Synergistic Inhibitory Effect of Lactobacillus Cell Lysates and Butyrate on Poly I:C-Induced IL-8 Production in Human Intestinal Epithelial Cells

Postbiotics include cell lysates (CLs), enzymes, cell wall fragments, and heat-killed bacteria derived from probiotics. Although postbiotics are increasingly being considered for their potential health-promoting properties, the effects of postbiotics on virus-mediated inflammatory responses in the intestine have not been elucidated. Hence, the present study aimed to examine whether CLs of Lactipantibacillus plantarum (LP CL) and Lacticaseibacillus rhamnosus GG (LR CL) could inhibit virus-mediated inflammatory responses in the human intestinal epithelial cell line HT-29 in vitro. Pretreatment with LP CL and LR CL significantly inhibited interleukin (IL)-8 production, which was induced by poly I:C, a synthetic analog of double-stranded RNA (dsRNA) viruses, at the mRNA and protein levels in HT-29 cells. However, peptidoglycans and heat-killed L. plantarum and L. rhamnosus GG did not effectively inhibit IL-8 production. LP CL and LR CL attenuated the poly I:C-induced phosphorylation of ERK and JNK and the activation of NF-κB, suggesting that these CLs could inhibit poly I:C-induced IL-8 production by regulating intracellular signaling pathways in HT-29 cells. Furthermore, among the short-chain fatty acids, butyrate enhanced the inhibitory effect of CLs on poly I:C-induced IL-8 production at the mRNA and protein levels in HT-29 cells, while acetate and propionate did not. Taken together, these results suggest that both LP CL and LR CL could act as potent effector molecules that can inhibit virus-mediated inflammatory responses and confer synergistic inhibitory effects with butyrate in human intestinal epithelial cells.

Pattern of pericardial calcification determines the mid-term postoperative outcome after pericardiectomy in chronic constrictive pericarditis

Background/Introduction

Although pericardiectomy is an effective treatment of constrictive pericarditis (CP), clinical outcome is not always successful. Pericardial calcification is a unique finding in CP. However, the amount and localization of calcification vary. Computer tomography (CT) can visualize the pericardial calcification with high sensitivity and provide the anatomical assessment.

Purpose

We investigated that how the pattern and amount of pericardial calcification affect the mid-term postoperative outcome after pericardiectomy in CP.

Methods

All of the patients who underwent total pericardiectomy in our hospital from 2010 to 2020 were derived from electrical medical records (n=105). Among them, preoperative CT scans (non-gated non-contrast) of 98 patients were available and, thus, 98 consecutive patients were finally analyzed. Medical records were reviewed in a retrospective manner. Cardiovascular event is defined as cardiovascular death or hospitalization associated with a heart failure symptom and all cause event is defined as all events that require admission. CT scan was analyzed by Aquarius Workstation, and the volume and localization pattern of pericalcification were derived. Pericardium calcium score was given as an Agatston score.

Results

Of 98 patients, 25 (25.5%) patients were hospitalized with heart failure symptom after pericardiectomy. Median follow up duration of patients is 172 weeks. A group with cardiovascular event had higher NYHA grade (P<0.001), lower calcium volume (P=0.004), and lower calcium score (P=0.01). Multivariate cox proportional analysis showed that high ln(calcium score) before pericardiectomy was dependent predictor of cardiovascular event (hazard ratio, 0.90; P=0.04) and all cause event (hazard ratio, 0.91, P=0.04) after pericardiectomy. When we set the cut off value at 7.22, based on ROC curve, there was a significant difference in cardiovascular event between the groups divided by this cutoff value in Kaplan-Meier curve (P=0.002) and multivariate cox proportional analysis (P=0.04). In the subgroup analysis, myocardium invasion and circumferential calcification were more common in the high calcium score group. Idiopathic & tuberculosis pericarditis were more associated with high calcium score group and post-operative pericarditis, other reasons (infection, radiation, etc) were more associated with low calcium group.

Conclusion

Low burden of pericardial calcification was associated high rate of mid-term clinical event after pericardiectomy CP. Preoperative evaluation of pericardial calcification pattern can be used as predictor of postoperative outcomes.

Funding Acknowledgement

Type of funding sources: None.

PCSK9 modulates the Wnt/beta-catenin signaling pathway in myocardial ischemia/reperfusion injury

Background

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a protein that affects cholesterol homeostasis. Recent research has found that PCSK9 has various effects on the heart that are unrelated to LDL cholesterol regulation. The Wnt/β-catenin signaling pathway plays a crucial role during heart development, and it is re-activated in response to cardiac injury. Low-density lipoprotein receptor-related proteins 5 (LRP5) act as co-receptors of Wnt ligands and are indispensable for Wnt/β-catenin signal transduction. However, it is not fully elucidated whether other members of the LDLR-superfamily may be targets of PCSK9.

Purpose

This study aimed to determine if LRP5 is a PCSK9 target, study the association between PCSK9 and Wnt/β-catenin signaling, and elucidate its effect on myocardial infarction in patients with ischemic cardiomyopathy.

Methods

The expression of Lrp5, phospho-β-catenin, total β-catenin was evaluated by western blot analysis, and the effects of overexpressed PCSK9 were tested under normoxia, hypoxia, or hypoxia/re-oxygenation (H/R) in mouse cardiomyocytes (HL-1). The transcriptional activity of β-catenin was assessed using the TOP-Flash/FOP-Flash luciferase reporter assay. In addition, the impact on various downstream targets of the Wnt/β-catenin signaling pathway was assessed using a quantitative real-time polymerase chain reaction. To examine whether PCSK9 regulates injury of cardiomyocytes in vivo, we subjected transgenic mice with cardiac-specific overexpression of PCSK9 (PCSK9 TG) and wild-type (WT) mice to either sham surgery or ischemia/reperfusion (I/R) surgery.

Results

Under hypoxic conditions, the Wnt/β-catenin signaling pathway-related genes were downregulated in HL-1 cells, as evidenced by lower Lrp5 and active phospho-β-catenin expression levels (0.5-fold, n=3, p<0.01). After H/R, the Wnt/β-catenin-related genes were recovered (1.5-fold, p<0.01) in the control group but not in the PCSK9 overexpressed group. In the luciferase reporter assay results, PCSK9 overexpression inhibited the recovery of β-catenin transcriptional activity after H/R, in contrast to the control group. Furthermore, mRNA levels of Axin2, Cyclin D1, which are the Wnt/β-catenin signaling downstream pathway targets, were down-regulated under hypoxia and recovered after H/R but did not recover in PCSK9 overexpressed cells. In the mouse I/R model, the overall protein levels of the Wnt/β-catenin signaling-related genes were down-regulated in PCSK9 TG mice compared to WT mice after I/R injury.

Conclusions

These results indicated that the regulation of PCSK9 is closely associated with the Wnt/β-catenin signaling pathway which may play a crucial role in damaged cardiomyocytes. It suggests that the regulation of PCSK9 could be a therapeutic target in patients with ischemic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.

Intravascular ultrasound-guided optimization for chronic total occlusion-percutaneous coronary intervention with multiple drug-eluting stents

Background

Multiple stenting in the chronic total occlusion (CTO) lesions is frequently required, however associated with poorer clinical outcomes. It is demonstrated that intravascular ultrasound (IVUS)-guided CTO-percutaneous coronary intervention (PCI) is related to a lower risk of adverse clinical events.

Purpose

We aimed to evaluate the clinical impact of stent optimization under IVUS guidance for multiple stenting, comparing with single stenting.

Methods

A total of 916 patients receiving drug-eluting stent (DES) under IVUS guidance were classified into two groups (stent optimization and non-optimization) according to optimization criteria (an absolute expansion criteria; minimal stent area ≥4.9 mm2 and a relative expansion criteria; 80% of mean reference lumen area). Of total population, 314 patients (34.3%) were treated with single stent and 575 patients (62.7%) were treated with multiple stents, respectively. Ischemic-driven target-lesion revascularization (TLR)/reocclusion was evaluated.

