Oral mirtazapine decreases the gastrointestinal adverse effects in cats on doxorubicin chemotherapy

Anorexia, depression, and vomiting are the common adverse effects of chemotherapy in humans and animals. Mirtazapine is primarily used as an appetite stimulant and antiemetic in dogs and cats. Therefore, we evaluated the efficacy of mirtazapine in reducing the gastrointestinal adverse effects in cats receiving doxorubicin chemotherapy. This single-masked, placebo-controlled crossover study enrolled 11 cats with malignant mammary gland tumors. The cats were randomly assigned to receive either mirtazapine (1.88 mg/cat) or placebo every 48 h for 2 weeks from the first initiation of doxorubicin chemotherapy. Each cat was then crossed over to the alternate group on the subsequent chemotherapy with a 1-week wash-out period. The owners were asked to record appetite score, activity score, episodes of vomiting and diarrhea for 2 weeks after each doxorubicin administration. Cats treated with mirtazapine showed significantly increased bodyweight compared with those on placebo (P = 0.010). The appetite and activity scores during mirtazapine treatment was significantly higher than those during placebo treatment (P = 0.005 and 0.018, respectively). Furthermore, the prevalence of episodes of vomiting during mirtazapine treatment was significantly lower than that during placebo treatment (P = 0.026). Our results demonstrate that mirtazapine can significantly increase bodyweight, appetite, and activity and reduce vomiting in cats after doxorubicin chemotherapy.

Chronic subdural haematoma mimicking extrapyramidal symptoms

A male patient in his 70s with chronic schizophrenia, who could previously walk independently, developed a gait disturbance without any significant neurological deficit. Initially, his short step length and unstable gait were thought to be related to extrapyramidal symptoms caused by medication side effects. We tapered his antipsychotic medication, but the unstable gait persisted. After 2 weeks of observation, we noted general weakness with left-side dominance, leading us to consider a focal brain lesion despite there being no recent history of falling or trauma. A CT scan of the brain showed chronic subdural haematoma and the patient underwent emergency surgery. After 14 days of treatment, he was discharged back to the chronic ward.

Kondo screening in a Majorana metal

Kondo impurities provide a nontrivial probe to unravel the character of the excitations of a quantum spin liquid. In the S = 1/2 Kitaev model on the honeycomb lattice, Kondo impurities embedded in the spin-liquid host can be screened by itinerant Majorana fermions via gauge-flux binding. Here, we report experimental signatures of metallic-like Kondo screening at intermediate temperatures in the Kitaev honeycomb material α-RuCl3 with dilute Cr3+ (S = 3/2) impurities. The static magnetic susceptibility, the muon Knight shift, and the muon spin-relaxation rate all feature logarithmic divergences, a hallmark of a metallic Kondo effect. Concurrently, the linear coefficient of the magnetic specific heat is large in the same temperature regime, indicating the presence of a host Majorana metal. This observation opens new avenues for exploring uncharted Kondo physics in insulating quantum magnets.

Development of metal radioactive liquid reference material for proficiency test

This study developed liquid reference materials containing various metals, to be used for quality assurance of radiation measurements of the most common metallic wastes generated during the operation or decommissioning of nuclear power plants. The liquid reference materials were prepared by assuming the dissolution of stainless-steel using acid and melting of the major metals present in the stainless steel, namely Fe, Ni, Cr, and Mn, along with the standard sources (134Cs, 137Cs, 60Co, 90Sr). The theoretical massic activity of the standard sources added to the samples and the measured reference values of the gamma and beta emitters in the samples were compared, and they showed good agreement within a one-sigma confidence interval (k = 1). Using the developed reference materials, a proficiency test was conducted on three domestic labs, and the results were evaluated using Z-score. While the evaluation results showed good agreement between the reference values and the reported values for 137Cs and 60Co, all participating labs reported lower values than the reference value for 134Cs. For 90Sr, two out of the three labs reported significantly higher values than the reference value. Based on the results of this study, the developed metal radioactive liquid reference material is expected to be registered as certified reference material (CRM) in the future. They will be used as the CRM for measuring and ensuring the quality of radioactive metal waste.

Single flow diverter to manage multiple intracranial aneurysms in a parent artery

BACKGROUND

Endovascular coil embolization has become an important method in the management of intracranial aneurysm. However, simultaneously coiling multiple intracranial aneurysms (MIAs) in unilateral parent artery in one-stage may fail or insufficient in geographic difficult aneurysm. Flow diverter (FD) has the potential to manage MIAs with nonamenable to coiling. Herein, we report periprocedural morphologic change and outcomes using single FD to manage unruptured MIAs in a parent artery.

