Effects of high-gravity acceleration forces and anti-gravity maneuver on the cardiac function of fighter pilots

The fighter pilots exposed to high gravitational (G) acceleration must perform anti-G maneuvers similar to the Valsalva maneuver. However, the effects of high-G acceleration and anti-G maneuvers on cardiac function have rarely been studied. This study aimed to investigate the effects of high-G forces on cardiac function of fighter pilots. Fighter pilots who underwent regular health check-ups and echocardiography were included (n = 29; 100% men, 41 ± 10 years old; mean flight time, 1821 ± 1186 h). Trainees who had not experienced any flights were included in the control group (n = 16; 100% men, 36 ± 17 years old). Echocardiographic data included left ventricular chamber size, systolic and diastolic functions, right ventricular systolic pressure (RVSP), inferior vena cava (IVC) collapsibility, and tricuspid annular plane systolic excursion (TAPSE). No significant differences in left ventricular ejection fraction, RVSP, or IVC collapsibility were observed between two groups. In the multivariate linear regression analysis with total flight time as an independent continuous variable for fighter pilots, TAPSE was positively correlated with total flight time. The experience of fighter pilots who were exposed to high-G acceleration forces and anti-G maneuvers did not cause cardiac structural changes, but the exposure might be associated with right heart function changes.

Sustained beneficial effect of β-blockers on clinical outcomes after discontinuation in patients with ST elevation myocardial infarction

Our previous study demonstrated that beneficial effect of β-blockers on clinical outcomes in patients with ST elevation myocardial infarction (STEMI). In clinical practice, β-blocker treatment is occasionally discontinued due to their side effect. The purpose of this study is to assess the impact of discontinuation of β-blockers on long-term clinical outcomes in patients with STEMI. We analyzed the data and clinical outcomes of 901 patients (716 males, 58 ± 13-year-old) STEMI patients who underwent successful primary percutaneous coronary intervention. At discharge of index STEMI, 598 patients were treated with β-blockers (491 males, 56 ± 12-year-old). After more than 1-month β-blocker treatment, β-blockers were stopped in 188 patients for any reason. We classified patients into continuation of β-blockers (410 patients, 56 ± 12-year-old) and discontinuation of β-blockers groups (188 patients, 57 ± 11-year-old) according to discontinuation of β-blockers. Occurrence of major adverse cardiovascular events (MACEs; death, recurrent MI and target vessel revascularization) during up to 10 years of follow-up was evaluated. Mean follow-up month was 56 ± 28 month. In 132 patients (22%), MACEs were occurred. The MACE-free survival rates in the 2 groups were not statistically different (log-rank P = .461). Adjusted hazard ratio (HR) of discontinuation of β-blockers for MACEs was 1.006 (95% confidence interval (CI) 0.701-1.445, P = .973; all cause of death, HR = 0.942, 95% CI = 0.547-1.622, P = .828; recurrent MI, HR = 0.476, 95% CI = 0.179-1.262, P = .136; target vessel revascularization, HR = 1.417, 95% CI = 0.865-2.321, P = .166). The MACE-free survival and survival rates of the non β-blockers treatment group was significantly worse than the discontinuation of β-blockers group (log-rank P = .003 and < 0.001, respectively). This study demonstrated that discontinuation of β-blockers was not associated with adverse cardiovascular outcomes after STEMI. The beneficial effect of β-blockers on clinical outcomes may persist in patients with initial β-blockers treatment at index STEMI.

Central hemodynamics and the discrepancy between central blood pressure and brachial blood pressure

Despite similar brachial blood pressure, central hemodynamics could be different. The objective of the present study was to investigate the factors, which could influence the discrepancy between central BP (cBP) and brachial blood pressure. Six hundred forty-seven patients (364 males, 48 ± 12 years old) were enrolled. Using applanation tonometry, cBP was noninvasively derived. The median difference between brachial systolic BP (bSBP) and central systolic BP (cSBP) was 8 mm Hg. We defined the discrepancy between bSBP and cSBP as differences >8 mm Hg. For adjustment of cBP, population was divided into 3 groups according to the cBP: group 1, <140 mm Hg of cSBP; group 2, 140 > cSBP < 160 mm Hg; group 3, =160 mm Hg of cSBP. All the central hemodynamic parameters of the patients, including augmentation pressure, augmentation index (AI), heart rate (75 bpm) adjusted augmentation index (AI@HR75), and subendocardial viability ratio, were measured. Using multivariate logistic regression analysis, we evaluated the factors which could influence the discrepancy between bSBP and cSBP. Age, gender, augmentation pressure, AI, and AI@HR75 were correlated with the discrepancy between bSBP and cSBP. AI@HR75 was significantly correlated with the discrepancy between bSBP and cSBP (β-coefficient = -0.376, P < .001 in group 1; β-coefficient = -0.297, P < .001 in group 2; and β-coefficient = -0.545, P < .001 in group 3). In groups 1 and 2, male gender was significantly correlated with the discrepancy between bSBP and cSBP (β-coefficient = -0.857, P = .035 in group 1; β-coefficient = -1.422, P = .039 in group 2). In present study, arterial stiffness might affect the discrepancy between bSBP and cSBP. Also, male gender was closely related to the discrepancy between bSBP and cSBP especially with cSBP <160 mm Hg. Not only cSBP, the discrepancy between cSBP and bSBP should be considered for understanding the central hemodynamics.

Impact of estimated pulse wave velocity on cardiovascular outcomes in a general population

Background

Estimated pulse wave velocity (ePWV), a simple surrogate estimate of carotid-femoral pulse wave velocity which was gold standard for measuring aortic stiffness, has been demonstrated to predict cardiovascular (CV) outcome. However, there was limited data on its predictive capacity for CV outcomes in the general population. The study aim was to investigate the independent association between ePWV and CV outcomes in general population.

Methods

A total of 10,030 subjects aged between 40 and 69 years were followed over 18-year period in the Ansan-Ansung cohort study. Levels of ePWV, which was calculated from an equation based on age and mean blood pressure, were categorized according to quartiles. A major adverse cardiovascular event (MACE) was defined as a composite of myocardial infarction, coronary artery disease, stroke, heart failure, peripheral artery disease, and cardiovascular death.

Results

The incidence rates of CV death, and MACE were 7.0% and 22.1% in the fourth (highest) quartile of ePWV and 0.1% and 4.5% in the first (lowest) quartile of ePWV. After adjusting for relevant covariates, patients with third and fourth quartile of ePWV showed significantly higher risk of CV death (hazard ratio [HR] 3.92; 95% confidence intervals [CI] 1.09–14.15 in third quartile and HR 8.53; 95% CI 2.13–34.10 in fourth quartile), and MACE (HR 1.54; 95% CI 1.15–2.08 in third quartile and HR 1.56; 95% CI 1.05–2.32) compared to the reference of first (lowest) quartile of ePWV. However, there were no improvement of C statistic for CV death and MACE when adding ePWV to the Cox regression models with 10-year atherosclerotic cardiovascular disease (ASCVD) risk.

Conclusion

These results suggest that ePWV predicted CV death and MACE in general population. The value of ePWV, a simple and useful indicator of aortic stiffness, is expected to serve as a potential marker to identify high risk groups of CV event in general population.

Funding Acknowledgement

Type of funding sources: None.

Influence of concomitant percutaneous transluminal angioplasty with percutaneous coronary intervention on outcomes in patients with stable lower extremity artery disease

Background

Patients with stable lower extremity artery diseases (LEAD) frequently present with coronary artery diseases; thus, concomitant percutaneous transluminal angioplasty (PTA) at the time of percutaneous coronary intervention (PCI) is often performed. We investigated the influence of concomitant PTA on both cardiovascular (CV) and limb outcomes in the Korean National Health Insurance Service registry.

Methods

Among 78,185 patients undergoing PCI between 2012 and 2015, 6,563 patients (279 for the PTA+PCI group vs. 6,284 for the PCI group) suffering from stable LEAD without limb ischemia were included. Major adverse CV events (MACEs) were defined as a composite of CV death, myocardial infarction (MI) and coronary revascularization. Patients were followed for at least 3 years.

Results

After 1:5 propensity score matching was conducted, 279 patients in the PTA+PCI group and 1,385 patients in the PCI group were compared. The risk of all-cause death was higher in the PTA+PCI group than in the PCI group, whereas the risks of MACE, MI, revascularization, stroke, CV death and bleeding event were not different between the 2 groups in the matched cohort. In contrast, the risks of end-stage renal diseases and unfavorable limb outcomes were higher in the PTA+PCI group than in the PCI group (Figure 1). Mediation analyses revealed that amputation and repeat Percutaneous transluminal angioplasty after discharge significantly mediated the association between the concomitant PTA and all-cause death (Figure 2).

