The relationship of circulating MOTS-c level with liver fibrosis and metabolic components in patients with metabolic dysfunction-associated fatty liver disease

OBJECTIVE

Mitochondrial open reading frame of the 12s ribosomal RNA type-c (MOTS-c) is a novel identified mitochondrial signal transmission peptide that plays an important role in glucose, amino acid and lipid metabolism. In this study, we aimed to investigate the relationship of circulating MOTS-c level with noninvasive scores of fibrosis and the components of metabolic syndrome (MetS) in patients with metabolic dysfunction-associated fatty liver disease (MAFLD).

PATIENTS AND METHODS

This was a single-center cross-sectional study, and the participants were divided into two groups based on their liver ultrasound results: the fatty liver group and the healthy control group. The MOTS-c level was measured by the ELISA method. Non-alcoholic fatty liver disease fibrosis score (NFS) and fibrosis 4 (FIB-4) were used to determine the level of liver fibrosis. Statistical analyses were performed using Statistical Package for Social Science 15.0 package program.

RESULTS

One hundred fifty patients (male, n=57) with MAFLD [median age 41.0 (14) years] and 84 healthy controls (male, n=34) [median age 36.0 (22) years] were included in this study. Patients with MAFLD had significantly lower MOTS-c levels than the healthy controls (p=0.009). The MOTS-c level was significantly lower in subjects with MetS (n=48) compared to those without MetS (n=186) (p=0.01). In the total population (n=234), MOTS-c levels negatively correlated with the presence of MAFLD, NFS, FIB-4, and components of MetS.

CONCLUSIONS

Individuals diagnosed with MetS and MAFLD tend to have lower levels of MOTS-c. Additionally, these lower levels are inversely correlated with both the components of MetS and noninvasive fibrosis scores. MAFLD negatively correlated to the MetS components and noninvasive scores of fibrosis.

Abstract P2-12-04: Surgeon performed intraoperative ultrasound accurately predicts margin status after neaoadjuvant chemotheraphy

Objective: Neoadjuvant chemotraphy (NACT) is the preferred option of treatment in locally advanced and select cases of early stage breast cancer, currently. One of the major aims is to downstage tumor status allowing more conservative surgery with the most acceptable cosmetic outcome. The presence or absence of residual invasive cancer after NACT, is one of the strong prognostic factors for risk of recurrence and the margin status is the other. Due to the excess degree of fibrosis after tumor shrinkage, to accurately predict margin status intraoperatively after NACT is a challenge for surgeon. The aim of the presented study is to evaluate the efficacy of continuous intraoperative ultrasound guided breast conserving surgery (IUG-BCS) in terms of margin status and re-excision rate. The relationship between intraoperative assessment of gross macroscopic and ultrasonographic margins and cavity shavings results, were also analyzed.

Methods: Between 2014 and 2017, IUG-BCS were performed to 194 patients after NACT. Surgeon performed continuous peroperative real-time sonographic margin assessment during resection, macroscopic evaluation, specimen US including sonographic analysis of six faces of each specimen, and shaved cavity margins for permanent pathologic assessment were the standard steps of our methodology.

Results: Of the 194 patients, 82 (42.5%) had pathologic complete response (pCR) after NAC. The sensitivity of intraoperative ultrasound localization was 100% (194/194 cases). Patients were on average 53 years old (range, 28-65). There was no difference with respect to patient characteristics including age, menopausal status, personal-family history, oral contraceptive usage, body mass index and tumor localization. Mean tumor size was 5.42 cm before NAC and 2.56 cm after NAC, for those excluding ypT0. Of the 112 patients without pCR, tumor free margins were obtained by means of IUG-BCS in 99% (665/672) of margins evaluated sonographically. Moreover, the involved margins were correctly identified by the surgeon via specimen sonography in %71.4 of the cases (5/7) which was confirmed by cavity shaving results. No frozen section analysis was performed and macroscopic evaluation of the specimen predicted nothing significant. According to permanent section analysis of the resected specimens and cavity shavings, no further intervention was required due to margin positivity. IUG-BCS with real-time specimen sonography were unable to predict involved margins in only two cases, both of them proved to be invasive lobular carcinoma without evidence of residual cancer on pathological examination of cavity shavings. Accordingly, negative margins were achieved in 100% of cases at the initial procedure verified by permanent analysis.

Conclusion: Continuous intraoperative ultrasound with specimen sonography is an invaluable and effective modality to achieve negative surgical margins after NACT. Furthermore, meticulous sonographic assessment of specimen margins together with cavity shavings from tumor bed could be a feasible method to decrease re-excision rates without frozen section analysis leading to cost-effectiveness. However, the accuracy of sonography should be questioned in case of lobular histology.

Citation Format: Karadeniz Cakmak G, Mutlu S, Sen H, Engin H, Bahadir B, Bakkal H. Surgeon performed intraoperative ultrasound accurately predicts margin status after neaoadjuvant chemotheraphy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-04.

Long-Term Outcome of Consecutive Patients With Previous Coronary Bypass Surgery, Treated With Newer-Generation Drug-Eluting Stents

Background

Percutaneous coronary intervention (PCI) in patients with previous coronary artery bypass grafting (CABG) is associated with adverse clinical events. Although newer generation drug‐eluting stents showed favorable short‐term safety profiles, there is a lack of long‐term outcome data. We evaluated the impact of previous CABG on 5‐year clinical outcomes of patients treated with PCI using newer‐generation drug‐eluting stents.

