Age-Dependent Female Survival Advantage in Hepatocellular Carcinoma: A Multicenter Cohort Study

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) has a higher incidence in males, but the association of sex with survival remains controversial. This study aimed to examine the effect of sex on HCC survival and its association with age.

METHODS

Among 33,238 patients with HCC from 12 Chinese tertiary hospitals, 4175 patients who underwent curative-intent hepatectomy or ablation were analyzed. Cancer-specific survival (CSS) was analyzed using Cox regression and Kaplan-Meier methods. Two propensity score methods and multiple mediation analysis were applied to mitigate confounding. To explore the effect of estrogen, a candidate sex-specific factor that changes with age, female participants' history of estrogen use, and survival were analyzed.

RESULTS

There were 3321 males and 854 females included. A sex-related disparity of CSS was present and showed a typical age-dependent pattern: a female survival advantage over males appeared at the perimenopausal age of 45 to 54 years (hazard risk [HR], 0.77; 5-year CSS, 85.7% vs 70.6%; P = .018), peaked at the early postmenopausal age of 55 to 59 years (HR, 0.57; 5-year CSS, 89.8% vs 73.5%; P = .015), and was not present in the premenopausal (<45 y) and late postmenopausal groups (≥60 y). Consistent patterns were observed in patients after either ablation or hepatectomy. These results were sustained with propensity score analyses. Confounding or mediation effects accounted for only 19.5% of sex survival disparity. Female estrogen users had significantly longer CSS than nonusers (HR, 0.74; 5-year CSS, 79.6% vs 72.5%; P = .038).

CONCLUSIONS

A female survival advantage in HCC depends on age, and this may be associated with age-dependent, sex-specific factors.

Value of contrast-enhanced ultrasonography in microwave ablation treatment of symptomatic focal uterine adenomyosis

PURPOSE

This study evaluated the value of contrast-enhanced ultrasonography (CEUS) in the ultrasound-guided microwave ablation (MWA) treatment of symptomatic focal uterine adenomyosis.

METHODS

This retrospective study was conducted between March 2020 and January 2023, enrolling 52 patients with symptomatic focal uterine adenomyosis who had undergone MWA. All patients were examined with CEUS before and after MWA. The non-perfused volume (NPV) was compared between CEUS and dynamic contrast-enhanced magnetic resonance imaging (DCEMRI) following ablation. Therapeutic efficacy and safety were evaluated at 3-, 6-, and 12-month follow-ups. Additionally, this study explored the correlations between pre-treatment CEUS features and a volume reduction ratio indicating sufficient ablation, defined as 50% or more at the 3-month follow-up.

RESULTS

No significant differences in NPV were noted between CEUS and DCE-MRI immediately after MWA and during follow-up (all P>0.05). At the 3-month follow-up, the median VRRs for the uterus and adenomyosis were 33.2% and 63.9%, respectively. Sufficient ablation was achieved in 69.2% (36/52) of adenomyosis cases, while partial ablation was observed in the remaining 30.8% (16/52). The identification of non-enhancing areas on pre-treatment CEUS was associated with sufficient ablation (P=0.016). At the 12-month follow-up, significant decreases were observed in both the uterine and adenomyosis volumes (all P<0.001). Dysmenorrhea and menorrhagia were significantly alleviated at 12 months, and no major complications were encountered.

CONCLUSION

CEUS can be used to evaluate the ablation zone of focal adenomyosis that has been treated with MWA, similarly to DCE-MRI. The identification of non-enhancing areas on pretreatment CEUS indicates satisfactory treatment outcomes.

[Study on revision of standard limits for benzene in"Standards for indoor air quality（GB/T 18883-2022）"in China]

Benzene, as a major indoor pollutant, has received widespread attention. In order to better control indoor benzene pollution and protect people's health, the limit value of benzene in the"Standards for indoor air quality (GB/T 18883-2022)'' was reduced from 0.11 mg/m3 to 0.03 mg/m3. This study reviewed and discussed the relevant technical contents of the determination of benzene limit value, including the exposure status of benzene, health effects, and derivation of the limit value. It also proposed prospects for the future direction of formulating indoor air benzene standards.

Safety and efficacy of microwave ablation for the treatment of low-risk papillary thyroid microcarcinoma: a prospective multicenter study

OBJECTIVES

To assess the safety and efficacy of ultrasound-guided thermal ablation for low-risk papillary thyroid microcarcinoma (PTMC) via a prospective multicenter study.

METHODS

From January 2017 through June 2021, low-risk PTMC patients were screened. The management details of active surveillance (AS), surgery, and thermal ablation were discussed. Among patients who accepted thermal ablation, microwave ablation (MWA) was performed. The main outcome was disease-free survival (DFS). The secondary outcomes were tumor size and volume changes, local tumor progression (LTP), lymph node metastasis (LNM), and complication rate.

RESULTS

A total of 1278 patients were included in the study. The operation time of ablation was 30.21 ± 5.14 min with local anesthesia. The mean follow-up time was 34.57 ± 28.98 months. Six patients exhibited LTP at 36 months, of whom 5 patients underwent a second ablation, and 1 patient received surgery. The central LNM rate was 0.39% at 6 months, 0.63% at 12 months, and 0.78% at 36 months. Of the 10 patients with central LNM at 36 months, 5 patients chose ablation, 3 patients chose surgery and the other 2 patients chose AS. The overall complication rate was 1.41%, and 1.10% of patients developed hoarseness of the voice. All of the patients recovered within 6 months.

CONCLUSIONS

Thermal ablation of low-risk PTMC was observed to be safe and efficacious with few minor complications. This technique may help to bridge the gap between surgery and AS as treatment options for patients wishing to have their PTMC managed in a minimally invasive manner.

CLINICAL RELEVANCE STATEMENT

This study proved that microwave ablation is a safe and effective treatment method for papillary thyroid microcarcinoma.

KEY POINTS

Percutaneous US-guided microwave ablation of papillary thyroid microcarcinoma is a very minimally invasive treatment under local anesthesia during a short time period. The local tumor progression and complication rate of microwave ablation in the treatment of papillary thyroid microcarcinoma are very low.

Efficacy and safety of percutaneous microwave ablation for adenomyosis in the posterior uterine wall

OBJECTIVE

To evaluate the efficacy and safety of percutaneous microwave ablation (PMWA) for treating adenomyosis in the posterior uterine wall.

METHODS

Thirty-six patients with symptomatic adenomyosis in the posterior uterine wall who had been subjected to PMWA were retrospectively enrolled in this study. 20 patients who had no ideal transabdominal puncture path due to the retroverted or retroflexed uterine position were treated with PMWA combined with Yu's uteropexy (Group 1). The other 16 patients were treated with PMWA only (Group 2). The non-perfused volume (NPV) ratio, symptomatic relief rate, recurrence rate, changes in clinical symptom scores, economic cost, and complications were compared.

RESULTS

The mean NPV ratio for the 36 patients was 90.2±18.3%, and the percentage of patients who obtained complete relief of dysmenorrhea and menorrhagia was 81.3% (26/32), and 69.6% (16/23) respectively. The recurrence rate was 11.1% (4/36). No major complication was observed. Minor complications included lower abdominal pain, fever, vaginal discharge, nausea, and/or vomiting after ablation, with incidences of 55.6%, 41.7%, 47.2%, and 19.4% respectively. Subgroup analysis showed no significant difference in the median value of NPV ratio, symptomatic relief rate of dysmenorrhea and menorrhagia, changes in clinical symptom scores, recurrence rate and economic cost between the two groups (all p > 0.05).

CONCLUSION

PMWA is an effective and safe treatment for adenomyosis in the posterior uterine wall.

ADVANCES IN KNOWLEDGE

This study focused on the ultrasound-guided PMWA treatment for adenomyosis in the posterior uterine wall. Yu's uteropexy, a new ancillary technique allowing safe PMWA for deep posterior uterine wall lesions in retroverted uterus, expanded the indications of PMWA for symptomatic adenomyosis.

Ultrasound-guided percutaneous microwave ablation for adenomyosis with abnormal uterine bleeding: clinical outcome and associated factors

OBJECTIVE

To investigate the factors affecting the efficacy of ultrasound (US)-guided percutaneous microwave ablation (PMWA) for adenomyosis with abnormal uterine bleeding (AUB-A).

METHODS

Baseline data of patients with AUB-A who underwent US-guided PMWA treatment between October 2020 and October 2021, including demography characteristics, laboratory and imaging examination results were retrospectively analyzed. 3D reconstruction of magnetic resonance imaging (MRI) was applied to quantitatively assess the local treatment responses, including ratio of non-perfusion volume to adenomyosis volume (NPVr), ablation rate of the endometrial-myometrial junction (EMJ), and surface area (SA) of the ablated part of the EMJ. Patients were followed up at 3, 6, and 12 months after treatment, and divided into two groups: group with complete relief (CR), and group with partial relief (PR) or no relief (NR). Data were compared between them.

RESULTS

Thirty-one patients were analyzed with a mean age of 38.7 ± 6.8 years (range: 24-48): 48.4% (15/31), 63.3% (19/30), and 65.5% (19/29) achieved CR at 3, 6, and 12 months, respectively. In univariate analysis, compared with the PR/NR group, serum CA125 levels were significantly lower in CR group at 3 months, while ablation rates of EMJ and SA of the ablated part of the EMJ were significantly higher at the three time points. Other baseline characteristics and NPVr did not differ between the two groups.

CONCLUSION

Baseline CA125 and ablation rate of the EMJ and SA of the ablated part of the EMJ are associated with the outcome of AUB-A patients after US-guided PMWA treatment.

[The impact of human umbilical cord-derived mesenchymal stem cells on the pancreatic function of type 2 diabetic mice and their regulatory role on NLRP3 inflammasomes]

Objective: To investigate the effect and regulation of umbilical cord-derived mesenchymal stem cells (UC-MSCs) on islets function and NOD-like receptor family, pyrin domain containing 3 (NLRP3) and autophagy in type 2 diabetic mellitus (T2DM) mice. Methods: Experimental study. Twenty, 8-week-old, male C57BL/6J mice were selected and divided into a normal control group (n=5) and a high-fat feeding modeling group (n=15). The model of T2DM was established by high-fat feeding combined with intraperitoneal injection of low-dose streptozotocin. After successful modeling, those mice were divided into a diabetes group (n=7) and a UC-MSCs treatment group (n=7). The UC-MSCs treatment group was given UC-MSCs (1×106/0.2 ml phosphate buffer solution) by tail vein infusion once a week for a total of 4 weeks; the diabetes group was injected with the same amount of normal saline, and the normal control group was not treated. One week after the treatment, mice underwent intraperitoneal glucose tolerance tests and intraperitoneal insulin tolerance tests, and then the mice were sacrificed to obtain pancreatic tissue to detect the expressions of interleukin-1β (IL-1β) and pancreatic and duodenal homeobox 1 (PDX-1) by immunofluorescence. The bone marrow-derived macrophages were stimulated with lipopolysaccharide and adenosine triphosphate (experimental group) in vitro, then co-cultured with UC-MSCs for 24 h (treatment group). After the culture, enzyme-linked immunosorbent assay was used to detect the secretion level of IL-1β in the supernatant, and immunofluorescence staining was used to detect the expression of NLRP3 inflammasome, and related autophagy proteins. Statistical analysis was performed using unpaired one-way analysis of variance, repeated measure analysis of variance. Results: In vivo experiments showed that compared with the diabetes group, the UC-MSCs treatment group partially repaired islet structure, improved glucose tolerance and insulin sensitivity (all P<0.05), and the expression of PDX-1 increased and IL-1β decreased in islets under confocal microscopy. In vitro experiments showed that compared with the experimental group, the level of IL-1β secreted by macrophages in the treatment group was decreased [(85.9±74.6) pg/ml vs. (883.4±446.2) pg/ml, P=0.001], the expression of NLRP3 inflammasome and autophagy-related protein P62 was decreased, and the expressions of microtubule-associated protein 1 light chain 3β (LC3) and autophagy effector Beclin-1 were increased under confocal microscopy. Conclusions: UC-MSCs can reduce the level of pancreatic inflammation in T2DM mice, preserving pancreatic function. This might be associated with the ability of UC-MSCs to inhibit the activity of NLRP3 inflammasomes in macrophages and enhance autophagy levels.