Conclusions

CPTA at the time of PCI is not associated with an increased risk of CV events but may increase the risk of all-cause death by increasing unfavorable renal and limb outcomes in patients with stable LEAD.

Funding Acknowledgement

Type of funding sources: None.

Efficacy and safety of low-dose antihypertensive combination of amlodipine, telmisartan, and chlorthalidone: A randomized, double-blind, parallel, phase II trial

The aim of this clinical trial was to assess the efficacy and safety of low‐dose triple combinations of amlodipine, telmisartan, and chlorthalidone in patients with essential hypertension. After a 2‐week placebo run‐in period, 176 patients were randomized to seven treatment groups (placebo, quarter‐dose combination, third‐dose combination, half‐dose combination, amlodipine 5 mg, amlodipine 10 mg, and telmisartan 80 mg) and administered the assigned study drug orally for 8 weeks. The primary efficacy endpoint was the change in the mean sitting systolic blood pressure (BP) (MSSBP) at Week 8. The MSSBP and mean sitting diastolic BP in the quarter‐dose and half‐dose groups were significantly lower compared to the placebo and amlodipine 5 mg groups, with similar BP‐lowering effects observed compared to the amlodipine 10 mg and telmisartan 80 mg groups. However, the third‐dose group showed significant BP improvement only compared to the placebo group. A similar pattern was observed for the control rate of hypertension and response rates. Additional analysis was conducted after correcting for gender and age effects, and, as a result, the third‐dose group showed similar results with regard to the BP‐lowering effect as the quarter‐dose and half‐dose groups. In terms of safety, no special adverse events and clinically significant results were noted, and all dose groups of the triple combination are considered safe for use in essential hypertension patients. The current findings indicated that low‐dose triple combination of amlodipine, telmisartan, and chlorthalidone over 8 weeks effectively improved the BP‐lowering effect in patients with essential hypertension without any safety concerns.

Efficacy and Safety of 3 Versus 6 Months of Dual-Antiplatelet Therapy in Patients Implanted With a Coroflex ISAR Stents: A Prospective, Multicenter, Randomized Clinical Trial

BACKGROUND

The optimal duration of dual-antiplatelet therapy (DAPT) after implantation of a drug-eluting stent (DES), especially recently developed polymer-free DESs, is unknown. This study examined the efficacy and safety of 3- versus 6-month DAPT in patients implanted with Coroflex ISAR polymer-free DESs.

METHODS

Between May 2015 and August 2020, 488 patients who underwent Coroflex ISAR stent implantation were enrolled in the study and randomly assigned to the 3-month (n=244) or 6-month (n=244) DAPT group.

RESULTS

At 1 year, the primary endpoint (composite of cardiovascular death, myocardial infarction, target vessel revascularization, and Bleeding Academic Research Consortium [BARC] type 2-5 bleeding) occurred in 9 (3.7%) patients in the 3-month DAPT group and in 7 (2.9%) patients in the 6-month DAPT group (hazard ratio 1.31; P=.60). There was no difference between the 3- and 6-month DAPT groups in either BARC type 2-5 bleeding (1.6% vs 0.8%; hazard ratio 2.00; P=.42) or any bleeding (2.9% vs 3.3%; hazard ratio 0.87; P=.80).

CONCLUSION

Compared with 6 months of DAPT, 3 months of DAPT did not increase the risk of primary endpoint 1 year after Coroflex ISAR stent implantation, although it should be noted that the trial has limited power to see differences due to low event rate and low recruitment rate.

Clinical Characteristics and Outcome of Immediate-Release Versus SLOW-Release Carvedilol in Heart Failure Patient (SLOW-HF): a Prospective Randomized, Open-Label, Multicenter Study

PURPOSE

Carvedilol demonstrated therapeutic benefits in patients with heart failure and reduced ejection fraction (HFrEF). However, it had a short half-life time mandating twice a day administration. We investigated whether slow-release carvedilol (carvedilol-SR) is non-inferior to standard immediate-release carvedilol (carvedilol-IR) in terms of clinical efficacy in patients with HFrEF.

METHODS

We randomly assigned patients with HFrEF to receive carvedilol-SR once a day or carvedilol-IR twice a day. The primary endpoint was the change in N-terminal pro B-natriuretic peptide (NT-proBNP) level from baseline to 6 months after randomization. The secondary outcomes were proportion of patients with NT-proBNP increment > 10% from baseline, mortality rate, readmission rate, changes in blood pressure, quality of life, and drug compliance.

RESULTS

A total of 272 patients were randomized and treated (median follow-up time, 173 days). In each group of patients taking carvedilol-SR and those taking carvedilol-IR, clinical characteristics were well balanced. No patient died during follow-up, and there was no significant difference in the change of NT-proBNP level between two groups (-107.4 [-440.2-70.3] pg/mL vs. -91.2 [-504.1-37.4] pg/mL, p = 0.101). Change of systolic and diastolic blood pressure, control rate and response rate of blood pressure, readmission rate, and drug compliance rate were also similar. For safety outcomes, the occurrence of adverse reactions did not differ between carvedilol-SR group and carvedilol-IR group.

CONCLUSION

Carvedilol-SR once a day was non-inferior to carvedilol-IR twice a day in patients with HFrEF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03209180 (registration date: July 6, 2017).

Clinical impact of guideline-based practice and patients' adherence in uncontrolled hypertension

Background

Chronic diseases like hypertension need comprehensive lifetime management. This study assessed clinical and patient-reported outcomes and compared them by treatment patterns and adherence at 6 months among uncontrolled hypertensive patients in Korea.

Methods

This prospective, observational study was conducted at 16 major hospitals where uncontrolled hypertensive patients receiving anti-hypertension medications (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) were enrolled during 2015 to 2016 and studied for the following 6 months. A review of medical records was performed to collect data on treatment patterns to determine the presence of guideline-based practice (GBP). GBP was defined as: (1) maximize first medication before adding second or (2) add second medication before reaching maximum dose of first medication. Patient self-administered questionnaires were utilized to examine medication adherence, treatment satisfaction and quality of life (QoL).

Results

A total of 600 patients were included in the study. Overall, 23% of patients were treated based on GBP at 3 months, and the GBP rate increased to 61.4% at 6 months. At baseline and 6 months, 36.7 and 49.2% of patients, respectively, were medication adherent. The proportion of blood pressure-controlled patients reached 65.5% at 6 months. A higher blood pressure control rate was present in patients who were on GBP and also showed adherence than those on GBP, but not adherent, or non-GBP patients (76.8% vs. 70.9% vs. 54.2%, P < 0.001). The same outcomes were found for treatment satisfaction and QoL (P < 0.05).

Conclusions

This study demonstrated the importance of physicians’ compliance with GBP and patients’ adherence to hypertensive medications. GBP compliance and medication adherence should be taken into account when setting therapeutic strategies for better outcomes in uncontrolled hypertensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00183-1.

Associations between changing patterns of ST-T waves morphologies in rest electrocardiography and cardiovascular risk in an asymptomatic low risk population: a report from Ansan-Ansung cohort study

Background

While clinical significance of ST-T wave abnormalities (STA) in rest electrocardiography (ECG) on long-term cardiovascular outcomes has been on debate, few studies have been reported on the association between the changes in ST-T waves in rest ECG and cardiovascular outcomes in low risk populations. We investigate the changing patterns of STA in rest ECG and the predictive value of the changes in ST-T wave in rest ECG for cardiovascular events in an asymptomatic general population.

Methods

A longitudinal community-based cohort study was conducted for 12 years. Koreans aged 40–69 years were followed biennially through scheduled revisit for comprehensive assessments. Among 10,030 participants, 6,648 participants who did not have any cardiovascular diseases, angina-related symptoms or pathologic Q waves in rest ECG at baseline were included for analysis. Changes in STAs were defined using the changes between ECG at baseline and that at the first revisit. A major adverse cardiovascular events was defined as a composite of cardiac death, myocardial infarction, clinical diagnosis of coronary artery disease and stroke.