Results

Under IVUS guidance, 316 patients (34.5%) met IVUS criteria for stent optimization The achieving rates were 53% in the single stent group and 24% in the multiple stents group, respectively, (p<0.001). During a median of 4.7 years, the multiple stent group showed a significantly higher TLR/reocclusion rate, compared with the single stent group (12.8% vs. 5.2%, adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.20–5.25, p=0.01). (Figure 1) Meeting both the absolute and relative expansion criteria was associated with a significantly low rate of TLR/reocclusion rate (12.5% vs. 5.2%, adjusted HR 0.34, 95% CI: 0.15–0.79, p=0.01). Under IVUS-guidance, there was no significant difference between multiple stenting and single stenting in case of achieving the optimization criteria (6.5% vs. 4.2%, p=0.11), whereas non-optimization group in the patients with multiple stenting showed a significantly higher rate of TLR/reocclusion, compared with IVUS-optimization group in the patients with single stenting (14.5% vs. 4.2%, p=0.002). (Figure 2)

Conclusions

In CTO-PCI with DES, multiple stenting significantly increased the risk of TLR/reocclusion. IVUS-guided optimization for multiple stenting showed a comparable long-term risk of TLR/reocclusion to single stenting with IVUS optimization. Hence, achieving IVUS expansion criteria may help to reduce the risk of TLR/reocclusion in CTO-PCI with multiple DES overlapping.

Funding Acknowledgement

Type of funding sources: None.

Risk calculator to predict 30-day mortality in left-sided infective endocarditis. The EURO-ENDO score

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, despite improvements in therapeutic strategies. Nonetheless, there is no prospective risk model to estimate IE mortality.

Purpose

We sought to develop and validate a calculator to predict 30-day mortality risk regarding to perform surgery or medical treatment alone in left-sided IE.

Methods

This is a prospective, multicenter registry that included patients between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Patients with possible or definite left-sided IE were included in the analyses. Clinical, biological, microbiological and imaging data were collected. The primary end point was 30-day mortality in patients with left-sided IE. The risk calculator was based on multivariable Cox regression models. The accuracy of the logistic regression models was assessed by discrimination and calibration using C-statistic and Hosmer-Lemeshow test.

Results

Among 3116 patients included, 2171 patients presented left-sided IE and 257 patients (11.8%) died during the first 30 days of IE diagnosis. After multivariable Logistic regression analysis, eleven variables were associated with 30-days mortality and were included in the calculator: previous cardiac surgery, previous stroke/TIA, creatinine >2 mg/dL, S. aureus infection, embolic events on admission, heart failure or cardiogenic shock, vegetation size >14 mm, presence of abscess, severe regurgitation, double left-sided IE and no left valve surgery. There was an excellent correlation between the predicted 30-days mortality in both models with or without performing left valve surgery (area under the receiver operator curve: 0.798 and 0.758, respectively). Moreover, calibration by Hosmer-Lemeshow were 0.085 and 0.09, respectively).

Conclusion(s)

Our risk score in patients with left-sided IE provides an accurate individualized estimation of 30-day mortality according to perform or not perform left-valve surgery. It allows medical professionals to determine whether submitting patients to surgery or not, and thus improve their prognosis.

Funding Acknowledgement

Type of funding sources: None.

Role of combined exercise stress echocardiography and cardiopulmonary exercise test in chronic thromboembolic disease

Background

Chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension could cause significant exercise limitations. However, interventional or surgical treatments for CTEPD with mild pulmonary hypertension or normal pressure are on controversy.

Purpose

We aimed to evaluate cardiopulmonary function through cardiopulmonary exercise test (CPET) with stress echocardiography and to determine whether exercise pulmonary hypertension can explain exercise limitations in CTEPD patients with mPAP <30mmHg.

Methods

Patients diagnosed as CTEPD with mPAP less than 30mmHg was derived from our pulmonary hypertension center registry from April 2014 to October 2021.Transthoracic echocardiography (TTE) was performed at baseline (resting state) and immediately after CPET. TTE derived parameters and CPET parameters were compared with hemodynamic parameters measured by right catheterization.

Results

Total 37 patients were enrolled. Of these, Thirty-five patients had previously been diagnosed with CTEPH and had undergone PEA, BPA, or both. Most of the patients complained dyspnea of WHO functional class II or III. Pulmonary vascular resistance (PVR) was slightly higher than normal (185.0±102.2 dyne sec cm–5). Also VO2max was decreased in CPET (23.1±6.5 mL/kg/min). In correlation analysis, the higher the mPAP and PVR at rest, the lower VO2max during exercise. Meanwhile basal right ventricular (RV) function was normal, an increase in RVSP was notably observed during exercise (RVSP: pre-exercise 36.2±11.9, post-exercise 60.7±19.3, p value <0.001). Furthermore RV function deteriorated during exercise (TAPSE: pre-exercise 16.1±4.8, post-exercise 12.9±5.0, p value <0.001).

Conclusions

CTEPD patients with mild or normal PAP showed limited exercise capacity with exercise induced hypertension. Even in the mPAP less than 30mmHg, PVR and mPAP was significantly associated with exercise capacity. CPET with stress echocardiography could help to identify the main cause of exercise limitation in CTEPD patients and possibly provide the guideline for treatment plan.

Funding Acknowledgement

Type of funding sources: None.

Niemann-Pick Disease Type C Diagnosed Using Neonatal Cholestasis Gene Panel

Niemann-Pick disease type C (NPC) is a neurovisceral lysosomal storage disorder caused by mutations in the NPC1 and NPC2 genes. These mutations cause the accumulation of unesterified cholesterol and other lipids in the lysosomes. NPC has a broad spectrum of clinical manifestations, depending on the age of onset. A 15-day-old infant presented at the Seoul National University Children's Hospital with neonatal cholestasis and hepatosplenomegaly, with the onset of jaundice at 5 days of age. Despite supportive treatment, the patient was considered for a liver transplant because of progressive liver failure. Unfortunately, the patient died from gastrointestinal bleeding before undergoing the transplant. The neonatal cholestasis gene panel revealed two novel likely pathogenic variants in the NPC1 gene (c.1145C>G [p.Ser382*] and c.2231_2233del [p.Val744del]). The patient was diagnosed with NPC, and both parents were found to be carriers of each variant. In infants presenting with neonatal cholestasis, a gene panel can help diagnose NPC.

Predictors of mortality in patients with left-side infective endocarditis, the ESC-EORP EURO-ENDO registry

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, ranging from 16% to 25%, despite improvement in diagnostic and therapeutic strategies, mainly due to complications and heterogeneity of the disease. Baseline risk stratification is essential, in order to focus an aggressive management toward high-risk patients.

Purpose

We sought to assess the association between surgery and 30-day mortality rate as related to vegetation size.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicentre observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Multivariable logistic regression analysis was performed to assess variables associated with 30-day mortality. Besides, univariable analysis was performed to assess best vegetation size cut-off related to 30-day mortality.

Results

Among 2171 patients with left-side IE, 257 patients (11.8%) died during the first 30 days of IE diagnosis. Patient characteristics and univariable analysis are summarized in TABLE 1. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >14mm, with a HR =2.00 (95% CI 1.59–2.51, p<0.0001) and a Harrell's Concordance of 0.58. After multivariable logistic regression analysis, factors associated with 30-day mortality risk were: vegetation size >14mm (OR =2.68, 95% CI [1.96–3.67], p<0.0001), previous stroke or transient ischemic attack (TIA) (OR =1.60, 95% CI [1.07–2.40], p=0.0235), creatinine >2mg/dL (OR =2.45, 95% CI [1.73–3.47], p<0.0001), presence of embolic events (OR =2.64, 95% CI [1.86–3.74], p<0.0001), hemorrhagic stroke (OR=3.71, 95% CI [1.80–7.64], p=0.0004), presence of heart failure or cardiogenic shock (OR =3.50, 95% CI [2.57–4.77], p<0.0001) and no cardiac surgery during the event (OR =4.07, 95% CI [2.93–5.67], p<0.0001). The C-statistic of the logistic model to predict 30-day mortality was 0.795.

