First Report of Pseudomonas cichorii Causing Bacterial vein necrosis on Perilla plants [Perilla frutescens (L.) Britton.] in South Korea

Perilla (Perilla frutescens L.) is the second most important upland crop and the third largest edible oil crop in Korea (Shin and Kim 1994). During a disease survey in Busan, Korea in September 2021, symptoms of vein necrosis were observed in perilla plants, with incidences of approximately 30% and 50% in two fields. Symptoms of spots on the perilla appeared as leaf dryness and spots with water-soaked blotches largely concentrated on the mid-veins of leaves. The lesions were initiated with water-soaked spots on the leaf or stem and gradually turned black or brown. Necrosis was also observed in the stems. A bacterium was isolated on Luria-Bertani (LB) agar from diseased leaf tissues that were surface-disinfected with 70% ethyl alcohol for 3-5 min and then washed with sterile water three times. Three pieces of sterilized leaf tissue (size: 0.5 × 0.5 cm) were mixed with 500 µL sterile water for 30 min, and then the suspension was serially diluted and spread on LB agar. Subsequently, isolates were cultivated on LB agar and King's Medium B agar (KMB) (Schaad et al. 2001), and they were predominantly cream-colored and circular bacterial colonies with undulated margins. The bacterial colonies on KMB displayed fluorescence under 365 nm UV light. The isolates were analyzed with the GEN III MicroPlate (Biolog, Hayward, CA, USA), and all isolates were identified as Pseudomonas cichorii, a devastating plant bacterium that damages a wide range of host plants worldwide, including in South Korea (Hikichi et al. 2013; Ramkumar et al. 2015). To identify the species of the bacterial pathogen, genomic DNA of four isolates (BS4922, BS4167, BS4345, and BS4560) was extracted, and the 16S rRNA gene and hrcRST gene were amplified with universal primers, 27F/1492R and Hcr1/Hcr2, and sequencing was then done (Patel et al. 2019). In the BLAST analysis, the 16S rRNA sequences (GenBank OM060656, OM275434, OM275435, OM275436) showed a 100% and 99% similarity to P. cichorii strains MAFF 302698 (AB724286) and P. cichorii strain Pc-Gd-4 (KU923373), respectively. Further, hrcRST gene sequences (GenBank OM143596, OM268864, OM268865, and OM268866) showed high similarity (>99%) with P. cichorii strain P16-51 (MG518230). A pathogenicity test of the four isolates was performed on 3 - 4 weeks old perilla plants by creating wounds with a needle on the lower leaves and stems, and then the plants were inoculated by spraying inoculum (108 CFU/ml). The plants that served as the negative control were wounded and sprayed with unsterilized water. The inoculated perilla plants were placed in a greenhouse at 28 ± 2oC , 80-85% relative humidity, and a natural photoperiod. The inoculation site began to show symptoms of water-soaked brown lesions. Disease symptoms such as leaf dryness, water-soaked blotches on the mid-vein of leaves, and necrosis on plant stems were observed in the inoculated plants 7-10 days after inoculation, whereas the plants of the negative control group did not show any symptoms. The bacteria were re-isolated from the diseased tissues of the plants, and DNA sequence analysis identified them as P. cichorii. Additionally, all isolates induced hypersensitivity reactions in tobacco and tomato leaves within 24 h after inoculation. To our knowledge, this is the first report of P. cichorii infecting perilla in South Korea. The findings in this study will provide the basic information for the development of diagnostic tools and management measures against P. cichorii in perilla.

Comparative effectiveness of early rhythm control versus rate control for cardiovascular outcomes according to sex in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health & Welfare, Republic of Korea

Background

Rhythm control is associated with better cardiovascular outcomes than usual care among patients recently diagnosed with atrial fibrillation (AF). However, there are limited data on the outcomes of AF ablation according to sex. The purpose of this study was to evaluate gender differences in the effects of early rhythm control compared to rate control on the primary composite outcome of cardiovascular death, ischaemic stroke, hospitalisation for heart failure (HF), or myocardial infarction.

Methods

We conducted a retrospective population-based cohort study including 22635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011-2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used.