Methods and Results

In this patient‐level pooled analysis of the prospective TWENTE (The Real‐World Endeavor Resolute versus Xience V Drug‐Eluting Stent Study in Twente) trial and nonenrolled TWENTE registry, we assessed a consecutive series of patients who underwent PCI with newer‐generation drug‐eluting stents for non–ST‐segment–elevation acute coronary syndromes or stable angina. Of all 1709 patients, 202 (11.8%) had a history of CABG. Patients with previous CABG had significantly higher 5‐year rates of cardiac death (10.4% versus 4.3%; P<0.001) and target vessel revascularization (25.0% versus 8.1%; P<0.001). These differences remained statistically significant after adjustment for differences in baseline characteristics. Landmark analysis revealed that from 1‐ to 5‐year follow‐up, the rates of cardiac death (8.1% versus 3.2%; P<0.001) and target vessel revascularization (17.1% versus 5.9%; P<0.001) were significantly higher in patients with previous CABG. Among patients with a history of CABG, PCI of an obstructed vein graft was associated with a higher rate of 5‐year target vessel revascularization (P=0.003).

Conclusions

At 5‐year follow‐up after PCI with newer‐generation drug‐eluting stents, the risk of cardiac death and target vessel revascularization was significantly higher in patients with previous CABG. The target vessel revascularization rate was highest in patients who underwent PCI of obstructed vein grafts.

Value of the SYNTAX score for periprocedural myocardial infarction according to WHO and the third universal definition of myocardial infarction: insights from the TWENTE trial

AIMS

The SYNTAX score is a tool to quantify the complexity of coronary artery disease. We investigated the relation between the SYNTAX score and the occurrence of a periprocedural myocardial infarction (PMI) according to the historical definition of the World Health Organization (WHO) and the recently updated universal definition of MI.

METHODS AND RESULTS

The SYNTAX score was calculated in 1,243 patients enrolled in TWENTE, a randomised trial which assessed second-generation drug-eluting stents. PMI was defined by the WHO definition and the third universal definition of MI. Patients were divided into tertiles of the SYNTAX score: ≤7 (n=430); >7 and <15 (n=390); ≥15 (n=423). PMI according to the WHO definition occurred more frequently in patients in the highest SYNTAX score tertile (7.3% vs. 3.1% vs. 1.6%, p<0.001) compared to the mid and lowest tertile. Similar findings were seen for universal PMI (9.9% vs. 7.7% vs. 3.7%, p<0.01). After multivariate analysis, SYNTAX score was a significant independent correlate of PMI for both definitions: the highest SYNTAX score tertile had an almost five times higher risk for WHO PMI, and a three times higher risk for universal PMI.

CONCLUSIONS

In a broad patient population treated with second-generation DES, the SYNTAX score was able to stratify the risk of PMI.

Outcome After Myocardial Infarction Treated With Resolute Integrity and Promus Element Stents: Insights From the DUTCH PEERS (TWENTE II) Randomized Trial

INTRODUCTION AND OBJECTIVES

In acute myocardial infarction (MI), novel highly deliverable drug-eluting stents (DES) may be particularly valuable as their flexible stent designs might reduce device-induced traumas to culprit lesions. The aim of the study was to assess the safety and efficacy of percutaneous coronary interventions with 2 novel durable polymer-coated DES in patients with acute MI.

METHODS

The prospective, randomized DUTCH PEERS (TWENTE II) multicenter trial compares Resolute Integrity and Promus Element stents in 1811 all-comer patients, of whom 817 (45.1%) were treated for ST-segment elevation MI or non-ST-segment elevation MI and the 2-year outcome is available in 99.9%. The primary clinical endpoint is target vessel failure (TVF), a composite of cardiac death, target vessel related MI, or target vessel revascularization.

RESULTS

Of all 817 patients treated for acute MI, 421 (51.5%) were treated with Resolute Integrity and 396 (48.5%) with Promus Element stents. At the 2-year follow-up, the rates of TVF (7.4% vs 6.1%; P = .45), target lesion revascularization (3.1% vs 2.8%; P = .79), and definite stent thrombosis (1.0% vs 0.5%; P = .69) were low for both stent groups. Consistent with these findings in all patients with acute MI, outcomes for the 2 DES were favorable and similar in both, with 370 patients with ST-segment elevation MI (TVF, 5.1% vs 4.9%; P = .81) and 447 patients with non-ST-segment elevation MI (TVF, 9.0% vs 7.5%; P = .56).

CONCLUSIONS

Resolute Integrity and Promus Element stents were both safe and efficacious in treating patients with acute MI. The present 2-year follow-up data underline the safety of using these devices in this particular clinical setting.

Relationship between betatrophin levels and metabolic parameters in patients with polycystic ovary syndrome

To evaluate the status of serum betatrophin levels and potential relations between metabolic parameters and betatrophin levels in patients with polycystic ovary syndrome. We included patients newly diagnosed with PCOS in our study. Fifty-seven female patients (30 patients with PCOS and 27 healthy control subjects) were enrolled in this study. Serum betatrophin levels were measured using a betatrophin enzyme-linked immunosorbent assay kit. Insulin resistance was calculated using the homeostasis model of the assessment-insulin resistance index formula. The betatrophin level was 1538,85 ng/L in the patient group and 2440,46 ng/L in the control group, and the difference was statistically significant (p=0.003). A significantly negative correlation was found between betatrophin level and insulin, HOMA-IR, and BMI. Betatrophin levels in patients with PCOS are lower than those without PCOS and inversely related to insulin resistance.