Results

Among 5,924 participants without STA at baseline, only 187 participants (3.2%) developed new STA. Among 724 patients (10.9%) with STA at baseline, 274 patients (37.8%) persistently showed STA at the first revisit. MACEs occurred more frequently in the participants persistently with STA and those with newly-developed STA than in the participants persistently without STA (Figure 1). Multivariate Cox-proportional hazard models showed that a higher risk of MACE was only associated with the persisted STA (HR 1.69; 95% CI 1.10–2.63). In participants with baseline STA, persisted T-wave flattening was associated with a higher risk of MACE, whereas T-wave inversion, either persisted or fluctuated was not associated with a higher risk of MACE, compared with persistent absence of STA (Figure 2). In the participants without baseline STAs, multivariate Cox-proportional hazard model showed that newly-developed T-wave flattening (HR 1.85; 95% CI 0.20–2.84), not T-wave inversion (HR 1.50; 95% CI 0.85–2.65) was associated with a higher risk of MACE. Survival receiver operating curve analysis showed that the changes in STAs had a C-index of 0.538 (95% CI 0.511–0.558), a sensitivity of 13.0% and a specificity of 92.5% and add only a small value to the predictive power of 10-year atherosclerotic cardiovascular diseases risk estimator (C-index without STA changes 0.708 [0.681–0.736] vs. C-index with STA changes 0.721 [0.694–0.748]).

Conclusions

STAs uncommonly developed while frequently disappeared spontaneously in the asymptomatic general population. Persisted STA and newly developed STA in rest ECG were predictive of future cardiovascular events in the asymptomatic general population. However, the changes in STAs did not significantly improve the predictive value of the conventional risk estimator, when added.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Foundation of Korea Figure 1Figure 2

Simulation and validation for count-based binary decision of target blood pressure achievement in home blood pressure monitoring data analysis for clinical practice

Introduction

Home blood pressure monitoring (HBPM) is a useful tool to identify hypertension and to decide whether a patient's blood pressure (BP) is controlled. The use of automatized oscillometric BP measurement devices has become increasingly popular with help of information technology and internet of things to the devices. However, applying HBPM to daily clinical practices is still challenging, because most patients with hypertension are in age groups not familiar to digital devices and internet and high BP criteria using average home BP values are often useless in outpatient clinics without easily accessible average BP calculation tools. Therefore, we developed a simple and straightforward method to interpret HBPM through counts of BP ≥135/85 mmHg.

Methods

We simulated 400 cases of HBPM using a random number generator function in statistical software. The simulated average home systolic BP (SBP) and its standard deviation (SD) were 125±15 mmHg and 12±5 mmHg and the number of HBP readings was 24 times. The simulated diastolic BP (DBP) was randomly selected to 50–75% of the SBP. The validation of the binary interpretation method was conducted using actual HBPM data from 386 subjects in a rural area of South Korea. Receiver operating characteristics curve analysis was conducted, and linear regression and logarithmic models were fitted between the numbers of home BP ≥135/85 mmHg and mean BP. Hypertension was defined with average home BP ≥135/85 mmHg.

Results

In the simulated cohort, hypertension was presented in 197 cases (49.3%). The C-index of the numbers of BP readings ≥135/85 mmHg was 0.994 (95% confidence interval [CI] 0.990–0.998), and ≥12 of 24 BP readings ≥135/85 mmHg showed a sensitivity of 95.4%, a specificity of 95.1% and an accuracy of 95.3% for the diagnosis of hypertension. In validation cohort, the numbers of home BP measurements varied from 8 to 81 times. The validation cohort similarly showed that the C-index of the ratio between the number of high BP readings (≥135/85 mmHg) to the number of BP measurements (R-NHBP/NBP) was 0.985 (95% CI, 0.976–0.994) and the best accuracy was shown at R-NHBP/NBP of ≥0.45. R-NHBP/NBP of ≥0.5 showed a sensitivity of 0.957, a specificity of 0.907 and an accuracy of 0.927. The accuracy of the R-NHBP/NBP of ≥0.5 decreased as SD and the range of SBP increased, whereas it did not change with the number of measurements (Figure 1). R-NHBP/NBP &lt;0.2 predicted normotension and R-NHBP/NBP &gt;0.8 predicted hypertension in 95% confidence. Mean widths of the 95 prediction intervals for the average SBP and DBP were 18.2 mmHg and 12.6 mmHg, respectively (Figure 2).

Conclusion

Counting the number of BP ≥135/85 mmHg can provide accurate assessments for the BP levels. R-NHBP/NBP of ≥0.5 is a simple and accurate marker of high BP in HBPM, and R-NHBP/NBP could be a useful tool to assess BP levels in patients practicing HBPM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Translesional Fractional Flow Reserve is Related to Plaque Components in Coronary Artery Disease: A Study Combining Pressure Wire and NIRS-IVUS Analysis

OBJECTIVES

It remains unclear whether atherosclerotic plaque structure or composition is related to translesional biomechanical stresses in coronary artery disease. The aim of this study was to evaluate the association between translesional pressure parameters (using a pressure wire) and plaque characteristics (using a combined near-infrared spectroscopy [NIRS] and intravascular ultrasound [IVUS] imaging catheter).

METHODS

Fractional flow reserve (FFR), delta (Δ) FFR, and Δ pressure were obtained during adenosine-induced maximum hyperemic status. Lipid core burden index (LCBI) and maximum LCBI within 2 mm (maxLCBI2mm) and tomographic anatomy were evaluated by NIRS-IVUS.

RESULTS

Sixty-six lesions from 57 patients were analyzed (57 lesions for FFR, 45 lesions for ΔFFR). There was a negative correlation between FFR and maxLCBI2mm (r=-0.264; P=.049) and a positive correlation between ΔFFR and maxLCBI2mm (r=0.299; P=.049). ΔFFR of lesions with maxLCBI2mm ≥500 was significantly higher than maxLCBI2mm <500 (0.159 ± 0.085 vs 0.104 ± 0.075, respectively; P=.04). By receiver-operating characteristic curve analysis, ΔFFR ≥0.1 was a predictor for maxLCBI2mm ≥500 (area under curve, 0.707; 95% confidence interval, 0.552-0.862; P=.03). On multivariate analysis, ΔFFR was the only predictor of maxLCBI2mm (β=0.347; P=.03).

CONCLUSION

ΔFFR across a coronary artery lesion is related to lipid core burden assessed using NIRS-IVUS and might be a meaningful predictor of high-risk plaque (plaque with high lipid content).

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with hepatocellular carcinoma: a multicentre retrospective study

AIM

To evaluate the effectiveness and safety of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding variceal rebleeding in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This multicentre retrospective study enrolled 79 patients with HCC who underwent RTO for the prevention of variceal rebleeding. Successful occlusion of the gastrorenal shunt and obliteration of the gastric varices were achieved in 74 patients, with a technical success rate of 93.7%. Of the remaining 74 patients (mean age, 64.9±10.3 years; 56 men), 66 (90.4%) had gastroesophageal varices and seven (9.6%) had isolated gastric varices. Thirty-two patients (43.8%) underwent balloon-occluded RTO, 40 patients (54.8%) underwent plug-assisted RTO, and one patient (1.4%) underwent coil-assisted RTO. No patients had major procedural complications.

RESULTS

Rebleeding occurred in seven patients (9.6%) during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 90.8±3.6% and 88.6±4.1%, respectively. The median survival was 12.6 (95% confidence interval [CI] 8-17.3) months. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 83.2±4.4%, 51.1±6.6%, and 32.7±7%, respectively. New or worsening ascites and oesophageal varices occurred in 12 (16.4%) and 13 patients (17.8%), respectively, during the follow-up period. Overt hepatic encephalopathy occurred in one patient (1.4%) during the follow-up period. The Child-Pugh score remained comparable to that at baseline at 1 and 3 months.

CONCLUSION

RTO was effective and safe in preventing variceal rebleeding in patients with HCC.

Safety and efficacy of transarterial embolisation for treatment of dorsal pancreatic artery haemorrhage

AIM

To evaluate the safety and efficacy of transarterial embolisation (TAE) of dorsal pancreatic artery (DPA) haemorrhage.

MATERIALS AND METHODS

Nineteen consecutive patients (M:F = 16:3, mean age 59.6 years) who underwent TAE of DPA in three tertiary medical centres between January 2001 to January 2020 were reviewed retrospectively. Angiographic features and the technical and clinical outcomes of TAE were analysed.