Results

Among patients with early AF treatment (initiated within 1 year since diagnosis), compared with rate control, rhythm control was associated with a similar lower risk of the primary composite outcome both women (weighted incidence rate per 100 person-years: 8.68 in rhythm control vs. 10.3 in rate control; hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.69 to 0.90; P<0.001) and men (weighted incidence rate per 100 person-years: 6.33 in rhythm control vs. 8.32 in rate control; HR 0.77, 95% CI 0.67 to 0.88; P<0.001). However, the effective initiation time for rhythm control therapy was within 6 and 11 months after AF diagnosis in female and male patients, respectively. Moreover, the effective times for other outcomes were different between genders (hospitalization for HF; female within 2 months, male within 9 months/ ischemic stroke; female within 11 months, male immediately).

Conclusions

Early initiation of rhythm control was associated with a lower risk of primary outcome in both genders. However, the effective rhythm control treatment initiation time for primary outcome, stroke and HF-related admission was different in both genders. For rhythm control treatment to be effective, women should start treatment earlier than men.

Learning curve of left bundle branch area pacing with standard stylet-driven pacing leads: a single center prospective observational study in Korea

Funding Acknowledgements

Type of funding sources: None.

Background

Although cardiac pacing is an essential therapy for bradycardia, conventional right ventricular pacing (CRVP) can cause electrical-mechanical dyssynchrony. Left Bundle Branch Area Pacing (LBBAP) is a new conduction system pacing strategy that includes a normal conduction system and therefore maintains synchronous ventricular contraction. Most of the experience with LBBAP is done in a lumen-less lead with fixed helix design, and this device is not available in sometimes.

Purpose

This study aimed to evaluate the learning curve of LBBAP using standard stylet-driven lead with extendable helix design.

Methods

This study enrolled patients who underwent permanent cardiac pacemaker implantation at a University Hospital in South Korea from December 2020 to October 2021. LBBAP was performed with a 5.6Fr stylet-driven pacing lead with an extendable helix. The learning curve was assessed by analyzing fluoroscopy time and procedure time.

Results

In 65 patients who underwent LBBAP during the observation period, mean fluoroscopy time and procedural time were 17.1 ± 17.2 minutes and 64.2 ± 33.5 minutes, respectively in this study. The learning curve for achieving LBBAP appears to plateau after around 24th case with a progressive reduction in procedure time. This is a significantly shorter period of time when compared to the previously reported learning curves of his bundle pacing (30-50cases), previously developed conduction system pacing strategy.

Conclusion

During initial experience with LBBAP, fluoroscopy and procedural time continue to improve with operator experience. For physicians who are experienced at cardiac pacemaker implantation, the steepest part of the learning curve of LBBAP appears to be over the first 20-25 cases.

COVID-19 L·OVE repository is highly comprehensive and can be used as a single source for COVID-19 studies

Background and Objective

The coronavirus disease 2019 Living OVerview of Evidence (COVID-19 L·OVE) is a public repository and classification platform for COVID-19 articles. The repository contains more than 430,000 articles as of September 20, 2021 and intends to provide a one-stop shop for COVID-19 evidence. Considering that systematic reviews conduct high-quality searches, this study assesses the comprehensiveness and currency of the repository against the total number of studies in a representative sample of COVID-19 systematic reviews.

Methods

Our sample was generated from all the studies included in the systematic reviews of COVID-19 published during April 2021. We estimated the comprehensiveness of COVID-19 L·OVE repository by determining how many of the individual studies in the sample were included in the COVID-19 L·OVE repository. We estimated the currency as the percentage of studies that was available in the COVID-19 L·OVE repository at the time the systematic reviews conducted their own search.

Results

We identified 83 eligible systematic reviews that included 2,132 studies. COVID-19 L·OVE had an overall comprehensiveness of 99.67% (2,125/2,132). The overall currency of the repository, that is, the proportion of articles that would have been obtained if the search of the reviews was conducted in COVID-19 L·OVE instead of searching the original sources, was 96.48% (2,057/2,132). Both the comprehensiveness and the currency were 100% for randomized trials (82/82).

Conclusion

The COVID-19 L·OVE repository is highly comprehensive and current. Using this repository instead of traditional manual searches in multiple databases can save a great amount of work to people conducting systematic reviews and would improve the comprehensiveness and timeliness of evidence syntheses. This tool is particularly important for supporting living evidence synthesis processes.

