The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery stenosis-a nationwide cohort study

BACKGROUND

In post-stroke atrial fibrillation (AF) patients who have indications for both oral anticoagulant (OAC) and antiplatelet agent (AP), e.g., those with carotid artery stenosis, there is debate over the best antithrombotic strategy. We aimed to compare the risks of ischemic stroke, composite of ischemic stroke/major bleeding and composite of ischemic stroke/intracranial hemorrhage (ICH) between different antithrombotic strategies.

METHODS

This study included post-stroke AF patients with and without extracranial artery stenosis (ECAS) (n = 6390 and 28,093, respectively) identified from the Taiwan National Health Insurance Research Database. Risks of clinical outcomes and net clinical benefit (NCB) with different antithrombotic strategies were compared to AP alone.

RESULTS

The risk of recurrent ischemic stroke was higher for patients with ECAS than those without (12.72%/yr versus 10.60/yr; adjusted hazard ratio [aHR] 1.104, 95% confidence interval [CI] 1.052-1.158, p < 0.001). For patients with ECAS, when compared to AP only, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy was associated with lower risks for ischaemic stroke (aHR 0.551, 95% CI 0.454-0.669), the composite of ischaemic stroke/major bleeding (aHR 0.626, 95% CI 0.529-0.741) and the composite of ischaemic stroke/ICH (aHR 0.577, 95% CI 0.478-0.697), with non-significant difference for major bleeding and ICH. When compared to AP only, warfarin monotherapy was associated with higher risks of major bleeding (aHR 1.521, 95% CI 1.231-1.880), ICH (aHR 2.045, 95% CI 1.329-3.148), and the composite of ischaemic stroke and major bleeding. With combination of AP plus warfarin, there was an increase in ischaemic stroke, major bleeding, and the composite outcomes, when compared to AP only. NOAC monotherapy was the only approach associated with a positive NCB, while all other options (warfarin, combination of AP-OAC) were associated with negative NCB.

CONCLUSIONS

For post-stroke AF patients with ECAS, NOAC monotherapy was associated with lower risks of adverse outcomes and a positive NCB. Combination of AP with NOAC or warfarin did not offer any benefit, but more bleeding especially with AP-warfarin combination therapy.

Risk of Incident Atrial Fibrillation and Subsequent Use of Oral Anticoagulants in Patients with Dementia

BACKGROUND

 Dementia and atrial fibrillation (AF) have many shared risk factors. Besides, patients with dementia are under-represented in randomized trials, and even if AF is present, oral anticoagulants (OACs) are not prescribed frequently. This study aimed to report the incidence of newly diagnosed AF in dementia patients, and the impacts of use of vitamin K antagonist (VKA; e.g., warfarin) and non-VKA OAC (NOACs) on stroke and bleeding outcomes.

METHODS

 Our study utilized the Taiwan National Health Insurance Research Database. A total of 554,074 patients with dementia were compared with 554,074 age- and sex-matched patients without dementia regarding the risk of incident AF. Among patients with dementia who experienced incident AF, the risks of clinical events of patients treated with warfarin or NOACs were compared with those without OACs (reference group).

RESULTS

 The risk of incident AF was greater for patients with dementia compared with those without (adjusted hazard ratio [aHR]: 1.054; 95% confidence interval [CI]: 1.040-1.068 for all types of dementia, aHR: 1.035; 95% CI: 1.020-1.051 for presenile/senile dementia, and aHR: 1.125; 95% CI: 1.091-1.159 for vascular dementia). Among patients with dementia and experienced incident AF, warfarin use was associated with a higher risk of ischemic stroke (aHR: 1.290; 95% CI: 1.156-1.440), intracranial hemorrhage (ICH; aHR: 1.678; 95% CI: 1.346-2.090), and major bleeding (aHR: 1.192; 95% CI: 1.073-1.323) compared with non-OACs. NOAC use was associated with a lower risk of ischemic stroke (aHR: 0.421; 95% CI: 0.352-0.503) and composite risk of ischemic stroke or major bleeding (aHR: 0.544; 95% CI: 0.487-0.608) compared with non-OACs. These results were consistent among the patients after the propensity matching.

CONCLUSION

 In this large nationwide cohort, the risk of newly diagnosed AF was higher in patients with dementia (all dementia, presenile/senile dementia, and vascular dementia) compared with those without dementia. For patients with dementia who experienced incident AF, NOAC use was associated with a better clinical outcome compared with non-OAC. Patients with dementia require a holistic approach to their care and management, including the use of NOACs to reduce the risks of clinical events.

Which dose of apixaban is suitable for Asian patients with atrial fibrillation who have a serum creatinine < 1.5 mg/dL but an estimated glomerular filtration rate < 50 mL/min?

Introduction

Reduced-dose (Low-dose [LD]) apixaban is recommended in patients with atrial fibrillation (AF) who fulfill 2 of 3 criteria: age ≥ 80 years, body weight ≤ 60 kg, and a serum creatinine (sCr) ≥ 1.5 mg/dl. However, the suitable (appropriate) dose for Asian patients who have a sCr < 1.5 mg/dl but an estimated glomerular filtration rate (eGFR) < 50 mL/min is unknown.

Methods

This is a retrospective study using the Chang Gung Memorial hospital medical database in Taiwan. A total of 13,508 AF patients receiving oral anticoagulants (OACs) from 2012 to 2018 were reviewed and 1595 patients with a sCr < 1.5 mg/dL and an eGFR < 50 mL/min who met 1 criterion of dose reduction of apixaban other than sCr (that is, age ≥ 80 years or body weight < 60 kg) were identified. Clinical outcomes were compared between LD and SD apixaban versus warfarin.

Results

Their OACs use was as follows: 343 receiving apixaban (128 patients on standard dose [SD] and 215 on LD), 174 receiving warfarin, and 1078 on other NOACs. Patients with an eGFR < 50 mL/min had higher risk of mortality (adjusted hazard ratio [aHR], 1.264; 95 % confidence interval [CI], 1.086-1.472) and composite endpoint of 'ischemic stroke/systemic embolism (IS/SE) or major bleeding or mortality (aHR, 1.202; 95 % CI, 1.056-1.370) compared to those with an eGFR ≥ 50 mL/min whereas the risk of IS/SE and major bleeding were similar. LD apixaban was associated with lower risk of composite endpoint of IS/SE or major bleeding (aHR, 0.567; 95 % CI, 0.331 - 0.972), mortality (aHR, 0.336; 95 % CI, 0.138 - 0.815), and 'IS/SE or major bleeding or mortality (aHR, 0.551; 95 % CI, 0343 - 0.886) compared to warfarin while the risk was comparable between SD apixaban and warfarin (aHR, 0.745; 95 % CI, 0.402 - 1.378; aHR, 0.407; 95 % CI, 0.145 - 1.143; aHR, 0.619; 95 % CI, 0.354 - 1.084, respectively).

Conclusion

In patients with sCr < 1.5 mg/dL and eGFR < 50 mL/min, SD and LD apixaban were comparable in the prevention of IS/SE, but LD apixaban was superior in reducing the composite endpoint of 'IS/SE or major bleeding or mortality'. Therefore, LD apixaban might be a preferred dose for this population.