RESULTS

The clinical presentations were a bloody drain from the Jackson-Pratt drainage tube (n=8), melaena (n=7), abdominal pain (n=4), and haematochezia (n=3). Angiographic findings included pseudoaneurysm (n=14), contrast media extravasation (n=4), or abrupt cut-off of the arterial branch (n=1). The NBCA (N-butyl-cyanoacrylate; n=4), microcoils (n=4), and a combination of these agents (n=7) were used as embolic agents. The most common origin of the DPA in the present study cohort was the splenic artery (n=7), followed by the coeliac trunk (n=4), common hepatic artery (n=4), and superior mesenteric artery (n=4). Technical and clinical success rates were 100% and 84.2% (16/19), respectively. Of the three clinically unsuccessful cases, two patients were revealed to have newly developed bleeding from another artery. The other patient expired 1 day after the TAE procedure due to a progression of hepatic failure. In one patient, an asymptomatic non-target embolisation occurred in the right posterior tibial artery as a procedure-related complication. No major complications were observed.

CONCLUSION

TAE is safe and effective for the management of bleeding from the DPA. It is important to be aware of the DPA as a potential bleeding source, including the relevant clinical characteristics.

Low-dose CT angiography of the lower extremities: a comparison study of image quality and radiation dose

AIM

To investigate the image quality and radiation dose of ultralow-dose (ULD) and low-dose (LD) lower-extremity computed tomography (CT) angiography (LE-CTA) using the advanced modelled iterative reconstruction (ADMIRE) algorithm to detect peripheral arterial disease (PAD) in comparison with standard-dose (SD) CT.

MATERIALS AND METHODS

One hundred and seven consecutive patients were examined using LE-CTA at 70 kVp and a dual-source scanner to achieve three image sets using 30% (ULD), 70% (LD), and 100% (SD) tube loads. Qualitative analysis was conducted by examining the three image sets for overall quality. The image quality of arterial segments was analysed by two independent readers. In addition, the CT dose index (CTDI_vol) was measured in the three image sets.

RESULTS

The mean overall quality scores were 3.4±0.6 for ULD CT, 3.9±0.3 for LD CT, and 3.9±0.2 for SD CT. Both readers scored the arterial segments as 2-4 (adequate-excellent) in the three image sets. In addition, 89.4% (93/104) and 54.8% (57/104) segments of PAD with calcified plaques were scored 4 between SD and LD CT and between SD and ULD CT, respectively, and 45.2% (47/104) segments had a lower score by one point in ULD CT compared with SD CT. The mean CTDI_vol was 4.1±1.1 mGy for SD CT, 2.9±0.8 mGy for LD CT, and 1.2±0.3 mGy for ULD CT.

CONCLUSIONS

LD/ULD CT at 70 kVp using ADMIRE reconstruction enables a reduction in the radiation dose while enabling adequate evaluation or follow-up of PAD based on LE-CTA.

Efficacy and Safety of Nebivolol and Rosuvastatin Combination Treatment in Patients with Concomitant Hypertension and Hyperlipidemia

PURPOSE

We evaluated the efficacy and safety of nebivolol and rosuvastatin combination treatment in patients with hypertension and hyperlipidemia.

PATIENTS AND METHODS

Eligible patients, after more than 4 weeks of therapeutic lifestyle change, were randomly assigned to three groups: 5 mg nebivolol plus 20 mg rosuvastatin (NEBI/RSV), 20 mg rosuvastatin (RSV), or 5 mg nebivolol (NEBI). Treatments lasted 8 weeks.

RESULTS

Efficacy was analyzed using data from 276 patients. Sitting systolic and diastolic blood pressures differed between the NEBI/RSV and RSV groups (LSmean difference = -5.89 and -5.99 mmHg; 95% confidence interval [CI] = -9.88 to -1.90 mmHg and -8.13 to -3.84 mmHg, respectively). Reductions in the two pressures did not differ between the NEB/RSV and NEB groups. The percent reduction in low-density lipoprotein (LDL) cholesterol differed between the NEBI/RSV and NEBI groups (LSmean difference = -47.76%, 95% CI = -52.69 to -42.84%) but not between the NEBI/RSV and RSV groups. The blood pressure (BP) control rate was higher in the NEBI/RSV group than in the RVS group (51.09% vs 29.67%, p = 0.003). The LDL cholesterol goal achievement rate was higher in the NEBI/RSV group than in the NEBI group (85.87% vs 11.83%, p < 0.001). The incidence of adverse drug reactions in the NEBI/RSV, RSV, and NEBI groups was 8.51%, 7.45%, and 8.60%, respectively (p = 0.950).

CONCLUSION

Nebivolol plus rosuvastatin treatment is effective in reducing BP and LDL cholesterol levels and is safe in patients with hypertension and hypercholesterolemia without the loss of BP or the LDL cholesterol-lowering effect of each drug.

TRIAL REGISTRATION

CRIS registration number KCT0002148.

Relationship between arterial stiffness and variability of home blood pressure monitoring

Variability of blood pressure (BP) is known as a prognostic value for the subsequent target organ damage in hypertensive patients. Arterial stiffness is a risk factor for cardiovascular morbidity and mortality. The relationship between the arterial stiffness and the BP variability has been controversial. The objective of the present study was to investigate the relationship between arterial stiffness and home BP variability in patients with high normal BP and new onset hypertension (HTN).Four hundred sixty three patients (252 males, 49 ± 12 year-old) with high normal BP or HTN were enrolled. Using radial applanation tonometry, pulse wave analysis (PWA) was performed for evaluation of systemic arterial stiffness. All patients underwent both home BP monitoring (HBPM) and PWA. Home BP variability was calculated as the standard deviation (SD) of 7 measurements of HBPM. Multiple linear regression analysis was performed to estimate and test the independent effects of home BP variability on the arterial stiffness.Mutivariate analysis showed that both systolic and diastolic morning BP variabilities were correlated with arterial stiffness expressed as augmentation pressure (AP, β-coefficient = 1.622, P = .01 and β-coefficient = 1.07, P = .035). The SDs of systolic and diastolic BP of evening were also associated with AP (β-coefficient = 1.843, P = .001 and β-coefficient = 1.088, P = .036). The SDs of morning and evening systolic BP were associated with augmentation index (AI, β-coefficient = 1.583, P = .02 and β-coefficient = 1.792, P = .001) and heart rate (75 bpm) adjusted AI (β-coefficient = 1.592, P = .001 and β-coefficient = 1.792, P = .001).In present study, the variability of systolic BP was closely related with arterial stiffness. The home BP variability might be important indicator of arterial stiffness.

Supramolecular Regulation of Polydopamine Formation by Amyloid Fibers

Polydopamine (PD) and melanin species are chemically complex systems, the formation and properties of which are incompletely understood. Inspired by the role of functional amyloids in melanin biosynthesis, this paper examines the influences of the supramolecular structure of amyloids on oxidative polymerization of dopamine. Kinetic analyses on the formation of PD species in the presence of hen egg white lysozyme (HEWL) fibers or soluble HEWL revealed that both forms gave rise to the total quantity of PD species, but the rate of their formation could be accelerated only by the amyloid form. PD species formed with HEWL fibers showed a morphology of bundled fibers, whereas those with soluble HEWL had a mesh-like structure. Amyloid fibers of recombinant Pmel17 had properties similar to those of HEWL fibers in modulating PD formation. The results presented here suggest how nature designs functionality with an amyloid structure and can help understand and engineer chemistries of other functional amyloids.

Radiomics Study of Thyroid Ultrasound for Predicting BRAF Mutation in Papillary Thyroid Carcinoma: Preliminary Results

BACKGROUND AND PURPOSE

It is not known how radiomics using ultrasound images contribute to the detection of BRAF mutation. This study aimed to evaluate whether a radiomics study of gray-scale ultrasound can predict the presence or absence of B-Raf proto-oncogene, serine/threonine kinase (BRAF) mutation in papillary thyroid cancer.

MATERIALS AND METHODS

The study retrospectively included 96 thyroid nodules that were surgically confirmed papillary thyroid cancers between January 2012 and June 2013. BRAF mutation was positive in 48 nodules and negative in 48 nodules. For analysis, ROIs from the nodules were demarcated manually on both longitudinal and transverse sonographic images. We extracted a total of 86 radiomics features derived from histogram parameters, gray-level co-occurrence matrix, intensity size zone matrix, and shape features. These features were used to build 3 different classifier models, including logistic regression, support vector machine, and random forest using 5-fold cross-validation. The performance including accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve, of the different models was evaluated.

RESULTS

The incidence of high-suspicion nodules diagnosed on ultrasound was higher in the BRAF mutation-positive group than in the mutation-negative group (P  =  .004). The radiomics approach demonstrated that all classification models showed moderate performance for predicting the presence of BRAF mutation in papillary thyroid cancers with an area under the curve value of 0.651, accuracy of 64.3%, sensitivity of 66.8%, and specificity of 61.8%, on average, for the 3 models.