METHODS

Over a 3-year period, a total of 63 patients with 126 MIAs successful managed by single FD with complete angiographic follow-up. There were 49 women and 14 men, with ages ranging from 42 to 77 years (mean: 59 years). We retrospectively assessed the clinical data, aneurysm characteristic, angiographic and clinical outcomes of all patients and compared with 171 patients with single aneurysm managed by FD.

RESULTS

Sixty-one patients with 118 aneurysms (94%) located in internal carotid artery or middle cerebral artery (n = 4, 3%), two patients with four aneurysms (4%) were found in the basilar artery. The mean aneurysm size was 5.6 mm (range from 1.8 to 38 mm). Mean angiographic follow-up was 14 months. Complete obliteration of aneurysm was achieved in 102 aneurysms (83%), subtotal or partial aneurysm obliteration was demonstrated in 18 aneurysms (15%), unchanged aneurysm morphology in three (2%). Aneurysm morphology synchronized alteration in 55 patients (87%), other eight patients (13%) with 16 aneurysms showed different morphologic alteration in angiographic follow-up. Four patients (6.3%) had intraprocedural ischemic complication. During the follow-up period, 61 patients (97%) were neurologic stable; there was no hemorrhagic or ischemic event.

CONCLUSION

Single FD was feasible to treat MIAs in a parent artery with both effective and safe in one-stage management. Most aneurysms synchronized alteration of morphology in a mid-term follow-up. The procedure was almost the same with FD managing single aneurysm, but longer FD is needed in MIAs.

Association of left atrial ejection fraction and cardiovascular outcomes in Asian patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme

Background

The optimal method of risk stratification of hyp­ertrophic cardiomyopathy (HCM) patients, especially in the Asian population, is unknown. Left atrial ejection fraction (LAEF) is an emerging risk marker for cardiovascular outcomes. This study aimed to investigate whether LAEF was associated with cardiovascular outcomes in Asian patients with HCM.

Methods

This was a retrospective cohort study performed in a tertiary academic centre involving 291 consecutive patients diagnosed with HCM between 2010 and 2017. We collected the relevant clinical characteristics of these patients and retrospectively analysed the index transthoracic echocardiograms for novel left atrial indices including LAEF. We obtained the maximum (LAVmax) and minimum left atrial volumes (LAVmin) using the biplane method of disks in apical 4- and 2-chamber views. LAEF was derived by dividing the difference between LAVmax and LAVmin by LAVmax. We assessed the patients for outcomes of (1) heart failure requiring admission, and (2) a composite of adverse outcomes including all-cause mortality, ventricular tachycardia / ventricular fibrillation (VT/VF) events, appropriate device therapy if an implantable cardioverter defibrillator (ICD) was implanted, stroke and heart failure hospitalization.

Results

The patients had a mean age of 59.0 ± 16.7 years-old at diagnosis and had a male preponderance (71.2%). The most common comorbidities were hypertension, diabetes mellitus and ischemic heart disease. On univariable logistic regression analysis, maximum and minimum left atrial volume index (LAVI) as well as LAEF showed a significant association with heart failure and the predefined composite outcome. On Cox regression analysis adjusting for variables of age, sex, left ventricular ejection fraction (LVEF), left ventricular maximal wall thickness >30mm, significant left ventricular outflow tract (LVOT) gradient of > 30mmHg and more than moderate mitral regurgitation, maximum and minimum LAVI as well as LAEF retained an association with heart failure admission but only minimum LAVI and LAEF were associated with the composite outcome [(OR 0.019, 95% CI 0.02-0.230, p=0.002), (OR 0.226, 95% CI 0.053-0.960, p=0.044), (OR 1.030, 95% CI 1.016-1.045, p<0.001), and (OR 1.016, 95% CI 1.005-1.026, p=0.004) respectively].

Conclusion

LAEF was an independently associated with congestive heart failure as well as a composite of adverse outcomes in Asian patients with HCM.

Adsorption and purification of biogas inside graphitic nanopores: molecular dynamics simulation approach

Biogas is one of the most common sources of biomass energy. Due to the associated environmental pollution and costs, desulfurization, and purification are the most important challenges of biogas power generation. Using all-atom molecular dynamics (MD), we systematically simulated the isothermal adsorption behavior of biogas (comprising CH₄, CO₂, H₂O, H₂S, and H₂) in graphite (Gr) slit nanopores. The impact of slit width, system temperature, and moisture content on the adsorption energy, adsorption ratio, and diffusion coefficient of biogas molecules was investigated. Simulation results revealed that due to strong interactions between graphite and H₂S, graphite slits of width d = 48 ~ 80 Å displayed significant selective adsorption of H₂S molecules. At temperatures between 300 and 500 K, Gr slits can effectively separate H₂S in biogas. Moreover, as the moisture content of biogas (vol%) increases from 0 to 20%, the formation and interactions of hydrogen bonds between water molecules create H₂O films accumulating on the Gr surface and taking up the adsorption sites, which reduces the amount of hydrogen sulfide that can be adsorbed. Our findings provide important insights into the material design for biogas purification. A schematic representation of molecular interactions between adsorbates and the wall for biogas mixtures (comprising CH₄, CO₂, H₂O, H₂S, and H₂) inside graphitic nanopores.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