Coronary artery dominance and the risk of adverse clinical events following percutaneous coronary intervention: insights from the prospective, randomised TWENTE trial

AIMS

To investigate the prognostic value of coronary dominance for various adverse clinical events following the implantation of drug-eluting stents.

METHODS AND RESULTS

We assessed two-year follow-up data of 1,387 patients from the randomised TWENTE trial. Based on the origin of the posterior descending coronary artery, coronary circulation was categorised into left and non-left dominance (i.e., right and balanced). Target vessel-related myocardial infarction (MI) was defined according to the updated Academic Research Consortium (ARC) definition (2x upper reference limit of creatine kinase [CK], confirmed by CK-MB elevation), and periprocedural MI (PMI) as MI ≤48 hours following PCI. One hundred and thirty-six patients (9.8%) had left and 1,251 (90.2%) non-left dominance. Target lesions were more frequently located in dominant arteries (p<0.005). Left dominance was associated with more severe calcifications (p=0.006) and more bifurcation lesions (p=0.031). Non-left dominance tended to be less frequent in men (p=0.09). Left coronary dominance was associated with more target vessel-related MI (14 [10.3%] vs. 62 [5.0%], p=0.009). Left dominance independently predicted PMI (adjusted HR 2.19, 95% CI: 1.15-4.15, p=0.017), while no difference in other clinical endpoints was observed between dominance groups.

CONCLUSIONS

In the population of the TWENTE trial, we observed a higher incidence of periprocedural myocardial infarction in patients who had left coronary dominance.

Sex Difference in Chest Pain After Implantation of Newer Generation Coronary Drug-Eluting Stents: A Patient-Level Pooled Analysis From the TWENTE and DUTCH PEERS Trials

OBJECTIVES

This study sought to assess sex differences in chest pain after percutaneous coronary intervention (PCI) with newer generation drug-eluting stents (DES).

BACKGROUND

Sex-based data on chest pain after PCI with DES are scarce.

METHODS

The authors performed a patient-level pooled analysis of the TWENTE and DUTCH PEERS randomized trials, in which patients were treated with newer generation permanent polymer-coated DES. At 1 and 2 years, clinical follow-up was available in 99.8% and patient-reported chest pain data in 94.1% and 93.6%, respectively.

RESULTS

Among all 3,202 patients, the 871 (27.2%) women were older (67.5 ± 10.2 years vs. 62.8 ± 10.6 years; p < 0.001) and had more cardiovascular risk factors: diabetes (24.2% vs. 17.8%; p < 0.001), hypertension (63.6% vs. 51.6%; p < 0.001), and positive family history (54.5% vs. 50.1%; p = 0.03). At 1- and 2-year follow-up, women reported more clinically relevant chest pain (16.3% vs. 10.5%; p < 0.001, and 17.2% vs. 11.1%; p < 0.001, respectively). Multivariate analysis demonstrated that female sex independently predicted clinically relevant chest pain at 1- and 2-year follow-up both during daily activities and at minimum physical exertion/at rest (1 year adjusted odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2 to 2.4; p = 0.002; and adjusted OR: 1.8; 95% CI: 1.3 to 2.5; p < 0.001; 2-year adjusted OR: 1.8; 95% CI: 1.3 to 2.6; p < 0.001; and adjusted OR: 1.7; 95% CI: 1.3 to 2.3; p = 0.001). Nevertheless, the 2-year rates of death, myocardial infarction, revascularization, stent thrombosis, and various composite clinical endpoints were similar for both sexes.

CONCLUSIONS

Although the incidence of adverse cardiovascular events was low and similar for both sexes, women showed a statistically significantly higher prevalence of clinically relevant chest pain, which might be largely related to mechanisms other than epicardial coronary obstruction.

Are small adrenal incidentalomas solely a radiological finding?

OBJECTIVE

The criterium defining the threshold size of adrenal incidentaloma (AI) is a size greater than 1 cm diameter. However, data concerning AI≤1 cm in diameter is scant. The aim of this study was to evaluate the function of adrenal masses≤1 cm and to compare them with adrenal masses>1 cm.

MATERIALS AND METHODS

The study included 130 consecutive patients with AI (38 and 92 AI at ≤ 1 cm and > 1 cm, respectively). The patients were evaluated according to demographic and hormonal characteristics.

RESULTS

The prevalence of SCS was 5.3 and 12% in AI≤1 cm and > 1 cm diameter, respectively. Hyperaldosteronism was found only in patients with > 1 cm AI. Pheochromocytoma were not found in either group. Patients with > 1 cm AI had a higher prevalence of SCS and primary hyperaldosteronism than patients with ≤ 1 cm AI, but the difference was not significant. The prevalence of diabetes and hypertension was high both in non-functional AI with ≤ 1 cm and > 1 cm patients and showed no significant difference between the 2 groups.

CONCLUSION

Our study is the first to focus on the clinical and hormonal characteristics of patients with ≤ 1 cm AI. Those with AI≤1 cm harboured SCS, as was the case for AI>1 cm. Similar to AI>1 cm, non-functional AI≤1 cm also had a higher prevalence of diabetes and hypertension.