CONCLUSIONS

Radiomics study using thyroid sonography is limited in predicting the BRAF mutation status of papillary thyroid carcinoma. Further studies will be needed to validate our results using various diagnostic methods.

Interventional treatment of arterial injury during blind central venous catheterisation in the upper thorax: experience from two centres

AIM

To evaluate the safety and clinical efficacy of interventional treatment for arterial injury during blind, central venous catheterisation in the upper thorax at two tertiary medical centres.

MATERIALS AND METHODS

Eighteen consecutive patients (37-81 years; M:F=8:10) who underwent interventional treatment for the arterial injuries that occurred during central venous catheterisation without any imaging guidance between November 2007 and December 2018 were included. Clinical data, angiographic findings, detailed interventional procedures, and technical and clinical outcomes were analysed retrospectively.

RESULTS

Arterial injury sites were the subclavian artery/branches (n=12), axillary artery/branches (n=2), and common carotid artery (n=4). The target vein was not correlated with the corresponding artery/branches in eight patients (44.4%); internal jugular vein to subclavian artery branches. Angiographic findings were pseudoaneurysm (66.7%, 12/18), contrast medium extravasation (22.2%, 4/18), or both (11.1%, n=2). A stent graft was inserted for the main trunk injuries in nine patients, with (n=2) or without (n=7) prior arterial branch embolisation to prevent potential endoleak, while embolisation for the arterial branch injuries was performed in nine patients. Direct percutaneous access with thrombin injection to the pseudoaneurysm or residual arteriovenous fistula was utilised in two. The technical and clinical success rate was 94.4% (17/18) each. There were no procedure-related complications. In one patient without immediate clinical success, there was a persistent pseudoaneurysm after stent graft placement, which was treated with in-stent balloon dilation.

CONCLUSION

Interventional treatment serves as a safe and effective treatment modality for inadvertent arterial injury related to blind, central venous access catheterisation in the upper thorax.

Impact of new-onset diabetes on clinical outcomes after ST segment-elevated myocardial infarction

Objective. Patients with diabetes have higher mortality rate than patients without diabetes after ST-segment elevated myocardial infarction (STEMI). Prognosis of patients with new onset diabetes (NOD) after STEMI remains unclear. The aim of this study was to evaluate the prognosis of patients with NOD compared to that of patients without NOD after STEMI. Design. This study was a retrospective observational study. We enrolled 901 STEMI patients. Patients were divided into diabetic and non-diabetic groups at index admission. Non-diabetic group was divided into NOD and non-NOD groups. Kaplan-Meier analysis and Cox's proportional hazard regression models were used to compare major adverse cardiac events (MACE) free survival rate and hazard ratio for MACE between NOD and non-NOD groups. Results. Mean follow-up period was 59 ± 28 months. Diabetes group had higher MACE than non-diabetes group (p = .038). However, MACE was not different between NOD and non-NOD groups (p = 1.000). After 1:2 propensity score matching, incidence of MACE was not different between the two groups. In Kaplan-Meier survival curves, MACE-free survival rates were not statistically different between NOD and non-NOD groups either (p = .244). Adjusted hazard ratios of NOD for MACE, all-cause of death, recurrent myocardial infarction, and target vessel revascularization were 0.697 (95% confidence interval [CI]: 0.362-1.345, p = .282), 0.625 (95% CI: 0.179-2.183, p = .461), 0.794 (95% CI: 0.223-2.835, p = .723), and 0.506 (95% CI: 0.196-1.303, p = .158), respectively. Conclusion. This retrospective observational study with a limited statistical power did not show a different prognosis in patients with and without NOD.

P5298Influence of the changes in body fat on all-cause and cardiovascular mortality in a general population: a report from Ansan-Ansung cohort in the Korean genome environment study

Background

Paradoxical beneficial effects of obesity on all-cause and cardiovascular mortality have been reported in multiple cohort studies based on patients with cardiovascular disease as well as general populations. However, the association between the presence of obesity at baseline and the better survival rates could not be directly interpreted into the beneficial effect of gain in obesity or fatness on the mortality, which makes it difficult to provide any recommendation for the management of obesity. Therefore, we investigated the influence of the changes in body fat on all-cause and cardiovascular mortality in a general population.

Methods

A population-based cohort study has been conducted for 12 years (from 2001 to 2012). A total of 5,259 subjects in whom body compositions using a bio-impedance method were measured at least 2 times during the observational period were included. The causes of death was identified from the nation-wide database in KOSTAT. I20-I82 and R99 in the International Classification of Disease-10 codes were defined as a cardiovascular death. The subjects were evenly divided into 3 groups by the percentages of the changes in body fat (Δ%BF; decreased [Δ%BF <0.0%] vs. increased [Δ%BF 0.0–13.7%] vs. highly increased [Δ%BF ≥13.7%]). Inverse probability of treatment weighting was applied to balance the covariate differences among the groups.

Results

The age was 51.2±8.5 years and 51.6% was male. Median observation duration was 163 (the interquartile range: 157–168) months. The all-cause death and cardiovascular death occurred most frequently in the decreased Δ%BF group and least frequent in the highly increased Δ%BF group in both unweighted and weighted cohort. Multivariate Cox proportional hazard models showed that the risk of all-cause death was lower in the increased and highly increased Δ%BF groups (hazard ratio [HR] 0.61 [0.47–0.80] and 0.24 [0.17–0.34], respectively) and the risk of cardiovascular death was lower in the highly increased Δ%BF group (HR 0.20 [0.08–0.48]), compared to those in the decreased Δ%BF group after adjustment for all covariates including physical activities and the changes in muscle mass. The risk of all-cause death and cardiovascular death linearly decreased with increasing Δ%BF (HR 0.72 [0.67–0.77] and 0.70 [0.60–0.82], respectively).

Conclusion

The increase in body fat is associated with a lower risk of all-cause death and cardiovascular death in a middle-age general population, independently with physical activities and the changes in muscle mass.

P5665The independent effect of insulin resistance on incidence of atrial fibrillation in non-diabetics

Purpose

Patients with diabetes mellitus have an elevated risk of atrial fibrillation (AF). However, whether insulin resistance may elevate risk of AF incidence in non-diabetic is inconsistent. The aim of our study was to verify the association between insulin resistance and incidence of AF in non-diabetics.

Methods

We evaluated population-based cohorts embedded in the Korean Genome Epidemiology Study. Insulin resistance was expressed as Homeostasis Model Assessment for Insulin resistance (HOMA-IR). Baseline data including HOMA-IR and electrocardiography (ECG) were obtained at 2001. Subsequent biennial ECG was performed for identification of AF until 2016.

Results

Among the 8220 participants (46.8% male; median age 49 years), 25 participants had AF (0.3%) at baseline and 101 participants developed AF (1.2%) during follow up of 12 years. In multivariate Cox regression analysis, high HOMA-IR (≥1.4) was significantly associated with incident AF compared with low HOMA-IR (<1.40) (adjusted hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.3–3.0). In subgroup analysis, these association was consistent regardless of obesity (BMI<25; adjust HR 1.8, 95% CI 1.1–3.0, BMI≥25; adjust HR 2.3, 95% CI 1.3–4.0)

Subgroup analysis

Conclusion

Based on prospective cohort study, insulin resistance (HOMA-IR) was associated with AF independently of obesity in non-diabetics.

Relationship between arterial stiffness and circadian pattern of blood pressure

Arterial stiffness is a risk factor for cardiovascular morbidity and mortality. The relationship between the arterial stiffness and the circadian pattern of blood pressure (BP) has been controversial. The objective of the present study was to investigate the relationship between arterial stiffness by pulse wave analysis (PWA) and variables of 24-hour ambulatory BP monitoring (ABPM) in patients with high normal BP or hypertension (HTN).Five hundred forty-eight patients (304 males, 48 ± 12-year-old) with high normal BP or HTN were enrolled. BP was measured at the outpatient clinic and 24-hour ABPM was performed. Using radial applanation tonometry, PWA was performed for evaluation of systemic arterial stiffness. Patients were classified into four groups according to the dipping patterns: a nocturnal dipping group, an isolated systolic non-dipping group, an isolated diastolic non-dipping group and a both systolic and diastolic non-dipping group. For adjustment of age, population was divided to 2 groups: old group ≥55 year-old (n = 158, 75 males), young group <55 year-old (n = 390, 229 males).According to the dipping patterns, augmentation pressure (AP), augmentation index (AI) and heart rate (75 bpm) adjusted AI (AI@HR75) showed statistically significant difference (P = .011, .009, and .018, respectively). Multivariate analysis showed that isolated diastolic non-dipping was correlated with arterial stiffness expressed as AI and AI@HR 75, only in young group (β-coefficient = 12.6, P = .04 and β-coefficient = 7.503, P = .028, respectively).Arterial stiffness might be closely related with the pattern of non-dipping in young patients with HTN and high normal BP.