Conclusion

Left-side infective endocarditis had a high 30-day mortality rate (11.8%). Presence of a large vegetation size (>14mm), embolic events, hemorrhagic stroke, renal failure, presence of heart failure or cardiogenic shock were associated with an increase in 30-day mortality. Performing cardiac surgery had a protective effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC-EORP EURO-ENDO project from the ESC society

Predictors of mortality in patients with right-side and cardiac device-related infective endocarditis, the esc-eorp euro-endo registry

Background/Introduction

Mortality in right-sided infective endocarditis (RSIE) and cardiac device-related IE (CDRIE) rates have increased mainly due derived complications and heterogeneity of the disease. A better understanding of associated risk factors to mortality in these entities are required in order to develop an efficient therapy.

Purpose

The aim of this study was to assess 30-day mortality rate and variables associated in RSIE and CDRIE.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicenter observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Univariable analysis was performed to assess variables associated with 30-day mortality.

Results

Among 269 patients with RSIE, 24 patients (9.8%) died during the first 30-day of IE diagnosis. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >19mm, with a HR = 2.88 (95% CI 1.26–6.58, p=0.01) and a Harrell's Concordance of 0.632. Factors associated with 30-days mortality by univariable analysis were: vegetation size >19mm (OR = 2.99, 95% CI [1.31–6.84], p=0.009), previous stroke or transient ischemic attack (OR = 5.10, 95% CI [1.19–21.88], p=0.029), HIV infection (OR = 3.52, 95% CI [1.03–12.10], p=0.046), chronic renal failure (OR = 2.66, 95% CI [1.06–6.71], p=0.038), congestive heart failure at admission (OR = 2.34, 95% CI [1.00–5.47], p=0.050) and severe regurgitation (OR = 3.77, 95% CI [1.56–9.09], p=0.003).

On the other side, among the 227 patients with CDRIE, 24 patients (8.8%) died during the first 30-day of IE diagnosis. Factors associated with an increase in 30-day mortality by univariate analysis were: age per 10 years (OR = 1.49, 95% CI [1.02–2.18], p=0.039), heart failure history (OR = 3.88, 95% CI [1.39–10.80], p=0.009), congestive heart failure on admission (OR = 5.80, 95% CI [2.31–14.55], p<0.001) and cardiogenic shock on admission (OR = 13.37, 95% CI [3.75–47.64], p<0.001). An increase in left ventricular ejection fraction (LVEF) per 10% was a protective factor (OR = 0.66, 95% CI [0.49–0.90], p=0.008).

Conclusions

Patients with RSIE and CDRIE had a not negligible 30-day mortality rate (9.8% and 8.8%, respectively). Factors associated with RSIE and CDRIE mortality are different; while in the right side location, the mortality was related with vegetation size and comorbidities, in the case of CDRIE, the mortality was mainly associated to the presence of heart failure.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Euro-Endo registry by European Society of Cardiology

Bacteriocin-Like Inhibitory Substance (BLIS) Activity of Enterococcus faecium DB1 Against Biofilm Formation by Clostridium perfringens

The antibiofilm effect of bacteriocin-like inhibitory substance (BLIS) from Enterococcus faecium DB1 against Clostridium perfringens was investigated in the present study. BLIS of E. faecium DB1 significantly reduced biofilm formation by C. perfringens in a dose-dependent manner for 24 and 48 h. In particular, treatment with BLIS of E. faecium DB1 significantly inhibited biofilm formation by C. perfringens on chicken meat and stainless steel coupon surfaces. Moreover, BLIS of E. faecium DB1 decreased the viability of C. perfringens biofilm and planktonic cells, indicating that the reduction of biofilm formation by C. perfringens might be achieved by killing the bacterial cells. Taken together, the present results suggest that BLIS of E. faecium DB1 can be a promising antibiofilm agent to eradicate C. perfringens.

Risk factors for the delayed diagnosis of extrapulmonary TB

BACKGROUND: Extrapulmonary TB (EPTB) is more difficult to diagnose than pulmonary TB. The delayed management of EPTB can lead to complications and increase the socio-economic burden.METHODS: Patients newly diagnosed with EPTB were retrospectively enrolled from 11 general hospitals in South Korea from January 2017 to December 2018. The basic characteristics of patients were described. Univariable and multivariable analyses were performed between early and delayed diagnosis groups to identify risk factors for delayed diagnosis and treatment in EPTB.RESULTS: In total, 594 patients were enrolled. Lymph node TB (28.3%) was the predominant form, followed by abdominal (18.4%) and disseminated TB (14.5%). Concurrent lung involvement was 17.8%. The positivity of diagnostic tests showed no significant difference between the two groups. Acute clinical manifestations in disseminated, pericardial and meningeal TB, and immunosuppression were associated with early diagnosis. Delayed diagnosis was associated with outpatient clinic visits, delayed sample acquisition and diagnostic departments other than infection or pulmonology.CONCLUSION: The delay in diagnosis and treatment of EPTB was not related to differences in microbiological characteristics of Mycobacterium tuberculosis itself; rather, it was due to the indolent clinical manifestations that cause referral to non-TB-specialised departments in the outpatient clinic and delay the suspicion of TB and diagnostic testing.

Clinical features and prognosis of patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease

<sec> <title>BACKGROUND</title> Idiopathic pulmonary fibrosis (IPF) and chronic obstructive pulmonary disease (COPD) share common risk factors. They could therefore be expressed in a single patient. However, the prevalence, clinical characteristics and prognosis of individuals with comorbid IPF and COPD are not known. </sec> <sec> <title>METHOD</title> From 2003 to 2007, the Korean Interstitial Lung Disease Study Group created a register for idiopathic interstitial pneumonia using 2002 ATS/ERS (American Thoracic Society/European Respiratory Society) criteria. Of the 1546 IPF patients assessed, 143 had decreased lung function consistent with COPD (IPF-COPD). COPD was diagnosed based on age (≥40 years) and pulmonary function (forced expiratory volume in 1 sec [FEV₁]/forced vital capacity [FVC] ratio < 0.7). </sec> <sec> <title>RESULTS</title> The median age of the IPF-COPD group was 71.0 years (interquartile range 66.0-76.0); most patients were male (88.1%). FVC (%) was significantly higher in the IPF-COPD group; however, FEV₁ (%) was significantly lower in the IPF-COPD group (P < 0.001). Diffusing capacity of the lung for carbon monoxide (DL_CO) was not significantly different between the two groups. In survival analysis, age and FVC (%), but not COPD, were significantly associated with prognosis (respectively P = 0.003, 0.001 and 0.401). COPD severity was also not related to prognosis (P = 0.935). </sec> <sec> <title>CONCLUSION</title> The prevalence of IPF-COPD was estimated to be ∼9.2% among all IPF patients; prognosis of patients with IPF-COPD was not worse than those with IPF alone. </sec>.

P914 Changes of echocardiographic parameters in primary mitral regurgitation and determinants of symptom: an assessment from the Asian valve registry data

[Background]Clinicians often have a difficulty in determining the presence of mitral regurgitation (MR)-relatedsymptoms because of subjectivity.However, there are few actual measurement data for echocardiographic left ventricular (LV) and left atrial (LA) size related to the severity of MR and the relationship between MR-related symptoms and these echocardiographic parameters.

[Purpose] The purpose of this study was to clarify actual values for echocardiographic parameters related to severity of MR and determinant factors of MR-related symptoms.

[Methods] Among patients enrolled in the Asian Valve Registry, we investigated 778 consecutive patients with primary MR showing sinus rhythm. Symptoms were determined by NYHA (≤ II or ≥ III).

[Results]MR severity was mild in 106, moderate in 285, and severe in 387 patients. LA volume index, LV end-diastolic diameter, and LV mass index increased with increasing MR grade [LA volume index: 47.9 (mild), 56.2 (moderate), and 64.9 ml/m2(severe) (p &lt; 0.001), LV end-diastolic diameter: 51.2, 54.5, 58.1 mm (p &lt; 0.001), and LV mass index: 101, 109, 123 g/m2(p &lt; 0.001)]. Regarding moderate and severe MR, 70 patients (10.4%) were symptomatic. Table shows multivariable analysis for being symptomatic in moderate and severe MR patients. LV mass index (p = 0.040), ejection fraction (p &lt; 0.001), female gender (p = 0.004), and heart rate (p = 0.007) were independent factors for MR-related symptoms.