Uterine artery embolization combined with percutaneous microwave ablation for the treatment of prolapsed uterine submucosal leiomyoma: A case report

BACKGROUND

Vaginal myomectomy is the most common form of radical treatment for prolapsed submucosal leiomyoma and is typically performed under general anesthesia. However, an alternative treatment approach is needed for patients who cannot tolerate general anesthesia. We describe a case with such a patient who was successfully treated via a minimally invasive method under local anesthesia.

CASE SUMMARY

A 46-year-old female suffered from abnormal uterine bleeding, severe anemia, and a reduced quality of life attributed to a massive prolapsed submucosal leiomyoma. She could not tolerate general anesthesia due to a congenital thoracic malformation and cardiopulmonary insufficiency. A new individualized combined treatment, consisting uterine artery embolization (UAE), percutaneous microwave ablation (PMWA) of the pedicle and the endometrium, and transvaginal removal of the leiomyoma by twisting, was performed. The lesion was completely removed successfully under local anesthesia without any major complications. The postoperative follow-up showed complete symptom relief and a significant improvement in the quality of life.

CONCLUSION

UAE combined with PMWA can be performed under local anesthesia and is a promising alternative treatment for patients who cannot tolerate general anesthesia.

Effect of Collagen-Reactive Functional Monomer on Etch-and-Rinse Adhesives

In this study, we evaluated a novel functional monomer (4-formylphenyl acrylate [FA]) that can specifically and covalently bind to the dentin collagen matrix as a potential alternative hydrophobic diluent-like monomer for improving the durability of dentin bonding. Experimental adhesives with different FA contents (0%, 10%, 20%, and 30%) were evaluated as partial substituents for the hydrophilic monomer 2-hydroxyethyl methacrylate, with the commercial adhesive One-Step (Bisco, Inc.) employed as the positive control. Their degree of conversion, viscosity, hydrophobicity, mechanical properties, and water absorption/solubility were measured as the comprehensive characterization. In situ zymographic assays were performed to determine the extent to which FA inhibits the endogenous hydrolytic activity of dentin. Finally, the bonding performances of the novel adhesives were evaluated with microtensile strength tests and scanning electron microscopy. The results showed that the incorporation of FA significantly improved the mobility of experimental adhesives attributable to the dilution property of FA. In contrast to the possible compromised rate of polymerization by hydroxyethyl methacrylate, FA exhibited typical characteristics of favorable copolymerization with polymerizable monomers in adhesives and improved the degree of conversion of experimental adhesives. The rigidity and hydrophobic properties of the phenyl framework of the FA molecule conferred superior mechanical properties and hydrolysis resistance to the novel experimental adhesives. An inhibitory effect on gelatinolytic activities within the hybrid layer was also observed in the in situ zymographic assays, even at a low FA concentration (10%). In conjunction with the significantly improved infiltration found via scanning electron microscopy, the experimental adhesives containing FA possessed significantly better-maintained microtensile strength, even after aging. Thus, the incorporation of this novel monomer endowed the experimental adhesives with multiple enhanced functionalities. These remarkable advantages highlight the suitability of the monomer for further applications in clinical practice.

Comparison of risk of hyperkalemia between SGLT2 inhibitors and DPP4-inhibitors in patients with type 2 diabetes

Funding Acknowledgements

Type of funding sources: None.

Background

Hyperkalemia is a common complication and increases the risk of cardiac arrhythmias and mortality in patients with type 2 diabetes (T2DM), especially in those with diabetic nephropathy. We investigated the risk of hyperkalemia in patients initiated on SGLT2 inhibitors versus DPP-4 inhibitors among patients with T2DM.

Methods

This study included patients with T2DM who initiated on SGLT2 inhibitors or DPP-4 inhibitors between January 01, 2015 and December 31, 2019 from a territory-wide clinical registry in Hong Kong (Clinical Data Analysis and Reporting System [CDARS]). A multivariable cox proportional hazards analysis, adjusting for key confounders, was used to compare the risk of central laboratory-determined hyperkalemia (serum potassium ≥6.0mmol/L) and hypokalemia (serum potassium &lt;3.5mmol/L), respectively, between SGLT2 inhibitors and DPP-4 inhibitors.

Results

10193 new users of SGLT2 inhibitors were matched to 17305 new users of DPP-4 inhibitors. During the 2-year follow-up, there were 104 hyperkalemia events (incident rate [IR] = 5.17 per 1000 person-years) among SGLT2 inhibitors and 306 events (IR = 9.09 per 1000 person-years) among DPP-4 inhibitors, of which SGLT2 inhibitors were associated with a lower risk of incident hyperkalemia (Adjusted HR: 0.66 [95%CI 0.53-0.83], p&lt;0.001), compared to DPP-4 inhibitors. The incident hypokalemia was similar between SGLT2 inhibitors and DPP-4 inhibitors (Adjusted HR: 0.91 [95%CI 0.81-1.03], P=0.13).

Conclusion

SGLT2 inhibitors reduced incident hyperkalemia, but without increasing incident hypokalemia compared to DPP-4 inhibitors.

Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes

Background

Circulating thrombospondin-2 (TSP2) levels were associated with the development of heart failure (HF) in recent studies. However, these studies included only a minority of patients with type 2 diabetes, which is associated with an increased HF risk. As hyperglycemia induces TSP2 expression and its tissue expression increases in type 2 diabetes, we investigated the prospective association of circulating TSP2 with incident HF hospitalization (HHF), and its associations with longitudinal changes of echocardiographic parameters in type 2 diabetes.

Methods

Baseline serum TSP2 levels were measured in 4949 patients with type 2 diabetes to determine its association with incident HHF using multivariable Cox regression analysis. In the echocardiographic study, baseline serum TSP2 levels were measured in another 146 patients with type 2 diabetes but without cardiovascular diseases who underwent detailed transthoracic echocardiography at baseline and after 1 year.

Results

Over a median follow-up of 7.8 years, 330 of 4949 patients (6.7%) developed incident HHF. Baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.31, 95%CI 1.06–1.62, p = 0.014) after adjustments for baseline conventional cardiovascular risk factors, atrial fibrillation, estimated glomerular filtration rate, albuminuria and high-sensitivity C-reactive protein level, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop-diuretics, aspirin, insulin, metformin and sodium-glucose co-transporter 2 inhibitors. Moreover, baseline serum TSP2 levels were independently associated with increase in average E/e’ and left atrial volume index (p = 0.04 and < 0.01, respectively).

Conclusion

Serum TSP2 levels were independently associated with both incident HHF and deterioration in diastolic function in type 2 diabetes.

Trial registration

Not Applicable

Supplementary information

The online version contains supplementary material available at 10.1186/s12933-022-01646-x.

Peak atrial longitudinal strain as an independent predictor of composite endpoint in patients received aortic valve replacement for severe aortic stenosis: a prospective cohort study

Objective

Severe aortic stenosis (AS) is the primary valvular heart disease, treatable only by aortic valve replacement (AVR). The prognostic value of pre-operative left atrial (LA) function on post-AVR clinical outcomes is uncertain. The study aims to evaluate the prognostic value of pre-operative peak atrial longitudinal strain (PALS) as a surrogate of LA function on post AVR all-cause mortality and heart failure hospitalisation.

Methods

Patients aged 18 years old or above with severe AS were recruited and assessed using speckle-tracking echocardiography pre-operatively. Severe AS was defined according to 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease. PALS was measured. Based on the median value of PALS, patients were stratified into PALS &lt;15.94% and PALS &gt;15.94%. Patients with underlying pre-operative atrial fibrillation, other moderate to severe valvular heart diseases and cancers were excluded. Patients were followed up until death, heart failure hospitalisation or end of the study. The primary outcome is a composite endpoint of all-cause mortality and heart failure hospitalisation. The association of PALS with the composite endpoint was evaluated by Cox Proportional Hazards analysis.

Results

A total of 128 patients (mean age 65.32±9.42 years, 56.3% male) were prospectively analyzed. Patients were followed up for a mean period of 3.9±2.4 years. A total of 65 of 128 patients (50.8%) belonged to PALS&lt;15.94%. During the study period, 23 patients developed the adverse events. A lower pre-operative PALS, both as a continuous or a categorical variable, were associated with a higher unadjusted risk of adverse events (Continuous; HR, 0.93; 95% CI 0.88–0.98; p=0.011; PALS &lt;15.94%; HR, 4.94; 95% CI, 1.67–14.58; p=0.004).

Conclusion

The study demonstrated a lower pre-operative PALS is associated with all-cause mortality and heart failure admission in patients with severe AS undergoing AVR. Evaluation of LA function by assessing speckle tracking derived PALS may aid in prognostication for patients undergoing AVR.

Funding Acknowledgement

Type of funding sources: None.

Ultrasound-guided percutaneous microwave ablation for uterine fibroids: mid-term local treatment efficiency and associated influencing factors

OBJECTIVE

To investigate the mid-term local treatment efficiency of ultrasound-guided percutaneous microwave ablation (MWA) for uterine fibroids (UFs) and the associated influencing factors.

METHODS

From July 2020 to October 2021, a total of 28 patients with 52 UFs who had undergone ultrasound-guided MWA were retrospectively included in this study. Pre-treatment clinical characteristics, conventional ultrasound and contrast-enhanced ultrasound (CEUS) features were analyzed to explore their correlation with volume reduction ratios (VRRs) of sufficient ablation (i.e. a VRR of at least 50% at the 3 month follow-up). The patients were assessed at 1-, 3-, 6 month follow-up after MWA treatment and the assessment included VRR, adverse events, uterine fibroid symptom (UFS) and quality of life (QoL) scores, and clinical symptoms.

RESULTS

The procedures of percutaneous MWA for UFs were tolerated well and no major complications occurred in all patients. At the 1-, 3-, 6 month follow-up, the median VRRs of UFs were 30.1%, 46.9%, and 65.8%, respectively. At the 3 month follow-up, 44.4% of fibroids obtained sufficient ablation while the remaining 55.6% obtained partial ablation (i.e. a VRR of <50%). Non-enhancing area during the early phase (i.e. within 30 s after injecting contrast agent) on pre-treatment CEUS was present in 22.2% UFs, which was associated with sufficient ablation at the 3 month follow-up (p < 0.05). In addition, the relevant clinical symptoms of all patients were alleviated or removed. The UFS and QoL score after MWA decreased significantly in comparison with those after MWA (p = 0.04 and p = 0.057, respectively), indicating a remarkable improvement of clinical symptom and QoL.