Sex difference in the association of the triglyceride glucose index with obstructive coronary artery disease

Insulin resistance (IR) is associated with cardiovascular disease in non-diabetic patients. The triglyceride-glucose (TyG) index, incorporating serum glucose and insulin concentrations, is a surrogate insulin resistance marker. We investigated its association with obstructive coronary artery disease (CAD) and sex differences therein. Patients with stable angina pectoris requiring invasive coronary angiography between January 2010 and December 2018 were enrolled. They were divided into two groups according to TyG index. Two interventional cardiologists diagnosed obstructive CAD by angiography review. Demographic characteristics and clinical outcomes were compared between groups. Relative to lower index, patients with higher (≥ 8.60) TyG index had higher BMIs and more prevalent hypertension, diabetes, and elevated lipid profiles [total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), fasting plasma glucose (FPG)]. Higher TyG index increased women's obstructive CAD risk after multivariate adjustment (adjusted odds ratio (aOR) 2.15, 95% confidence interval (95% CI) 1.08-4.26, p = 0.02) in non-diabetic populations compared with men. No sex difference was found for diabetic patients. Higher TyG index significantly increased the obstructive CAD risk, overall and for non-diabetic women. Larger-scale studies are needed to confirm our findings.

Plasma asymmetric dimethylarginine is associated with vulnerable plaque and long-term outcomes in stable coronary artery disease

Asymmetric dimethylarginine (ADMA) is considered to be an atherogenic molecule. We aimed to investigate the relationship between ADMA and plaque vulnerability assessed by optical coherence tomography (OCT) in patients with stable coronary artery disease (CAD). Two hundred and forty-five patients with stable CAD undergoing OCT-guided percutaneous coronary intervention were included in this study and were divided into two groups according to their ADMA levels. Micro-vessel, macrophage accumulation, thin-cap fibroatheroma, intra-plaque calcium and lipid core content, and vulnerable score (VS) were evaluated by OCT analysis. The patients with higher ADMA levels had significantly higher calcium and lipid content (p < 0.001, respectively). There were significantly more micro-vessel and macrophage (32.8%, p = 0.004 and 52.5%, p < 0.001, respectively) and higher VS (87.7 ± 17.6, p < 0.001) in the higher ADMA group. Moreover, plasma ADMA level was significantly correlated with the intra-plaque lipid, calcium content and VS (p < 0.001, respectively). Plasma ADMA level was identified as an independent predictor of future adverse cardiovascular events, following OCT-guided PCI. In patients with stable CAD, higher plasma ADMA levels were significantly associated with the presence of intra-plaque lipid, calcification, vulnerable plaque, and poor long-term outcomes.

The clinical impact of serum 1,5-anhydro-D-glucitol levels on coronary artery calcification and adverse outcomes assessed by coronary optical coherence tomography in diabetic patients

Background

Serum 1,5-anhydro-D-glucitol (1,5-AG) is a novel biomarker for short-term glycemic status and postprandial hyperglycemia. The association between serum 1,5-AG levels and coronary artery calcification (CAC) through a quantitative assessment using optical coherence tomography (OCT) is unclear. We aimed to evaluate this association using OCT in patients with diabetes mellitus (DM).

Methods

From June 2016 to December 2019, we prospectively enrolled 256 patients who underwent OCT-guided percutaneous coronary intervention (PCI). Half of the patients had diabetes. Patients were followed up for a mean period of 1.8 ± 0.8 years (median: 2.2 years). The relative calcium index and relative lipid core index measured by quantitative OCT analysis were used to evaluate the intra-plaque calcium and lipid levels of culprit plaques. We also analyzed the correlation between serum 1,5-AG levels and long-term major adverse cardiovascular events.

Results

Serum 1,5-AG levels were significantly lower in diabetic patients than in non-diabetic patients (DM vs. non-DM: 55.6 ± 27.9 μg/mL vs. 63.7 ± 26.1 μg/mL, p = 0.016), and lower in fibrocalcified lesions than in fibrotic or fibrolipidic lesions (fibrocalcified vs. fibrotic or fibrolipidic: 42.8 ± 19.1 vs. 72.9 ± 25.2 or 66.4 ± 27.5 μg/mL, p &lt; 0.001, respectively). In addition, we found a significant inverse correlation between serum 1,5-AG levels and relative calcium index (r = −0.729, p &lt; 0.001). In multivariate Cox regression analysis, low serum 1,5-AG level was identified as an independent predictor for major adverse cardiovascular events in diabetic patients (p = 0.043), but not in non-diabetic patients (p = 0.748) after adjusting for age and sex.

Conclusion

This study revealed that low serum 1,5-AG levels were associated with an increased risk of CAC as assessed by OCT, especially in diabetic patients. Low serum 1,5-AG levels may predict future major adverse cardiovascular events in diabetic patients undergoing OCT-guided PCI.

Effect of timing of coronary revascularization in patients with post-infectious myocardial infarction

Objectives

Acute infection is a well-known provocative factor of acute myocardial infarction (AMI). Prognosis is worse when it is associated with sepsis. Coronary revascularization is reported to provide benefit in these patients; however, the optimal timing remains uncertain.

Methods

This retrospective study was performed at a tertiary center in Taipei from January 2010 to December 2017. 1931 patients received coronary revascularization indicated for AMI. Among these, 239 patients were hospitalized for acute infection but later developed AMI. Patients with either an ST-elevation myocardial infarct or the absence of obstructive coronary artery disease were excluded. Revascularization was performed via either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). We defined early and delayed revascularization groups if it was performed within or after 24 hours of the diagnosis of AMI, respectively. We evaluated whether the timing of revascularization altered 30-day and one-year all-cause mortality.

Results

At one month, 24 (26%) patients died in early revascularization group and 32 (22%) patients in delayed revascularization group. At one year, 40 (43%) and 59 (40%) patients died on early and delayed revascularization groups respectively. Early revascularization did not result in lower 30-day all-cause mortality (P = 0.424), and one-year all-cause mortality (Hazard ratio (HR): 0.935; 95% confidence interval (CI): 0.626–1.397, P = 0.742) than delay revascularization.

Conclusions

Timing of coronary revascularization of post infectious acute coronary syndrome may be arranged according to individual risk category as those without sepsis.

Risk of Ischemic Bowel Disease in Patients With Atrial Fibrillation Receiving Warfarin or Non-vitamin K Antagonist Oral Anticoagulants

Background

Although atrial fibrillation (AF) is a risk factor for ischemic bowel disease, data regarding the incidence of ischemic bowel disease in patients with anticoagulated AF were limited.

Methods

The present study used the Taiwan NHIRD and included newly diagnosed patients with AF aged ≥ 20 years without ischemic bowel disease from 2012 to 2018. A total of 69,549 patients taking warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) constituted the final study group. We aimed to study the incidence of ischemic bowel disease in patients with AF receiving warfarin or NOACs. Secondary endpoints were also analyzed, including ischemic stroke, systemic embolism, myocardial infarction, mortality, intracranial hemorrhage (ICH), major bleeding, and composite adverse events (ischemic bowel disease or ICH or major bleeding).

Results

There were 43,787 patients taking NOACs and 25,762 patients taking warfarin. The overall incidence rate of ischemic bowel disease was 0.036% per year and increased with the CHA2DS2-VASc scores [0.013% for patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 0.022% for those with a CHA2DS2-VASc score of 1 (men) or 2 (women), and 0.039% for those with a CHA2DS2-VASc score ≥ 2 (men) or ≥ 3 (women)]. The risk of ischemic bowel disease was similar between NOAC and warfarin groups (0.036%/year vs. 0.037%/year; adjusted hazard ratio 0.802, p = 0.430), whereas the NOAC group had a significantly lower risk of secondary endpoints compared to the warfarin group.