Myeloid dendritic cells with elevated CD1c expression in non-infectious uveitis patients exhibited mature phenotype through the regulation of TNFa-p38 MAPK pathway (HUM1P.273)

Our longitudinal data has shown that the level of CD1c+ myeloid dendritic cells 1 (mDC1) from peripheral blood reflects disease activity in autoimmune non-infectious uveitis patients. However, the role of CD1c+ mDC1 is not clear in autoimmune uveitis patients. Here, we demonstrate that the mDC1 in patients with non-infectious uveitis (n=74) was increased compared to age and gender-matched healthy controls (n=96). The increased CD1c+ mDC1 exhibited high HLADR expression and less antigen uptake. CD1c+ mDC1 were further divided into two subpopulations based on the level of CD1c expression. CD1chi mDC1 subpopulation showed less antigen uptake and higher HLADR expression compared to CD1clo mDC1 subpopulation. Importantly, the CD1chi mDC1 subpopulation was significantly increased in uveitis patients. By utilizing monocyte-derived dendritic cells (MoDCs) for in vitro studies, MoDCs with less antigen uptake and higher levels of CD1c induced more CD4+ T helper cell activation and proliferation. TNFa, increased in uveitis patient sera, reduced the antigen uptake in a dose-dependent manner and increased the phosphorylated p38 expression on MoDCs. A p38 inhibitor significantly inhibited the expression of CD1c during dendritic cell differentiation from monocytes. In conclusion, CD1c is a maturation marker of mDC1, increased in uveitis patients and correlated with disease activity. The high CD1c expression and low antigen uptake are mediated by the TNFa-activated p38 MAPK pathway.

Three-year clinical outcome of patients with bifurcation treatment with second-generation Resolute and Xience V stents in the randomized TWENTE trial

BACKGROUND

Only limited data from large randomized clinical trials have been published on the long-term performance of second-generation drug-eluting stents in bifurcation lesions.

METHODS

We investigated in patients in the randomized TWENTE trial the long-term safety and efficacy of treating bifurcation lesions with 2 widely applied second-generation drug-eluting stents, the zotarolimus-eluting Resolute stent (Medtronic Inc, Santa Rosa, CA) and the everolimus-eluting Xience V stent (Abbott Vascular, Santa Clara, CA). Three-year follow-up was available in 99.3%. Patients were categorized into treatment for ≥1 bifurcation lesion versus treatment for nonbifurcation lesions only.

RESULTS

Among the 1,391 patients of the TWENTE trial, 362 (26%) were treated for bifurcation lesions. At 3-year follow-up, target-vessel failure did not differ between patients treated for bifurcation versus nonbifurcation lesions (13.1% vs 12.6%; P = .84), whereas the periprocedural myocardial infarction rate was higher in patients with bifurcation lesions (6.9% vs 3.1%; P < .01). Of the 362 patients with bifurcation lesion treatment, 179 (49.4%) were treated with Resolute and 183 (50.6%) with Xience V. There was no significant difference in target-vessel failure between the Resolute and Xience V groups with bifurcation treatment (13.6% vs 12.6%; P = .78), and their incidence of definite-or-probable stent thrombosis was low and similar (1.1% vs 0.5%, respectively; P = .62).

CONCLUSION

Despite a significant difference in periprocedural myocardial infarction, 3-year clinical outcome after implantation of second-generation stents was favorable and similar for patients with and without bifurcation lesions. In addition, we observed no difference in long-term clinical outcome after bifurcation lesion treatment with Resolute and Xience V stents.

Impact of previous coronary artery bypass surgery on clinical outcome after percutaneous interventions with second generation drug-eluting stents in TWENTE trial and non-enrolled TWENTE registry

BACKGROUND

Patients with previous coronary artery bypass grafting (CABG) who underwent percutaneous coronary intervention (PCI) have an increased repeat revascularization rate, but data on contemporary second-generation drug-eluting stents (DES) are scarce.

METHODS

We evaluated 1-year clinical outcome following secondary revascularization by PCI in patients of the TWENTE trial and non-enrolled TWENTE registry, and compared patients with previous CABG versus patients without previous CABG.

RESULTS

Of all 1709 consecutive patients, 202 (11.8%) had previously undergone CABG (on average 11.2±8.5 years ago). CABG patients were older (68.5±9.4 years vs. 64.1±10.7 years, P<0.001) and more often had diabetes (28.7% vs. 20.9%, P=0.01) and previous PCI (40.1% vs. 19.8%, P<0.001) compared to patients without previous CABG. Nevertheless, a higher target vessel revascularization (TVR) rate following PCI in the CABG patients (9.4% vs. 2.3%, P<0.001) was the only significant difference in clinical outcome at 1-year follow-up (available for 99.6%). Among CABG patients, the TVR rate was significantly higher in patients treated for graft lesions (n=65; 95.4% in vein grafts) than in patients treated for native coronary lesions only (n=137) (18.5% vs. 5.1%, P=0.002). Among 1638 patients with PCI of native coronary lesions only, there was only a non-significant difference in TVR between patients with previous CABG versus patients without previous CABG (5.1% vs. 2.3%, P=0.08).

CONCLUSIONS

Patients with previous CABG showed a favorable safety profile after PCI with second-generation DES. Nevertheless, their TVR rate was still much higher, driven by more repeat revascularizations after PCI of degenerated vein grafts. In native coronary lesions, there was no such difference.