CONCLUSION

Ultrasound-guided MWA is an effective and safe method to treat patients with UFs. Non-enhancing area during the early phase on pretreatment CEUS is associated with mid-term local treatment efficiency, which might be used to predict treatment outcome.

ADVANCES IN KNOWLEDGE

Non-enhancing area during the early phase on pretreatment CEUS is an important factor associated with mid-term local treatment efficiency. This is the first study finding that CEUS feature can be used as a marker for the prediction of mid-term local treatment response.

Ultrasound-guided microwave ablation for symptomatic abdominal wall endometriosis and treatment response evaluation with contrast-enhanced imaging: The first experience

INTRODUCTION: Abdominal wall endometriosis (AWE) is a relatively uncommon condition associated with diagnostic and therapeutic difficulties among all the extra pelvic endometriosis. The main therapies include surgery and oral contraceptive administration. Percutaneous cryoablation and high intensity focused ultrasound (HIFU) are also proven to be valid alternatives. Microwave ablation (MWA) as one of the thermal ablation methods has not been applied in the treatment of AWE yet. Herein the feasibility of ultrasound (US) –guided MWA for AWE was explored and treatment response evaluation was carried out using contrast-enhanced imaging. METHODS: Three consecutive patients who underwent US-guided MWA for AWE with typical symptoms were included in the retrospective study. US, magnetic resonance imaging (MRI), laboratory tests, and US-guided core-needle biopsy were conducted for pre-treatment assessment and ruling out malignancy. The interventional procedure was carried out under local anesthesia with the microwave system and the output power was 60w. Post-treatment contrast-enhanced ultrasound (CEUS) was performed to evaluate the instant treatment response. The follow-up intervals were 1 month, 6 months, and 12 months after treatment. The clinical symptoms and condition of AWE lesions were recorded in each follow-up. RESULTS: The MWA procedure was completed in all the patients with no blood perfusion inside each lesion by instant CEUS after treatment. The mean ablation time was 687 seconds (s) for a single patient (ranged from 660s to 742s). Clinical symptoms were relieved evidently at the end of the follow-up. The pain according to the visual analogue scale (VAS) decreased from 4–6 before treatment to 0–2 after treatment. Mild to moderate complications included slightly abdominal pain and fat liquefaction occurred. In terms of technical outcomes, the volume of all six lesions reduced in different degrees at the end of follow-up (ranged: 16.6% to 100% ). CONCLUSION: US-guided MWA may be a feasible and promising approach for symptomatic AWE.

Sequential thermal ablation in combination with sclerotherapy using lauromacrogol as a successful translative therapy for an unresectable huge biliary cystadenocarcinoma: The first experience assisted by contrast-enhanced ultrasound

Biliary cystadenocarcinoma (BCAC) is an extremely rare intrahepatic cystic tumor. Patients usually present with nonspecific symptoms such as abdominal pain, abdominal distention, and abdominal mass. This tumor occurs most commonly in the left hemiliver and is thought to mainly develop from a benign biliary cystadenoma (BCA). At present, the disease is mainly diagnosed by ultrasound, CT, MR, and other imaging methods, and the main treatment is radical surgical resection. We reported a 75-year-old female with an unresectable huge BCAC (i.e., 161×145×122 mm in three orthogonal directions) and poor general condition (40 in Karnofsky Performance Status, KPS) who received sequential thermal ablation (i.e., cryoablation and microwave ablation) in combination with sclerotherapy using lauromacrogol. The diagnosis of intrahepatic BCAC was confirmed pathologically. Preablation grayscale US showed the BCAC with a clear boundary, regular shape, and cystic-solid mixed echogenicity, which appeared as a huge multilocular cystic lesions with thick internal sepatations. Preablation contrast-enhanced ultrasound (CEUS) showed honeycomb-like hyper-enhancement of the thick internal sepatations and cystic wall in the arterial and portal phase, and sustained enhancement of the thick internal sepatations and cystic wall in the late phase. 6-month postablation CEUS showed non-enhancement in most parts of the lesion in the arterial phase and 6-month postablation MRI showed the volume reduction ratio (VRR) was about 70% . The abdominal pain and abdominal distension were relieved remarkably, and her quality of life was greatly improved (70 in KPS). In conclusion, sequential thermal ablation in combination with sclerotherapy provides a successful translative therapy for this unresectable huge BCAC with a poor general condition, which makes subsequent curative surgery or ablation possible.

Repeated ultrasound-guided percutaneous thermal ablation combined with systemic therapy achieves a stable condition in an end-stage patient with more than 10 liver metastases from breast cancer: The importance of sonazoid assisted contrast-enhanced ultrasound and fusion imaging

The liver is one of the most frequent metastatic sites of breast cancer with a relatively poor prognosis. Systemic chemotherapy is an effective treatment but the efficacy is different between the subtypes of breast cancer. Percutaneous thermal ablation is considered to be a minimally invasive and effective local treatment for breast cancer liver metastases (BCLM). This case report described a patient with BCLM who adopted a strategy of systemic chemotherapy and repeated ultrasound (US) -guided percutaneous thermal ablation procedures. The survival time already reached 8 years till now with the metastases well-controlled and acceptable life quality was achieved.

Role of prenatal cardiovascular magnetic resonance imaging in determining pregnancy risk in repaired Tetralogy of Fallot patients

Funding Acknowledgements

Type of funding sources: None.

Addressing pregnancy risks poses as a new challenge among women with repaired tetralogy of Fallot (TOF). The high-output state of pregnancy may predispose women to late complications of repaired TOF. However, guidelines regarding antenatal and or perinatal cardiovascular assessment has not been outlined. Noninvasive modalities such as cardiac magnetic resonance imaging (CMR) that do not require the utilization of ionizing radiation are feasible methods of assessment. Risk stratification of baseline CMR parameters has been sparsely investigated among repaired TOF cohorts. This study aims to identify baseline CMR parameters that may predict adverse outcomes of pregnancy among women with repaired TOF.

Sixty-five successful pregnancies were recorded from a cohort of 105 pregnant episodes. Patients with CMR studies performed within 5 years prior to delivery events were included. Adverse clinical outcomes of interest included arrhythmia, heart failure admissions, gestational hypertension, pre-eclampsia toxemia and all-cause mortality. Baseline CMR parameters regarding ventricular mechanics such as left and right ventricular end-diastolic and end-systolic volumes, left and right ventricular ejection fractions and pulmonary regurgitant fraction were measured, and their association with adverse clinical outcomes were evaluated using an independent-samples t-test.

Within all 65 successful pregnancies, 26 baseline CMR images were obtained and included in this study. The mean maternal age was 29.7 ± 6.7 years old with a mean birth weight of 2.91 ± 0.49 kg at a mean gestational age of 38.4 ± 2.0 weeks. There was a total of 12 patients with adverse clinical outcome: 5 patients with heart failure hospitalizations, 4 patients with gestational hypertension, 4 patients with arrhythmia and 2 patients with pre-eclampsia toxemia.

Assessment of baseline CMR parameters of ventricular mechanics revealed that increased left ventricular end-diastolic volumes (LVEDV) (144.7mL/m2 ± 4.9; P = 0.011), left ventricular end-systolic volumes (LVESV) (65.1mL/m2 ± 9.4; P = 0.004), right ventricular end-diastolic volumes (RVEDV) (235.2 ± 29.0; P = 0.021) and right ventricular end-systolic volumes (RVESV) (122.2mL/m2 ± 38.1; P = 0.033) were associated with an increased incidence of arrhythmia during pregnancy. Nonetheless, there was no significant association between baseline ventricular mechanics with heart failure, gestational hypertension, and pre-eclampsia toxemia. 

Baseline assessment of cardiac magnetic resonance imaging among pregnant TOF women revealed that larger left and right ventricular volumes were associated with arrythmia development during pregnancy. Further studies with larger cohort sizes evaluating the role of antenatal and perinatal cardiovascular imaging assessment using CMR in predicting the risks of cardiovascular complications during pregnancy are warranted.

Incidence, clinical correlates and associated outcomes of dementia in heart failure: a population-based cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Dementia, in the setting of heart failure (HF), portends poorer outcomes and poses great challenges in its clinical management.

Purpose

We investigated the incidence, types, clinical correlates, and the prognostic impact of dementia in a population-based cohort of patients with HF. Further, we examined the interactions of age and sex, and education status with dementia incidence.

Methods

The previously validated Hong Kong Clinical Data Analysis Reporting System (CDARS), a territory-wide database was interrogated to identify patients with HF (N= 202,121) from 1995 to 2018. Associations of clinical correlates with incident dementia and its risk with all-cause mortality were assessed using competing risk/multivariable Cox regression models where appropriate.

Results

Among a total cohort aged ≥18 years with HF (mean age: 75.3 ± 13.0 years, 51.3% women), new-onset dementia occurred in 22,145 (11.0%) over a median follow-up of 5.5 years. Alzheimer’s disease occurred in 27.0%; vascular dementia (18.1%) and unspecified dementia (in 55.1%). Age-standardized rate of dementia incidence in women was 1297 (95%CI, 1276-1318) (vs. 744, 95%CI, 723-765) per 10000 population in men. Other independent predictors of dementia include: Increasing age (HR 1.08), Female sex (HR 1.19), Nil/&lt; primary (vs tertiary) education (HR 1.29), Parkinson’s disease (HR 1.73), head injury (HR 1.37), peripheral vascular disease (HR 1.31), stroke (HR 1.29), depression (HR 1.18), alcohol intake (HR1.17), anaemia (HR 1.14), hypertension (HR 1.08), among other common comorbidities in HF (Figure 1A).

Notably, a significant interaction (p &lt; 0.001) between age and sex on dementia incidence was observed, such that women in all age groups were observed to have higher sHR compared to men (Figure 1B). After accounting for competing risk, dementia was not associated with adjusted hazard of all-cause mortality.

Conclusions

Female sex, lower socioeconomic status, increasing age and common comorbidities were associated with higher hazards of incident dementia. Abstract Figure 1A and Figure 1B

Serial echocardiography assessment and clinical outcomes among pregnant women with Tetralogy of Fallot

Funding Acknowledgements

Type of funding sources: None.

Following advancements in intracardiac repair of Tetralogy of Fallot (TOF), a greater proportion of patients survive well beyond child-bearing age. Pulmonary regurgitation (PR) and subsequent progressive right ventricular dilatation occur frequently as an intrinsic complication of surgical repair of TOF. High-output states such as pregnancy may exacerbate these late complications. The advocation of pre-pregnancy pulmonary valve replacement to mitigate pregnancy-related cardiac burden has remained controversial. This study aims to delineate the outcomes of pregnancy among women with repaired TOF.

105 pregnant episodes among were identified from a cohort of 240 adult female patients with TOF between 1990 to 2021. Patients with echocardiographic studies performed within 1 year prior to and following delivery were included for cardiac functional analysis. A paired sample t-test was performed to compare echocardiographic parameters between pre-delivery and post-delivery periods. Linear regression was used to identify changes to identify significant changes in echocardiographic parameters among patients with a baseline of severe PR.