Not Applicable

Supplementary information

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

Sleep apnea and temporal changes in cardiac repolarization in patients undergoing coronary artery bypass grafting

Background

In coronary artery bypass grafting (CABG), despite re-establishing coronary reperfusion, myocardial recovery and restoration of contractility often occur later, and the risk of adverse cardiovascular events persists during the post-CABG period. The occurrence of adverse cardiovascular events is linked to abnorm-al cardiac repolarisation that can be measured by surface electrocardiograms (ECGs). Sleep apnoea is an emerging cardiovascular risk factor. The relationship between sleep apnoea, abnorm-al cardiac repolarisation, and the occurrence of adverse cardiovascular events is not well studied.

Purpose

We investigated the impact of sleep apnoea on the change in repolarisation after CABG, and if the change in repolarisation is associated with the occurrence of major adverse cardiac and cerebrovascular events (MACCE).

Methods

Between November 2013 and December 2018, 1007 patients from 4 hospitals underwent an overnight sleep study prior to a non-emergent CABG. ECGs were acquired prospectively within 48h before the CABG (T1), and within 24h after the CABG (T2). QTc intervals were measured in three consecutive heart beats in one lead - the preferential lead measurements were lead II, followed by lead V5. QTc intervals were measured using the BRAVO algorithm by Analysing Medical Parameters for Solutions (AMPS) LLC. The change of T2 from T1 for QTc (ΔQTc) was derived. The mean follow-up duration was 2.1 years. MACCE was a composite of cardiovascular death, myocardial infarction, stroke, and unplanned revascularisation.

Results

A total of 954 patients (median age: 62 years; male: 86%) survived the initial 24 hours and had quality ECGs for analysis. Lead II and V5 were measured in 72% and 25% of the cohort, respectively. A total of 115 patients developed MACCE (MACCE group). Compared with the non-MACCE group, the MACCE group was older, had (a) a higher prevalence of smoking, hypertension, diabetes mellitus, and chronic kidney disease, (b) higher apnoea-hypopnoea index (AHI) and oxygen desaturation index (ODI), and (c) a smaller ΔQTc (Table). In Cox regression analysis, a smaller ΔQTc was independently associated with occurrence of MACCE (HR: 1.003; 95% CI: 1.000–1.006; p=0.032).

Older age, history of previous stroke, chronic kidney disease, more severe sleep apnoea (higher AHI, ODI, and severe oxygen desaturation) were associated with smaller ΔQTc. After adjusting for the effects of confounding variables, a higher ODI was independently associated with a smaller ΔQTc (correlation coefficient: −0.58; p&lt;0.001).

Conclusions

In patients undergoing a non-emergent CABG, a smaller ΔQTc during the first 24 hours after the CABG is associated with a higher incidence of MACCE. A higher pre-operative ODI based on a sleep study is an independent predictor of a smaller ΔQTc. This suggests that change in QTc within 24 hours after CABG could be due to sleep apnoea, and it is a novel predictor of occurrence of MACCE at medium term follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Transition Award and Clinician Scientist Award from the National Medical Research Council of Singapore (award numbers: NMRC/TA/012/2012; NMRC/CSA-INV/002/2015)

Metabolic associated fatty liver disease increases risk of adverse events after acute coronary syndrome

 

Metabolic Associated Fatty Liver Disease (MAFLD) was recently introduced as an alternative definition for fatty liver, that has been linked to an increased risk of systemic end-organ damage. However, current studies have not examined the impact of MAFLD on patients presenting with acute coronary syndrome (ACS). Here, we present a retrospective analysis on the short and long-term outcomes of ACS patients with MAFLD.

Methods

A retrospective analysis was conducted in a tertiary care centre. Hepatic steatosis and fibrosis was examined with hepatic steatosis index and fibrosis-4 (FIB-4) index. The primary and secondary outcomes of the analysis were long term all-cause mortality, and in-hospital all-cause mortality, stroke, heart failure and cardiogenic shock respectively. Adjusted analysis was conducted for primary and secondary outcomes with covariates including age, sex, race, type of ACS and previous myocardial infarction.