Conclusion

We reported the incidence of ischemic bowel disease in patients with anticoagulated AF from a nationwide cohort database and observed a positive correlation between the increase of CHA2DS2-VASc scores and the incidence rate. Moreover, NOAC was as effective as warfarin for the risk of ischemic bowel disease.

Effects of aggressive predilatation, sizing, and postdilatation strategy for coronary bioresorbable vascular scaffolds implantation

BACKGROUND

The results of the recent Amsterdam Investigator-Initiated Absorb Strategy All-Comers trial showed that the predilatation, sizing, and postdilatation (PSP) technique did not lower the long-term rates of scaffold thrombosis and adverse events. We evaluated the impact of aggressive PSP bioresorbable vascular scaffold (BRS) implantation on the short- and long-term clinical outcomes.

METHODS

From June 2014 to December 2016, 150 patients with BRS implantation were enrolled and received successful percutaneous coronary intervention (PCI), of whom 104 received aggressive PSP technique (high-pressure predilatation and lesion preparation in addition to the traditional PSP technique). Short- and long-term outcomes were compared.

RESULTS

All patients underwent successful PCI and BRS implantation with final Thrombolysis in Myocardial Infarction grade 3 flow. The baseline and procedure characteristics were similar in both groups. Debulking techniques were used in 13 (8.7%) patients. Intracoronary imaging modalities were used in 73 (48.7%) patients. After BRS implantation, no adverse events were observed within 30 days in both groups. During the mean follow-up period of 2.98 ± 0.77 years, 12 (8.0%) patients experienced major adverse cardiovascular events (MACEs), including one cardiovascular death (0.6%), three nonfatal myocardial infarction (2.0 %), and 11 target-vessel revascularization (7.3 %). Multivariate Cox regression analysis showed that aggressive PSP remained an independent protective factor for MACEs. Moreover, the use of intracoronary imaging and rotablation atherectomy was associated with better clinical outcomes.

CONCLUSION

Lesion preparation by aggressive PSP in BRS implantation was associated with better long-term clinical outcomes.

Optimal anticoagulation in elderly patients with atrial fibrillation: Which drug at which dose?

Aging is an important risk factor for adverse events in elderly patients with atrial fibrillation (AF) and complicates the management of anticoagulation. Underuse of oral anticoagulants (OACs) is common in elderly patients because of comorbidities, the altered physiological function of multiple organs, frailty, risk of falls, and the lack of randomized controlled trials (RCTs) specifically for elderly patients. Nevertheless, current data still support OACs use for reducing ischemic stroke with positive net clinical benefits. Sub-analyses of RCTs and real-world cohort studies showed that non-vitamin K antagonist OACs (NOACs) would be more favorable choices compared to warfarin for stroke prevention in the elderly. This review will discuss important data on stroke prevention and the use of NOACs in elderly AF patients.

Obesity paradox in patients with chronic total occlusion of coronary artery

BACKGROUND

Obesity is associated with metabolic syndrome which increases further risk of coronary artery disease and adverse cardiovascular events. Impact of body mass index (BMI) on long-term outcome in patients with coronary chronic total occlusion (CTO) is less clear.

METHOD AND RESULTS

From January 2005 to November 2020, a total of 1301 patients with coronary angiographic confirmed CTO were enrolled in our study. Patients were divided into two groups: low BMI group: 18-24.99 kg/m² and high BMI group ≥25 kg/m² . Clinical outcomes were 3-year all-cause mortality, 3-year cardiovascular mortality and 3-year non-fatal myocardial infarct. During the 3-year follow-up period, all-cause mortality was significantly higher in patients with low BMI group compared to those in high BMI groups (14% vs. 6%, p = .0001). Kaplan-Meier analysis showed patients with high BMI groups had significant better survival compared with those in low BMI group (p = .0001). In multivariate analysis, higher BMI was independently associated with decreased risk of 3-year all-cause mortality (Hazard ratio [HR]: 0.534; 95% confidence interval [CI]: 0.349-0.819, p = .004) after controlling for age, renal function, prior history of stroke, coronary artery bypass graft, co-morbidities with peripheral arterial disease, heart failure and revascularization status for CTO. In propensity-matched multivariate analysis, high BMI remained a significant predictor of 3-year all-cause mortality (HR, 0.525; 95% CI, 0.346-0.795, p = .002).

CONCLUSION

Higher BMI was associated with better long-term outcome in patients with coronary CTO.

Technical Characteristics and Feasibility of Coronary Angiography and Percutaneous Coronary Interventions Performed after Transcatheter Aortic Valve Replacement with Self-Expanding Valves

BACKGROUND

Coronary angiography (CA) or percutaneous coronary intervention (PCI) after transcatheter aortic valve replacement (TAVR) may become technically challenging after implantation of the self-expanding Medtronic CoreValve (MCV) device, which extends above the coronary ostia. The aim of this study was to investigate the incidence and feasibility of CA or PCI and the outcomes of PCI after TAVR with the MCV device.

METHODS

From July 2014 to April 2020, among 209 patients treated with TAVR with a MCV device, 14 (7%) underwent CA or PCI after the procedure at a mean duration of 28 ± 15 months at our institution.

RESULTS

The mean age of the patients was 83 ± 6 years. Thirteen (93%) patients underwent CA due to angina symptoms with a positive noninvasive test, and 1 underwent CA for acute coronary syndrome. Most of the CA and PCI procedures were performed through a radial approach: 11 patients (79%) via the right radial artery, 1 (7%) the left radial artery, and 2 (14%) through the right femoral artery. CA of the left and right coronary arteries was successfully achieved in 13 patients (93%) with Judkin left (3.5 to 5) diagnostic catheters and in 11 patients (79%) with Judkin right (4) diagnostic catheters. The second-line catheter of choice was the Amplatz left (AL) 1 catheter for the right coronary artery and AL 2 for the left coronary artery. Procedural success was achieved in all 5 patients who underwent post-TAVR PCI without procedural or in-hospital complications. The use of a Guideliner microcatheter facilitated stent delivery in one patient.

CONCLUSIONS

Coronary angiography or PCI following TAVR with a MCV device is feasible and safe, but requires understanding of the three-dimensional geometry of the prosthetic valve and its relationship to the coronary ostia.

Elevated serum galectin-1 concentrations are associated with increased risks of mortality and acute kidney injury in critically ill patients

Background

Galectin-1 (Gal-1), a member of the β-galactoside binding protein family, is associated with inflammation and chronic kidney disease. However, the effect of Gal-1 on mortality and acute kidney injury (AKI) in critically-ill patients remain unclear.

Methods

From May 2018 to March 2020, 350 patients admitted to the medical intensive care unit (ICU) of Taipei Veterans General Hospital, a tertiary medical center, were enrolled in this study. Forty-one patients receiving long-term renal replacement therapy were excluded. Serum Gal-1 levels were determined within 24 h of ICU admission. The patients were divided into tertiles according to their serum Gal-1 levels (low, serum Gal-1 < 39 ng/ml; median, 39–70 ng/ml; high, ≥71 ng/ml). All patients were followed for 90 days or until death.