Within all pregnant episodes (n = 105), 65 successful pregnancies, 16 spontaneous miscarriages, 21 termination of pregnancies and 3 ectopic pregnancies were recorded. The mean maternal age was 28.9 (±6.7) years with deliveries at 37.86 (30-41) gestational weeks. Cardiovascular events occurred in 19 pregnancies with 4 patients having gestational hypertension, 4 patients with pre-eclampsia toxemia, 7 patients with heart failure symptoms and 4 patients with arrhythmias. Other complications included 4 patients with gestational diabetes mellitus, 3 patients with impaired glucose tolerance, 2 patients with anemia, 3 patients with maternal thyroid disease and 1 patients with proteinuria.

Echocardiographic studies demonstrated significant changes in left ventricular ejection fraction (LVEF) (Pre-delivery = 60.69 ±8.73; post-delivery = 59.39 ±9.36) (P = 0.007), left ventricular end diastolic volume (LVEDV) (Pre-delivery: 89.71mL ±18.22mL; Post-delivery: 80.96mL ±12.32mL; P = 0.007), left end systolic volume (LVESV) (Pre-delivery: 35.43 ±12.36; Post-delivery: 32.70 ± 8.83; P = 3.7x10-5) and right ventricular index of myocardial performance score (Pre-delivery: 0.34 ±0.12; Post-delivery: 0.33 ±0.12; P = 0.007). Patients with severe PR was found to have significantly worse right ventricular global longitudinal strain (RV GLS) (P = 0.029). 2 patients progressed to severe PR following delivery.

Adult female patients with TOF can have viable pregnancies with acceptable mortality and morbidity. Deterioration in echocardiographic parameters were identified when comparing between pre-delivery and post-delivery studies. TOF patients should be closely monitored throughout and post-delivery for detection of deterioration of cardiac function and clinical symptoms.

A Novel Chemical Binding Primer to Improve Dentin Bonding Durability

The dentin collagen matrix that is not completely enveloped by resin adhesive is vulnerable to degradation by intrinsic collagenases during the etch-and-rinse process, which contributes to the deterioration of the bonding interface. Current commercial adhesives have no functional components that can form covalent bonds to the dentin collagen matrix. In this study, a photocurable aldehyde, 4-formylphenyl acrylate (FA), was synthesized and for the first time applied as a primer in adhesive dentistry to covalently bind to collagen. Experimental groups with different concentrations of FA (1%, 3%, 5%, 7%, 9%) were prepared as primers. The cytotoxicity was evaluated by live/dead-cell staining and thiazolyl blue tetrazolium bromide assay. The interaction of FA with collagen was examined by attenuated total reflection Fourier transform infrared spectroscopy, hydroxyproline release under the degradation of type I collagenase, and thermogravimetric analysis. An optimal group was selected based on the degree of conversion of 2 universal adhesives and further divided depending on the treatment time (20 s, 30 s, 1 min, 2 min). The bonding performances were evaluated by microtensile strength before and after aging. Finally, the bonding interface was observed under confocal laser scanning microscopy and scanning electron microscope. The results indicated that FA demonstrated good biocompatibility, dentin modification capability, and infiltration. It not only effectively cross-linked dentin collagen to improve its stability against enzymatic hydrolysis and modify the adhesive interface but also potentially acted as a diluting monomer to induce deep penetration of adhesive resin monomers into the dentin. The bonding strength after aging was improved without jeopardizing the degree of conversion of 2 commercial adhesives. Such prominent advantages of using FA to improve the bonding performance promotes its further application in adhesive dentistry.

Period-Dependent Survival Benefit of Percutaneous Microwave Ablation for Hepatocellular Carcinoma: A 12-Year Real-World, Multicentric Experience

INTRODUCTION

Although microwave ablation (MWA) is a promising technique for hepatocellular carcinoma (HCC) treatment, its 10-year efficacy is unknown.

OBJECTIVE

The objective of the study was to assess whether the advances in MWA for HCC translated into a real-world survival benefit.

METHODS

This retrospective study included 2,354 patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 to B from 5 hospitals, with at least 2 years of follow-up for all the patients. Recurrence and survival were analyzed using the Kaplan-Meier method with time-period stratification.

RESULTS

A total of 5,326 HCCs (mean diameter, 2.9 cm ± 1.2) underwent 4,051 sessions of MWA with a median follow-up of 61.3 (0.6-169.5 range) months during 3 periods (2007-2010, 2011-2014, and 2015-2018). Technical success was achieved in 5,194 (97.5%) tumors with significant improvement over time, especially for >3.0-cm HCC (p < 0.001). Local tumor progression (LTP) showed no period-dependent advance, with >3.0-cm HCC and perivascular location being the risk factors for LTP. The median intrahepatic metastasis time was 27.6 (95% confidence interval [CI]: 25.2-28.8) months, with 5- and 10-year occurrence rates of 68.8% and 79.4%, respectively. The 5- and 10-year overall survivals were 63.9% and 41.1%, respectively, and BCLC stage 0, A, and all B patients showed an observable survival improvement over time (p < 0.001). The median disease-free survival time increased from 19.4 (95% CI: 16.5-22.6) months in 2007-2010 to 28.1 (95% CI: 25.9-32.3) months in 2015-2018. The improved survival for early recurrent (≤2 years) patients was period-dependent, as verified by Cox regression analyses. The major complications rate per procedure was 3.0% (122/4,051).

CONCLUSIONS

These real-world data show that MWA provided an upward trend in survival for HCC patients with BCLC stage 0-B over a 12-year follow-up period. An encouraging clear survival benefit in early recurrent patients was also observed.

The first experience of ultrasound-guided percutaneous microwave ablation for extracranial schwannoma of the cervical vagus nerve in carotid space and treatment response evaluation with contrast-enhanced imaging

Schwannoma is a benign tumor that originates from Schwann cells in the nerve sheathing of cranial, other peripheral, or autonomic nerves. Patients often present with painless mass as the chief complaint. The main symptoms of this tumor are related to its size and specific nerve origin. At present, the pretreatment diagnosis is mainly made by ultrasound, CT, MR, or biopsy, and the main treatment is surgical resection. We reported a new treatment method for cervical schwannoma in a 65-year-old woman with a history of non-small cell lung cancer (NSCLC). When the patient's neck mass was initially found with hoarseness and severe cough, it was considered as cervical lymph node metastasis of lung cancer due to her medical history. And she was diagnosed with schwannoma by core-needle biopsy after chemotherapy failed and the tumor shrank after the radiotherapy with no improvement of the clinical symptoms. After considering the physical condition, the patients were treated in our department for minimal invasiveness treatment. The patient was definitively diagnosed with cervical vagus schwannoma and was treated with ultrasound-guided microwave ablation of schwannoma under general anesthesia with systematic evaluation and improved preoperative examination. Her condition was stable, and the symptoms of severe cough disappeared after anesthesia resuscitation and the ablation. The tumor continued to shrink after the operation with no recurrence of cough symptoms. Ultrasound-guided percutaneous microwave ablation (MWA) for cervical vagus schwannomas might be a minimally invasive, effective, and relatively safe alternative to conventional treatment for those patients with severe symptoms.

Thermal ablation and immunotherapy for hepatocellular carcinoma: Recent advances and future directions

Hepatocellular carcinoma (HCC) is one of most common cancers that cause death in the world. Thermal ablation (TA) is an important alternative treatment method for HCC patients who are not appropriate for surgery or liver transplantation. Particularly for small and early HCCs, TA can be considered as the first-line curative treatment. However, local and distant recurrence rates are still high even though the TA equipment and technology develop rapidly. Immunotherapy is a novel systemic treatment method to enhance the anti-tumor immune response of HCC patients, which has the potential to reduce the tumor recurrence and metastasis. The combination of local TA and systemic immunotherapy for HCCs may be an ideal treatment for enhancing the efficacy of TA and controlling the recurrence. Herein we summarize the latest progress in TA, immunotherapy, and their combination for the treatment of patients with HCC and discuss the limitations and future research directions of the combined therapy.

Prognostic role of right ventricular geometry and function in patients undergoing double valve surgery

Introduction

Multiple valvular heart disease, a combination of stenotic and regurgitant lesions occurring on two or more valves, is a highly prevalent condition. For these patients, surgical correction is the only definitive treatment to improve prognosis, yet concomitant aortic and mitral (double) valve surgery is associated with poor post-operative outcomes. While current guidelines outline left ventricular dimensions and function as surgical triggers, little is known regarding the importance of right ventricular (RV) remodelling in these patients.

Purpose

We sought to evaluate the prognostic value of RV remodelling in patients undergoing double valve surgery.

Methods

RV remodelling was characterised by transthoracic echocardiography in 152 patients undergoing concomitant aortic and mitral valve replacement (n=118) or aortic valve replacement and mitral valve repair (n=34). Four patterns of RV remodelling were defined according to the presence of RV dilation (tricuspid annulus diameter&gt;35mm) and RV systolic dysfunction (percentage RV fractional area change &lt;35%): normal RV size and systolic function (pattern 1); dilated RV with normal systolic function (pattern 2); RV systolic dysfunction with normal RV size (pattern 3); and dilated RV with systolic dysfunction (pattern 4). Adverse events were defined as the composite of all-cause mortality and hospitalisation for heart failure.

Results

Overall, 62 (41%), 31 (20%), 35 (23%), and 24 (16%) patients were classified as RV remodelling patterns 1, 2, 3, and 4, respectively. Patients with advanced RV remodelling patterns were more frequently male, had worse renal function, and a higher EuroSCORE II. During a median follow-up of 43 months, 41 adverse events (22 heart failure hospitalisation and 19 deaths) occurred. Patients with patterns 3 and 4 RV remodelling had an increased risk of adverse events compared to pattern 1 (log-rank χ2 27.42; p&lt;0.001; Figure 1). After adjustments for EuroSCORE II and significant tricuspid regurgitation, RV remodelling patterns 3 (Hazard Ratio [HR] 3.24, 95% Confidence Interval [CI] 1.27–8.24, p=0.014) and 4 (HR 6.18, 95% CI 2.49–15.32, p&lt;0.001) were independently associated with poor post-operative outcomes. Importantly, RV remodelling patterns provided incremental prognostic value to EuroSCORE II (χ2 increased from 18 to 38, p&lt;0.001).

Conclusion

In patients with concomitant aortic and mitral valve disease, RV remodelling is frequent and associated with poorer outcomes. Our study highlights the involvement of the RV in left-sided valvular heart disease and underlines the importance of preoperative assessment of RV geometry and function in patients undergoing double valve surgery.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The evolving characteristics and outcomes of acute myocardial infarction in Hong Kong, 1999–2018

Background

The burden of myocardial infarction (MI) with its assorted comorbid complications is increasing parallel to rising life expectancy. Careful characterisation of patient characteristics and identification of short- and long-term complications is critical to their management. Nonetheless, data on the evolving profiles of patient features and outcomes, particularly in an Asian population, remain sparse.

Purpose

We aim to describe the evolving characteristics and outcomes of MI patients in Hong Kong in the past 2 decades.