A Phase III, Multicenter, Randomized, Double-blind, Active Comparator Clinical Trial to Compare the Efficacy and Safety of Combination Therapy With Ezetimibe and Rosuvastatin Versus Rosuvastatin Monotherapy in Patients With Hypercholesterolemia: I-ROSETTE (Ildong Rosuvastatin & Ezetimibe for Hypercholesterolemia) Randomized Controlled Trial

PURPOSE

Combination therapy with ezetimibe and statins is recommended in cases of statin intolerance or insufficiency. The objective of this study was to compare the efficacy and safety of combination therapy with ezetimibe and rosuvastatin versus those of rosuvastatin monotherapy in patients with hypercholesterolemia.

METHODS

I-ROSETTE (Ildong ROSuvastatin & ezETimibe for hypercholesTElolemia) was an 8-week, double-blind, multicenter, Phase III randomized controlled trial conducted at 20 hospitals in the Republic of Korea. Patients with hypercholesterolemia who required medical treatment according to National Cholesterol Education Program Adult Treatment Panel III guidelines were eligible for participation in the study. Patients were randomly assigned to receive ezetimibe 10 mg/rosuvastatin 20 mg, ezetimibe 10 mg/rosuvastatin 10 mg, ezetimibe 10 mg/rosuvastatin 5 mg, rosuvastatin 20 mg, rosuvastatin 10 mg, or rosuvastatin 5 mg in a 1:1:1:1:1:1 ratio. The primary end point was the difference in the mean percent change from baseline in LDL-C level after 8 weeks of treatment between the ezetimibe/rosuvastatin and rosuvastatin treatment groups. All patients were assessed for adverse events (AEs), clinical laboratory data, and vital signs.

FINDINGS

Of 396 patients, 389 with efficacy data were analyzed. Baseline characteristics among 6 groups were similar. After 8 weeks of double-blind treatment, the percent changes in adjusted mean LDL-C levels at week 8 compared with baseline values were -57.0% (2.1%) and -44.4% (2.1%) in the total ezetimibe/rosuvastatin and total rosuvastatin groups, respectively (P < 0.001). The LDL-C-lowering efficacy of each of the ezetimibe/rosuvastatin combinations was superior to that of each of the respective doses of rosuvastatin. The mean percent change in LDL-C level in all ezetimibe/rosuvastatin combination groups was >50%. The number of patients who achieved target LDL-C levels at week 8 was significantly greater in the ezetimibe/rosuvastatin group (180 [92.3%] of 195 patients) than in the rosuvastatin monotherapy group (155 [79.9%] of 194 patients) (P < 0.001). There were no significant differences in the incidence of overall AEs, adverse drug reactions, and serious AEs; laboratory findings, including liver function test results and creatinine kinase levels, were comparable between groups.

IMPLICATIONS

Fixed-dose combinations of ezetimibe/rosuvastatin significantly improved lipid profiles in patients with hypercholesterolemia compared with rosuvastatin monotherapy. All groups treated with rosuvastatin and ezetimibe reported a decrease in mean LDL-C level >50%. The safety and tolerability of ezetimibe/rosuvastatin therapy were comparable with those of rosuvastatin monotherapy. ClinicalTrials.gov identifier: NCT02749994.

Osseous versus Nonosseous Spinal Epidural Arteriovenous Fistulas: Experiences of 13 Patients

BACKGROUND AND PURPOSE

Spinal epidural arteriovenous fistulas are rare vascular malformations. We present 13 patients with spinal epidural arteriovenous fistulas, noting the various presenting symptom patterns, imaging findings related to bone involvement, and outcomes.

MATERIALS AND METHODS

Among 111 patients with spinal vascular malformations in the institutional data base from 1993 to 2017, thirteen patients (11.7%) had spinal epidural arteriovenous fistulas. We evaluated presenting symptoms and imaging findings, including bone involvement and mode of treatment. To assess the treatment outcome, we compared initial and follow-up clinical status using the modified Aminoff and Logue Scale of Disability and the modified Rankin Scale.

RESULTS

The presenting symptoms were lower back pain (n = 2), radiculopathy (n = 5), and myelopathy (n = 7). There is overlap of symptoms in 1 patient (No. 11). Distribution of spinal epidural arteriovenous fistulas was cervical (n = 3), thoracic (n = 2), lumbar (n = 6), and sacral (n = 2). Intradural venous reflux was identified in 7 patients with congestive venous myelopathy. The fistulas were successfully treated in all patients who underwent treatment (endovascular embolization, n = 10; operation, n = 1) except 2 patients who refused treatment due to tolerable symptoms. Transarterial glue (n = 7) was used in nonosseous types; and transvenous coils (n = 3), in osseous type. After 19 months of median follow-up, the patients showed symptom improvement after treatment.

CONCLUSIONS

Although presenting symptoms were diverse, myelopathy caused by intradural venous reflux was the main target of treatment. Endovascular treatment was considered via an arterial approach in nonosseous types and via a venous approach in osseous types.

Importance of prognostic value of neutrophil to lymphocyte ratio in patients with ST-elevation myocardial infarction

The ratio between the absolute number of neutrophils and the number of lymphocytes (NLR) has recently emerged as a potential new biomarker predicting worse clinical conditions ranging from infectious disease to cardiovascular disease. Prognostic significance of NLR in patients with ST-elevation myocardial infarction (STEMI) is not established. This study aimed to investigate prognostic impact of NLR in patients with STEMI.We analyzed the data and clinical outcomes of 30-day survivors with STEMI who received successful coronary intervention from 2006 to 2010. NLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count at admission. Occurrence of major adverse cardiovascular events (MACEs; death, recurrent MI, target vessel revascularization (TVR)) at 5 years was evaluated.We enrolled 326 patients and mean follow-up duration was 68 ± 36 months. The mean NLR was 4.7 ± 5.2. Among all patients, all-cause mortality occurred in 46 patients (14%). Initial NLR was higher in patients who experienced all-cause mortality (6.39 ± 8.9 vs 4.2 ± 3.1, P = .004). In a multivariate regression model, the higher NLR was independently associated with increased risk for all-cause mortality (Hazard ratio, 1.085; 95% confidence interval, 1.002-1.174, P = .044).Increased NLR was associated increased rate of all-cause mortality in 30-day survivors after index STEMI, who received successful coronary intervention.

Transcatheter arterial embolization for iatrogenic bleeding after endoscopic ultrasound-guided pancreaticobiliary drainage

PURPOSE

The purpose of this study was to report the incidence of massive bleeding after endoscopic ultrasound-guided transmural pancreaticobiliary drainage (EUS-TPBD) and the clinical outcomes in patients with this condition treated with transcatheter arterial embolization (TAE).

PATIENTS AND METHODS

We performed a 9-year retrospective analysis of 797 EUS-TPBD procedures (excluding gallbladder or pseudocysts) in 729 patients. Among them, twelve (12/729, 1.65%) patients were referred for TAE to manage active bleeding adjacent to the TPBD sites. There were 8 men and 4 women with a mean age of 66.1 years±13.4 (SD) (range: 45-89 years). The clinical and procedure data of these 12 patients were reviewed.

RESULTS

Thirteen TAE procedures in 12 patients were performed. The bleeding sites were the left hepatic artery (n=7), the right hepatic artery (n=3), the left gastric artery (n=1), the left accessory gastric artery (n=1) and gastroduodenal artery (n=1). TAE was performed with gelatin sponge particles (n=1), coil (n=1) and n-butyl-2 cyanoacrylate with/without coils (n=11), with technical and clinical success rates of 100% (13/13) and 85% (11/13), respectively. Re-bleeding following embolization with gelatin sponge particles occurred in one patient. Procedure-related ischemic hepatitis was observed in another patient with pancreatic cancer with portal vein involvement.

CONCLUSION

On the basis of our results, TAE using n-butyl-2 cyanoacrylate seems safe and effective for the treatment of bleeding after EUS-TPBD procedures. When the portal vein is compromised, TAE of the hepatic artery can cause ischemic liver damage.