Results

A total of 5770 patients were included in the analysis, and 21% of ACS patients had concomitant MAFLD. MAFLD resulted in a 23% increase in long-term all-cause mortality compared to non-MAFLD (HR: 1.230, CI: 1.065 to 1.420, p=0.005). MAFLD increased the risk of in-hospital mortality, stroke, heart failure and cardiogenic shock compared to non-MAFLD. A sensitivity analysis conducted based on MAFLD with advance fibrosis, chronic kidney disease and diabetes also demonstrated significantly increased effect size magnitude of all-cause mortality, compared to non-MAFLD.

Conclusion

MAFLD represents an encapsulation of metabolism dysregulation and has been associated with increased risk of systematic disease. The present study shows that MAFLD is associated with significantly increased adverse prognostic outcomes after ACS compared to non-MAFLD. An increase in awareness of MAFLD is required beyond the field of hepatology for improvements in multidisciplinary care and management.

Funding Acknowledgement

Type of funding sources: None.

Reconstructed meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting for left main disease

Background

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results.

Objectives

We performed a systematic review from inception to 23 May 2021 and one-stage reconstructed individual-patient data meta-analysis (IPDMA) that included 10-year mortality outcomes.

Methods

The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke and unplanned revascularization at 5 years. We did IPDMA using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups.

Results

Of 583 articles retrieved, 5 RCTs were included. A total of 4595 patients from these 5 RCTs were randomly assigned to PCI (N=2297) or CABG (N=2298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6% respectively (HR 1.093, 95% CI: 0.925–1.292; p=0.296). PCI conferred similar time-to-MI (RMST ratio 1.006, 95% CI: 0.992–1.021, p=0.391) and stroke (RMST ratio 1.005, 95% CI: 0.998–1.013, p=0.133) at 5 years. Unplanned revascularization was more frequent following PCI compared with CABG (HR 1.807, 95% CI: 1.524–2.144, p&lt;0.001) at 5 years.

Conclusion

This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data

Background and aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p&lt;0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p&lt;0.001; HR: 1.856, 1.380–2.497, p&lt;0.001 respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Funding Acknowledgement

Type of funding sources: None.

A 10-year cohort on prognostic outcomes in patients presenting with acute myocardial infarction complicated by cardiogenic shock and/or cardiac arrest

Background

Cardiogenic shock (CS) and cardiac arrest (CA) complicating acute myocardial infarction (AMI) portend unfavourable outcomes. This study examined the prognosis of patients presenting with AMI complicated by CS and/or CA.

Methods

Consecutive patients presented with AMI to a percutaneous coronary intervention-capable tertiary institution between 2011 and 2021 were studied. Patients were stratified based on the presence or absence of CS (CS+ or CS−) and CA (CA+ or CA−). The primary outcome was 30-day cardiovascular-related mortality. Subgroup analyses based on AMI-type and sex were conducted. Kaplan-Meier curves for cardiovascular-related mortality based on the AMI-type and sex were constructed.

Results

The study included 11,608 AMI patients, 283 of whom had CS+/CA+, 1,068 had CS+/CA−, 54 had CS−/CA+ and 10,203 had CS−/CA−. Cardiovascular-related mortality was significantly higher for CS+/CA+ (57.6%), followed by CS+/CA− (41.6%), CS−/CA+ (20.4%) and CS−/CA− (2.4%). Kaplan-Meier curves demonstrated CS+/CA+ group had the highest mortality (HR=36.26; 95% CI: 29.71–44.25, p&lt;0.001), followed by CS+/CA− (HR=21.59; 95% CI: 18.47–25.24, p&lt;0.001) and CS−/CA+ (HR=9.18; 95% CI: 5.02–16.80, p&lt;0.001), with CS−/CA− as the reference. Those with NSTEMI had consistently higher cardiovascular-related mortality rates than their STEMI counterparts for all groups, apart from the CS+/CA+ group. The sex-specific analysis demonstrated that the survival curves for females with CS+/CA+, CS+/CA− and CS−/CA+ converged, whilst the survival curves for males diverged over time. The multivariable Cox regression revealed the presence of CS and CA are independent predictors of cardiovascular-related mortality, but not NSTEMI, when adjusted for age, gender, diabetes, left ventricular ejection fraction, chronic renal failure, and culprit vessel.

Conclusions

AMI associated with CA and CS portends the least favourable survival, followed by those with CS or CA alone. Excess mortality was observed in the traditionally perceived lower-risk groups, particularly in women. This calls for increased awareness amongst clinicians when managing this subset of high-risk patients.

Funding Acknowledgement

Type of funding sources: None.