Comparison of 3 biodegradable polymer and durable polymer-based drug-eluting stents in all-comers (BIO-RESORT): rationale and study design of the randomized TWENTE III multicenter trial

AIM

To evaluate the safety and efficacy of 2 novel drug-eluting stents (DES) with biodegradable polymer-based coatings versus a durable coating DES.

METHODS AND RESULTS

BIO-RESORT is an investigator-initiated, prospective, patient-blinded, randomized multicenter trial in 3540 Dutch all-comers with various clinical syndromes, requiring percutaneous coronary interventions (PCI) with DES implantation. Randomization (stratified for diabetes mellitus) is being performed in a 1:1:1 ratio between ORSIRO sirolimus-eluting stent with circumferential biodegradable coating, SYNERGY everolimus-eluting stent with abluminal biodegradable coating, and RESOLUTE INTEGRITY zotarolimus-eluting stent with durable coating. The primary endpoint is the incidence of the composite endpoint target vessel failure at 1 year, consisting of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization. Power calculation assumes a target vessel failure rate of 8.5% with a 3.5% non-inferiority margin, giving the study a power of 85% (α level .025 adjusted for multiple testing). The impact of diabetes mellitus on post-PCI outcome will be evaluated. The first patient was enrolled on December 21, 2012.

CONCLUSIONS

BIO-RESORT is a large, prospective, randomized, multicenter trial with three arms, comparing two DES with biodegradable coatings versus a reference DES with a durable coating in 3540 all-comers. The trial will provide novel insights into the clinical outcome of modern DES and will address the impact of known and so far undetected diabetes mellitus on post-PCI outcome.

Complex patients treated with zotarolimus-eluting resolute and everolimus-eluting Xience V stents in the randomized TWENTE trial: comparison of 2-year clinical outcome

OBJECTIVE

To assess the differences in clinical outcome between complex patients treated with Resolute zotarolimus-eluting stents (ZES) versus Xience V everolimus-eluting stents (EES).

BACKGROUND

Nowadays, many complex patients with coronary disease are treated with percutaneous coronary interventions, using drug-eluting stents (DES).

METHODS

We analyzed 2-year outcome data of 1,033 complex patients of the TWENTE trial, treated with second-generation Resolute ZES or Xience V EES. Complex patients had at least one of the following characteristics: renal insufficiency (creatinine ≥ 140 µmol/l); ejection fraction < 30%; acute myocardial infarction (MI) within previous 72 hrs; >1 lesion/vessel; >2 vessels treated; lesion length > 27 mm; bifurcation; saphenous vein graft lesion; arterial bypass graft lesion; in-stent restenosis; unprotected left main lesion; lesion with thrombus; or lesion with total occlusion. Target vessel failure (TVF), the primary composite endpoint of the trial, was defined as cardiac death, target vessel-related MI, or target vessel revascularization.

RESULTS

Among the 1,033 complex patients, 529 (51%) were treated with Resolute ZES and 504 (49%) with Xience V EES. Patient- and procedure-related characteristics were similar between DES groups. After 2-year follow-up, outcome was also similar between DES groups. TVF occurred in 12.1% of patients treated with Resolute ZES and 12.3% of patients treated with Xience V EES. In addition, DES groups did not differ significantly in cardiac death, MI, or target vessel revascularization-the individual components of TVF.

CONCLUSION

Complex patients treated with Resolute ZES and Xience V EES showed similar safety and efficacy during 2-year follow-up. © 2014 Wiley Periodicals, Inc.

Third-generation zotarolimus-eluting and everolimus-eluting stents in all-comer patients requiring a percutaneous coronary intervention (DUTCH PEERS): a randomised, single-blind, multicentre, non-inferiority trial

BACKGROUND

Third-generation, permanent-polymer-based drug-eluting stents with novel, flexible designs might be more easily delivered than previous generations of stents in complex coronary lesions, but might be less longitudinally stable. We aimed to assess the safety and efficacy in all-comer patients of two third-generation stents that are often used clinically, but that have not yet been compared, and one of which has not previously been assessed in a randomised trial.

METHODS

In this investigator-initiated, single-blind, multicentre, randomised, two-arm, non-inferiority trial, patients aged 18 years and older who required a percutaneous coronary intervention with implantation of a drug-eluting stent were recruited from four study sites in the Netherlands. We randomly assigned patients by independently managed computer-generated allocation sequences in a 1:1 ratio to receive either cobalt-chromium-based zotarolimus-eluting stents (Resolute Integrity, Medtronic, Santa Rosa, CA, USA) or platinum-chromium-based everolimus-eluting stents (Promus Element, Boston Scientific, Natick, MA, USA). Patients and analysts were masked to the allocated stent, but treating clinicians were not. The primary endpoint of target-vessel failure was a composite of safety (cardiac death or target-vessel-related myocardial infarction) and efficacy (target-vessel revascularisation) at 12 months, analysed by intention to treat (with a non-inferiority margin of 3·6%). This trial is registered with ClinicalTrials.gov, number NCT01331707.