Results

Mortality in the ICU and at 90 days was greater among patients with elevated serum Gal-1 levels. In analyses adjusted for the body mass index, malignancy, sepsis, Sequential Organ Failure Assessment (SOFA) score, and serum lactate level, the serum Gal-1 level remained an independent predictor of 90-day mortality [median vs. low: adjusted hazard ratio (aHR) 2.11, 95% confidence interval (CI) 1.24–3.60, p = 0.006; high vs. low: aHR 3.21, 95% CI 1.90–5.42, p < 0.001]. Higher serum Gal-1 levels were also associated with a higher incidence of AKI within 48 h after ICU admission, independent of the SOFA score and renal function (median vs. low: aHR 2.77, 95% CI 1.21–6.34, p = 0.016; high vs. low: aHR 2.88, 95% CI 1.20–6.88, p = 0.017). The results were consistent among different subgroups with high and low Gal-1 levels.

Conclusion

Serum Gal-1 elevation at the time of ICU admission were associated with an increased risk of mortality at 90 days, and an increased incidence of AKI within 48 h after ICU admission.

Non-vitamin K antagonist oral anticoagulants versus warfarin in AF patients ≥ 85 years

BACKGROUND

Atrial fibrillation (AF) prevalence and its risk of stroke rise with ageing. We aimed to investigate the outcomes of NOAC and warfarin in AF patients aged ≥ 85 years.

METHODS

This is a retrospective study using Taiwan National Health Insurance Research Database. A total of 15,361 patients aged ≥ 85 years with AF on oral anticoagulants were identified. The end points included ischaemic stroke, intracranial haemorrhage (ICH), major bleeding, all-cause mortality and composite adverse events (ICH or major bleeding or all-cause mortality). Clinical outcomes were compared between each NOAC and warfarin after propensity matching.

RESULTS

Before propensity matching, patients taking warfarin were older, more female with more comorbidities than NOACs users. After propensity matching, baseline characteristics did not differ significantly between matched subjects receiving warfarin and each NOAC. Compared to warfarin, dabigatran was associated with a lower risk of ICH (hazard ratio [HR] 0.496), mortality (HR 0.558) and adverse events (HR 0.628), while rivaroxaban was associated with a lower risk of ischaemic stroke (HR 0.781), ICH (HR 0.453), mortality (HR 0.558) and adverse events (HR 0.636). Apixaban was associated with a lower risk of mortality (HR 0.488) and adverse events (HR 0.557) compared to warfarin. (all P < .05).

CONCLUSION

For the efficacy, NOACs were associated with a comparable or lower risk of ischaemic stroke compared to warfarin. For adverse events, NOACs were associated with a lower risk of all-cause mortality and composite adverse events. In the elderly AF population, NOACs could be a more favourable choice for stroke prevention.

Long term clinical impact of successful recanalization of chronic total occlusion in patients with and without type 2 diabetes mellitus

BACKGROUND

Diabetes mellitus is one of the risk factors for coronary artery disease and frequently associated with multivessels disease and poor clinical outcomes. Long term outcome of successful revascularization of chronic total occlusions (CTO) in diabetes patients remains controversial.

METHODS AND RESULTS

From January 2005 to December 2015, 739 patients who underwent revascularization for CTO in Taipei Veterans General Hospital were included in this study, of which 313 (42%) patients were diabetes patients. Overall successful rate of revascularization was 619 (84%) patients whereas that in diabetics and non-diabetics were 265 (84%) and 354 (83%) respectively. Median follow up was 1095 days (median: 5 years, interquartile range: 1-10 years). During 3 years follow-up period, 59 (10%) in successful group and 18 (15%) patients in failure group died. Although successful revascularization of CTO was non-significantly associated with better outcome in total cohort (hazard ratio (HR): 0.593, 95% confidence interval (CI) 0.349-0.008, P: 0.054), it might be associated with lower risk of all-cause mortality (HR: 0.307, 95% CI 0.156-0.604, P: 0.001) and CV mortality (HR: 0.266, 95% CI 0.095-0.748, P: 0.012) in diabetics (P: 0.512). In contrast, successful CTO revascularization didn't improve outcomes in non-diabetics (all P > 0.05). In multivariate cox regression analysis, successful CTO revascularization remained an independent predictor for 3-years survival in diabetic subgroup (HR: 0.289, 95% CI 0.125-0.667, P: 0.004). The multivariate analysis result was similar after propensity score matching (all-cause mortality, HR: 0.348, 95% CI 0.142-0.851, P: 0.021).

CONCLUSIONS

Successful CTO revascularization in diabetes may be related to better long term survival benefit but not in non-diabetic population.

Association of Ischemic Stroke, Major Bleeding, and Other Adverse Events With Warfarin Use vs Non-vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation With a History of Intracranial Hemorrhage

IMPORTANCE

Current guidelines recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). Data regarding warfarin sodium use compared with NOAC use in patients with AF with a history of intracranial hemorrhage (ICH) are limited.

OBJECTIVE

To compare the clinical outcomes of warfarin use and NOAC use in patients with AF with a history of ICH using a nationwide cohort with AF.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide cohort study from January 1, 2012, to December 31, 2016, was performed using data from the Taiwan National Health Insurance Research Database. The dates of analysis were July 1 to September 1, 2019. The study population comprised patients with AF with a history of ICH and a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, prior stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease], age 65-74 years, sex category [female]) of at least 1 for men or at least 2 for women who had received warfarin or NOACs. The clinical outcomes were examined using Cox proportional hazards regression analyses among the study population before and after propensity score matching.

EXPOSURES

Oral anticoagulation with warfarin or NOACs.

MAIN OUTCOMES AND MEASURES

The clinical outcomes measured were all-cause mortality, ischemic stroke, ICH, major bleeding, and adverse events.

RESULTS

The study cohort included 4540 patients (mean [SD] age, 76.0 [10.5] years; 2653 men [58.4%]), with 1047 patients receiving warfarin (mean [SD] age, 75.1 [11.4] years; 571 men [54.5%]) and 3493 patients receiving NOACs (mean [SD] age, 76.3 [10.2] years; 2082 men [59.6%]). Compared with warfarin use, NOAC use was associated with statistically significantly lower risk of all-cause mortality (adjusted hazard ratio [aHR], 0.517; 95% CI, 0.457-0.585), ICH (aHR, 0.556; 95% CI, 0.389-0.796), and major bleeding (aHR, 0.645; 95% CI, 0.525-0.793), whereas the rate of ischemic stroke was similar in the 2 groups (aHR, 0.879; 95% CI, 0.678-1.141). These results were generally consistent after propensity score matching among 973 patients in each group.

CONCLUSIONS AND RELEVANCE

Among patients with AF with prior ICH, NOAC use was associated with lower rates of ICH and major bleeding compared with warfarin use, whereas the rate of ischemic stroke was similar in the 2 groups. Among patients with AF with prior ICH, NOACs could be the preferred choice for stroke prevention.

Associations of antithrombotic agent use with clinical outcomes in critically ill patients with troponin I elevation in the absence of acute coronary syndrome

Introduction

To evaluate efficacy of antithrombotic agents in critically ill patients with elevated troponin I level during intensive care unit (ICU) admission.