[Conclusions] LV and LA parameters on echocardiography worsened as MR severity progressed. Larger LV mass index and lower ejection fraction were independent determinant factors for MR-related symptoms. We should also pay attention to LV hypertrophy in patients with primary MR.

Determinant factors for mitral regurgita Model 1 Model 2 OR (95% CI) P-value OR (95% CI) P-value Age, per 1-y increment 1.03 (1.00-1.05) 0.035 1.02 (0.99-1.05) 0.053 Sex (female) 2.23 (1.20-4.16) 0.011 2.28 (1.31-3.98) 0.004 Hear rate, per 1 bpm increment 1.03 (1.00-1.05) 0.025 1.03 (1.01-1.05) 0.007 LVDs index, per 1 mm increment 0.99 (0.90-1.09) 0.90 EF, per 1% increment 0.95 (0.92-0.99) 0.019 0.96 (0.93-0.98) &lt;0.001 LV mass index, per 10 g/m2increment 1.12 (1.01-1.25) 0.033 1.09 (1.005-1.18) 0.040 LA volume index, per 10 mL/m2increment 0.96 (0.90-1.03) 0.23 E wave, per 1cm/s increment 1.81 (0.70-4.66) 0.23 TR pressure gradient &gt;40 mmHg 2.11 (0.97-4.57) 0.057 Hypertention 1.40 (0.75-2.63) 0.29

P5279Pericardial inflammation basced on cardiac magnetic resonance imaging in patients with tuberculous pericarditis

Background

While constrictive pericarditis has been traditionally considered a disabling disease, reversible constrictive pericarditis has been described in previous studies. But there are limited studies on cardiac imaging of tuberculous pericarditis. In particular, no studies on cardiac magnetic resonance imaging (CMR) have been reported. We aimed to investigate CMR findings including pericardial late gadolinium enhancement (LGE) and T2 fat suppression and black blood sequences in patients with tuberculous pericarditis.

Methods

We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Definite diagnosis of tuberculous pericarditis is based on the identification of Mycobacterium tuberculosis in pericardial fluid or tissue; probable diagnosis was made when there was other evidence of tuberculosis elsewhere in patients with unexplained pericarditis. We performed CMR at initial diagnosis. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months with or without steroids. Echocardiography was also conducted at initial diagnosis and 6 months later.

Results

Total 39 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Ten patients were diagnosed as definite tuberculous pericarditis. CMR finding at initial diagnosis divided into five groups: 1) pericardial effusion only (n=20, 51.3%), 2) effusive constrictive pericarditis (n=5, 12.8%), 3) constrictive pericarditis (n=11, 28.2%), 4) pericardial abscess formation (n=4, 10.3%) and 5) absence of pericardial effusion and constrictive physiology (n=1, 2.6%). One of the 4 patients with pericardial abscess formation was together with pericardial effusion and the other was accompanied by effusive constrictive pericarditis. Pericardial thickness increased to more than 4mm in 25 patients (64.1%) and the mean pericardial thickness was 10.0±6.9mm. Delayed enhancement of pericardium was noticed in 29 patients (74.4%). In T2 fat suppression and black blood sequences, 30 patients showed increased T2 signal intensity indicating inflammation with extensive edema. Pericardial thickening (>4mm) with constriction (n=15) was not statistically significant in the delayed enhancement and increased T2 signal intensity compared with pericardial thickening without constrictive pericarditis (n=10) (delayed enhancement 93.8% vs. 77.8% p=0.287; increased T2 signal intensity 88.9% vs. 87.5%, p=0.713). After 6 months, only 3 patients still had constrictive pericarditis in echocardiography.

Effusive constrictive pericarditis

Conclusions

Pericardial thickening is associated with delayed enhancement and increased T2 signal intensity in patients with tuberculous pericarditis regardless of constrictive pericarditis. Even though there were hemodynamic feature of constrictive pericarditis and pericardial inflammation with extensive edema in CMR at initial diagnosis, 80% of the patients were improved from constrictive pericarditis.

Acknowledgement/Funding

None

P783Guideline-directed therapy at discharge is important in patients with heart failure and atrial fibrillation

Background

There are limited and conflicting data regarding the prognostic implication of guideline-directed therapy, especially in heart failure (HF) patients with atrial fibrillation (AF). Thus, this study evaluated the relationship between guideline adherence to recommended therapy at discharge and relevant 60-day clinical outcomes in acute HF patients with AF having reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF).

Methods and results

Of 5,625 acute HF patients in the Korean Acute Heart Failure Registry, 2,071 with documented AF (HFrEF, n=986; HFpEF, n=1,085) were separately analysed. A guideline adherence score was calculated for the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and anticoagulants. In HFrEF patients with AF, there was significant trend of increase in mortality (p for trend <0.001) and composite endpoint (p for trend = 0.002) according to guideline adherence. Poor adherence was associated with a significantly high risk of mortality (hazard ratio [HR], 4.75; 95% confidence interval [95% CI], 1.77–12.74) and composite endpoint (HR, 2.36; 95% CI, 1.33–4.18). In HFpEF patients with AF, there was a significant increasing trend for rehospitalization (p for trend = 0.04) and composite endpoint (p for trend = 0.03). However, the beneficial effect of good guideline adherence was statistically non-significant for all clinical outcomes

Conclusion

Better adherence to guidelines was associated with a better 60-day prognosis in both HFrEF and HFpEF patients with AF. However, the beneficial effect of guideline adherence was more pronounced in HFrEF patients with AF.

P2860The effects of single nucleotide polymorphisms in Korean patients with early-onset lone atrial fibrillation after catheter ablation

Background

The status of SNPs among patients with extremely early-onset lone AF and the association with outcome of catheter ablation has not been evaluated before. This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early-onset (<40 years old) lone AF and effects on the outcome after catheter ablation.

Methods

A total of 89 consecutive patients (mean age 35.7±3.7 years, 81 males) with drug-refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included. Sixteen SNPs including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543 and rs3825214 were genotyped. Serial 48-day Holter electrocardiographic recordings were acquired to detect AF recurrences during long-term follow up.

Results

Wild type of rs7193343 [CC; 0/7 (0%) vs. CT; 22/40 (55.0%) vs. TT; 18/41 (43.9%), p=0.025] and rs11047543 [GG; 26/69 (37.7%) vs. GA; 13/18 (72.2%) vs. AA; 0/0, p=0.009] and homozygous variant of rs3825214 [AA; 16/31 (51.6%) vs. AG; 22/43 (51.2%) vs. GG; 2/13 (15.4%), p=0.05] were significantly associated with lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n=0–3), Kaplan-Meier survival analysis showed incremental prognostic value according to the number of variant alleles (p=0.002) (Figure 1).

Figure 1

Conclusions

Polymorphisms on rs7193343, rs3825214 and rs11047543 modulate the risk for AF recurrence after catheter ablation during long term follow up in Korean patients with early-onset lone AF.

Acknowledgement/Funding

Korean Society of Cardiology

Lysophosphatidylserine receptor P2Y10: A G protein-coupled receptor that mediates eosinophil degranulation

BACKGROUND

P2Y10, along with GPR34 and GPR174, is a G protein-coupled receptor that is activated by an endogenous lipid mediator lysophosphatidylserine (LysoPS). Its expression pattern and its function are completely unknown. We have previously shown that P2Y10 is one of the highly up-regulated genes at the late differentiation stage during in vitro eosinophilopoiesis.

OBJECTIVE

We explored the expression and functions of P2Y10 in human cord blood (CB)-derived and peripheral blood (PB) eosinophils.

METHODS

Real-time PCR, FACS, Western blot, ELISA, and chemotaxis assays were performed to determine the expression and function of P2Y10.