Legacy effects of infection in patients with heart failure: a national cohort study of 31,318 patients in Taiwan

Background

Although infection is a common cause of hospitalization in patients (pts) with heart failure (HF), the long-term cardiovascular (CV) prognosis in HF after infection is not well studied.

Methods and results

From 2009 to 2015, 310,485 pts with their first HF admissions and survival to discharge were identified from the National Health Insurance Research Database. Among the pts, 103,505 (33.3%) were readmitted within 1 year after HF discharge for infection, including pneumonia (44.2%), urinary tract infection (UTI) (37.9%), skin and soft tissue infections (9.7%), and others (8.1%). Those without admission for any infection were controls. We compared the primary composite endpoint, including all-cause death, acute myocardial infarction (AMI), stroke, and hospitalization for HF (HHF) between the 2 groups after the infection episode. After propensity score matching, the clinical characteristics (age 71.7±13.9 years, male 52.0%) and treatment were similar between the groups (n=15,659 in each group). In a mean follow-up time of 4.3±2.9 years, 86.2% pts with a history of infection admission and 63.6% pts in the control group met the primary endpoint. Multivariate Cox proportional hazards analysis showed the infection group had a higher risk of the primary composite endpoint (HR 1.760, 95% CI 1.714–1.807), including all-cause death (HR 1.587, 95% CI: 1.540–1.636), HHF (HR 1.993, 95% CI 1.922–2.066), AMI (HR 1.332, 95% CI 1.224–1.450), and stroke (HR 1.769, 95% CI 1.664–1.882). In infection group, HHF was the earliest outcome event with a mean time of 17.5 months and mortality is the second early event with a mean time of 23 months after discharge from the infection episode. Pneumonia carried a higher risk than UTI for the primary composite endpoint (HR 1.140, 95% CI 1.104–1.178).

Conclusions

One-third of HF pts discharged from the hospital experienced acute infection that required readmission. The pts had worse CV prognosis after readmission for infectious disease compared to those without infection

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This study is supported by National Cheng Kung University Hospital and Tainan Hospital, Ministry of Health and Welfare, Taiwan.

Higher long-term mortality in patients with concomitant acute coronary syndrome and aortic stenosis

Background

Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors, and their concomitant presentation is increasing in incidence with the aging population. Yet literature regarding the prognosis of patients with concomitant ACS and AS remains scarce.

Methods

This retrospective cohort study examined consecutive patients presenting with ACS (ST-segment elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and concomitant AS between 1 January 2011 and 31 March 2021 in a tertiary hospital. The cohort was divided into mild, moderate and severe AS based on index echocardiogram. The primary outcome was all-cause mortality. Kaplan-Meier curves were constructed to compare all-cause mortality among the three groups of patients, based on ACS type and left ventricular ejection fraction (LVEF). Multivariable Cox regression was performed to identify independent predictors of all-cause mortality.

Results

Of a total of 563 patients, 264 had mild (46.9%), 193 moderate (34.3%) and 106 severe AS (18.8%). The mean follow-up duration was 2.5 (± 2.4) years. Majority of patients (72.5%) presented with NSTEMI. Patients with moderate and severe AS had higher rates of all-cause mortality compared to those with mild AS (49.7% vs. 51.4% vs. 35.6% respectively, p=0.002). Concomitant moderate (HR 1.439, 95% CI 1.012–2.048, p=0.043) and severe AS (HR 1.844, 95% CI 1.159–2.933, p=0.010) were independent predictors of all-cause mortality after adjusting for age, gender, LVEF, ACS type, chronic kidney disease, diabetes, hypertension, coronary artery bypass grafting and aortic valve replacement as a time-dependent variable. The Kaplan-Meier curves demonstrated excess mortality in moderate and severe AS, compared to the mild AS group (p&lt;0.001), with similar survival trends observed in the STEMI and the NSTEMI groups, as well as those with preserved LVEF.

Conclusion

Regardless of the ACS presentation type, long-term excess mortality in those with concomitant moderate or severe AS was observed. The adverse prognosis typically observed in patients with concomitant severe AS, in the setting of ACS, extends to patients with moderate AS.

Funding Acknowledgement

Type of funding sources: None.

Experimental animal models and evaluation techniques in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the most lethal type of cerebral stroke without effective therapy. Although clinical trials with various surgeries have been conducted, none have improved clinical outcomes compared to the current medical management for ICH. Several ICH animal models, including autologous blood injection, collagenase injection, thrombin injection, and microballoon inflation methods, have been developed to elucidate the underlying mechanisms of ICH-induced brain injury. These models could also be used for discovering new therapy for ICH preclinically. We summarize the existing ICH animal models and the evaluation parameters used to measure the disease outcomes. We conclude that these models, resembling the different aspects of ICH pathogenesis, have their advantages and disadvantages. None of the current models closely represent the severity of ICH seen in clinical settings. More appropriate models are needed to streamline ICH's clinical outcomes and be used for validating newly developed treatment protocols.