COVID-19 susceptibility and clinical outcomes in autoimmune inflammatory rheumatic diseases (AIRDs): a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to assess the susceptibility to and clinical outcomes of COVID-19 in autoimmune inflammatory rheumatic disease (AIRD) and following AIRD drug use.

MATERIALS AND METHODS

We included observational and case-controlled studies assessing susceptibility and clinical outcomes of COVID-19 in patients with AIRD as well as the clinical outcomes of COVID-19 with or without use of steroids and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

RESULTS

Meta-analysis including three studies showed that patients with AIRD are not more susceptible to COVID-19 compared to patients without AIRD or the general population (OR: 1.11, 95% CI: 0.58 to 2.14). Incidence of severe outcomes of COVID-19 (OR: 1.34, 95% CI: 0.76 to 2.35) and COVID-19 related death (OR: 1.21, 95% CI: 0.68 to 2.16) also did not show significant difference. The clinical outcomes of COVID-19 among AIRD patients with and without csDMARD or steroid showed that both use of steroid (OR: 1.69, 95% CI: 0.96 to 2.98) or csDMARD (OR: 1.35, 95% CI: 0.63 to 3.08) had no effect on clinical outcomes of COVID-19.

CONCLUSIONS

AIRD does not increase susceptibility to COVID-19, not affecting the clinical outcome of COVID-19. Similarly, the use of steroids or csDMARDs for AIRD does not worsen the clinical outcome.

Clinical characteristics and treatments of multi-system inflammatory syndrome in children: a systematic review

OBJECTIVE

Multisystem inflammatory syndrome in children (MIS-C) can occur in association with coronavirus disease 2019 (COVID-19). It is not easy to differentiate MIS-C from severe COVID-19 or Kawasaki disease based on symptoms. The aim of this study was to describe the clinical and laboratory characteristics of MIS-C.

PATIENTS AND METHODS

We searched PubMed/Medline for case series and reports of MIS-C published until June 20, 2020. From a total of nine articles involving 45 cases, various clinical and laboratory data were extracted. Each target case was evaluated by using different diagnostic criteria.

RESULTS

The average age at onset of MIS-C was 8.6 years. In 80% of cases, the age of patients ranged from 5 to 15 years. Fever (100%) and shock (82%) were the most common presenting symptoms. Sixty percent of cases met the diagnostic criteria for typical or atypical Kawasaki disease. Biomarkers indicative of inflammation, coagulopathy, or cardiac injury were characteristically elevated as follows: ferritin (mean: 1,061 ng/mL), CRP (217 mg/L), ESR (69 mm/hr), IL-6 (214.8 pg/mL), TNFα (63.4 pg/mL), D-dimer (3,220 ng/mL), PT (15.5 s), troponin I (1,006 ng/L), and BNP (12,150 pg/mL). Intravenous immunoglobulin was administered in all target cases, and inotropic agents were commonly used as well. No case of death was observed.

CONCLUSIONS

This study demonstrated that MIS-C is a serious condition that presents with fever, rash, as well as cardiovascular and gastrointestinal symptoms. Although it is challenging to differentiate MIS-C from Kawasaki disease or severe COVID-19, initiation of appropriate treatments through early diagnosis is warranted.

Continuing perioperative estrogen therapy does not increase venous thromboembolic events in transgender patients: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to compare the risk of venous thromboembolic events (VTE) between patients suspending and continuing estrogen therapy perioperatively, in male to female gender-affirming surgery (vaginoplasty).

MATERIALS AND METHODS

The authors conducted a systematic review and meta-analysis of existing research on male to female gender-affirming study, which compared the risk of VTE among the usage of estrogen perioperatively.

RESULTS

A total of 209 studies were identified as potentially eligible among PubMed, Embase, and Cochrane library databases. Among the studies, 191 studies were excluded due to their abstract inappropriateness. Out of the remaining 18 studies, only 3 articles were eligible and were finally included. Meta-analysis was performed and showed odds ratio of 0.77 (95% CI: 0.04, 14.01).