Electrically controllable THz asymmetric split-loop resonator with an outer square loop based on VO2

In this paper, we propose an asymmetric split-loop resonator with an outer square loop (ASLR-OSL) based on vanadium dioxide (VO₂) which can actively control the transmission characteristics of a terahertz wave while maintaining a high quality factor of the asymmetric split-loop resonator (ASLR) by adding an outer square loop. The proposed ASLR-OSL demonstrated transmission characteristics similar to those of ASLR, and the transmission characteristics of ASLR-OSL were successfully controlled by directly applying a bias voltage. These results show a simple method for imposing active properties on a common metamaterial having a high quality factor by adding a loop structure.

S-amlodipine plus chlorthalidone vs. S-amlodipine plus telmisartan in hypertensive patients unresponsive to amlodipine monotherapy: study protocol for a randomized controlled trial

Background

The efficacy of a combination of a calcium channel blocker (CCB) plus chlorthalidone (diuretic) versus a CCB plus an angiotensin receptor blocker (ARB) in patients not responding to CCB monotherapy has not been evaluated previously. We plan to compare the efficacy and safety of S-amlodipine (CCB) plus chlorthalidone versus S-amlodipine plus telmisartan (ARB) combinations among hypertension patients unresponsive to amlodipine monotherapy.

Methods/design

This study is a prospective, randomized, double-blind, multicenter, parallel, non-inferiority phase 4 study. Hypertension patients who have been treated with amlodipine (5 mg) or S-amlodipine (2.5 mg) monotherapy for ≥2 weeks and whose mean diastolic blood pressure (DBP) is greater than 90 mmHg will be randomized to either S-amlodipine (2.5 mg) plus chlorthalidone (25 mg) or S-amlodipine (2.5 mg) plus telmisartan (40 mg) therapy. The primary efficacy endpoint is mean sitting DBP change after 12 weeks of treatment. The study objective is to prove the non-inferiority of the former combination (test drug) as compared to the latter one (control) with a non-inferiority margin of 3 mmHg in mean DBP change. The secondary endpoints are 6-week DBP change, 6- and 12-week sitting systolic BP (SBP) change, and the attainment of the target BP (SBP < 140 mmHg or DBP < 90 mmHg). Urine albumin, albumin/creatinine ratio (ACR), pulse wave velocity, central BP, 24-h ambulatory BP monitoring, and body fluid composition analysis will be performed at each hospital’s discretion. The sample size was estimated as 170 in total with 1:1 randomization.

Discussion

This is the first study comparing the efficacy of a CCB plus chlorthalidone versus a CCB plus an ARB in patients who are not responding to CCB single therapy. The study result will help clinicians to choose between chlorthalidone and telmisartan in CCB-unresponsive patients.

Trial registration

ClinicalTrials.gov, NCT03226340. Registered on 2 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2636-1) contains supplementary material, which is available to authorized users.

Clinical outcomes of 23 patients who had repeat pelvic arterial embolisation for uncontrolled post-partum haemorrhage at a single centre

AIM

To evaluate the safety and efficacy of repeated pelvic arterial embolisation (PAE) for uncontrolled postpartum haemorrhage (PPH) after a single session of PAE and to compare angiographic findings between the two sessions of PAE.

MATERIALS AND METHODS

A total of 23 consecutive patients (age range, 23-44 years) who underwent repeated PAE for uncontrolled PPH between March 2001 and January 2016 in Severance Hospital were reviewed. The interval times between the two sessions of PAE, the angiographic findings, embolic materials, arteries embolised during PAE, and the clinical outcomes were reviewed retrospectively.

RESULTS

Overall clinical success was achieved after repeated PAE in 21 of 23 patients (91.3%). There were no procedure-related, major complications. On angiography, active bleeding from the uterine collateral arteries was more frequently observed in the second session of PAE (p>0.05), and embolisation of the anterior division of the internal iliac artery was significantly higher during the second session of PAE. Use of permanent embolic materials was significantly higher during the second session of PAE. Recanalisation of a previously embolised artery was identified in 14 patients (60.9%) during the second session.

CONCLUSION

Repeated PAE is safe and effective for managing recurrent bleeding after a single session of PAE. Repeated PAE is related to a higher chance of embolisation of the anterior division of the internal iliac artery, with the use of permanent embolic materials. Recanalisation of a previously embolised artery seems to be a principal source of rebleeding during a repeated session of PAE.

Assessment of clinical effect and treatment quality of immediate-release carvedilol-IR versus SLOW release carvedilol-SR in Heart Failure patients (SLOW-HF): study protocol for a randomized controlled trial

Background

Carvedilol is a non-selective, third-generation beta-blocker and is one of the cornerstones for treatment for patients with heart failure and reduced ejection fraction (HFrEF). However, due to its short half-life, immediate-release carvedilol (IR) needs to be prescribed twice a day. Recently, slow-release carvedilol (SR) has been developed. The aim of this study is to evaluate whether carvedilol-SR is non-inferior to standard carvedilol-IR in terms of its clinical efficacy in patients with HFrEF.

Methods/design

Patients with stable HFrEF will be randomly assigned in a 1:1 ratio to the carvedilol-SR group (160 patients) and the carvedilol-IR group (160 patients). Patients aged ≥ 20 years, with a left ventricular ejection fraction ≤ 40%, N-terminal pro B-natriuretic peptide (NT-proBNP) ≥ 125 pg/ml or BNP ≥ 35 pg/ml, who are clinically stable and have no evidence of congestion or volume retention, will be eligible. After randomization, patients will be followed up for 6 months. The primary endpoint is the change in NT-proBNP level from baseline to the study end. The secondary endpoints include the proportion of patients with NT-proBNP increment > 10% from baseline, composite of all-cause mortality and readmission, mortality rate, readmission rate, changes in blood pressure, quality of life, and drug compliance.

Discussions

The SLOW-HF trial is a prospective, randomized, open-label, phase-IV, multicenter study to evaluate the therapeutic efficacy of carvedilol-SR compared to carvedilol-IR in HFrEF patients. If carvedilol-SR proves to be non-inferior to carvedilol-IR, a once-daily prescription of carvedilol may be recommended for patients with HFrEF.

Trial registration

ClinicalTrials.gov, ID: NCT03209180. Registered on 6 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2470-5) contains supplementary material, which is available to authorized users.

Myocardial Mass Contributes to the Discrepancy Between Anatomic Stenosis Severity Assessed by Intravascular Ultrasound and Fractional Flow Reserve in Intermediate Lesions of the Coronary Artery

OBJECTIVES

The present study investigated the major contributors to the discrepancy between the minimal lumen area (MLA) and fractional flow reserve (FFR).

BACKGROUND

There was considerable discrepancy between MLA or diameter stenosis (DS) and FFR.

METHODS

We enrolled 744 patients with intermediate stenoses of the left anterior descending artery (LAD). Summed epicardial coronary artery length distal to the target stenosis was obtained from each longest view of the vessels on the coronary angiograms. Mismatching was defined as a lesion with FFR of >0.80 and MLA smaller than the best cut-off value (BCV) for predicting FFR of ≤0.80. Reverse mismatching was defined as a lesion with FFR of ≤0.80 and MLA larger than the BCV.

RESULTS

Summed epicardial coronary artery length was longer at the lesions of proximal LAD than that of middle LAD (380 mm ± 82 mm vs. 341 mm ± 80 mm, P < 0.001). Reverse mismatching was found more frequently in the proximal than middle LAD (28.3% vs. 5.5%, P < 0.001). Independent predictors of FFR ≤ 0.80 were age, male, multi-vessel disease, proximal LAD lesion, MLA, DS, plaque burden at distal reference, lesion length and summed epicardial coronary artery length. Proximal LAD lesion was an independent predictor of reverse mismatching (hazard ratio 3.162, 1.858-5.382, P < 0.001).

CONCLUSIONS

Myocardial mass subtended by a lesion is an important factor predicting FFR ≤0.80 and discrepancy between FFR and MLA. Myocardial mass subtended by a lesion should be considered when determining the revascularization therapy by intravascular ultrasound parameters. © 2017 Wiley Periodicals, Inc.

Histogram analysis of greyscale sonograms to differentiate between the subtypes of follicular variant of papillary thyroid cancer

AIM

To evaluate the diagnostic value of histogram analysis using ultrasound (US) to differentiate between the subtypes of follicular variant of papillary thyroid carcinoma (FVPTC).

MATERIALS AND METHODS

The present study included 151 patients with surgically confirmed FVPTC diagnosed between January 2014 and May 2016. Their preoperative US features were reviewed retrospectively. Histogram parameters (mean, maximum, minimum, range, root mean square, skewness, kurtosis, energy, entropy, and correlation) were obtained for each nodule.