Methods and results

It was a retrospective observational study which was conducted in a tertiary teaching hospital in Taipei, Taiwan. All patients hospitalized in ICU for >3 days and with available serum troponin I data from December 2015 to July 2017 were included. Patients with definite diagnosis of acute myocardial infarction (AMI) were excluded. We divided patients with troponin I elevation into three groups; no prescription, chronic prescription and new prescription of antithrombotic agents during ICU admission. We defined new prescription when patients were on antithrombotic agents, including antiplatelet agents, direct oral anticoagulants, and warfarin after troponin I was found to be elevated at ICU admission and chronic prescription, if antithrombotic agents were on medication list more than 30 days before ICU admission. Primary outcomes were 30-day and one-year all-cause mortality. Of 597 subjects who met inclusion criteria, 407 (68%) patients had elevated troponin I (>0.1 ng/mL) on ICU admission. These patients had increased 30-day [hazard ratio (HR), 1.679; 95% confidence interval (CI), 1.132–2.491; p = 0.009] and one-year (HR, 1.568; 95% CI, 1.180–2.083; p = 0.002) all-cause mortality compared with those without elevated troponin I. In patients with elevated troponin I, there was no significant difference of 30-day all-cause mortality among three groups (p = 0.051) whereas patients on chronic prescription showed significant survival benefit in one-year all-cause mortality when compared to those without or with new prescription (p = 0.008).

Conclusions

In critically ill patients, elevated troponin I in the absence of AMI was associated with poor prognosis. Newly prescribed antithrombotic agents in ICU didn’t reveal the difference in short and long-term prognosis while chronic antithrombotic agent use was associated with better one-year survival rate, suggesting that these drugs play a protective role in this high-risk population.

Uninterrupted non-vitamin K antagonist oral anticoagulants during implantation of cardiac implantable electronic devices in patients with atrial fibrillation

BACKGROUND

For patients with atrial fibrillation (AF) receiving cardiac implantable electronic device (CIED) implantations, current consensus recommends uninterrupted non-vitamin K antagonist oral anticoagulant (NOAC) considering low incidence of bleeding or thrombo-embolic events. It remains unknown whether uninterrupted strategy outweighs discontinuation method for patients receiving NOAC.

METHODS

From January 1, 2013 to June 1, 2017, we enrolled 100 patients (mean age 78.3 ± 10.2 years, 58% male) with AF taking NOAC for stroke prevention eligible for CIED implantation in a tertiary medical center, Taipei, Taiwan. NOAC was continued without skipping any doses during the surgery. The baseline characteristics, underlying diseases, CHA2DS2-VASc score, and clinical course of every patient were reviewed and analyzed.

RESULTS

Among these patients, 28 were on dabigatran, 61 on rivaroxaban, 10 on apixaban, and one on edoxaban, respectively. There were no adverse events except one case of pericardial effusion and another one with large pocket hematoma. One patient receiving implantable cardioverter defibrillator implantation had late onset of pericardial effusion with impending tamponade necessitating pericardiocentesis. Another patient had large pocket hematoma, which spontaneously resolved within 1 month without further intervention. No periprocedural mortality and stroke occurred.

CONCLUSION

Uninterrupted NOAC during CIED implantations may be an acceptable option especially in patients with high risk for thromboembolism. However, special caution should be paid during defibrillator implantation considering relatively higher risk of bleeding, perhaps due to the larger size of the defibrillator lead.

Epigenetic therapies by targeting aberrant histone methylome in AML: molecular mechanisms, current preclinical and clinical development

While the current epigenetic drug development is still largely restricted to target DNA methylome, emerging evidence indicates that histone methylome is indeed another major epigenetic determinant for gene expression and frequently deregulated in acute myeloid leukaemia (AML). The recent advances in dissecting the molecular regulation and targeting histone methylome in AML together with the success in developing lead compounds specific to key histone methylation-modifying enzymes have revealed new opportunities for effective leukaemia treatment. In this article, we will review the emerging functions of histone methyltransferases and histone demethylases in AML, especially MLL-rearranged leukaemia. We will also examine recent preclinical and clinical studies that show significant promises of targeting these histone methylation-modifying enzymes for AML treatment.

Efficacy and Safety of Valsartan/Hydrochlorothiazide Fixed-dose Combination Compared with Amlodipine Monotherapy as First-line Therapy for Mild to Moderate Hypertension

This double-blind, active- and randomized-controlled study compared the efficacy and safety of a fixed-dose combination of valsartan/hydrochlorothiazide 80 mg/12.5 mg once daily ( n = 32) with amlodipine monotherapy 5 mg once daily ( n = 33) for 8 weeks in patients with mild to moderate hypertension. Non-inferiority of valsartan/hydrochlorothiazide to amlodipine was demonstrated by comparable reductions in sitting systolic blood pressure (SBP), sitting diastolic blood pressure (DBP), and daytime, night-time and 24-h SBP and DBP on ambulatory blood pressure monitoring. Between-group comparisons of adverse events and changes in laboratory parameters did not reach statistical significance, except for uric acid which showed a significant increase in the valsartan/hydrochlorothiazide group compared with the amlodipine group, but was still below the laboratory's upper limit of normal. In conclusion, the use of the fixed-dose combination of valsartan/hydrochlorothiazide 80 mg/12.5 mg once daily as a starting regimen in patients with mild to moderate hypertension was shown to have non-inferior efficacy and comparable safety for daily practice compared with amlodipine 5 mg once daily monotherapy.

Relation of Chlamydia pneumoniae infection in Taiwan to angiographically demonstrated coronary artery disease and to the presence of acute myocardial infarction or unstable angina pectoris

Reports of the association of Chlamydia pneumoniae (C. pneumoniae) infection with coronary artery disease (CAD) are scarce in the Oriental population. We therefore conducted a case-control study to explore this issue in Taiwan. There were 242 consecutive subjects (166 men and 76 women) who underwent cardiac catheterization at the National Taiwan University Hospital Cardiac Catheterization Laboratory. Patients with CAD (n = 156) had > or = 1 coronary artery lesion of > 50% diameter stenosis on angiography. Controls (n = 86) had no demonstrable CAD angiographically. Antibodies to C. pneumoniae were tested by using an enzyme-linked immunosorbent assay. The prevalence of antibodies to C. pneumoniae was as follows: immunoglobulin-G (IgG), 50% (122 of 242 patients); immunoglobulin-A (IgA), 72% (176 of 242 patients); and either IgG or IgA, 79% (192 of 242 patients ). The odds ratio (OR) for CAD with either IgG or IgA was 1.4 (95% confidence interval [CI] 0.7 to 2.7, p = 0.31). After adjusting for the known CAD risk factors, the OR decreased to 0.8 (95% CI 0.3 to 2.1, p = 0.60). The OR for unstable angina or acute myocardial infarction with the presence of either IgG or IgA was 0.5 (95% CI 0.2 to 1.1, p = 0.08) and 0.4 ( 95% CI 0.1 to 1.0, p = 0.049) after adjusting for other risk factors. These results suggest a high prevalence of C. pneumoniae infection in Taiwan. However, C. pneumoniae infection is not associated with angiographically documented CAD, and, in contrast, is a negative predictor for the development of acute coronary syndromes.