CONCLUSIONS

Perioperative estrogen therapy does not increase VTE risk on male to female gender-affirming surgery. Therefore, estrogen therapy may be continued perioperatively in vaginoplasty. More prospective studies are needed.

Rationale and design of a screening study to detect schistosomiasis-associated pulmonary hypertension in Ethiopia and Zambia

Schistosomiasis is a major cause of pulmonary arterial hypertension (PAH) worldwide, but the prevalence and risk factors for schistosomiasis-associated PAH (SchPAH) development are not well understood. Schistosomiasis-associated hepatosplenic disease (SchHSD) is thought to be a major risk factor for PAH development. Herein, we describe our plans for prospectively screening SchHSD subjects for clinical evidence of PAH at two major academic medical centers and national referral hospitals in Addis Ababa, Ethiopia and Lusaka, Zambia. The screening study will primarily be conducted by echocardiography, in addition to clinical assessments. Plasma samples will be drawn and banked for subsequent analysis based on preclinical animal model rationale. If successful, this study will demonstrate feasibility of conducting prospective cohort studies of SchPAH screening in schistosomiasis-endemic regions of Africa, and provide initial data on clinic-based disease prevalence and potential mechanistic biomarkers underlying disease pathogenesis.

Experimental Schistosoma japonicum-induced pulmonary hypertension

BACKGROUND

Schistosomiasis, a major cause of pulmonary arterial hypertension (PAH) worldwide, is most clearly described complicating infection by one species, Schistosoma mansoni. Controlled exposure of mice can be used to induce Type 2 inflammation-dependent S. mansoni pulmonary hypertension (PH). We sought to determine if another common species, S. japonicum, can also cause experimental PH.

METHODS

Schistosome eggs were obtained from infected mice, and administered by intraperitoneal sensitization followed by intravenous challenge to experimental mice, which underwent right heart catheterization and tissue analysis.

RESULTS

S. japonicum sensitized and challenged mice developed PH, which was milder than that following S. mansoni sensitization and challenge. The degree of pulmonary vascular remodeling and Type 2 inflammation in the lungs was similarly proportionate. Cross-sensitization revealed that antigens from either species are sufficient to sensitize for intravenous challenge with either egg, and the degree of PH severity depended on primarily the species used for intravenous challenge. Compared to a relatively uniform distribution of S. mansoni eggs, S. japonicum eggs were observed in clusters in the lungs.

CONCLUSIONS

S. japonicum can induce experimental PH, which is milder than that resulting from comparable S. mansoni exposure. This difference may result from the distribution of eggs in the lungs, and is independent of which species is used for sensitization. This result is consistent with the clearer association between S. mansoni infection and the development of schistosomiasis-associated PAH in humans.

A Systematic Review and Bibliometric Analysis of Applications of Artificial Intelligence and Machine Learning in Vascular Surgery

INTRODUCTION

Artificial intelligence (AI) and machine learning (ML) have seen increasingly intimate integration with medicine and healthcare in the last two decades. The objective of this study was to summarize all current applications of AI and ML in the vascular surgery literature and to conduct a bibliometric analysis of the published studies.

METHODS

A comprehensive literature search was conducted through EMBASE, MEDLINE, and Ovid HealthStar from inception until February 19, 2021. Reporting of this study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Title and abstract screening, full-text screening, and data extraction were conducted in duplicate. Data extracted included study meta-data, the clinical area of study within vascular surgery, type of AI/ML method used, data set, and the application of AI/ML. Publishing journals were classified as having either a clinical scope or technical scope. Author academic background was classified as clinical, non-clinical (e.g., engineering) or both, depending on author affiliation.

RESULTS

The initial search identified 7434 studies, of which 249 were included for final analysis. The rate of publications is exponentially increasing, with 158 (63%) studies being published in the last 5 years. Studies were most commonly related to carotid artery disease (118, 47%), abdominal aortic aneurysms (51, 20%), and peripheral arterial disease (26, 10%). Study authors employed an average of 1.50 (range: 1-6) distinct AI methods in their studies. The application of AI/ML methods broadly related to predictive models (54, 22%), image segmentation (49, 19.4%), diagnostic methods (46, 18%), or multiple combined applications (91, 37%). The most commonly used AI/ML methods were artificial neural networks (155/378 use cases, 41%), support vector machines (64, 17%), k-nearest neighbors algorithm (26, 7%), and random forests (23, 6%). Data sets to which these AI/ML methods were applied frequently involved ultrasound images (87, 35%), CT images (42, 17%), clinical data (34, 14%) or multiple data sets (36, 14%). Overall, 22 (9%) studies were published in journals specific to vascular surgery, with the majority (147/249, 59%) being published in journals with a scope related to computer science or engineering. Among 1576 publishing authors, 46% had exclusively a clinical background, 48% a non-clinical background, and 5% had both a clinical and non-clinical background.