Prenatal exposure to nickel and atopic dermatitis at age 3 years: a birth cohort study with cytokine profiles

BACKGROUND

Nickel, the fifth most common element on Earth, is the leading inducer of contact allergies in humans, with potent immunological effects. Nickel-induced contact allergies predominantly affect females. Maternal exposure to nickel has been associated with several developmental abnormalities. However, how a maternal nickel exposure affects the development of atopic diathesis and immune abnormalities in children has never been addressed.

OBJECTIVES

We aimed to determine whether maternal Ni exposure affects the development of atopic dermatitis and immune abnormalities in their children.

METHODS

Using a birth cohort study, we analysed 140 mother-child pairs recruited in 2012-2015 from central Taiwan. Maternal exposure to nickel was estimated using urinary nickel levels measured by inductively coupled plasma mass spectrometry (ICP-MS). The serum levels of 65 analytes and IgE in 3-year-old children were profiled with a multiplex ELISA. The correlation between the maternal urinary nickel concentration and serum analyte levels was assessed using Spearmen's correlation. Multivariant regression analysis was performed to evaluate the association between maternal urinary nickel levels and serum analyte concentrations in their children.

RESULTS

The geometric means of the maternal urinary nickel and the children's serum IgE levels were 2.27 μg/L and 69.71 IU/ml, respectively. The maternal nickel exposure was associated with increased serum levels of IL-1β, IL-2, TNF-α, and leukaemia inhibitory factor (LIF) but with decreased serum levels of matrix metalloproteinase-1 (MMP-1), IL-2R, and eotaxin-1 in the children. In addition, the development of childhood atopic dermatitis at 3 years old was significantly associated with the child's serum levels of IgE and IL-2R, but it was negatively associated with the maternal nickel exposure.

CONCLUSIONS

This is the first study showing the potential immunological effects of maternal nickel exposure in their children at an early developmental stage.

Flow diverter manages very small aneurysm of the internal carotid artery

BACKGROUND

Endovascular aneurysm coiling is a minimally invasive method to manage intracranial aneurysms. However, aneurysm coiling may fail in very small aneurysms (VSAs); thus, flow diverter (FD) is recommended as an alternative in these difficult aneurysms. Herein, we report our experience and outcomes of FD to treat VSA of the internal carotid artery (ICA).

METHODS

Over a 3-year period, a total of 70 patients with 87 unruptured VSAs of the ICA were managed by FD. There were 54 men and 16 women, with a mean age of 57 (range, 41-75) years. We retrospectively assessed the clinical data, aneurysm characteristics, and angiographic as well as clinical outcomes of patients treated by FD and compared with larger aneurysms.

RESULTS

Fifty aneurysms (58%) were located in the supraclinoid ICA, followed by paraclinoid ICA (n = 31, 36%) and cavernous ICA (n = 6, 7%). Most aneurysms (n = 72, 83%) were between 2 and 3 mm in size. The mean aneurysm size was 2.3 mm (range, 1.5-3 mm). Follow-up angiographic data (mean, 13 months) were available in 54 patients with 68 aneurysms. Successful FD deployment in an ideal position to bride aneurysm was achieved in 86 of 87 aneurysms (99%). Complete obliteration (CO) was achieved in 63 aneurysms (93%). Compared with larger aneurysms (>3 mm), VSAs had the tendency to achieve CO ( p < 0.05) in a midterm follow-up. Two patients (2.8%) had intraprocedural complications, including in-stent thrombosis (n = 1) and distal embolism (n = 1). One patient (1.4%) suffered from mild limb weakness.

CONCLUSION

The use of FD to manage VSA was technically feasible, and the procedure was simpler than those of larger aneurysms. FD stenting of VSAs was confirmed to be effective and safe and had higher CO rate than those in larger aneurysms in a midterm angiographic follow-up.

Vascular Trauma in the Extremities: Factors Associated with the Outcome and Assessment of Amputation Indexes

BACKGROUND

Traumatic vascular injury in the extremities may be associated with a low mortality rate but can lead to limb loss that seriously affects patients' functionality. Multiple scoring systems have been designed to evaluate the prognosis, but none are 100% predictive. The management of traumatic vascular injury remains challenging and depends mostly on the surgeon's experience.

OBJECTIVES

We identified the risks associated with limb loss and further investigated the utility of current amputation indexes.