Methods

From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. The primary outcome was 30-day all-cause death, while secondary outcomes include haemorrhagic stroke, and pneumonia, at both 30 days and 5 years. Temporal trends in baseline characteristics were evaluated using Poisson regression, while trends in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications.

Results

A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Over time, while there was no change in the proportion of females (P=0.196), the increase in mean age (APC 0.23% [0.21 to 0.24], P&lt;0.001) was concordant with the increase in mean CCI (APC 5.1%, [4.8 to 5.3], P&lt;0.001), with more patients suffering from baseline comorbidities (Figure 1; range of APC 1.7% to 4.3%; all P&lt;0.001). The proportion of ST elevation increased significantly (APC 2.5% [2.4 to 2.5], P&lt;0.001).

The adjusted all-cause 30-day mortality rate decreased increased significantly (APC 0.3% [0.1 to 0.5], P=0.005). The increasing trend was significant in older patients (≥70 years), non-ST elevation, and female, while there was a decreasing trend mortality rate in ST elevation and young patients; no significant trend was observed in male. Strikingly, there is an alarming increase in the rate of haemorrhagic stroke (APC 3.4% [2.3 to 4.4], P&lt;0.001) and pneumonia (APC 1.5% [1.3 to 1.7], P&lt;0.001) at 30 days (Figure 2). Although the rate of 5-year all-cause death declined slightly (APC −0.8% [−0.9 to −0.6], P&lt;0.001), there were increasing rates of haemorrhagic stroke (APC 1.0% [0.3 to 1.7], P=0.004) and pneumonia (APC 3.8% [3.6 to 4.1], P&lt;0.001). Patients who were older, had ST elevation, and more comorbid were more likely to develop pneumonia.

Conclusions

Patients with MI have evolved to be older and more comorbid. Alarmingly, despite reduction in long-term all-cause death over time, the reduction was small; risk of death in short-term significantly increased and patients suffer from more complications including haemorrhagic stroke and pneumonia. These results highlight the emergence of extra-cardiac outcomes that drive poor prognosis and accentuate the need to develop tailored strategies to tackle these potentially lethal complications.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical Discipline; The Sanming Project of HKU-SZH Cardiology

Microbiology of infective endocarditis in Hong Kong from 2000 to 2019: a 20-year analysis

Background

Infective endocarditis (IE) is associated with high mortality and complex microbiological profile. The antibiotic prophylaxis guidelines underwent a major revision in 2009 to reduce unnecessary antibiotic exposure. Substantial geographic variations in microbiological profiles exist, of which the understanding in an Asian population is lacking.

Purpose

We aim to describe the trends in the microbiology of IE in Hong Kong in the past 2 decades.

Methods

All patients aged 20 or above diagnosed with incident IE with blood culture results from 2000–2019 were included from a well-validated territory-wide database in Hong Kong, and were classified as 7 groups of causative organisms as shown in Figure 1. To evaluate the association between microbiology and 1-year all-cause death, a multivariable Cox proportional-hazards model was used, adjusted with demographics and comorbidities. Temporal trends in the proportion of each organism were characterised using Poisson regression. Interrupted time series analysis was used to evaluate the change in the organism-specific incidence after the revision of guidelines.

Results

In a total of 5,657 patients (age 59.9±18.3 years, 37.2% females), there were 2,185 (38.6%) patients with culture-negative endocarditis. Staphylococcus aureus (22.4%) and Streptococci (20.5%) were the most common organisms identified.

Over time, there was a significant reduction in the proportion of culture-negative endocarditis (annual percentage change [APC] −2.3% [−2.8 to −1.7], P&lt;0.001), and a significant increase in the proportion of endocarditis due to Staphylococcus aureus (APC 1.6% [0.7 to 2.4], P&lt;0.001) and Streptococci (APC 2.3% [1.4 to 3.3], P&lt;0.001) (Figure 1). After guidelines revision in 2009, there was no significant change in organism-specific incidence (all P-values for relative change&gt;0.05).

Compared to patients with culture-negative endocarditis, those infected with Staphylococcus aureus (hazard ratio [HR] 2.19 [1.94–2.47], P&lt;0.001), other Staphylococci (HR 1.56 [1.20–2.01], P&lt;0.001), Enterococci (HR 1.60 [1.25–2.05], P&lt;0.001), other microorganisms (HR 1.30 [1.05–1.60], P=0.015), and mixed microorganisms (HR 2.40 [2.02–2.84], P&lt;0.001) had a higher risk of 1-year all-cause death (Figure 2).

There was a significant increase in the proportion of methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (APC 4.1% [1.9 to 6.3], P&lt;0.001), with no significant interval change after 2009. Patients infected with MRSA had a higher all-cause death (HR 2.00 [1.70–2.36], P&lt;0.001).

Conclusions

Different causative organisms carry variable mortality signals in infective endocarditis. Over time, there were fewer cases of culture-negative endocarditis, and the revision of antibiotic prophylaxis guidelines did not result in a significant change in the microbiological profile. There was an increasing trend for MRSA endocarditis, which was associated with a higher risk of death.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Epidemiology of infective endocarditis in Hong Kong, 2000–2019

Background/Introduction

Despite improvements in diagnostic and therapeutic strategies, the mortality and morbidity of infective endocarditis (IE) remain high. The incidence, outcomes, and surgical intervention of IE, particularly in an Asian population, are poorly understood and characterised, and the effect of antibiotic prophylaxis guidelines revision on the incidence of IE remains unexplored.

Purpose

We aim to describe temporal changes in the epidemiology and surgical intervention for IE in Hong Kong in the past 2 decades.

Methods

From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. The temporal trends in the incidence of IE, rate of surgical intervention, and mean Charlson Comorbidity Index (CCI) were characterised using Poisson regression analysis and expressed in annual percentage change (APC [95% CI]). Interrupted time series analysis was used to evaluate the change in incidence after the revision of antibiotic prophylaxis guidelines. The association between surgical intervention and mortality was evaluated using propensity score analytics. Temporal trends in 1-year all-cause mortality were evaluated using multivariable Cox regression.

Results

A total of 5,657 patients (59.9±18.3 years, 37.2% females) were included. The crude incidence remained was stable from 2000 to 2019 (APC 0.1% [−0.5 to 0.7], P=0.675), and remained unchanged following the revision of antibiotic prophylaxis guidelines in 2008 (relative risk of change 0.90 [0.64 to 1.00], P=0.065) (Figure 1). Concordant with an increase in the mean age of IE patients (APC 0.9% [0.8 to 1.1], P&lt;0.001), the comorbidity burden grew substantially from 2000 (CCI 0.55±1.27) to 2019 (CCI 1.09±1.66).

The rate of surgical intervention significantly increased from 5.3% in 2000 to 17.8% in 2019 (APC 2.7% [1.1 to 4.3], P=0.004), and surgical intervention at 1 year was associated with a 45% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.55 [0.46 to 0.65], P&lt;0.001). Nevertheless, the crude all-cause mortality rate at 1 year increased from 27.4% in 2000 to 31.5% in 2019, with no significant trend after adjustment for demographics and comorbidities (APC −0.7% [−1.6 to 0.1], P=0.087).

Conclusions

In this large cohort of Asian patients, the incidence of IE remained static and did not change following the revision of antibiotic prophylaxis guidelines. Over time, patients with IE have evolved to be older and more comorbid. Despite an increasing rate of surgical intervention that conferred improved survival, the mortality of IE remained irresistibly high.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Prognostic value of longitudinal assessment of hepatorenal function and nutritional status in patients undergoing valvular heart surgery

Background

Hepatorenal dysfunction and malnutrition are frequent extracardiac consequences of valvular heart disease (VHD) and have emerged as prominent drivers of adverse prognosis in selected valvular interventions. Nonetheless, data in a general VHD population is sparse, and their interaction and changes following valvular surgery remain unexplored.

Purpose

We aim to characterise the temporal changes, interaction, and prognostic implications of hepatorenal dysfunction and malnutrition before and after valvular surgery.

Methods

Baseline and temporal changes in hepatorenal dysfunction (assessed by the modified model for end-stage liver disease [MELD-XI] score) and nutritional status (assessed by Controlling Nutritional Status [CONUT] score) were correlated with adverse events (composite of all-cause mortality and hospitalisation for heart failure) using Cox proportional hazards model, adjusted with clinical and echocardiographic covariates, medications, type of valvular procedure, and cardiac surgery risk-stratification models (EuroSCORE II and STS score).

Results

Our study included 909 patients who underwent valvular surgery. At baseline, 216 (24%) and 554 (61%) had hepatorenal dysfunction (MELD-XI &gt;12.43) and malnutrition (CONUT ≥2), respectively. MELD-XI scores were modestly correlated with CONUT scores (R=0.36, p&lt;0.001), with concomitant hepatorenal dysfunction and malnutrition present in 177 (19%) patients.

Over a median follow-up of 4.1 years, 101 (11%) patients died and 119 (13%) were hospitalised for heart failure. There was a stepwise increase in mortality (χ2 89.1, p&lt;0.001) and adverse events (χ2 92.9, p&lt;0.001) from patients with normal hepatorenal function and nutrition to concomitant hepatorenal dysfunction and malnutrition (Figure 1). This association remained consistent in fully adjusted models. MELD-XI and CONUT scores significantly improved the discriminatory accuracy of EuroSCORE II (area under the curve [AUC]: 0.80 vs 0.73, p&lt;0.001) and STS score (AUC: 0.79 vs 0.72, p=0.004) for all-cause mortality.

In patients with MELD-XI and CONUT scores 1 year after surgery (n=707), ΔMELD-XI (follow-up MELD-XI minus baseline MELD-XI score) and ΔCONUT scores were significantly associated with adverse events (HR 1.08, 95% CI 1.03–1.14, p=0.001 for ΔMELD-XI; HR 1.18, 95% CI 1.02–1.35, p=0.02 for ΔCONUT). Patients remaining with hepatorenal dysfunction and malnutrition experienced worse survival (log-rank χ2 65.2, p&lt;0.001) and adverse events (log-rank χ2 90.4, p&lt;0.001) (Figure 2).

Conclusions

In patients undergoing valvular surgery, hepatorenal function and nutritional status at baseline, and their temporal changes, are strongly linked to clinical outcomes. These results highlight the role of hepatorenal and nutritional assessment for risk-stratification in valvular surgery.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Survival benefits and optimal timing for surgical intervention for infective endocarditis

Background

Surgery is often indicated in patients with infective endocarditis (IE), but the survival benefits of surgical intervention have not been validated in large-scale studies. Although previous studies appeared to support early surgical intervention, the optimal timing of intervention remains uncertain.

Purpose

We aim to evaluate the benefits of surgery and identify the optimal timing of surgical intervention for patients with IE.

Methods

From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. Patients were divided into those who received surgical intervention within 1 year of IE (surgical cohort) and those who did not (control cohort). The two cohorts were then compared using inverse probability weighting of the covariate balancing propensity score, which included demographics, comorbidities, and causative organism as covariates. Outcomes of interest include, at 1 year, all-cause death, and the development of complications. A Cox proportional hazards model was used to evaluate the association between surgical intervention and death, with “doubly-robust estimation” used to minimise the effect of confounders. For complications, a Fine-Gray model was used to account for competing risk.