CONCLUSION

There is an exponentially growing body of literature describing the use of AI and ML in vascular surgery. There is a focus on carotid artery disease and abdominal aortic disease, with many other areas of vascular surgery underrepresented. Neural networks and support vector machines composed most AI methods in the literature. As AI/ML continues to see more expanded applications in the field, it is important that vascular surgeons appreciate its potential and limitations. Additionally, as it sees increasing use, there is a need for clinicians with expertise in AI/ML methods who can optimize its transition into daily practice.

Prognostic value of blood pressure in ambulatory heart failure: a meta-analysis and systematic review. Ambulatory blood pressure predicts heart failure prognosis

Previous primary studies have explored the association between blood pressure (BP) and mortality in ambulatory heart failure (HF) patients reporting varying and contrasting associations. The aim is to determine the pooled BP prognostic value and explore potential reasons for between-study inconsistency. We searched Medline, Cochrane, EMBASE and CINAHL from January 2005 to October 2018 for studies with ≥ 50 events (mortality and/or hospitalization) and included BP in a multivariable model in ambulatory HF patients. We pooled hazard ratios (random effects model) for systolic BP (SBP) or diastolic BP (DBP) effect on mortality and/or hospitalization risk. We used a priori defined sub-group analyses to explore heterogeneity and GRADE approach to assess the certainty of the evidence. Seventy-one eligible articles (239,467 screened) at low to moderate risk of bias included 235,752 participants. Higher SBP was associated with reduced all-cause mortality (HR 0.93, 95%CI 0.91-0.95, I2 = 87.13%, moderate certainty), all-cause hospitalization events (HR 0.91, 95%CI 0.88-0.93, I2 = 44.4%, high certainty) and their composite endpoint (HR 0.93 per 10 mmHg, 95%CI 0.91-0.94, I2 = 86.3%, high certainty). DBP did not demonstrate a statistically significant effect for all outcomes. The association strength was significantly weaker in studies following patients with either LVEF > 40%, higher average SBP (> 130 mmHg), increasing age and diabetes. All other a priori subgroup hypotheses did not explain between study differences. Higher ambulatory SBP is associated with reduced risk of all-cause mortality and hospitalization. Patients with lower BP and reduced LVEF are in a high-risk group of developing adverse events with moderate certainty of evidence.

Role of Adjuvant Therapy in Esophageal Cancer Patients After Neoadjuvant Therapy and Esophagectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to analyze esophageal cancer patients who previously underwent neoadjuvant therapy followed by a curative resection to determine whether additional adjuvant therapy is associated with improved survival outcomes.

SUMMARY BACKGROUND DATA

Neoadjuvant therapy followed by surgery is the standard of care for locally advanced esophageal cancer, whereas adjuvant therapy is typically employed for patients with residual disease. However, the role of adjuvant therapy after a curative resection is still uncertain.

METHODS

MEDLINE, EMBASE, and CENTRAL databases were searched for studies comparing patients with esophageal cancer who underwent neoadjuvant therapy and curative resection with and without adjuvant therapy. Primary outcome was overall survival (OS), and random effects meta-analysis was conducted where appropriate. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence.

RESULTS

Ten studies involving 6462 patients were included. When compared to patients who received neoadjuvant therapy and esophagectomy alone, adjuvant therapy groups experienced a significant decrease in mortality by 48% at 1 year (Risk Ratio (RR) 0.52, 95% confidence interval [CI] 0.41-0.65, P < 0.001, moderate certainty). This reduction in mortality was carried through to 5-year follow-up (RR 0.91, 95% CI 0.86-0.96, P < 0.001, moderate certainty). The difference between the adjuvant therapy and the control group was uncertain regarding the secondary outcomes.

