, and good clinical outcomes have been reported in such cases when used concurrently with ACL reconstruction. However, it is unclear whether early chondral damage progression can be prevented following meniscal repair with ACL reconstruction, as meniscal damage is a potential risk factor for the development of osteoarthritis. The purpose of this study was to evaluate the zone-specific chondral damage that occurs after arthroscopic meniscal repair with concomitant ACL reconstruction. Our hypothesis was that meniscal repair with ACL reconstruction would not decrease the rate of progression of chondral damage compared to that observed in isolated ACL reconstruction with intact menisci.

Methods

This study included 40 patients who underwent anatomic double-bundle ACL reconstruction. We divided the patients into the following two groups: Group A with an intact meniscus (20 knees) and Group M requiring meniscal repair (20 knees). Chondral damage was evaluated arthroscopically in six compartments and 40 sub-compartments, and these features were graded using the International Cartilage Repair Society lesion classification. The cartilage damage in each sub-compartment and compartment was compared between the two groups both at reconstruction and at second-look arthroscopy (average 16 months postoperatively). At the latest follow-up examination (average 37 months postoperatively), the International Knee Documentation Committee (IKDC) score was compared between the two groups.

Results

Group M had a significantly worse cartilage status than Group A in five sub-compartments (mainly in the medial compartment) at reconstruction and in nine sub-compartments (mainly in the bilateral compartments) at second-look arthroscopy. The mean IKDC score was better in Group A than in Group M (Group A; 90 vs. Group M; 86). The overall success rate of meniscal repairs was 92% (23 of 25 menisci) at second-look arthroscopy.

Conclusion

The progression of post-traumatic chondral damage may occur at a faster rate in patients who require ACL reconstruction and meniscal repair than in patients with intact menisci.

Photonic integration based on a ferroelectric thin-film platform

Photonic-integrated circuits (PICs) using ferroelectric materials are expected to be used in many applications because of its unique optical properties such as large electro-optic coefficients. In this study, a novel PIC based on a ferroelectric thin-film platform was designed and fabricated, where high-speed optical modulator, spot-size converters (SSCs), and a variable optical attenuator (VOA) were successfully integrated. A ferroelectric lanthanum-modified lead zirconate titanate (PLZT) thin film was epitaxially-grown by using a modified sol-gel method, and it exhibits large electro-optic coefficients (>120 pm/V) and low propagation loss (1.1 dB/cm). The optical modulator, a Mach-Zehnder type, exhibited a half-wave voltage (V_π) of 6.0 V (V_πL = 4.5 Vcm₎ and optical modulation up to 56 Gb/s. Also, the VOA (with attenuation range of more than 26 dB) was successfully integrated with the modulator. As a result, it is concluded that the developed ferroelectric platform can pave the way for photonic integration.

Usefulness of medication instruction sheets for sharing information on cancer chemotherapy within the health care team

Patients receiving cancer chemotherapy may experience a number of potentially severe adverse drug reactions. It is crucial for all members of the health care team to monitor the effect of medicines on the patient to ensure the safety and efficacy of the chemotherapy. The present study prepared medication instruction sheets (MISs) on hematological malignancy and conducted a questionnaire survey to verify their usefulness among physicians, dentists, and nurses. MISs were prepared for 103 chemotherapy and 44 pretreatment regimens for hematopoietic stem cell transplantation in the Department of Hematology at Kyushu University Hospital. Eight questions were prepared to investigate whether MISs could help physicians, dentists, and nurses manage cancer chemotherapy more safely, effectively, and efficiently, as well as in the sharing of information. A total of 35 medical staff working in inpatient wards, including 8 physicians, 3 dentists, and 24 nurses, participated in the questionnaire survey. All of the staff responded to the questionnaire survey, which showed that the MISs were favorably accepted by the participants. There was no negative opinion on the management of chemotherapy using the MISs. The MIS was a useful tool for sharing information on cancer chemotherapy between patients and medical staff and for enabling efficient management, thereby improving the safety and efficacy of treatment.

The accuracy of a newly developed guide system in medial meniscus posterior root repair: a comparison between two aiming guides

Purpose

Posterior root repair of the medial meniscus (MM) can prevent rapid progression of knee osteoarthritis in patients with a MM posterior root tear (MMPRT). The anatomic reattachment of the MM posterior root is considered to be critical in a transtibial pullout repair. However, tibial tunnel creation at the anatomic attachment is technically difficult. We hypothesized that a newly developed point-contact aiming guide [Unicorn Meniscal Root (UMR) guide] can create the tibial tunnel at a better position rather than a previously designed MMPRT guide. The aim of this study was to compare the position of the created tibial tunnel between the two meniscal root repair guides.

Materials and methods

Thirty-eight patients underwent transtibial pullout repairs. Tibial tunnel creation was performed using the UMR guide (19 cases) or MMPRT guide (19 cases). Three-dimensional computed tomography images of the tibial surface were evaluated using the Tsukada’s measurement method postoperatively. The expected anatomic center of the MM posterior root attachment was defined as the center of three tangential lines referring to three anatomic bony landmarks (anterior border of the posterior cruciate ligament, lateral margin of the medial tibial plateau, and retro-eminence ridge). The expected anatomic center and tibial tunnel center were evaluated using the percentage-based posterolateral location on the tibial surface. The distance between the anatomic center and tunnel center was calculated.

Results

The anatomic center of the MM posterior root footprint was located at a position of 79.2% posterior and 39.5% lateral. The mean of the tunnel center in the UMR guide was similar to that in the MMPRT guide (posterior direction, P = 0.096; lateral direction, P = 0.280). The mean distances between the tunnel center and the anatomic center were 4.06 and 3.99 mm in the UMR and MMPRT guide group, respectively (P = 0.455).

Conclusions

The UMR guide, as well as the MMPRT guide, is a useful device to create favorable tibial tunnels at the MM posterior root attachment for pullout repairs in patients with MMPRTs.

Level of evidence

IV