RESULTS

As CB cells differentiated towards eosinophils, P2Y10 mRNA and protein were abundantly expressed. P2Y10 was the most highly expressed in the granulocytes from PB, to a lesser extent in monocytes, and least in lymphocytes. Further fractionation of granulocytes revealed that eosinophils express P2Y10 much more strongly than do neutrophils. PB eosinophils solely expressed P2Y10 among the three LysoPS receptors, while PB neutrophils expressed the three at comparable levels. LysoPS activated both CB and PB eosinophils to induce a robust ERK phosphorylation. Importantly, LysoPS was capable of triggering degranulation of ECP in PB eosinophils. This response was significantly reduced by pharmacological inhibitors of TNF-alpha-converting enzyme (TACE), epidermal growth factor receptor (EGFR), and ERK1/2, which were known to be required in P2Y10-mediated signalling pathways. However, LysoPS had no effect on chemotaxis, differentiation, or eosinophil survival.

CONCLUSIONS AND CLINICAL RELEVANCE

LysoPS provokes eosinophil degranulation through P2Y10. Therefore, P2Y10 is a potential therapeutic target to control eosinophil-associated diseases.

Active surveillance for carbapenem-resistant Enterobacteriaceae, vancomycin-resistant enterococci and toxigenic Clostridium difficile among patients transferred from long-term care facilities in Korea

A 10-month active surveillance study was conducted to assess carriage of carbapenemase-producing Enterobacteriaceae (CPE), vancomycin-resistant enterococci (VRE) and toxigenic Clostridium difficile colonization among patients transferred to hospital from long-term care facilities (LTCFs). Four (1.4%) patients with carbapenem-resistant Enterobacteriaceae (none of which were CPE), 59 (21%) patients with VRE and 20 (7.1%) patients colonized with toxigenic C. difficile were identified from 282 rectal specimens. There was no outbreak of VRE infection during the study period. The low prevalence of CPE carriage suggests that screening all admissions from LTCFs for CPE would not be cost-effective, and that screening and use of contact precautions for VRE should be reconsidered.

Rapidly Progressive Lactic Acidosis in Patients with Flufenoxuron Poisoning

Flufenoxuron is an insect growth regulator which inhibits chitin (exoskeleton) biosynthesis in insect's body. Not much is known about its toxicity to human. This report describes three patients who developed worsening lactic acidosis and hypotension after ingestion of flufenoxuron-containing materials. Two of the three patients received continuous renal replacement therapy and survived. (Hong Kong j.emerg.med. 2014;21:181-184)

An Unusual Case of Blunt Traumatic Pulmonary Artery Pseudoaneurysm Detected within a Day

Chest trauma can injure intrathoracic vessels, usually affecting the aorta and arch branches; however, a traumatic pulmonary artery pseudoaneurysm (PAP) has been reported, albeit relatively rarely. Blunt chest trauma as an aetiology for a PAP is even more rare than penetrating chest trauma. There is usually a time delay from several days to several months between injury and detection of a PAP. Traditionally, operative management has been recommended because of the risk of PAP rupture. Here, we describe an unusual case of a PAP following blunt trauma that was detected early on computed tomography, 8 hours after injury, and the PAP resolved with conservative management.

Diagnostic value of haemoglobin A1c in post-partum screening of women with gestational diabetes mellitus

AIMS

The aim of this study was to evaluate whether women with gestational diabetes mellitus could be screened using HbA_1c for glucose metabolism status at 6-12 weeks post-partum.

METHODS

We enrolled 699 pregnant women diagnosed with gestational diabetes mellitus from October 2005 to December 2013. A 75-g oral glucose tolerance test (OGTT) and HbA_1c measurement were performed at 6-12 weeks after delivery.

RESULTS

The prevalence of overt diabetes and pre-diabetes were 5.2% (n = 36) and 49.1% (n = 343), respectively, when using the 75-g OGTT as the gold standard. HbA_1c alone identified 2.9% (n = 20) as having overt diabetes and 32.2% (n = 225) as having pre-diabetes. When American Diabetes Association cut-offs were applied, the sensitivity and specificity for HbA_1c to diagnose overt diabetes were 19.4% and 98.0%, respectively. Pre-diabetes, according to the HbA_1c criterion, had 41.2% sensitivity and 72.2% specificity. The misclassifications identified 97 positive differences, 233 negative differences and 369 ties (P < 0.05). The area under the receiver operating characteristic curves for detecting diabetes and pre-diabetes were 0.615 [95% confidence interval (95% CI), 0.515 to 0.716] and 0.588 (95% CI, 0.545 to 0.630), respectively.

CONCLUSIONS

HbA_1c may not be sensitive enough for an accurate diagnosis, but it is highly specific for diagnosing overt diabetes at 6-12 weeks post-partum in women with previous gestational diabetes mellitus.

Lobeglitazone and pioglitazone as add-ons to metformin for patients with type 2 diabetes: a 24-week, multicentre, randomized, double-blind, parallel-group, active-controlled, phase III clinical trial with a 28-week extension

We aimed to compare the efficacy and safety of lobeglitazone and pioglitazone as add-ons to metformin in patients with type 2 diabetes. Patients who were inadequately controlled by metformin were randomized and treated once daily with either lobeglitazone (0.5 mg, n = 128) or pioglitazone (15 mg, n = 125) for 24 weeks, with a 28-week extension trial of lobeglitazone treatment in patients who consented. The primary endpoint was the change in glycated haemoglobin (HbA1c) concentration from baseline to week 24. At week 24, the mean change from baseline in HbA1c was -0.74% for the lobeglitazone group and -0.74% for the pioglitazone group, with a mean difference of 0.01% [95% confidence interval (CI) of difference, -0.16 to 0.18]. The effects of lobeglitazone on lipid variables and the adverse events associated with lobeglitazone were similar to those observed with pioglitazone. Lobeglitazone was not inferior to pioglitazone as an add-on to metformin in terms of their efficacy and safety.

Anagliptin and sitagliptin as add-ons to metformin for patients with type 2 diabetes: a 24-week, multicentre, randomized, double-blind, active-controlled, phase III clinical trial with a 28-week extension

We conducted a 24-week, multicentre, double-blind, randomized study with a 28-week extension to compare the efficacy and safety of anagliptin and sitagliptin as an add-on to metformin in patients with type 2 diabetes. Patients inadequately controlled on metformin were randomized to either anagliptin (100 mg twice daily, n = 92) or sitagliptin (100 mg once daily, n = 88). The primary endpoint was the change in glycated haemoglobin (HbA1c) from baseline to week 24. The mean changes in HbA1c were -0.85 ± 0.70% (p < 0.0001) for anagliptin and -0.83 ± 0.61% (p < 0.0001) for sitagliptin, with a mean difference of -0.02% (95% confidence interval of difference, -0.22 to 0.18%). In both groups, the fasting proinsulin : insulin ratio significantly decreased from baseline, with improved insulin secretion. Safety profiles were similar in each group. In conclusion, the non-inferiority of the efficacy of anagliptin to sitagliptin as an add-on therapy was established with regard to efficacy and safety.

Effects of Trichostatin A on In vitro Development of Porcine Embryos Derived from Somatic Cell Nuclear Transfer

Many different approaches have been developed to improve the efficiency of animal cloning by somatic cell nuclear transfer (SCNT), one of which is to modify histone acetylation levels using histone deacetylase inhibitors (HDACi) such as trichostatin A (TSA). In the present study, we examined the effect of TSA on in vitro development of porcine embryos derived from SCNT. We found that TSA treatment (50 nM) for 24 h following oocyte activation improved blastocyst formation rates (to 22.0%) compared with 8.9% in the non-treatment group and total cell number of the blastocysts for determining embryo quality also increased significantly (88.9→114.4). Changes in histone acetylation levels as a result of TSA treatment were examined using indirect immunofluorescence and confocal microscopy scanning. Results showed that the histone acetylation level in TSA-treated embryos was higher than that in controls at both acetylated histone H3 lysine 9 (AcH3K9) and acetylated histone H4 lysine 12 (AcH4K12). Next, we compared the expression patterns of seven genes (OCT4, ID1; the pluripotent genes, H19, NNAT, PEG1; the imprinting genes, cytokeratin 8 and 18; the trophoblast marker genes). The SCNT blastocysts both with and without TSA treatment showed lower levels of OCT4, ID1, cytokeratin 8 and 18 than those of the in vivo blastocysts. In the case of the imprinting genes H19 and NNAT, except PEG1, the SCNT blastocysts both with and without TSA treatment showed higher levels than those of the in vivo blastocysts. Although the gene expression patterns between cloned blastocysts and their in vivo counterparts were different regardless of TSA treatment, it appears that several genes in NT blastocysts after TSA treatment showed a slight tendency toward expression patterns of in vivo blastocysts. Our results suggest that TSA treatment may improve preimplantation porcine embryo development following SCNT.