FINDINGS

Between Nov 25, 2010, and May 24, 2012, 1811 eligible all-comer patients, with 2371 target lesions, were enrolled in the study. 370 (20%) patients presented with ST-elevation myocardial infarction and 447 (25%) with non-ST-elevation myocardial infarction. 906 patients were assigned to receive zotarolimus-eluting stents and 905 to receive everolimus-eluting stents. Ease of stent delivery was shown by very low numbers of patients requiring treatment other than their assigned study treatment (six [1%] in the zotarolimus-eluting stent group vs five [1%] in the everolimus-eluting stent group; p=0·22). 12-month follow-up results were available for 1810 patients (one patient in the zotarolimus-eluting stent group withdrew consent). The primary endpoint was met by 55 (6%) of 905 patients in the zotarolimus-eluting stent group and 47 (5%) of 905 in the everolimus-eluting stent group. The zotarolimus-eluting stent was non-inferior to the everolimus-eluting stent (absolute risk difference 0·88%, 95% CI -1·24% to 3·01%; upper limit of one-sided 95% CI 2·69%; non-inferiority p=0·006). We noted no significant between-group differences in individual components of the primary endpoint. Definite stent thrombosis occurred in three (0·3%) patients in the zotarolimus-eluting stent group and six (0·7%) patients in the everolimus-eluting stent group (p=0·34). Longitudinal stent deformation was seen only in the everolimus-eluting stent group (nine [1·0%] of 905 vs 0 of 906, p=0·002; nine of 1591 [0·6%] everolimus-eluting stents implanted became deformed), but was not associated with any adverse events.

INTERPRETATION

Both stents were similarly efficacious and safe, and provided excellent clinical outcomes, especially in view of the large number of patients who presented with acute myocardial infarctions.

FUNDING

Boston Scientific, Medtronic.

The comparative evaluation of treatment outcomes in pediatric displaced supracondylar humerus fractures managed with either open or closed reduction and percutaneous pinning

PURPOSE OF THE STUDY

The aim of this study was to evaluate comparatively the outcomes of pediatric displaced supracondylar fractures of humerus which were treated with either closed reduction and percutaneous pinning (CRPP) or open reduction and percutaneous pinning (ORPP).

MATERIAL AND METHODS

The study included 100 children with displaced supracondylar fractures of the humerus, who were treated with either CRPP (group 1) or ORPP (group 2); the numbers of subjects in the study groups were equal. The treatment outcomes were assessed clinically and radiologically.

RESULTS

Ninety-six percent excellent or good cosmetic results were achieved in both groups, and 94% / 90% excellent or good functional results were achieved in groups 1 and 2 (respectively). There was no signifiant difference between Baumann and humero-capitellar angles of intact and operated sides in both groups, but there was an average carrying angle difference of 2,96 degrees in the group 1 and 1,52 degrees in the group 2 and these differences were statistically signifiant. Five cases (10%) from each group had superfiial pin tract infection. Hypertrophic incision scar occurred in 6 (12%) patients performed ORPP.

CONCLUSION

Both CRPP and ORPP are successful treatment methods in the management of non-complicated and non-comminuted displaced supracondylar fractures of the humerus in pediatric ages and their outcomes are similar. Incision scar and the long duration of operation are the disadvantages of open surgery. For fiing the fracture, placement of two K-wires from the medial and lateral aspects which cross each other is enough to achieve a good stability. In ORPP practices, lateral incision is a simple and reliable approach despite of the dissatisfying scar tissue formation.

Clinical outcome following stringent discontinuation of dual antiplatelet therapy after 12 months in real-world patients treated with second-generation zotarolimus-eluting resolute and everolimus-eluting Xience V stents: 2-year follow-up of the randomized TWENTE trial

OBJECTIVES

The aim of this study was to assess the safety and efficacy of the implantation of Resolute zotarolimus-eluting stents (ZES) (Medtronic Inc., Santa Rosa, California) and Xience V everolimus-eluting stents (EES) (Abbott Vascular, Santa Clara, California) following strict discontinuation of dual antiplatelet therapy (DAPT) after 12 months.

BACKGROUND

Only limited long-term follow-up data are available from head-to-head comparisons of second-generation drug-eluting stents.

METHODS

The randomized TWENTE (The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente) trial is an investigator-initiated study performed in a population with many complex patients and lesions and only limited exclusion criteria. Patients were randomly assigned 1:1 to ZES (n = 697) or EES (n = 694).

RESULTS

Two-year follow-up information was available on all patients. The rate of continuation of DAPT beyond 12 months was very low (5.4%). The primary endpoint of target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization, did not differ between ZES and EES (10.8% vs. 11.6, p = 0.65), despite fewer target lesion revascularizations in patients with EES (2.6% vs. 4.9%, p = 0.03). The patient-oriented composite endpoint was similar (16.4% vs. 17.1%, p = 0.75). Two-year rates of definite or probable stent thrombosis were 1.2% and 1.4%, respectively (p = 0.63). Very late definite or probable stent thrombosis occurred only in 2 patients in each study arm (0.3% vs. 0.3%, p = 1.00).

CONCLUSIONS

After 2 years of follow-up and stringent discontinuation of DAPT beyond 12 months, Resolute ZES and Xience V EES showed similar results in terms of safety and efficacy for treating patients with a majority of complex lesions and off-label indications for drug-eluting stents. (The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente [TWENTE]; NCT01066650).

Effects of treatment regimens on survival in patients with malignant pleural mesothelioma

BACKGROUND AND OBJECTIVE

In this study, we aimed to investigate the factors affecting the survival of patients with malignant pleural mesothelioma (MPM) according to their treatment regimens, including best supportive care (BSC), chemotherapy, surgical group and multimodality (MM) therapy.