The surgical cohort was subdivided into early (≤7 days of hospitalisation) or late surgical intervention; a similar propensity score analytic approach was used to evaluate the effects of early vs. late intervention, with those who died within the 7 days excluded to ensure a fair comparison.

Results

A total of 5,657 patients (age 59.9±18.3 years, 37.2% females) were included, of which 930 (16.4%) received surgical intervention in 1 year. Overall, the surgical cohort had a 45% risk reduction in all-cause death (hazard ratio [HR] 0.55, 95% CI [0.46 to 0.65], P&lt;0.001) (Figure). This association remained consistent in subgroup analysis stratified by age, sex, and causative organisms (Table 1).

The surgical cohort also had a lower risk of complications, including acute kidney injury (HR 0.61, 95% CI 0.43 to 0.87, P=0.006), systemic embolism (HR 0.35 [0.23 to 0.55], P&lt;0.001), ischaemic stroke (HR 0.37 [0.24 to 0.55], P&lt;0.001), cardiac dysrhythmia (HR 0.79 [0.66 to 0.95], P=0.011), and pneumonia (HR 0.36 [0.26 to 0.49], P&lt;0.001).

In the surgical cohort, compared to those who had early surgery (N=181), those with delayed surgery had a lower risk of all-cause death (HR 0.58 [0.34 to 0.99], P=0.045) (Figure) and complications (Table 2) at 1 year. In those who had early surgery, patients who received ultra-early surgery (≤3 days of hospitalisation, N=104) did not have a significantly different risk of death (HR 1.19 [0.47 to 3.34], P=0.654).

Conclusions

Surgical intervention significantly reduced the risk of death and complications in patients with infective endocarditis. Delayed surgical intervention appeared to be more protective.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Trends and sex differences in characteristics and outcomes in myocardial infarction: a 20-year analysis

Background

There are considerable sex differences in patients with myocardial infarction (MI). However, the recent temporal trends in characteristics and outcomes in women vs. men, particularly in an Asian population, remain poorly understood.

Purpose

We aim to evaluate the sex differences in characteristics and outcomes, and how have these differences evolved over the past 2 decades in patients with MI.

Methods

From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. Outcomes of interest include, at 30 days, all-cause death, new-onset heart failure (HF), and ischaemic stroke. Trends in sex differences in baseline characteristics were evaluated using linear and Poisson regression, while differences in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications. A Fine-Gray model was used to evaluate HF and ischaemic stroke to account for competing risk, with all-cause death defined as competing event.

Results

A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Women were older (79.5±11.7 vs. 69.6±13.8 years, P&lt;0.001) and had a more pronounced increasing trend in age over time (interaction P&lt;0.001). Women were also more comorbid overall (Charlson Comorbidity Index [CCI] 1.25 vs 0.85, age-adjusted P&lt;0.001), but the rising trend in CCI over time was less pronounced than in men (interaction P&lt;0.001) (Figure 1). Women had more baseline hypertension, diabetes, and severe renal disease than men (age-adjusted P&lt;0.001), while the increasing trends in these comorbidities were all more pronounced in men than in women (all interaction P&lt;0.001). Women were more likely to have ST-elevation overall (P&lt;0.001).

Although the crude 30-day mortality rate was higher in women (32.6% vs 23.9%), after adjustment for confounders, they had a lower risk of death (hazard ratio [HR] 0.97, 95% CI [0.96 to 0.99], P=0.003). There was no significant difference in the decreasing trend in 30-day mortality between both sexes (interaction P=0.787) (Figure 1). Women had a higher risk of developing HF (HR 1.04 [1.01 to 1.08], P=0.012) and ischemic stroke (HR 1.36 [1.24 to 1.48], P&lt;0.001) in 30 days.

Among patients aged ≤55 (N=15,324), women (N=2,161, 14.1%) had higher risks of all-cause death (HR 1.61 [1.40 to 1.85], P&lt;0.001), HF (HR 1.64 [1.17 to 2.32], P=0.004), and ischemic stroke (HR 1.69 [1.14 to 2.51], P=0.010) in 30 days, even after adjustment for covariates. The excess mortality in women declined over time (interaction P=0.002).

Conclusions

Women MI patients were older and more comorbid compared to men, which contributed to the higher risk of death, HF, and ischemic stroke among women. Among young MI patients, the increased risk for adverse outcomes among women was particularly pronounced, though the sex differences in mortality reduced over time.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

[Risk factors of perivalvular leakage after transcatheter aortic valve replacement with Venus-A valve]

Objective: To investigate the risk factors of moderate or severe perivalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) with Veneus-A valve. Methods: This study was a single-center case-control study. The clinical data of patients with severe aortic stenosis, who underwent TAVR in the Department of Cardiology of Second Affiliated Hospital of Army Medical University from October 2017 to January 2021, were analyzed. According to the circumferential extent of prosthetic valve paravalvular regurgitation measured by transthoracic echocardiography before discharge (patients who died in hospital were referred to transesophageal echocardiography results after valve implanted), the patients were divided into moderate or severe PVL group and mild or non-PVL group. The clinical features, CT scan and analysis results of aortic root were compared between the two groups. Multivariate logistic regression analysis was used to identify the independent risk factors of postoperative moderate or severe PVL, and receiver operating characteristic (ROC) curve was used to explore the predictive value of related factors. Results: Eighty-two patients (mean age: (70.9±6.5) years, 46 males) were included in the analysis, there were 16 patients in the moderate or severe PVL group and 66 patients in the mild or non-PVL group. The proportion of male gender, depth of valve implantation, size of valve annulus and left ventricular outflow tract (LVOT), and coverage index of LVOT were significantly higher in moderate or severe PVL group than those in mild or non-PVL group (Pall<0.05). As there was a strong collinearity among the valve annular short diameter, LVOT short diameter and LVOT coverage index (partial correlation coefficient R 0.251-0.779, P<0.05), these parameters were not entered in regression model. Multivariate logistic regression analysis showed that valve implantation depth(OR=1.239,95%CI 1.036-1.442,P=0.023), aortic angulation(OR=1.128, 95%CI 1.044-1.312,P=0.038)and LVOT tract coverage index (OR=1.123, 95%CI1.003-1.315, P=0.032) were independent risk factors for moderate or severe PVL after TAVR. The ROC curve showed that the valve implantation depth could predict the occurrence of moderate or severe PVL after TAVR (area under ROC curve (AUC)=0.697, 95%CI 0.554-0.851, P=0.039). Conclusion: Among patients with severe aortic stenosis who undergo TAVR with Venus-A valve, the implantation depth, aortic angulation and LVOT coverage index are independent risk factors of moderate/severe PVL after TAVR, among which valve implantation depth could be used to predict the occurrence of moderate/severe PVL after TAVR.

US-guided percutaneous microwave ablation (MWA) of submandibular gland: A new minimal invasive and effective treatment for refractory sialorrhea and treatment response evaluation with contrast-enhanced imaging techniques

A 33 years' old male complained of excessive salivation with frequent swallowing and spitting, which resulted in communication disturbance, reduced quality of life, and social embarrassment for 19 years. He had been diagnosed as sialorrhea and submandibular gland hyperfunction by stomatologist, then had unilateral submandibular gland resection 13 years ago, but the symptom relief was not satisfactory. After that, he had been treated with glycopyrrolate for less than a year, which was withdrawn because of the short duration of symptomatic control after each tablet take-in and intolerable side effects. With the wish to receive a new treatment with long term effectiveness, low re-operation risk and normal preserved saliva secretion function, the patient was subject to MWA for the right submandibular gland. After systematic clinical evaluation, US-guided percutaneous MWA was successfully performed with an uneventful post-operative course. The volume of the right submandibular gland and ablated area were measured precisely by an ablation planning software system with automatic volume measurement function based on three-dimensional reconstruction of the pre-operative and post-operative enhanced magnetic resonance imaging (MRI) raw data. Finally, the ablated volume was calculated as 62.2% of the whole right submandibular gland. The patient was discharged 1 day after the operation, with symptoms relieved significantly, the mean value of whole saliva flow rate (SFR) decreased from 11 ml to 7.5 ml per 15 minutes. During the follow up by phone three months after operation, the patient reported that the treatment effect was satisfactory, whereas the SFR value became stable as 7 ml per 15 minutes, drooling frequency and drooling severity (DFDS) score decreased from 6 to 5, drooling impact scale (DIS) score decreased from 43 to 26. US-guided percutaneous MWA of submandibular gland seems to be an alternative, minimal invasive, and effective treatment for refractory sialorrhea.We described a patient with refractory sialorrhea treated successfully with ultrasound (US) guided percutaneous microwave ablation (MWA).

US-guided percutaneous microwave ablation for hyperthyroidism and immediate treatment response evaluation with contrast-enhanced ultrasound

Hyperthyroidism is a common disease mainly manifested by hyperexcitability of multiple systems and hypermetabolism. Currently, antithyroid drugs (ATDs), radioiodine therapy (RIT), and surgery are mainly used in the clinical treatment for primary hyperthyroidism. We reported a case of a 28-year-old female who received a novel treatment for primary hyperthyroidism. This patient had poor control of thyroid function while taking ATD, and her oral Methimazole (MMI) dose varied repeatedly between 20 mg qd and 15 mg qd, failing to maintain a stable status. To minimize the possible complication and to achieve drug reduction or withdrawal, she refused RIT and surgery and showed up in our department. The patient, diagnosed with Graves' disease (GD) and met the surgical indication after systematic clinical evaluation, was subject to ultrasound-guided percutaneous microwave ablation (MWA) of the partial thyroid gland with continuous oral administration of 20 mg qd MMI. The post-ablation condition was stable and the patient was discharged 2 days after the operation. Thyroid ultrasound and serum thyroid function test were examined regularly after ablation and the MMI dosage was gradually reduced according to the results of the biochemical examination. Five weeks after the operation, the patient completely discontinued the medication. Ultrasound-guided percutaneous microwave ablation is minimally invasive, safe, and effective, and has potential to be an alternative treatment besides the 3 classical treatments of hyperthyroidism.

Laparoscopy-guided percutaneous microwave ablation for symptomatic 12.8 cm hepatic hemangioma with low blood loss and short hospital stay post-operation: A case report and literature review

We described a patient with symptomatic giant hepatic hemangioma (GHH) treated with laparoscopic guided percutaneous microwave ablation (MWA). A 58 years' old woman was referred to our hospital who presented with upper abdominal distension and appetite loss for more than 1 year. The medical history included untreated multiple hepatic hemangiomas (HH) that had been detected 13 years ago and hypertension for more than 12 years. Initial laboratory tests revealed D-dimer mild increase and negative tumor markers. Magnetic resonance (MR) imaging demonstrated multiple nodules of different sizes in the liver and the largest lesion was located on the left lobe (longest diameter 12.8 cm), which replaced the whole enlarged left lobe and compressed the gastric body and inferior vena cava. Contrast-enhanced ultrasound (CEUS) and contrast-enhanced MR imaging both showed the typical enhancement pattern of hemangioma and abnormal perfusion was seen in the surrounding liver parenchyma. With the laparoscopy guidance, we performed microwave ablation till the whole tumor was seen atrophy. The total operation duration was 2 hours, with intra-operative blood loss less than 20 ml. The post-operative course was uneventful. The patient was discharged 3 days after the operation. Abdominal distension decreased, appetite improved, blood pressure controlled at normal level after the operation. MR revealed significant volume reduction of the tumor after the operation.