Esophageal mucosal mast cell infiltration and changes in segmental smooth muscle contraction in noncardiac chest pain

Mast cells release potent mediators that alter enteric nerve and smooth muscle functions and may contribute to the pathogenesis of functional gastrointestinal disorders. The goal of this study was to determine if mucosal mast cell infiltration was associated with smooth muscle segmental changes in esophageal contraction. All patients with noncardiac chest pain (NCCP) were divided into two groups consisting of patients with non-erosive reflux disease or functional chest pain (FCP) according to the results of ambulatory 24 hours esophageal pH monitoring and high-resolution manometry. Pressure-volume (PV) was calculated by multiplying the length of the esophageal segment, duration of the contraction, and mean pressure over the entire space-time box (P mean). Quantification of mast cells was performed in five consecutive nonoverlapping immunostained sections. Spearman correlation analysis showed that the distal segment PV correlated with the mast cell count in all of the patients combined and in patients with FCP with correlation coefficients of 0.509 and 0.436, respectively (P = 0.004 and P = 0.042). Similar findings were observed for the segmental ratio of distal to proximal smooth muscle PV in all patients and in patients with FCP (correlation coefficients 0.566; P = 0.001 and correlation coefficients 0.525; P = 0.012, respectively). Mucosal mast cell infiltration was associated with distal esophageal contraction as a key pathophysiologic factor of NCCP.

A canine model of Alzheimer's disease generated by overexpressing a mutated human amyloid precursor protein

Canines are considered the most authentic model for studying multifactorial human diseases, as these animals typically share a common environment with man. Somatic cell nuclear transfer (SCNT) technology along with genetic engineering of nuclear donor cells provides a unique opportunity for examining human diseases using transgenic canines. In the present study, we generated transgenic canines that overexpressed the human amyloid precursor protein (APP) gene containing well-characterized familial Alzheimer's disease (AD) mutations. We successfully obtained five out of six live puppies by SCNT. This was confirmed by observing the expression of green fluorescence protein in the body as a visual transgenic marker and the overexpression of the mutated APP gene in the brain. The transgenic canines developed AD-like symptoms, such as enlarged ventricles, an atrophied hippocampus, and β-amyloid plaques in the brain. Thus, the transgenic canines we created can serve as a novel animal model for studying human AD.

Outcome of percutaneous transluminal angioplasty in diabetic patients with critical limb ischaemia

OBJECTIVE

We investigated the clinical outcome of percutaneous transluminal angioplasty (PTA) which has not been fully established in diabetic patients with critical limb Ischaemia (CLI) compared with non-diabetics.

DESIGN AND PATIENTS

A total of 73 limbs of 52 patients (50 limbs of 34 diabetic patients and 23 limbs of 18 non-diabetics) who underwent PTA for CLI (Rutherford-Becker category 4, 5 or 6) were enrolled. Rates of amputation and restenosis, and ankle brachial index (ABI), were assessed before and after PTA during a 36-month follow-up period.

RESULTS

Diabetic patients had a higher rate of major amputations after PTA (10 vs. 0%, P<0.05); however, total amputation (12.0 vs. 8.7%, P=0.62) and restenosis rates (4.0 vs. 8.7%, P=0.38) were not significantly different compared with non-diabetic patients. ABI at 3 months after PTA was significantly improved in both diabetic and non-diabetic patients (0.70±0.20 vs. 0.93±0.19, P<0.01 in diabetic patients; 0.69±0.25 vs. 0.92±0.17, P<0.01 in non-diabetics). Improved ABI was maintained for 36 months in both groups and did not show a significant difference (0.88±0.21 vs. 0.89±0.20, P=0.89).

CONCLUSION

Our results, showing that the outcome of PTA in diabetic patients is not inferior to that in non-diabetics, suggest the potential benefit of primary PTA, instead of bypass surgery, for CLI in diabetic patients who are at high risk of perioperative complications.

Clinical characterization and molecular classification of 12 Korean patients with pseudohypoparathyroidism and pseudopseudohypoparathyroidism

CONTEXT

Pseudohypoparathyroidism (PHP) is defined as resistance toward parathyroid hormones. PHP and pseudopseudohypoparathyroidism (PPHP) are rare disorders resulting from genetic and epigenetic aberrations within or upstream of the GNAS locus. This study investigated the clinical characteristics and performed a molecular analysis of PHP and PPHP.

METHODS

A total of 12 patients with (P)PHP from 11 unrelated families (4 with PHP-Ia, 6 with PHP-Ib, and 2 with PPHP) were characterized using both clinical and molecular methods. Clinical features included the presenting symptoms, Albright hereditary osteodystrophy features, and resistance to hormones. Comprehensive analysis of the GNAS and STX16 loci was undertaken to investigate the molecular defects underlying (P)PHP.

RESULTS

All PHP-Ib patients displayed hypocalcemic symptoms. All PHP-Ia patients showed resistance toward TSH, in addition to PTH. In most patients with PHP, when the diagnosis of PHP was first established, hypocalcemia and hyperphosphatemia were associated with a significant increase in serum PTH levels. One patient with PHP-Ia was diagnosed with growth hormone deficiency and showed a good response to human recombinant growth hormone therapy. 6 patients with PHP-Ia and PPHP showed 5 different mutations in the GNAS gene. 5 patients with PHP-Ib displayed a loss of differentially methylated region (DMR) imprints of the maternal GNAS. One PHP-Ib patient showed a de novo microdeletion in STX16 and a loss of methylation of exon A/B on the maternal allele. No patients revealed paternal disomy among 4 patients with PHP-Ib.

CONCLUSIONS

Identification of the molecular causes of PHP and PPHP explains their distinctive clinical features and enables confirmation of the diagnosis and exact genetic counseling.

The effects of statins on the clinical outcomes of Clostridium difficile infection in hospitalised patients

BACKGROUND

An association between exposure to statin drugs and favourable treatment outcomes for various types of infections has been established.

AIM

To determine the clinical characteristics and treatment outcomes of Clostridium difficile infection (CDI) among hospitalised patients taking statin drugs.

METHODS

The medical records were reviewed for consecutive in-patients with CDI confirmed by positive toxin assay (A or B), C. difficile culture, or the presence of pseudomembrane on endoscopy. Treatment success was defined as the resolution of diarrhoea within 6 days of therapy. The primary end points were assessed by average symptom recovery time and treatment response (success or failure).

RESULTS

Among 949 patients, the overall response to metronidazole was 91.9%. The baseline characteristics showed some differences between statin users and statin non-users with respect to mean disease severity score. In the multivariate analysis, successful treatment response was significantly associated with the absence of exposure to proton pump inhibitors (PPIs) (OR = 0.690, 95% CI = 0.513-0.929, P = 0.014) and with exposure to statins (OR = 1.449, 95% CI = 1.015-2.070, P = 0.041). Contrary to the treatment response, univariate and multivariate analyses failed to show that exposure to PPIs or statins affected symptom recovery times. Sixty-day CDI recurrence rates for those patients with statin exposure were significantly lower compared with those patients without statin exposure (3% vs. 7.3%, respectively; RR = 0.393, 95% CI = 0.167-0.926, P = 0.033).

CONCLUSION

Prior statin exposure in patients with C. difficile infection is associated with a successful response to treatment.