Disinfection of hospital waste sludge using hypochlorite and chlorine dioxide

Hypochlorite and chlorine dioxide were used to disinfect hospital waste-water sludge. Their abilities to inactivate pathogenic micro-organisms were compared. Reductions in indigenous coliform organisms and Pseudomonas aeruginosa were estimated. The results indicate that hypochlorite is a better disinfectant than chlorine dioxide for coliforms. Higher disinfection efficiency was obtained by treating a lower concentration of sludge. In addition, a higher agitation speed gave a higher disinfection efficiency with hypochlorite. The disinfection efficiencies of both disinfectants were higher against settled sludge than against thickened sludge. Therefore, it is recommended that disinfection should be performed on settled sludge rather than in a thickening tank.

Quantification of pathogenic micro-organisms in the sludge from treated hospital wastewater

The sludge from hospital waste treatment facilities is a potential source of infectious organisms. The average numbers of micro-organisms in the sludge of hospital wastewater in Taiwan were as follows: total count 8.1 x 10(7) cfu g-1 (dry weight of sludge), and 1.4 x 10(6), 3.6 x 10(5), 1.6 x 10(5), 2.2 x 10(5) and 5.5 x 10(4) cfu g-1 (dry weight of sludge) for total coliforms, faecal coliforms, faecal streptococci, Pseudomonas aeruginosa and Salmonella spp., respectively. Salmonella spp. were detected in 37% (10 of 27) of the sludges from hospital wastewaters. Therefore, the treatment of such sludge to reduce pathogenic micro-organisms should be considered.

Purinoceptor-stimulated phosphoinositide hydrolysis in Madin-Darby canine kidney (MDCK) cells

Extracellular nucleotides, acting through P2-purinoceptors, have been implicated in the regulation of ion transport in epithelia, including Madin-Darby canine kidney (MDCK) cells. In this study, experiments were conducted to characterize the P2-purinoceptor subtype on MDCK cells responsible for stimulating inositol phosphate (IP) accumulation using a range of nucleotide analogues. In Ca2+- and Mg2+-free Krebs-Henseleit solution (KHS), ATP, UTP, and ATPgammaS caused an increase in IP accumulation as a function of concentration with comparable kinetics. The order of potency for the nucleotide analogues was UTP = ATPgammaS > ATP = 2-chloro ATP (Cl-ATP) >> alpha,beta-methylene ATP (alpha,beta-MeATP) = 2-methylthio ATP (2MeSATP). Selective agonists for P1-, P2X- and P2Y-purinoceptors, such as N6-cyclopentyl adenosine, AMP, alpha,beta-MeATP, and 2MeSATP, had little effect. Stimulation of MDCK cells with maximally effective concentrations of ATP and UTP showed no additive effect and furthermore, ATP, UTP, and ATPgammaS induced cross-desensitization of the IP response, suggesting that ATP and UTP act upon a common nucleotide receptor, i.e. a P2U-purinoceptor. In Ca2+- and Mg2+-containing KHS, the concentration-response curves of ATP, UTP, and ATPgammaS were shifted to the right of those obtained in Ca2+- and Mg2+-free buffer, and asymptotic maxima were not reached, indicating that ATP4- and not MgATP2- or CaATP2- was the active agonist. Pretreatment of MDCK cells with pertussis toxin (PTX) inhibited ATP- and UTP-induced IP accumulation in a concentration-dependent fashion but did not completely abolish the IP accumulation, indicating that a PTX-sensitive G protein was partially involved in the IP response. In conclusion, ATP- and UTP-stimulated IP accumulation in MDCK cells appears to be mediated through the activation of P2U-purinoceptors coupled to a G protein that is partially sensitive to PTX. A form of nucleotide uncomplexed with divalent ions such as ATP4- seems to be the preferential agonist form for the purinoceptors on MDCK cells.

Effect of forskolin on bradykinin-induced calcium mobilization in cultured canine tracheal smooth muscle cells

The effects of increases in intracellular adenosine 3':5'-cyclic monophosphate (cyclic AMP) on bradykinin (BK)-induced generation of inositol phosphates (IPs) and Ca2+ mobilization were investigated in canine cultured tracheal smooth muscle cells (TSMCs). Pretreatment of TSMCs with either forskolin or dibutyryl cyclic AMP attenuated BK-stimulated responses. The inhibitory effects of these agents produced both a depression of the maximal response and a shift to the right of the concentration-response curves of BK. The water-soluble forskolin analogue L-858051, 7-deacetyl-7 beta-(r-N-methylpiperazino)-butyryl forskolin, significantly attenuated BK-stimulated IPs accumulation, while 1,9-dideoxy forskolin, an inactive forskolin, had little effect on IPs response. Moreover, SQ-22536, 9-(tetrahydro-2-furanyl)-9-H-purin-6-amine, an inhibitor of adenylate cyclase, and both H-89, N-(2-aminoethyl)-5-isoquinolinesulfonamide, and HA-1004, N-(2-guanidinoethyl)-5-isoquinolinesulfonamide, inhibitors of cyclic AMP-dependent protein kinase (PKA), reversed the ability of forskolin to attenuate BK-stimulated IPs accumulation. The KD and Bmax, values of the BK receptor for [3H]BK binding were not significantly changed by forskolin treatment for 30 min and 4 h. The AlF4(-)-induced IPs accumulation was attenuated by forskolin, indicating that G protein(s) are directly activated by AlF4- and uncoupled to phospholipase C by forskolin treatment. These results suggest that activation of cyclic AMP/PKA might inhibit the BK-stimulated PI breakdown and consequently reduce the [Ca2+]i increases or inhibit independently both responses, which is distal to the BK receptor in canine cultured TSMCs.

Pharmacological and functional characterization of bradykinin receptors in canine cultured tracheal epithelial cells

1. A direct [3H]-bradykinin ([3H]-BK) binding assay has been used to characterize the BK receptors in canine cultured tracheal epithelial cells (TECs). Based on receptor binding assay, TECs have specific, saturable, high-affinity binding sites for [3H]-BK. 2. The specific [3H]-BK binding was time- and temperature-dependent. Equilibrium of association of [3H]-BK with the BK receptors was attained within 30 min at room temperature and 1 h at 4 degrees C, respectively. 3. Analysis of binding isotherms yielded an apparent equilibrium dissociation constant (KD) of 1.5 +/- 0.2 nM and a maximum receptor density (Bmax) of 53.2 +/- 5.2 fmol mg-1 protein. The Hill coefficient for [3H]-BK binding was 1.00 +/- 0.02. The association (K1) and dissociation (K-1) rate constants were (7.6 +/- 1.1) x 10(6) M-1 min-1 and (9.2 +/- 1.5) x 10 M-3 min-1, respectively. KD, calculated from the ratio of K-1 and K1, was 1.2 +/- 0.3 nM, a value close to that calculated from Scatchard plots of binding isotherms. 4. Neither a B1 receptor selective agonist (des-Arg9-BK, 0.1 nM - 10 microM) nor antagonist ([Leu8, des-Arg9]-BK, 0.1 nM - 10 microM) significantly inhibited [3H]-BK binding to TECs, which excludes the presence of B1 receptors in canine TECs. 5. The specific binding of [3H]-BK to canine TECs was inhibited by the B2 receptor selective antagonists ([D-Arg0, Hyp3, Thi5, D-Tic7, Oic8]-BK (Hoe 140, 0.1 nM-10 microM) and [D-Arg0, Hyp3, Thi5.8, D-Phe7]-BK, 0.1 nM - 10 microM) and agonists (BK and kallidin, 0.1 nM-10 microM) with a best fit by a one-binding site model. The order of potency for the inhibition of [3H]-BK binding was kallidin = BK = Hoe 140 > [D-Arg0, Hyp3, Thi5,8, D-Phe7]-BK. 6. BK and kallidin significantly induced concentration-dependent accumulation of IPs with a half-maximal response (EC50) at 17.6 +/- 3.5 and 26.6 +/- 5.3 nM, respectively, while the B1-selective agonist, des-Arg9-BK did not stimulate IPs accumulation and the B1-selective antagonist [Leu8, des-Arg9]-BK did not inhibit BK-induced IPs accumulation. Two B2-selective antagonists, Hoe 140 and [D-Arg0, Hyp3, Thi5,8, D-Phe7]-BK, inhibited BK-stimulated IPs accumulation with apparent pKB values of 8.8 +/- 0.3 and 7.0 +/- 0.3, respectively. 7. It is concluded that the pharmacological characteristics of the BK receptors in canine cultured TECs are primarily of the B2 receptor subtype which might regulate the function of tracheal epithelium through the activation of this receptor subtype coupling to PI hydrolysis.