PATIENTS

A retrospective analysis was performed on clinical data and treatment outcomes of 400 patients registered in our hospital with MPM between January 1989 and April 2010.

RESULTS

Mean age (p < 0.001), presence of asbestos exposure (p = 0.0014), presence of smoking history (p < 0.001), Karnofsky performance status (p < 0.001), histological subtype (p = 0.034) and stage (p < 0.001) variables were found to be significantly different among the four treatment regimens. Mean survival time of all patients was 12.32 months. Mean survival time 10.5 months for the BSC group, 15.7 for the surgical group, 16.02 for the chemotherapy group, and 26.55 for the MM group. There were significant differences in mean survival time among the four treatment regimens. In addition, a significant difference was found in survival time between the two chemotherapy groups (p = 0.032). Mean survival time for cisplatin + gemcitabine was found to be 14.49 months and for cisplatin + pemetrexed, 18.34 months.

CONCLUSIONS

The MM group had better survival rates than the other groups. The new chemotherapy combination, cisplatin + pemetrexed, can be helpful in improving survival time.      

Usefulness and safety of the GuideLiner catheter to enhance intubation and support of guide catheters: insights from the Twente GuideLiner registry

AIMS

Optimal ostial seating and adequate back-up of guide catheters are required for challenging percutaneous coronary interventions (PCI). The GuideLiner™ (GL) (Vascular Solutions Inc., Minneapolis, MN, USA) is a guide catheter extension system that provides active back-up support by deep coronary intubation. We aimed to assess feasibility and safety of GL-use in routine clinical practice.

METHODS AND RESULTS

We prospectively recorded patient and procedural details, technical success, and in-hospital outcome of 65 consecutive patients undergoing "5-in-6" Fr GL-facilitated PCI of 70 target vessels. The GL was mainly used for PCI of complex coronary lesions: 97% (68/70) had American Heart Association/American College of Cardiology (AHA/ACC) lesion types B2/C; 53% (37/70) were distally located; and 23% (17/70) were heavily calcified. Indications were to increase back-up of the guide and facilitate stent delivery (59%; 41/70), achievement of coaxial alignment of the guide catheter (29%; 20/70), and selective contrast injections (13%; 9/70). Device success rate was 93% (65/70). There were no major complications and two minor complications managed without clinical sequelae: one air embolism and one stent dislodgement.

CONCLUSIONS

GL-use resulted in increased back-up and guide catheter alignment for stent delivery in unfavourable tortuous coronary anatomies and complex, heavily calcified, and often distally located lesions, which otherwise may have been considered unsuitable for PCI. Procedural success rate was high and there were no major complications.

DUrable polymer-based sTent CHallenge of Promus ElemEnt versus ReSolute integrity (DUTCH PEERS): rationale and study design of a randomized multicenter trial in a Dutch all-comers population

BACKGROUND

Drug-eluting stents (DES) are increasingly used for the treatment of coronary artery disease. An optimized DES performance is desirable to successfully treat various challenging coronary lesions in a broad population of patients. In response to this demand, third-generation DES with an improved deliverability were developed. Promus Element (Boston Scientific, Natick, MA) and Resolute Integrity (Medtronic Vascular, Santa Rosa, CA) are 2 novel third-generation DES for which limited clinical data are available. Accordingly, we designed the current multicenter study to investigate in an all-comers population whether the clinical outcome is similar after stenting with Promus Element versus Resolute Integrity.

METHODS

DUTCH PEERS is a multicenter, prospective, single-blinded, randomized trial in a Dutch all-comers population. Patients with all clinical syndromes who require percutaneous coronary interventions with DES implantation are eligible. In these patients, the type of DES implanted will be randomized in a 1:1 ratio between Resolute Integrity versus Promus Element. The trial is powered based on a noninferiority hypothesis. For each stent arm, 894 patients will be enrolled, resulting in a total study population of 1,788 patients. The primary end point is the incidence of target vessel failure at 1-year follow-up.

SUMMARY

DUTCH PEERS is the first randomized multicenter trial with a head-to-head comparison of Promus Element and Resolute Integrity to investigate the safety and efficacy of these third-generation DES.

A randomized controlled trial in second-generation zotarolimus-eluting Resolute stents versus everolimus-eluting Xience V stents in real-world patients: the TWENTE trial

OBJECTIVES

The aim of this study was to compare the safety and efficacy of Resolute zotarolimus-eluting stents (ZES) (Medtronic Cardiovascular, Santa Rosa, California) with Xience V everolimus-eluting stents (EES) (Abbott Vascular Devices, Santa Clara, California) at 1-year follow-up.

BACKGROUND

Only 1 randomized trial previously compared these stents.

METHODS

This investigator-initiated, patient-blinded, randomized noninferiority study had limited exclusion criteria (acute ST-segment elevation myocardial infarctions not eligible). Patients (n = 1,391; 81.4% of eligible population) were randomly assigned to ZES (n = 697) or EES (n = 694). Liberal use of stent post-dilation was encouraged. Cardiac biomarkers were systematically assessed. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, myocardial infarction not clearly attributable to non-target vessels, and clinically indicated target-vessel revascularization. An external independent research organization performed clinical event adjudication (100% follow-up data available). Analysis was by intention-to-treat.