Randomized comparison of the Pentax AirWay Scope and Macintosh laryngoscope for tracheal intubation in patients with obstructive sleep apnoea

BACKGROUND

Patients with obstructive sleep apnoea (OSA) can often present difficulties in intubation. This study aimed to compare the efficacy of the Pentax AirWay Scope (AWS) with that of the Macintosh laryngoscope for tracheal intubation in patients with OSA.

METHODS

Forty-six patients undergoing uvulopalatopharyngoplasty were randomly allocated to tracheal intubation with either the Macintosh laryngoscope or the Pentax AWS. In all patients, intubation was performed by one of two anaesthetists experienced with both devices. The primary and secondary endpoints of this study were the intubation difficulty scale (IDS) score and success/failure and duration of the first successful intubation attempt.

RESULTS

With the Pentax AWS, tracheal intubation was successful on the first attempt in all patients whereas four patients required repeated attempts at intubation with the Macintosh laryngoscope. The IDS score was significantly lower using the Pentax AWS and glottic exposure was better (the Cormack and Lehane grade 1 in all patients vs grade 2 or higher in all patients, P<0.0001). Average duration of successful intubation was shorter (12.9 vs 29.9 s, P=0.0002), and fewer manoeuvres were needed to improve the glottic exposure (0 in all patients vs 1 or more in 16 patients, P<0.0001) with the Pentax AWS, compared with the Macintosh laryngoscope.

CONCLUSIONS

In this study of patients with OSA, tracheal intubation by experienced anaesthetists was facilitated using the Pentax AWS compared with the Macintosh laryngoscope.

Identifying genes related to radiation resistance in oral squamous cell carcinoma cell lines

Radioresistance is one of the main determinants of treatment outcome in oral cancer, but the prediction of radioresistance is difficult. The authors aimed to establish radioresistant oral squamous cell carcinoma (OSCC) cell lines to identify genes with altered expression in response to radioresistance. To induce radioresistant cell lines, the authors treated OSCC cell lines with an accumulated dosage of 60Gy over 30 cycles of radiotherapy. They compared the results from cDNA arrays and proteomics between non-radiated and radioresistant cell lines in order to identify changes in gene expression. Western blot analysis was used to validate the results. The cDNA array revealed 265 commonly up-regulated genes and 268 commonly down-regulated genes in radioresistant cell lines, 30 of which were cancer-related genes. Proteomics identified 51 proteins with commonly altered expression in radioresistant cell lines, 18 of which were cancer-related proteins. Both the cDNA array and proteomics indicated that NM23-H1 and PA2G4 were over-expressed. Western blot analysis showed increased expression of NM23-H1, but not PA2G4, in radioresistant cell lines. The authors concluded that NM23-H1 may be a radioresistance-related gene and over-expression of NM23-H1 could serve as a biomarker to predict radioresistance in OSCC.

Increased apoB/A-I ratio independently associated with Type 2 diabetes mellitus: cross-sectional study in a Korean population

AIMS

The aim of this study was to investigate whether increased apolipoprotein B/apolipoprotein A-I ratio is associated with Type 2 diabetes mellitus independent of other risk factors for Type 2 diabetes.

METHODS

A total of 70,063 subjects (41,391 men and 28,672 women; mean age 41.5 years) who visited the Health Screening Center at Kangbuk Samsung Hospital for a routine medical check-up between January 2009 and December 2009 were enrolled in this study.

RESULTS

The mean apolipoprotein B/apolipoprotein A-I ratio in the study subjects was 0.66 ± 0.18. The prevalence of Type 2 diabetes increased across the apolipoprotein B/apolipoprotein A-I ratio quartiles (1.0%, 1.6%, 2.9%, and 4.8% for the 1st through 4th quartiles, respectively, P < 0.001) and homeostasis model assessment-insulin resistance (HOMA2-IR) also showed an increasing tendency by quartile (P < 0.001). The apolipoprotein B/apolipoprotein A-I ratio was correlated with age, adiposity, blood pressure, HOMA2-IR value, fasting glucose levels, and other inflammatory marker, including high-sensitivity C-reactive protein, and lipoprotein (a) levels (all P < 0.001). In a multiple logistic regression model, the highest apolipoprotein B/apolipoprotein A-I ratio quartile was associated with Type 2 diabetes, even after controlling for other risk factors for diabetes, such as age, gender, BMI, systolic blood pressure, HOMA2-IR values, high-sensitivity C-reactive protein levels, family history of diabetes, presence of metabolic syndrome, and conventional lipid parameters (odds ratio 1.31; 95% confidence interval 1.17-1.46, P < 0.001).

CONCLUSIONS

The apolipoprotein B/apolipoprotein A-I ratio was found to be associated with Type 2 diabetes independent of other risk factors for diabetes and conventional lipid parameters.

Serum 1,5-anhydroglucitol is associated with diabetic retinopathy in Type 2 diabetes

AIMS

To determine whether there is a relationship between 1,5-anhydroglucitol (1,5-AG), a marker of postprandial hyperglycaemia and glycaemic variability, and the presence of diabetic retinopathy and albuminuria in patients with Type 2 diabetes.

METHODS

Five hundred and sixty-seven patients with Type 2 diabetes (serum creatinine < 133 μmol/l), who were enrolled in the Seoul Metro-City Diabetes Prevention Program (SMC-DPP), were cross-sectionally assessed by multivariate logistic regression analysis.

RESULTS

After controlling for age, sex, binary HbA(1c) levels, duration of diabetes, triglyceride, systolic blood pressure, smoking status, history of hypertension and dyslipidaemia, and the use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medication, the odds ratios (95% CI) of diabetic retinopathy were 2.86 (1.12-7.25) for the first (lowest) quartile of 1,5-anhydroglucitol, 2.87 (1.25-6.61) for the second quartile and 0.88 (0.35-2.22) for the third quartile compared with the fourth quartile (P for trend = 0.010). Conversely, the associations between 1,5-anhydroglucitol and clinical albuminuria were non-significant after adjustment. Subjects with low 1,5-anhydroglucitol (< 10.0 μg/ml) were more likely to experience diabetic retinopathy than those with high 1,5-anhydroglucitol (≥ 10.0 μg/ml) under moderate glucose control (HbA(1c) < 8%, 64 mmol/mol) and there were no significant differences in the prevalence of diabetic retinopathy between the subgroup with HbA(1c) < 8% (64 mmol/mol) and low 1,5-anhydroglucitol and the subgroup with HbA(1c) ≥ 8% (64 mmol/mol).

CONCLUSIONS

1,5-Anhydroglucitol levels show close associations with diabetic retinopathy, especially among patients under moderate glucose control, but not with albuminuria. These results suggest that 1,5-anhydroglucitol might be a complementary marker for targeting higher risk group.

A novel disposable, transnasal esophagoscope: a pilot trial of feasibility, safety, and tolerance

A novel disposable transnasal esophagoscope, the E.G. Scan (IntroMedic Co. Ltd., Seoul, Korea), was developed for the evaluation of esophageal diseases while eliminating the inconvenience associated with sterilization, portability, patient monitoring, complications, and the economic burden of sedation. The feasibility, safety, and tolerability of the first version of the E.G. Scan was evaluated in this pilot study. Nasal esophagoscopy was performed successfully in 46 patients with known or suspected esophageal diseases. At least 50% of the Z-line was visualized by the E.G. Scan in 38 (82.6%) of 46 patients. Abnormalities were identified in 27 patients: erosive esophagitis (n=18), Barrett's esophagus (n=1), esophageal varices (n=7), and esophageal candidiasis (n=1). Nasal pain was absent or mild in most patients, and adverse events were not observed. Further technical improvement of the E.G. Scan would increase the diagnostic usefulness in future clinical practice.