Genetic grouping for the isolates of avian infectious bronchitis virus in Taiwan

In order to differentiate recent isolates of avian infectious bronchitis virus (IBV) in Taiwan, polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP), and direct sequencing methods were used to type 25 IBV Taiwan isolates. Two conserved sequences that flank the hypervariable region I (HVR I) in the N-terminus of S1 protein gene were chosen as primers. Sequences of 228-231 base pairs (bp) were amplified by PCR from 25 Taiwan isolates and 4 reference strains (H120, Conn, JMK, Holte). PCR products were digested with 5 restriction endonucleases, BsoFI, DdeI, MboII, AluI, RsaI, and different IBV isolates were grouped according to their RFLP patterns. The RFLP patterns of the 4 reference strains in this study matched the published sequences in GenBank. Except 1 vaccine strain, the other 24 Taiwan isolates were different from these 4 and 18 other IBV strains whose sequences were published. The data from PCR-RFLP and sequencing of IBV genomes showed that the 24 Taiwan isolates can be divided into 2 distinct groups, I and II. Seven RFLP patterns are identified in group I and only 1 in group II.

Complete two-handed laparoscopic appendectomy: report of 100 cases

A complete two-handed technique for laparoscopic appendectomy is described. From April 1992 to July 1994, 100 patients with suspected acute appendicitis were selected to undergo this approach. This technique allows the surgeon to manipulate instruments with both hands for dissecting, transecting and removing the appendix. The appropriate placement of three cannulas in the lower abdominal midline makes this technique possible. Monopolar cautery is used to dissect the mesoappendix and to cauterize the appendicular vessels. Two ligatures are placed at the junction of the appendix with the cecum. The appendix is clamped at its base by ratchet forceps and is extracted along with the forceps immediately after transection. None of the patients selected for this procedure required conversion to open appendectomy. Postoperative complications occurred in four patients, two with umbilical wound infections and two with intra-abdominal abscesses; 12 patients had perforated appendicitis. The results of this study suggest that a complete two-handed laparoscopic appendectomy can be safely and successfully accomplished in patients with suspected acute appendicitis.

Effect of phorbol ester on phosphoinositide hydrolysis and calcium mobilization induced by endothelin-1 in cultured canine tracheal smooth muscle cells

Regulation of the increase in inositol 1,4,5-trisphosphate (IP3) production and intracellular Ca2+ concentration ([Ca2+]i) by protein kinase C (PKC) was investigated in cultured canine tracheal smooth muscle cells (TSMCs). Stimulation of TSMCs by endothelin-1 (ET-1) led to IP3 formation and caused an initial transient peak followed by a sustained elevation of [Ca2+]i in a concentration-dependent manner. Pretreatment of TSMCs with phorbol 12-myristate 13-acetate (PMA, 1 microM) for 30 min blocked the ET-1-induced IP3 formation and Ca2+ mobilization. However, this inhibition was reduced after incubating the cells for 8 h with PMA. Following preincubation, ET-1-induced Ca2+ mobilization recovered with time and reached the same extent of control cells within 48 h. The concentrations of PMA that gave half-maximal inhibition (-logEC50) of ET-1-induced IP3 formation and increase in [Ca2+]i were 8.6 and 8.4 M, respectively. Prior treatment of TSMCs with staurosporine (1 microM), a PKC inhibitor, inhibited the ability of PMA to attenuate ET-1-induced responses, suggesting that the inhibitory effect of PMA is mediated through the activation of PKC. In parallel with the effect of PMA on the ET-1-induced IP3 formation and Ca2+ mobilization, a change of PKC activity was observed in TSMCs. PMA rapidly decreased PKC activity in the cytosol of TSMCs, while increasing it transiently in the membranes within 30 min. Thereafter the membrane-associated PKC activity decreased and persisted for at least 24 h of PMA treatment. Taken together, these results suggest that activation of PKC may inhibit the phosphoinositide hydrolysis and consequently attenuate the [Ca2+]i increase or inhibit independently both responses. The PMA-induced inhibition of responses to ET-1 was associated with an increase in membranous PKC activity.

Transaxillary endoscopic sympathectomy--a report of experience in 150 patients with palmar hyperhidrosis

We report our 1-year experience with transaxillary endoscopic sympathectomy in 150 patients with palmar hyperhidrosis (PH). The double-puncture technique of video laparoscopy was used in a transaxillary approach to perform the sympathectomy by either electrocautery (EC; 93.3%) or electroresection (ER; 7.7%). The procedure was successfully completed in 299 operated limbs and required conversion to open surgery in 1 operated limb because of extensive pleural adhesions. The mean operative time of EC was significantly less than that of ER. In a total of 29 procedures, there were three technical complications. Most patients (92.7%) were discharged after an overnight hospital stay. On the seventh postoperative day, the cure rate was 99.3%. During the mean follow-up period of 200.1 days, there was no recurrence in 130 patients. Apparent compensatory hyperhidrosis occurred in 28 patients (21.5%). In conclusion, transaxillary endoscopic sympathectomy offers a simple and effective treatment to patients with PH, resulting in a shorter hospital stay and convalescent period.

A comparison of the effects of electrical stimulation of the amygdala and hippocampus on subpallidal output neurons to the pedunculopontine nucleus

Recordings were made of the electrical activity of neurons in the subpallidal area of urethane-anesthetized rats. Output neurons from the subpallidal area to the pedunculopontine nucleus were identified by antidromic activation. The inputs to subpallidal neurons to single-pulse stimulation of the amygdala and hippocampus were investigated. More than two-thirds of the subpallidal neurons antidromically activated by pedunculopontine stimulation were inhibited by hippocampal stimulation and activated by amygdala stimulation. Subpallidal neurons not antidromically activated by pedunculopontine stimulation also responded to stimulation of the amygdala and hippocampus but no differential effects were observed. The relation of these findings to limbic influences on locomotor activity is discussed.