Contrast-enhanced ultrasound evaluation of a refractory ovarian endometrial cyst and ultrasound-guided aspiration sclerotherapy using urokinase and lauromacrogol

Endometriosis is one of the most common diseases that happen in reproductive women. The main symptoms include ovarian endometrial cyst, pelvic pain, and so on. We report a case of a 23-year-old woman with a refractory long-course ovarian endometrial cyst (OEC). The patient was previously identified to have a hypoechoic mass sized 9.7 cm in diameter on ultrasound (US) in the right ovary and was tentatively diagnosed as OEC in another tertiary hospital, who was then subjected to US-guided cyst sclerotherapy while the procedure was failed since only a very small amount of viscous and sticky fluid can be aspirated. The patient was then referred to our hospital for further treatment. Pretreat contrast-enhanced ultrasound (CEUS) showed non-enhancement of the mass with a thin cyst wall and a cyst-in-cyst pattern was observed. The possibility of ovarian malignancy was ruled out and the initial diagnosis of OEC was confirmed. The patient was then subjected to US-guided cyst sclerotherapy with lauromacrogol. The interventional procedure was eventful that no fluid was aspirated as what happened in the previous hospital. Thus urokinase was used to dissolve the old, viscious and sticky blood and finally, all the fluid was aspirated. The total consumption of urokinase was 60,000 U. Then lauromacrogol as a sclerosant was injected into the cyst cavity and the cyst wall was flushed repeatedly with lauromacrogol until the aspirated fluid became light red. Finally, 20 mL lauromacrogol was reserved in the cyst and the interventional procedure cost 2 hours The post-procedure course was uneventful without any discomfort, and the volume reduction rate of the cyst was 54%at 3-month follow-up. The visual analogue scale for the pain decreased from 4 before treatment to 1 after treatment, indicating a successful and effective outcome for the refractory long-course OEC.

[Clinical value of carbon nanoparticles tracer in gastric cancer surgery to increase the number of lymph nodes retrieval]

Objective: To investigate the clinical value of carbon nanoparticles zonal tracer technique in lymph node retrieval of gastric cancer (GC). Methods: A retrospective cohort study was carried out. Clinicopathological data of GC patients who underwent radical D2 resection with carbon nanoparticles tracer in The First Affiliated Hospital of Hainan Medical University and Hainan Cancer Hospital from December 2015 and February 2019 were collected. Those with postoperative pathology of T1-2, Borrmann IV type GC, distant metastasis, preoperative neoadjuvant chemotherapy and incomplete data were excluded. A total of 181 patients were enrolled in this study, including 113 cases from the First Affiliated Hospital of Hainan Medical University and 68 cases from Hainan Cancer Hospital. Patients were categorized into two groups based on the methods of carbon nanoparticles tracer: zonal tracer group and traditional tracer group. In the traditional tracer group, 0.1-0.3 ml of carbon nanoparticle was injected subserously at the upper, lower, left and right 4 injection points 0.5 cm away from the edge of the tumor in the normal serous membrane. In the zonal tracer group, on the basis of the traditional tracer group, 0.1-0.3 ml of carbon nanoparticle was injected subserously at the first branch of the suprapyloric right gastric artery into the stomach, the first branch of the subpyloric right gastroepiploic artery into the stomach, the first branch of the minor curvature left gastric artery into the stomach and the first branch of the greater curvature left gastroepiploic artery into the stomach, respectively. The display of lymphatic vessels in each location and lymph nodes in each group by the tracing method was observed. The number of black-stained lymph nodes, the black staining rate of lymph nodes, the total number of detected lymph nodes, the total number of positive lymph nodes, and the metastatic rate of lymph node were compared between the two groups. Results: Eighty-nine patients were assigned to zonal tracer group, and 92 patients to traditional tracer group. There were no significant differences in baseline information between the two groups (all P>0.05). The median number of black-stained lymph nodes (median: 25.0 vs. 13.5, Z=-7.158, P<0.001) and the black staining rate of lymph nodes [(70.8±12.0)% vs. (47.1±15.7)%, t=11.399, P<0.001) in the zonal tracer group were significantly higher than those in the traditional tracer group. The total detected number of lymph nodes (37.5±11.5 vs. 29.6±11.8, t=4.581, P<0.001) and the total number of negative lymph nodes (31.3±12.5 vs. 24.9±11.1, t=3.621, P<0.001) were significantly higher in the zonal tracer group than those in the traditional tracer group. There were no significant differences in the total number of positive lymph nodes (median: 4.0 vs. 3.0, Z=-1.485, P=0.137), lymph node metastatic rate [78.7% (70/89) vs. 72.8% (67/92), χ(2)=0.834, P=0.361] and metastatic degree [median: 11% vs. 10%, Z=-0.483, P=0.629] between the two groups. Conclusion: The carbon nanoparticles zonal tracer method can increase the black-staining rate of lymph nodes and the detected number of lymph nodes, thus improving the accuracy of gastric cancer staging.

Contrast-enhanced ultrasound-guided thrombin injection in the management of iatrogenic pseudoaneurysm (PSA): A case report and review of literatures

Pseudoaneurysm (PSA) formation is the most common arterial complication of endovascular procedures requiring arterial puncture. The present study reported a case of a 72-year-old male patient with iatrogenic femoral artery PSA treated with contrast-enhanced ultrasound (CEUS)-guided thrombin injection. Conventional ultrasound (US) and CEUS were used to diagnose, guide treatment, and evaluate the treatment efficacy. In the case, the PSA was successfully occluded with 1000 IU of thrombin. During the follow-up after 48 hours of thrombin injection, US found that the PSA had complete thrombosis without arterial supply. No complications occurrence in the course of the treatment. CEUS-guided thrombin injection for the treatment of PSA was effective and safety and the associated literatures were also reviewed.

[Clinical application effect of modified nasopharyngeal swab sampling for 2019 novel coronavirus nucleic acid detection]

Objective: To study the clinical application effect of modified nasopharyngeal swab sampling for 2019 novel coronavirus nucleic acid detection. Methods: This study covered the period from January 14 to March 1, 2020.The supine position method and the protective face screen were used to collect nasopharyngeal swabs from February 24 onwards, before which, the nasopharyngeal swabs were collected by sitting position method. All the patients who were diagnosed with suspected/confirmed 2019 novel coronavirus infection were admitted from February 19 with the nasopharyngeal swabs collected outside the hospital before admission. (1) Thirty-four swabbing operators meeting the inclusion criteria of the study were recruited in this retrospective cohort study. They were grouped according to the collection method of nasopharyngeal swabs. Sixteen operators of Wuhan Taikang Tongji Hospital who applied the supine position method and the protective face screen were included in supine position method+ protective face screen group (15 males and 1 female, aged 34-49 years); 18 operators (12 from the First Affiliated Hospital of Army Medical University (the Third Military Medical University), 1 from Wuhan Jiangxia Mobile Cabin Hospital, 5 from the East District of People's Hospital of Wuhan University) who applied the traditional sitting position method were included in sitting position method group (2 males and 16 females, aged 25-49 years). In supine position method+ protective face screen group, when collecting sample, the patient lay flat and wore a special protective face screen for nasopharyngeal swab sampling, with neck slightly extending and face turning to the opposite side of the operator about 10°. The self-designed questionnaire was used to investigate the cooperation, the incidence of nausea, coughing, sneezing, and struggling of patients evaluated by the operators, the operation time for a single swab sample, the fear of operation and the perceived exposure risk of operators in the two groups. (2) Sixty-five patients (22 males and 43 females, aged 25-91 years) admitted to Wuhan Taikang Tongji Hospital who successively received the sitting position method and supine position method+ protective face screen for nasopharyngeal swabs sampling and with complete nucleic acid detection results were included. The positive rates of nucleic acid detection by the two sampling methods of nasopharyngeal swabs of the patients were statistically analyzed. (3) Forty-one patients who could express their feelings accurately were selected out of those 65 patients (12 males and 29 females, aged 27-83 years). The comfort of patients in the process of sampling by the two methods was investigated. (4) Thirty-four patients (10 males and 24 females, aged 25-83 years) with two or more consecutive negative results of nucleic acid detection of nasopharyngeal swabs by sitting position method were selected from the above 65 patients. The positive rate of nucleic acid detection of nasopharyngeal swab of patients by supine position method+ protective face screen, i. e. negative to positive rate was statistically analyzed. Data were statistically analyzed with t test, Wilcoxon signed rank test, and chi-square test. Results: (1) Compared with those of sitting position method group, the cooperation score of patients evaluated by the operators in supine position method+ protective face screen group was significantly higher (Z=-4.928, P<0.01), the incidence of nausea, choking cough, sneezing, and struggling of patients evaluated by the operators, and the fear of operation score and the perceived exposure risk score of operators in supine position method+ protective face screen group were significantly lower (Z=-5.071, -5.046, -4.095, -4.397, -4.174, -5.049, P<0.01), and the operation time for a single swab sample in supine position method+ protective face screen group was significantly longer (t=223.17, P<0.01). (2) The positive rate of nucleic acid detection of nasopharyngeal swabs by supine position method+ protective face screen was 60.00% (39/65), which was obviously higher than 41.54% (27/65) by sitting position method (χ(2)=4.432, P<0.05). (3) The comfort score of the 41 patients during nasopharyngeal swabs sampling by supine position method+ protective face screen was significantly higher than that by sitting position method (Z=-5.319, P<0.01). (4) Of the 34 patients with two or more consecutive negative results of nucleic acid detection of nasopharyngeal swabs by sitting position method, the rate of negative to positive of nucleic acid detection was 26.47% (9/34) after sampling by supine position method+ protective face screen. Conclusions: Compared with the traditional sitting position method, detection of 2019 novel coronavirus nucleic acids of nasopharyngeal swabs collected by supine method combined with protective face screen is worth promoting, because of its better comfort of patients, low exposure risk for operators, in addition to reducing in the false negative result to some extent, which may help reduce false recurrence of discharged patients.

[Time-series analysis on the relationship between ambient PM2.5 and daily outpatient visits due to allergic conjunctivitis among children in Shenzhen]

Objective: To explore the short-term effects of ambient PM_2.5 on the outpatient visits of allergic conjunctivitis among children in Shenzhen. Methods: It was a ecological study. Data on daily visits including date of visit, sex and age from children with allergic conjunctivitis were collected from Shenzhen Eye Hospital and Shenzhen Children's Hospital in 2018. Related data on air pollution (PM_2.5, PM₁₀, SO₂, NO₂, CO and O₃) and meteorology (atmospheric pressure, temperature and relative humidity) were also collected. Pearson correlation analysis was used for normal distribution data and Spearman rank correlation analysis was used for non-normal distribution data. Generalized additive model was used to estimate the impact of PM_2.5 pollution on allergic conjunctivitis outpatients and the lagging effects. Results: In 2018, there were 16 133 allergic conjunctivitis outpatients in the two hospitals. The maximum age was 18 years and the minimum age was 2 months. Males accounted for 49.3%. The daily average concentration of PM_2.5 was 22 (15, 31) μg/m³. Changes of the concentration of PM_2.5 had a positive correlation with the amount of allergic conjunctivitis visits, and the Spearman correlation coefficient was 0.150 (P=0.004). The single pollutant model showed that the strongest effect appeared at 3 days (RR=1.111， 95%CI:1.071-1.152). A 10 μg/m³ increase of PM_2.5 would result in an excessive number of allergic conjunctivitis outpatients as much as 11.112% (95%CI：7.011%-15.212%). In the multiple air pollutants models, after the introduction of NO₂, O₃ and CO, the concentration of PM_2.5 showed an enhanced effect on the number of hospital visits due to allergic conjunctivitis on the same day, and the difference was statistically significant (P<0.05). Conclusion: Changes of the concentration of PM_{2.5 h}ad a positive correlation with daily outpatient visits of allergic conjunctivitis among children in Shenzhen. (Chin J Ophthalmol, 2020, 56: 608-614).