METHODS

We retrospectively reviewed 53 cases of traumatic vascular injury in the extremities at a tertiary referral medical center over the past ten years (January 2011-December 2020). The mangled extremity severity score (MESS), limb salvage index (LSI), and predictive salvage index (PSI) were used to assess the traumatized limbs. The injury characteristics and outcomes were evaluated using regression analysis.

RESULTS

The incidence of limb loss was 20.8% (n = 11), and open fractures were the most related factor. Extensive involvement of soft tissue, vascular injury combined with tibia or fibula fractures, initial shock status, and the amount of transfusion were associated with limb loss.

CONCLUSIONS

Our study identified the risk factors and clinical utility of MESS, PSI, and LSI. While both LSI and PSI had acceptable diagnostic accuracy, amputation should be decided based on a variety of criteria and clinical features. Salvaging any limb that has not become apparently futile seems logical, yet the presence of certain factors may suggest a worse outcome.

The emergent neurosurgical outcome of spontaneous intracranial hemorrhage in patients with chronic liver disease

Objectives

The influence of chronic liver disease (CLD) on emergent neurosurgical outcomes in patients with spontaneous intracerebral hemorrhage (ICH) remains unclear. CLD is usually associated with coagulopathy and thrombocytopenia, which contribute to a high rebleeding rate and poor prognosis after surgery. This study aimed to confirm the outcomes of spontaneous intracranial hemorrhage in patients with CLD after emergent neurosurgery.

Materials and Methods

We reviewed the medical records of all patients with spontaneous ICH from February 2017 to February 2018 at the Buddhist Tzu Chi Hospital, Hualien, Taiwan. This study was approved by the Review Ethical Committee/Institutional Board Review of Hualien Buddhist Tzu Chi Hospital (IRB111-051-B). Patients with aneurysmal subarachnoid hemorrhage, tumors, arteriovenous malformations, and those younger than 18 years were excluded. Duplicate electrode medical records were also removed.

Results

Among the 117 enrolled patients, 29 had CLD and 88 did not. There were no significant differences in essential characteristics, comorbidities, biochemical profile, Glasgow coma scale (GCS) score at admission, or ICH sites. The length of hospital stay (LOS) and length of intensive care unit stay (LOICUS) are significantly longer in the CLD group (LOS: 20.8 vs. 13.5 days, P = 0.012; LOICUS: 11 vs. 5 days, P = 0.007). There was no significant difference in the mortality rate between the groups (31.8% vs. 28.4%, P = 0.655). The Wilcoxon rank-sum test for liver and coagulation profiles between survivors and the deceased revealed significant differences in the international normalized ratio (P = 0.02), including low platelet counts (P = 0.03) between survivors and the deceased. A multivariate analysis of mortality found that every 1 mL increase in ICH at admission increased the mortality rate by 3.9%, and every reduction in GCS at admission increased the mortality rate by 30.7%. In our subgroup analysis, we found that the length of ICU stay and LOS are significantly longer in patients with CLD who underwent emergent neurosurgery: 17.7 ± 9.9 days versus 7.59 ± 6.68 days, P = 0.002, and 27.1 ± 7.3 days versus 16.36 ± 9.08 days, P = 0.003, respectively.

Conclusions

From our study's perspective, emergent neurosurgery is encouraged. However, there were more prolonged ICU and hospital stays. The mortality rate of patients with CLD who underwent emergent neurosurgery was not higher than that of patients without CLD.

Effect of iron deficiency without anaemia on days alive and out of hospital in patients undergoing valvular heart surgery

Comprehensive evidence regarding the treatment of non-anaemic iron deficiency in patients undergoing valvular heart surgery is lacking. This study aimed to investigate the association between non-anaemic iron deficiency and postoperative outcomes in these patients. We retrospectively analysed 321 patients of which 180 (56%) had iron deficiency (defined as serum ferritin < 100 ng.ml^-1 or < 300 ng.ml^-1 with transferrin saturation < 20%). While the iron-deficient group had lower pre-operative haemoglobin levels than the non-iron deficient group (median (IQR [range]) 134 (127-141 [120-172]) g.l^-1 , 143 (133-150 [120-179]) g.l^-1 , p = 0.001), there was no between-group difference in allogeneic red blood cell transfusion. Median (IQR [range]) days alive and out of hospital at postoperative day 90 was 1 day shorter in the iron-deficient group (80 (77-82 [9-85]) days vs. 81 (79-83 [0-85]) days, p = 0.026). In multivariable analysis, only cardiopulmonary bypass duration (p = 0.032) and intra-operative allogeneic red blood cell transfusion (p = 0.011) were significantly associated with reduced days alive and out of hospital at postoperative day 90. Iron deficiency did not exert any adverse influence on secondary outcomes except length of hospital stay. Our findings indicate that non-anaemic iron deficiency alone is not associated with adverse effects in patients undergoing valvular heart surgery when it does not translate into an increased risk of allogeneic transfusion.