RESULTS

Acute coronary syndromes were present in 52% and "off-label" feature in 77% of patients. Of the lesions, 70% were type B2/C; the post-dilation rate was very high (82%). In ZES and EES, TVF occurred in 8.2% and 8.1%, respectively (absolute risk-difference 0.1%; 95% confidence interval: -2.8% to 3.0%, p(noninferiority) = 0.001). There was no significant between-group difference in TVF components. The definite-or-probable stent thrombosis rates were relatively low and similar for ZES and EES (0.9% and 1.2%, respectively, p = 0.59). Definite stent thrombosis rates were also low (0.58% and 0%, respectively, p = 0.12). In EES, probable stent thrombosis beyond day 8 was observed only in patients not adhering to dual antiplatelet therapy.

CONCLUSIONS

Resolute ZES were noninferior to Xience V EES in treating "real-world" patients with a vast majority of complex lesions and "off-label" indications for drug-eluting stents, which were implanted with liberal use of post-dilation. (The Real-World Endeavor Resolute Versus XIENCE V Drug-Eluting SteNt Study: Head-to-head Comparison of Clinical Outcome After Implantation of Second Generation Drug-eluting Stents in a Real World Scenario; NCT01066650).

Scanning electron microscopic assessment of coating irregularities and their precursors in unexpanded durable polymer-based drug-eluting stents

OBJECTIVES

To assess and quantify coating irregularities on unexpanded and expanded durable polymer-based drug-eluting stents (DES) to gain insights into the origin of coating irregularities.

BACKGROUND

Previous scanning electron microscopy (SEM) studies in various expanded DES revealed differences in frequency and size of coating irregularities between DES types and specific distribution patterns, however, the origin of these irregularities is unclear.

METHODS

We assessed at bench side a total of 1,200 SEM images obtained in 30 DES samples (15 expanded and 15 unexpanded) of Cypher Select Plus, Taxus Liberté, Endeavor, Xience V, and resolute.

RESULTS

For most coating irregularities seen on expanded DES (72%; 23/32), a matching irregularity (n = 18/23) and/or its precursor (n = 11/23) was observed in unexpanded DES. Unexpanded Cypher select showed (small) crater lesions and cracks together with precursors of "peeling." On unexpanded Taxus Liberté, thinning of polymer, small bare metal areas, wrinkles, and one precursor type were found. Unexpanded endeavor showed cracks, small bare metal areas, crater lesions, and precursors of the latter. Unexpanded Xience V and resolute mainly revealed crater lesions and their precursors. On unexpanded versus expanded DES, there was no difference in measured frequency of coating irregularities and precursors (P = ns) with the exception of more bare metal areas on expanded Taxus Liberte (P = 0.01).

CONCLUSIONS

Most coating irregularities, or the potential to develop them, are inherent to the unexpanded DES. Important determinants of the formation of coating irregularities may be the stent geometry and the physical properties of the coating, while stent-balloon interaction plays no major role.

Is T3 and T6 sympathetic clipping more effective in primary palmoplantar hyperhydrosis?

OBJECTIVE

Our aim was to establish a standardized approach for patients with palmoplantar and axillary hyperhidrosis and to compare patient satisfaction and complication rates for two different operations.

MATERIALS AND METHODS

Between 2008 and 2010, 30 patients underwent conventional T3/4 clipping (group A), and 30 underwent only T3 and T6 clipping (group B). Both groups were compared with regard to compensatory sweating (CS), complications, patient satisfaction and recovery of plantar hyperhidrosis.

RESULTS

The CS rate was 60 % in group A and 47 % in group B. CS was significantly less in group B compared to group A ( P ≤ 0.001). The plantar hyperhidrosis recovery rate was higher in group B (n = 19) compared to group A (n = 13), but the difference was not statistically significant ( P ≥ 0.299). Patient satisfaction rate was 93.3 % in group A and 96.6 % in group B.

CONCLUSIONS

Our study showed that T3/6 clipping was as effective as T3/4 clipping for palmar and axillary hyperhidrosis. Our results revealed that this technique is more effective than T3/4 sympathectomy to treat plantar hyperhidrosis.

Comparison of intrathecal hyperbaric and isobaric levobupivacaine in urological surgery

AIM

The aim of our study was to compare the efficacy of hyperbaric and isobaric solutions of intrathecal levobupivacaine for transurethral endoscopic surgery.

METHODS

Urological patients who were scheduled for elective surgery under spinal anesthesia were enrolled. The heavy group received 13.5 mg of hyperbaric levobupivacaine, while the plain group received 13.5 mg isobaric levobupivacaine, both intrathecally in a 3 mL total volume. Sensory and motor block, hemodynamic parameters, pain scores, adverse effects, and analgesic requirements of the patients were recorded.

RESULTS

Values of the time to onset of T10 sensory block, time to maximum sensory block, regression to L1 dermatome, time to motor block Bromage 1, time to motor block Bromage 3, and time to the end of motor block (Bromage 0) were all smaller in group 1 than in group 2 (all P values <0.05). No difference between the groups with regard to time to two segment regression of sensory block could be detected. The mean duration of initial analgesic effect, extent of maximal block, and side effects were the same in both groups (P>0.05).

CONCLUSIONS

We concluded that the clinical efficacy of hyperbaric levobupivacaine was superior to the isobaric form in spinal anesthesia for transurethral resection.