Involvement of serotonin in mediation of inhibition of substantia nigra neurons by noxious stimuli

Neuronal activities of the substantia nigra pars compacta (SNC) are known to be inhibited by noxious stimuli. Extracellular recording of spontaneous firing of SNC neurons were made to investigate how such inhibition would be influenced by treatment with 5,7-dihydroxytryptamine (5,7-DHT) or p-chlorophenylalanine (PCPA) or by IV injection of the serotonin antagonist, cyproheptadine. Noxious stimuli were produced by tail pinching (TP) and tail heating (HW). In 5,7-DHT-treated experiment, the inhibition indices were 62.8 +/- 4.4 (TP) and 63.4 +/- 4.6 (HW)% for vehicle-treated control, then the inhibition indices were 26.3 +/- 2.6 (TP) and 27.8 +/- 2.9 (HW)% for 5,7-DHT-treated animals. As to the PCPA-treated experiment, the inhibition indices were 63.1 +/- 2.6 (TP) and 64.8 +/- 2.5 (HW)% for saline control rats, while the inhibition indices were 30.3 +/- 1.6 (TP) and 30.1 +/- 1.6 (HW)% for the PCPA-treated ones. Furthermore, in another observation, the firing rates of SNC neurons were reduced from the saline (control) level by 53.2 +/- 2.12 and 52.1 +/- 2.07% during the application of stimulation of TP and HW, respectively. Following the intravenous injection of cyproheptadine, the firing rates of those were reduced by only 6.71 +/- 1.38 and 4.38 +/- 1.79% for TP and HW, respectively. That is, the TP- and HW-induced inhibition were attenuated about 47% by the injection of cyproheptadine. The results strongly suggested that the serotonergic mechanism would be involved in the mediation of the inhibition of SNC neurons by noxious stimuli.

Subpallidal-pedunculopontine projections but not subpallidal-mediodorsal thalamus projections contribute to spontaneous exploratory locomotor activity

The contribution of the pedunculopontine nucleus to exploratory locomotion was investigated in rats. Locomotor activity recorded in a standard open-field apparatus was increased more than two-fold when wooden panels were inserted. This novelty-elicited locomotion was reduced significantly when procaine was injected bilaterally into the pedunculopontine nucleus but not when procaine was injected bilaterally into the mediodorsal thalamus, a second major projection site of the subpallidal area. These results support observations from earlier studies implicating hippocampal-accumbens-subpallidal-pedunculopontine projections in exploratory locomotion.

Calculated power absorption patterns for hyperthermia applicators consisting of electric dipole arrays

We have applied the plane-wave spectrum method to obtain a technique for calculating the internal fields in a lossy dielectric half-space irradiated by rather arbitrary sources. We used the technique to calculate power absorption profiles of some idealized aperture sources to gain insight into how the source parameters affect the power absorption profile. With this insight, we next calculated power absorption profiles of some linear electric dipole antenna arrays. From these results we developed a simpler method of optimizing the antenna parameters by calculating their field pattern in an infinite water medium, which does not require the PWS method and is therefore faster and cheaper. Using this technique, we found an antenna array with reasonably practical parameters that produces an appealing calculated power absorption profile. We also made some calculations based on a simple approximate model that indicate that a three-element dipole array on the front of a patient and a similar one on the back could produce deep central heating. Although our calculations are based on a somewhat crude dielectric half-space model of the body, the results provide valuable insight about power absorption profiles and indicate that practical systems for producing deep internal heating without overheating the surface of the body could be developed.

Effect of mouse anti-I region antiserum and complement on human mononuclear cell response to concanavalin A

Pretreatment of human peripheral blood mononuclear cells with mouse anti-Ia serum and complement was found to inhibit the subsequent T cell proliferative response to Con A. The cells from each individual tested were inhibited, regardless of DR allospecificity. Inhibition of Con A response by mouse anti-Ia antibodies and C was found to be due to elimination of adherent accessory cells (monocytes) rather than T cells. Anti-Ia serum appeared to recognize an essential subpopulation of human monocytes bearing cross-reactive antigens, since not all monocytes treated with anti-Ia serum and C were lysed. The use of highly restricted mouse anti-Ia serum demonstrated that the required monocyte population expressed antigens recognized by antibodies with activity to I-Ek products (Ia specificities Ia.7 and Ia.22). The required monocyte subpopulation was also recognized by a monoclonal antibody specific for Ia.7. Mouse anti-I-Ek alloantiserum or monoclonal anti-Ia.7 antibodies may be important tools with which to study human monocytes, and for further characterization of DR determinant requirements for monocyte-antigen presentation and monocyte-T cell interactions.

Effect of mouse anti-I region antiserum and complement on human mononuclear cell response to concanavalin A

Pretreatment of human peripheral blood mononuclear cells with mouse anti-Ia serum and complement was found to inhibit the subsequent T cell proliferative response to Con A. The cells from each individual tested were inhibited, regardless of DR allospecificity. Inhibition of Con A response by mouse anti-Ia antibodies and C was found to be due to elimination of adherent accessory cells (monocytes) rather than T cells. Anti-Ia serum appeared to recognize an essential subpopulation of human monocytes bearing cross-reactive antigens, since not all monocytes treated with anti-Ia serum and C were lysed. The use of highly restricted mouse anti-Ia serum demonstrated that the required monocyte population expressed antigens recognized by antibodies with activity to I-Ek products (Ia specificities Ia.7 and Ia.22). The required monocyte subpopulation was also recognized by a monoclonal antibody specific for Ia.7. Mouse anti-I-Ek alloantiserum or monoclonal anti-Ia.7 antibodies may be important tools with which to study human monocytes, and for further characterization of DR determinant requirements for monocyte-antigen presentation and monocyte-T cell interactions.

Inhibition of neuronal activity of the substantia nigra by noxious stimuli and its modification by the caudate nucleus

In urethane-anesthetized rats discharges of neurons of substantia nigra, pars compacta (SNC) were recorded extracellularly after natural somatic sensory stimulation and electrical stimulation of peripheral sensory nerves. (1) Among different modalities of somatic sensory stimulation tested, noxious stimuli were effective in reducing spontaneous discharges of SNC neurons. The inhibition appeared with a concomitant increase of spike amplitude. The same inhibitory effect was obtained by stimulating the sciatic nerve (SC) repetitively. In response to single shock stimulation of the SC the inhibition occurred at an average latency of 39.6 msec (S.E. 1.6 msec) and lasted for 221.6 msec on average (S.E. 10.8 msec). (2) The SC-induced inhibition of SNC neurons failed to reliably block ortho- and antidromic discharges evoked from the caudate nucleus (Cd). (3) In rats with the Cd lesioned the SC-induced inhibition was longer lasting than in controls. When the Cd was stimulated concurrently with SC stimulation, the inhibition from the SC was weakened. (4) In a majority of SNC neurons, their inhibition by SC stimulation, their inhibition by SC stimulation was antagonized by intravenous injection of haloperidol.

Cortically induced inhibition of neurons of rat substantia nigra (pars compacta)

The effects of electrical stimulation of prefrontal cortex upon neurons of substantia nigra (pars compacta) in anesthetized rats were mostly inhibition without antidromic excitation. By studying nigral neurons in which the inhibition from caudate-putamen was antagonized by iontophoretic bicuculline, it was found in only half of them that the same drug also antagonized the inhibition from prefrontal cortex.

Effects of brain monoamine depletion on thermoregulation, active avoidance, and food and water intake in rats

Intraventricular administration of 6-OHDA or 5,6-DHT suppressed food intake, whereas their effect on active avoidance produced a suppression with the former and an enhancement with the latter. The increased water intake was specifically associated with 5,6-DHT treatment in rats.