Flow-diverter stent to manage intracranial aneurysms: A single center experience

BACKGROUND

Endovascular coil embolization is an important method for managing intracranial aneurysms. However, aneurysm coiling may fail or be insufficient in geographically difficult aneurysms. A flow-diverter stent (FDS) is an alternative in these difficult coiling aneurysms. Thus, this study reports the experience and outcome of FDS management of intracranial aneurysms.

METHODS

Over 29 months, FDS treated 125 patients with 163 intracranial unruptured aneurysms. This study enrolled 31 men and 94 women, ranging from 17 to 81 years (mean, 58 years). Clinical data, aneurysm characteristics, and angiographic and clinical outcomes of patients treated by FDS were retrospectively assessed.

RESULTS

The current study found 151 (93%) aneurysms in the internal carotid artery. Most aneurysms (n = 118; 72%) were small (<7 mm). The mean aneurysm size was 6.2 mm (range, 2-38 mm). Follow-up angiography was available in 53 patients with 74 aneurysms (mean, 13 months). Successful FDS deployment in an ideal position was found in 125 of 130 patients (96%). Complete obliteration (CO) was achieved in 58 aneurysms (78%) in the mean 13-month angiographic follow-up. Smaller aneurysms (<7 mm) had a CO tendency than larger aneurysms (p < 0.01) in midterm follow-up. Seven patients (5.6%) had intraprocedural complications (in-stent thrombosis, three patients; distal embolic, two patients; iatrogenic carotid-cavernous fistula, and subarachnoid hemorrhage, one patient). Two patients (1.6%) suffered from permanent procedure-related morbidity (n = 1) or mortality (n = 1). No late hemorrhagic events or stent displacement occurred during the follow-up period.

CONCLUSION

Despite few procedural complications and some pieces of evidence of insufficient aneurismal treatment in a midterm angiographic follow-up, FDS was effective and safe in managing intracranial unruptured aneurysms, particularly in smaller aneurysms, which had better CO than larger ones.

Effect of Prolonged Mechanical Ventilation on Cough Function and TRPV1 Expression

Cough is a pivotal airway protective reflex, yet the effects of prolonged mechanical ventilation (PMV) on cough function are unknown. This study compared the cough function in subjects with PMV (≥ 21 days, n = 29) and those with short-term mechanical ventilation (SMV, ≤ 7 days, n = 27). Cough reflex sensitivity was measured by capsaicin provocation concentrations after extubation. The cough strength of respiratory muscles was assessed by involuntary cough peak expiratory flow (iCPEF). The mRNA expression of transient receptor potential vanilloid 1 (TRPV1), a cough sensor activated by capsaicin, in tracheal tissues was determined. We found that cough reflex sensitivity and iCPEF were significantly lower in the PMV group than in the SMV group. The tracheal expression of TRPV1 was similar in both groups, suggesting that changes in TRPV1 expression may not be a contributing factor. Our finding regarding the cough dysfunction after PMV highlights the need to implement effective airway clearance management and rehabilitation in this population.

Non-alcoholic fatty liver disease and type 2 diabetes - An Update

The global prevalence of non‐alcoholic fatty liver disease (NAFLD) is rising, along with the epidemic of diabesity. NAFLD is present in >70% of individuals with type 2 diabetes. Although the mutually detrimental relationship between NAFLD and type 2 diabetes has been well established, a multitude of recent studies have further shown that type 2 diabetes is closely linked to the development of cirrhosis, hepatocellular carcinoma, liver‐related morbidity and mortality. In contrast, NAFLD also negatively impacts type 2 diabetes both in terms of its incidence and related adverse clinical outcomes, including cardiovascular and chronic kidney diseases. In response to these global health threats, clinical care pathways for NAFLD and guidelines for metabolic dysfunction‐associated fatty liver disease have been developed. Several antidiabetic agents have been evaluated for their potential hepatic benefits with promising results. Furthermore, type 2 diabetes patients are increasingly represented in clinical trials of novel therapeutics for NAFLD. However, despite the wealth of knowledge in NAFLD and type 2 diabetes, lack of awareness of the disease and the potential weight of this problem remains a major challenge, especially among clinicians who are outside the field of hepatology and gastroenterology. This review therefore aimed to provide all diabetes care providers with a summary of the latest evidence that supports NAFLD as an emerging diabetic complication of increasing importance, and to present the current recommendations, focusing on the assessment and therapeutic strategies, on the management of NAFLD among type 2 diabetes patients.