[Experts consensus for the diagnosis, treatment, and prevention of Coronavirus disease 2019 in the elderly]

Coronavirus disease 2019 (COVID-19) can cause great damage to the elderly patients and lead to high mortality. The clinical presentations and auxiliary examinations of the elderly patients with COVID-19 are atypical, due to the physiological ageing deterioration and basal pathological state. The treatment strategy for the elderly patients has its own characteristics and treatment protocol should be considered accordingly. To improve the diagnosis, treatment, and prevention of COVID-19 in the elderly, the Expert Committee of Geriatric Respiratory and Critical Care Medicine, China Society of Geriatrics established the "Expert consensus for the diagnosis, treatment, and prevention of Coronavirus disease 2019 in the elderly" . We focused on the clinical characteristics and key points for better treatment and prevention of COVID-19 in the elderly. (1) For diagnosis, atypical clinical presentation of COVID-19 in the elderly should be emphasized, which may be complicated by underlying disease. (2) For treatment, strategy of multiple disciplinary team (mainly the respiratory and critical care medicine) should be adopted and multiple systemic functions should be considered. (3) For prevention, health care model about integrated management of acute and chronic diseases, in and out of hospital should be applied.

[Electrophysiological features of patients with subacute combined degeneration]

Objective: To investigate the electrophysiological features of patients with subacute combined degeneration (SCD). Methods: The electrophysiological data of 85 hospitalized patients in Department of Neurology, First Medical Centre, Chinese PLA General Hospital from January 2014 to September 2018 were retrospectively analyzed. Results: Abnormality rate of motor nerve conduction (27.4%(93/339)) was lower than that of sensory nerve conduction (45.9%(107/233)) (P<0.001). Abnormality of sensory nerve action potential amplitude was more frequent than conduction velocity abnormality (22.7%(53/233) vs 4.7%(11/233), P=0.001). Abnormality rate of needle electromyogram (EMG) was higher in lower limbs than upper limbs (31.9%(59/185) vs 5.7%(5/87), P<0.001). Spontaneous potentials were unrelated to disease duration or severity. Abnormal somatosensory evoked potential (SEP) results appeared more frequent in lower limbs (80.8%(118/146)) than upper limbs (61.1%(77/126)) (P<0.001). SEP abnormalities (71.7%(195/272)) were more common than nerve conduction abnormalities (35.0%(200/572)). Abnormal findings presented in 15/16 of visual evoked potential (VEP) studies. Neurological severity score were correlated with electrophysiological findings. Conclusions: Posterior funiculus is more likely to be affected than peripheral nerves in SCD patients. The sensory nerves rather than motor nerves, lower limbs rather than upper limbs, axons of sensory nerves rather than myelin, are more severely affected. Electrophysiological tests can provide evidence in early diagnosis, lesions location, and disease severity evaluation for SCD.

[Relationship of body mass index, waist circumference and waist-to-hip ratio with diabetes mellitus in community residents aged 15 years old and above in Pudong new district, Shanghai]

Objective: To analyze the relationship of body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) with diabetes mellitus in community residents aged ≥15 years in Pudong new district of Shanghai, and provide evidence for the prevention and treatment of diabetes mellitus. Methods: Using multi-stage stratified cluster sampling method, a total of 7 194 community residents aged ≥15 years were surveyed by using questionnaire, physical examination and laboratory tests in 2016. The relationship of BMI, waist circumference and waist-hip ratio with diabetes mellitus was analyzed by χ(2) test, single factor linear correlation and logistic regression analyses. Results: In 2016, the crude prevalence rate of diabetes mellitus in Pudong was 27.37%, which was 12.75% after standardization. The prevalence rate of diabetes mellitus was slightly higher in men than in women and was increased with age. The levels of FPG, 2 h plasma glucose and HbA1c were positively correlated with BMI, WC and WHR. After adjusting the confounding factors, multiple logistic regression analysis showed that obesity (OR=1.351, P<0.01), excessive waist circumference (OR=1.255, P<0.01) and high WHR (OR=1.291, P<0.01) were risk factors for diabetes mellitus. Conclusions: The increase of obesity, WC and WHR will increase the risk for diabetes mellitus. It is important to maintain healthy weight, especially the control of WC and WHR, reduce the accumulation of abdominal fat to reduce the risk for diabetes mellitus.

Efficacy and safety of CT-P6 versus reference trastuzumab in HER2-positive early breast cancer: updated results of a randomised phase 3 trial

PURPOSE

Neoadjuvant CT-P6, a trastuzumab biosimilar, demonstrated equivalent efficacy to reference trastuzumab in a phase 3 trial of HER2-positive early-stage breast cancer (EBC) (NCT02162667). We report post hoc analyses evaluating pathological complete response (pCR) and breast pCR alongside additional efficacy and safety measures.

METHODS

Following neoadjuvant treatment and surgery, patients received adjuvant CT-P6 or trastuzumab (6 mg/kg) every 3 weeks for ≤ 1 year.

RESULTS

In total, 271 and 278 patients received CT-P6 and trastuzumab, respectively. pCR and breast pCR rates were comparable between treatment groups regardless of age, region, or clinical stage. Overall, 47.6% (CT-P6) and 52.2% (trastuzumab) of patients experienced study drug-related treatment-emergent adverse events (TEAEs), including 17 patients reporting heart failure (CT-P6: 10; trastuzumab: 7). Two CT-P6 and three trastuzumab patients discontinued adjuvant treatment due to TEAEs.

CONCLUSION

Adjuvant CT-P6 demonstrated comparable efficacy and safety to trastuzumab at 1 year in patients with HER2-positive EBC, supporting CT-P6 and trastuzumab comparability.

Artificial intelligence in medical imaging of the liver

Artificial intelligence (AI), particularly deep learning algorithms, is gaining extensive attention for its excellent performance in image-recognition tasks. They can automatically make a quantitative assessment of complex medical image characteristics and achieve an increased accuracy for diagnosis with higher efficiency. AI is widely used and getting increasingly popular in the medical imaging of the liver, including radiology, ultrasound, and nuclear medicine. AI can assist physicians to make more accurate and reproductive imaging diagnosis and also reduce the physicians’ workload. This article illustrates basic technical knowledge about AI, including traditional machine learning and deep learning algorithms, especially convolutional neural networks, and their clinical application in the medical imaging of liver diseases, such as detecting and evaluating focal liver lesions, facilitating treatment, and predicting liver treatment response. We conclude that machine-assisted medical services will be a promising solution for future liver medical care. Lastly, we discuss the challenges and future directions of clinical application of deep learning techniques.

[Efficacy and safety of catheter-directed interventional therapy in patients with acute pulmonary embolism]

Objective: To evaluate the efficacy and safety of catheter-directed interventional therapy in patients with acute pulmonary embolism(PE). Methods: PE was diagnosed by CT pulmonary angiography(CTPA). After risk stratification, a total of 79 PE patients (age (58.9±14.9) years old)were treated with catheter-directed interventional therapy via pulmonary vessels. The changes of pulmonary hemodynamics were compared before and after treatment. The risk of complications and side effects were observed. Results: The pulmonary artery pressure was changed followed by interventional therapy. The interventional therapy significantly decreased mean pulmonary arterial pressure (mPAP) from (35.3±11.2)mmHg (1 mmHg=0.133 kPa) to (30.0±10.6)mmHg (t=8.803,P<0.05) and the echocardiographic derived right ventricular dimension to left ventricular dimension (RV/LV) ratio from 0.93±0.16 to 0.83±0.15 (t=6.868,P<0.05). The arterial partial pressure of oxygen was increased from (69.0±8.6)mmHg to (75.1±9.9)mmHg (t=8.561,P<0.05) . The oxygen saturation was also increased from (93.9±2.9)% to (95.1±1.9)% at 24 h after the treatment (t=2.621,P<0.05) . Patients were further grouped as high-risk group (n=28) and intermediate risk group (n=51). mPAP and RV/LV ratio were significantly reduced in the two subgroups (all P<0.05) and the range of reduction was more significant in the high-risk group. Five patients experienced minor bleeding complication, 3 patients suffered worsened dispone post procedure and were treated with mechanical ventilation, 1 patient died, and 1 patient developed recurrent PE. Conclusion: The catheter-directed interventional therapy improves pulmonary hemodynamics and reduces load of right ventricle both in high-risk or intermediate risk PE patients, this therapy strategy is safe and effective for patients with PE.

Effectiveness of ultrasound-guided percutaneous microwave ablation for symptomatic uterine fibroids: a multicentre study in China

PURPOSE

To evaluate the clinical efficacy of ultrasound-guided percutaneous microwave ablation (PMWA) therapy for symptomatic uterine fibroids in a multicentre study.

MATERIALS AND METHODS

Patients with symptomatic uterine fibroids who underwent PMWA at multiple treatment centres in China between January 2013 and August 2015 were prospectively studied to compare the reduction rate of uterine fibroids, haemoglobin level and uterine fibroid symptom and health-related quality of life questionnaire (UFS-QOL) scores before and at 3, 6 and 12 months after ablation.

RESULTS

A total of 311 patients (405 leiomyomas) from eight treatment centres underwent the treatment (age, 29-55 years; mean ± SD, 41 ± 5.11 years). The mean diameter of the myomas ranged from 2.03 to 12.50 cm (mean, 5.10 ± 1.28 cm) and the volume ranged from 4.40 to 1022.14 cm³ (mean, 95.01 ± 70.29 cm³). Forty-eight myomas were identified as FIGO type 1/2 fibroids, 256 as type 3/4 fibroids and 101 as type 5/6 fibroids. The mean ablation rate was 86.6% (54.0-100%). The mean reduction rate was 63.5%, 78.5% and 86.7% at 3, 6 and 12 months posttreatment, respectively. The haemoglobin level increased significantly from 88.84 ± 9.31 g/L before treatment to 107.14 ± 13.32, 116.05 ± 7.66 and 117.79 ± 6.51 g/L at 3, 6 and 12 months posttreatment, respectively (p = .000). The symptom severity score (SSS) and health-related quality of life (HRQL) scores were also significantly improved posttreatment compared with before treatment (p = .000).

CONCLUSION

PMWA is an effective, minimally invasive treatment for symptomatic leiomyomas that can significantly improve the quality of life of patients.