Biplane fluoroscopy-guided radiofrequency ablation combined with chemoembolisation for hepatocellular carcinoma: initial experience

OBJECTIVE

The purpose of this study was to assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous radiofrequency (RF) ablation combined with transcatheter arterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

METHOD

Our retrospective study was approved by the institutional review board and informed consent was waived. 18 patients with 19 HCCs (mean 2.5 cm diameter; range 2-4.2 cm) were treated with percutaneous RF ablation combined with TACE. After segmental TACE, 18 (95%) of 19 HCCs were visible on fluoroscopy. Shortly (median 2 days; range 1-4 days) after TACE, percutaneous RF ablation was performed under real-time biplane fluoroscopic guidance. We evaluated major complications, rate of technical success at immediate post-RF ablation CT images and local tumour progression at follow-up CT images.

RESULTS

Major complication was not observed in any patients. Technical success was achieved for all 18 visible HCCs. During the follow-up period (median 20 months; range 5-30 months), no local tumour progression was found.

CONCLUSION

Biplane fluoroscopy-guided RF ablation combined with TACE is technically feasible and effective for treatment of HCC.

Identification of 11 novel mutations in 49 Korean patients with mucopolysaccharidosis type II

Mucopolysaccharidosis type II (MPS II) or Hunter syndrome is a rare lysosomal storage disorder caused by a deficiency of iduronate-2-sulfatase (IDS). As MPS II is X-linked, patients are usually males with heterogeneous mutations ranging from point mutations to gross deletions and recombination. In 2003, we reported a mutation analysis of 25 patients with MPS II. In this study, 31 mutations in another 49 Korean patients (45 families) with MPS II are reported: 12 missense, nine deletions, four splicing, two nonsense, two insertions, one deletion/insertion, and IDS-IDS2 recombination mutations. Among these mutations, 11 were novel ones (4 missense mutations: Ser61Pro, Pro97Arg, Pro228Ala, and Pro261Ala; 5 deletions: c.344delA, c.420delG, c.768delT, c.1112delC and c.1402delC; 1 deletion/insertion: c.1222delinsTA; and 1 insertion mutation: c.359_360insATCC). The IDS-IDS2 recombination mutations were most frequently observed; all patients with this mutation had the severe MPS II phenotype. However, most of the patients (5/7) with the G374G splicing mutation had an attenuated phenotype, except for two sibling cases with the severe phenotype. Except for a few recurrent mutations such as the G374G, R443X, L522P, and recombination mutations, each patient had a unique individual mutation. Therefore, careful interpretation of genotype-phenotype correlations is warranted.

Unexplained Massive Pneumoperitoneum following Cardiopulmonary Resuscitation

Pneumoperitoneum following cardiopulmonary resuscitation (CPR) had been described as a rare complication. Pneumoperitoneum after CPR could be due to gastric perforation or intrathoracic air tracking into the abdominal cavity via the diaphragm as a result of bag-valve-mask ventilation, external chest compression or improper intubation. In most reported cases, the specific injuries could be identified. We reported an unusual case of pneumoperitoneum following CPR in which the specific cause was not definitely established. Emergency physicians should be aware of the mechanism and clinical signs suggesting of pneumoperitoneum during or after CPR.

Interventional management for complications following caesarean section

OBJECTIVES

This study aimed to evaluate the efficacy and safety of interventional management for various intractable complications following caesarean section.

METHODS

Between August 2005 and September 2009, 18 consecutive women were referred to interventional radiology for treatment of complications developing after caesarean section. Complications included vaginal bleeding (n = 14), haemoperitoneum with abdominal wall haematoma (n = 2), caesarean scar pregnancy (CSP) (n = 1) and post-caesarean fluid collection (n = 1).

RESULTS

17 women underwent transcatheter arterial embolisation (TAE) with a variety of embolic materials, and two women underwent percutaneous drainage (PCD) for fluid collection and haemoperitoneum. 5 of the 14 women with vaginal bleeding had extravasation of contrast media on angiography; the other 9 had no visible bleeding foci. The two women with haemoperitoneum with abdominal wall haematoma had injury to the inferior epigastric artery from angiography. TAE and PCD were successfully performed in both women. The CSP was successfully managed and the serum β-human chorionic gonadotropin (β-hCG) level finally normalised. Hysterectomy or dilatation and curretage was required in women with placenta accrete and undetectable bleeding foci.

CONCLUSION

Interventional management including TAE and PCD is effective and safe in controlling complications following caesarean section. Use of these procedures can help avoid high-risk surgery, but subsequent procedures including hysterectomy may be required in cases of placental abnormalities and undetectable bleeding foci.

Randomized controlled trial to investigate the effects of a newly developed formulation of phentermine diffuse-controlled release for obesity

AIM

To evaluate the efficacy and safety of a newly developed formulation of phentermine diffuse-controlled release (DCR) in patients with obesity.

METHODS

This was a randomized, double-blind, placebo-controlled trial of 12 weeks of treatment with phentermine DCR 30 mg (n = 37) or placebo (n = 37), administered once daily in patients with obesity with controlled diabetes, hypertension or dyslipidaemia. The efficacy was evaluated by changes in body weight and waist circumference from baseline at 12 weeks and also changes in metabolic parameters, including lipid profiles and blood pressure.

RESULTS

The participants in the phentermine DCR group showed significant reductions in body weight (-8.1 ± 3.9 vs. -1.7 ± 2.9 kg, p < 0.001) and waist circumference (7.2 ± 0.5 vs. 2.1 ± 0.6 cm, p < 0.001) compared with those in the placebo group. Weight reductions of 5% or greater from the baseline (95.8 vs. 20.8%, p < 0.001) and 10% or more (62.5 vs. 4.7%, p < 0.001) were achieved in the DCR phentermine group and placebo group, respectively. Total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels were significantly improved in the phentermine DCR group. However, there were no significant differences in systolic and diastolic blood pressure between the groups. Dry mouth and insomnia were the most common adverse events, but these were mild to moderate and transient.

CONCLUSIONS

Short-term phentermine DCR treatment resulted in significant reduction in weight and improvement of metabolic parameters, including waist circumference and some lipid profiles, without clinically severe adverse events. Further study is needed to show long-term efficacy and safety of phentermine DCR in Korean patients with obesity.

Influence of supplemental dietary poultry fat, phytase, and 25-hydroxycholecalciferol on the egg characteristics of commercial layers inoculated before or at the onset of lay with F-strain Mycoplasma gallisepticum

The effects of supplemental dietary poultry fat (PF), phytase (PHY), and 25-hydroxycholecalciferol (D3) on the egg characteristics of commercial layers inoculated with F-strain Mycoplasma gallisepticum (FMG) were investigated in 2 trials. Sham and FMG inoculations were administered at 12 (before lay) and 22 (onset of lay) wk and 4 dietary treatments [basal control diet (BCD); BCD with 0.75% supplemental PF; BCD with 1.50% supplemental PF; BCD with 1.50% supplemental PF, 0.013% PHY, and 0.025% D3] were initiated at 20 wk of age. Percentages of albumen, yolk, and eggshell weights; yolk:albumen ratio; yolk moisture and lipid concentrations; and eggshell weight per unit of surface area were determined at 24, 34, 44, 50, and 58 wk of age. Inoculation with FMG reduced yolk lipid concentration at wk 24 and increased yolk moisture concentration at wk 58. In birds inoculated on wk 22, percentage of yolk weight was lower in those inoculated with FMG compared with those that were sham-inoculated. Yolk:albumen ratio was lower in birds that were FMG-inoculated at 22 wk of age compared with those that were sham-inoculated at the same age or that were FMG-inoculated at 12 wk of age. Percentage of yolk weight was greater in birds inoculated at wk 22 and fed the BCD with 1.50% supplemental PF treatment compared with those inoculated at wk 22 and fed the BCD or BCD with 1.50% supplemental PF, 0.013% PHY, and 0.025% D3 treatments and compared with birds inoculated at wk 12 and fed the BCD with 0.75% supplemental PF treatment. In conclusion, inoculation with FMG before or at the onset of lay caused a decrease in yolk lipid content early in lay but an increase in yolk moisture late in lay, and FMG reduced percentage of yolk weight in birds inoculated on wk 22. Furthermore, when used in combination with added 1.50% PF in birds inoculated on wk 22, supplementary PHY and D3 prevented an increase in percentage of yolk weight that occurred in response to diets supplemented only with 1.50% PF.