RESULTS

The 152 nodules in 151 patients comprised 48 non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTPs; 31.6%), 60 invasive encapsulated FVPTCs (EFVPTCs; 39.5%), and 44 infiltrative FVPTCs (28.9%). The US features differed significantly between the subtypes of FVPTC. Discrimination was achieved between NIFTPs and infiltrative FVPTC, and between invasive EFVPTC and infiltrative FVPTC using histogram parameters; however, the parameters were not significantly different between NIFTP and invasive EFVPTC.

CONCLUSION

It is feasible to use greyscale histogram analysis to differentiate between NIFTP and infiltrative FVPTC, but not between NIFTP and invasive EFVPTC. Histograms can be used as a supplementary tool to differentiate the subtypes of FVPTC.

ErbB4 signaling in dopaminergic axonal projections increases extracellular dopamine levels and regulates spatial/working memory behaviors

Genetic variants of Neuregulin 1 (NRG1) and its neuronal tyrosine kinase receptor ErbB4 are associated with risk for schizophrenia, a neurodevelopmental disorder characterized by excitatory/inhibitory imbalance and dopamine (DA) dysfunction. To date, most ErbB4 studies have focused on GABAergic interneurons in the hippocampus and neocortex, particularly fast-spiking parvalbumin-positive (PV+) basket cells. However, NRG has also been shown to modulate DA levels, suggesting a role for ErbB4 signaling in dopaminergic neuron function. Here we report that ErbB4 in midbrain DAergic axonal projections regulates extracellular DA levels and relevant behaviors. Mice lacking ErbB4 in tyrosine hydroxylase-positive (TH+) neurons, but not in PV+ GABAergic interneurons, exhibit different regional imbalances of basal DA levels and fail to increase DA in response to local NRG1 infusion into the dorsal hippocampus, medial prefrontal cortex and dorsal striatum measured by reverse microdialysis. Using Lund Human Mesencephalic (LUHMES) cells, we show that NRG/ErbB signaling increases extracellular DA levels, at least in part, by reducing DA transporter (DAT)-dependent uptake. Interestingly, TH-Cre;ErbB4^f/f mice manifest deficits in learning, spatial and working memory-related behaviors, but not in numerous other behaviors altered in PV-Cre;ErbB4^f/f mice. Importantly, microinjection of a Cre-inducible ErbB4 virus (AAV-ErbB4.DIO) into the mesencephalon of TH-Cre;ErbB4^f/f mice, which selectively restores ErbB4 expression in DAergic neurons, rescues DA dysfunction and ameliorates behavioral deficits. Our results indicate that direct NRG/ErbB4 signaling in DAergic axonal projections modulates DA homeostasis, and that NRG/ErbB4 signaling in both GABAergic interneurons and DA neurons contribute to the modulation of behaviors relevant to psychiatric disorders.

Prognostic impact of left ventricular mass change in patients with ST-elevation myocardial infarction

Prognostic significance between progression of left ventricular hypertrophy (LVH) and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) is uncertain. The objective of this study was to investigate prognostic impact of progression of LV mass index (LVMI) in patients with STEMI.We analyzed the data and clinical outcomes of patients with STEMI who received successful coronary intervention. A total of 200 patients who had echocardiographic follow-up between 12 and 36 months were finally enrolled. According to change in LVMI compared to baseline LVMI, patients were classified into progression group and nonprogression group. Progression of LVMI was defined when increment of LMVI was greater than 10% compared to baseline LVMI. End points were major adverse cardiac events within 5 years, including death, recurrent MI, target vessel revascularization, and hospitalization due to heart failure.Progression of LVMI occurred in 55 patients. In the progression group, rate of recurrent MI was higher (13 vs 2%, P = .026) and the event-free survival of recurrent MI was significantly worse (log-rank P < .001) than that in the nonprogression group. Adjusted hazard ratio of progression of LVMI for recurrent MI was 10.253 (95% confidence intervals 2.019-52.061, P = .005).Increased LVMI was an independent predictor for adverse events, especially for recurrent MI, in patients with STEMI.

Current Awareness and Use of the Strain Echocardiography in Routine Clinical Practices: Result of a Nationwide Survey in Korea

Background

Because conventional echocardiographic parameters have several limitations, strain echocardiography has often been introduced in clinical practice. However, there are also obstacles in using it in clinical practice. Therefore, we wanted to find the current status of awareness on using strain echocardiography in Korea.

Methods

We conducted a nationwide survey to evaluate current use and awareness of strain echocardiography from the members of the Korean Society of Echocardiography.

Results

We gathered total 321 questionnaires from 25 cardiology centers in Korea. All participants were able to perform or interpret echocardiographic examinations. All participating institutions performed strain echocardiography. Most of our study participants (97%) were aware of speckle tracking echocardiography and 185 (58%) performed it for clinical and research purposes. Two-dimensional strain echocardiography was the most commonly used modality and left ventricle (LV) was the most commonly used cardiac chamber (99%) for clinical purposes. Most of the participants (89%) did not think LV strain can replace LV ejection fraction (LVEF) in their clinical practice. The common reasons for not performing routine use of strain echocardiography was diversity of strain measurements and lack of normal reference value. Many participants had a favorable view of the future of strain echocardiography.

Conclusion

Most of our study participants were aware of strain echocardiography, and all institutions performed strain echocardiography for clinical and research purposes. However, they did not think the LV strain values could replace LVEF. The diversity of strain measurements and lack of normal reference values were common reasons for not using strain echocardiography in clinical practice.

Liver-Wrapping, Nitric Oxide-Releasing Nanofiber Downregulates Cleaved Caspase-3 and Bax Expression on Rat Hepatic Ischemia-Reperfusion Injury

BACKGROUND

Hepatic ischemia-reperfusion injury (IRI) is an important determinant of the outcome of hepatic surgery, including re-section and transplantation. Previous studies have shown that nitric oxide (NO) has a protective effect against IRI. Therefore, many studies have examined methods for supplying NO. In this study, we investigated the effect of NO-releasing nanofibers on hepatic IRI in a rat model.

METHODS

Male Sprague-Dawley rats were divided into 4 groups: control, IRI only (n = 3); group 1, hepatic IRI and liver-wrapping with nanofiber lacking NO (n = 4); group 2, hepatic IRI and liver-wrapping with NO rapid-releasing nanofiber (n = 4); and group 3, hepatic IRI and liver-wrapping with NO slow-releasing nanofiber (n = 5).

RESULTS

The levels of aspartate aminotransferase and alanine aminotransferase were not significantly different between groups. On the basis of Western blots, Bax/β-actin levels were significantly lower in group 2 than in group 3 (P < .01). Cleaved Caspase-3/β-actin levels were significantly lower in group 2 than in the control, group 1, and group 3 (P < .05, .01, and .01, respectively). However, there were no significant differences in Bcl-2/β-actin between groups.

CONCLUSIONS

The liver-wrapping NO rapid-releasing nanofiber downregulated cleaved Caspase-3 and Bax expression. It has a protective effect by reducing apoptosis in hepatic IRI in rats.

The impact of microvascular resistance on the discordance between anatomical and functional evaluations of intermediate coronary disease

AIMS

In intermediate coronary artery disease, discordance between anatomical and functional assessments persists and the diagnostic accuracy of an anatomical evaluation is not satisfactory for determining functional significance. We aimed to evaluate the impact of microvascular resistance on "anatomical-functional discordance".

METHODS AND RESULTS

In 97 intermediate coronary lesions of 83 patients, minimum lumen area (MLA), fractional flow reserve (FFR), Δ(Pd/Pa-FFR), and hyperaemic microvascular resistance index (hMVRI) were measured using intravascular ultrasound and an intracoronary dual pressure and Doppler sensor-tipped guidewire. hMVRI correlated with FFR and Δ(Pd/Pa-FFR) (r=0.611, p<0.001; r=-0.509, p<0.001; respectively). After the lesions were categorised into four groups based on functional significance (FFR 0.8) and the MLA cut-off for that (2.5 mm2), hMVRI was higher with a lower Δ(Pd/Pa-FFR) regardless of the MLA group in lesions with FFR >0.8, compared with those in lesions with FFR ≤0.8. hMVRI was independently associated with FFR and Δ(Pd/Pa-FFR) (β=0.443, p<0.001; β=-0.389, p<0.001; respectively).

CONCLUSIONS

Coronary microvascular resistance is associated with anatomical-functional discordance and the ischaemic potential of intermediate epicardial stenosis. In determining a treatment strategy, anatomy alone is insufficient and an integrated physiologic approach is important.