CONCLUSION

Adjuvant therapy after neoadjuvant treatment and esophagectomy with negative resection margins provide an improved OS at 1 and 5 years with moderate to high certainty of evidence, but the benefit for disease-free survival and locoregional/distal recurrence remain uncertain due to limited reporting of these outcomes.

Siderophore-mediated zinc acquisition enhances enterobacterial colonization of the inflamed gut

Zinc is an essential cofactor for bacterial metabolism, and many Enterobacteriaceae express the zinc transporters ZnuABC and ZupT to acquire this metal in the host. However, the probiotic bacterium Escherichia coli Nissle 1917 (or "Nissle") exhibits appreciable growth in zinc-limited media even when these transporters are deleted. Here, we show that Nissle utilizes the siderophore yersiniabactin as a zincophore, enabling Nissle to grow in zinc-limited media, to tolerate calprotectin-mediated zinc sequestration, and to thrive in the inflamed gut. We also show that yersiniabactin's affinity for iron or zinc changes in a pH-dependent manner, with increased relative zinc binding as the pH increases. Thus, our results indicate that siderophore metal affinity can be influenced by the local environment and reveal a mechanism of zinc acquisition available to commensal and pathogenic Enterobacteriaceae.

Growth factors for treating chronic venous leg ulcers: A systematic review and meta-analysis

Chronic venous leg ulcers (VLU) are wounds that commonly occur due to venous insufficiency. Many growth factors have been introduced over the past two decades to treat VLU. This systematic review and meta-analysis evaluates the impact of growth factor treatments of VLU in comparison to control for complete wound healing, percent reduction in wound area, time to wound healing, and adverse events. A systematic review and meta-analysis of randomised trials was conducted. MEDLINE and EMBASE were searched up to December 2020. Studies were included if they compared a growth factor versus placebo or standard care in patients with VLU. From 1645 articles, 13 trials were included (n = 991). There was a significant difference between any growth factor and placebo in complete wound healing (P = 0.04). Any growth factor compared to placebo significantly increased the likelihood of percent wound reduction by 48.80% (P = <0.00001). There was no difference in overall adverse event rate. Most comparisons have low certainty of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation. This meta-analysis suggests that growth factors have a beneficial effect in complete wound healing of VLU. Growth factors may also increase percent reduction in wound area. The suggestion of benefit for growth factors identified in this review is not a strong one based on the low quality of evidence.

A longitudinal histologic evaluation of vitamin D receptor expression in the skeletal muscles of patients with a distal radius fracture

We investigated the effect of vitamin D supplementation on the expression of muscle vitamin D receptor (VDR) and cross-sectional area (CSA) in patients with a distal radius fracture (DRF). Significant increases in VDR expression and CSA were observed, especially in vitamin D-deficient patients.

PURPOSE

Vitamin D supplementation is known to enhance muscle mass and function, but whether the VDR is essential in this process remains unknown. We evaluated the change in VDR expression and CSA in the forearm muscles following vitamin D supplementation in patients with a DRF.

METHODS

We prospectively recruited 18 women with a median age of 63.5 years who have a DRF. We obtained two biopsies of the forearm muscle, first at the time of fracture repair and then during hardware removal. We supplemented 1000 IU of vitamin D per day during a median interval of 8 months. We examined the changes in VDR expression and CSA by immunohistochemistry.

RESULTS

The median serum 25-hydroxyvitamin D [25(OH)D] increased from 14.3 to 32.1 ng/mL (P = 0.001). The median VDR expression increased from 0.72 to 0.78 (P = 0.002), and the median CSA increased from 1290.0 to 1685.8 μm² (P = 0.022). Significant increases in VDR expression and CSA were observed in vitamin D-deficient patients [25(OH)D] < 20 ng/mL, but not in vitamin D-non-deficient patients. The changes in VDR expression and CSA were in the same direction in 13 patients, but in the opposite direction in 5 patients.

CONCLUSION

Vitamin D supplementation may increase muscle VDR expression and CSA in patients with a DRF, especially in vitamin D-deficient patients. The increase in CSA without an increase in VDR expression in some patients indicates that the effect of vitamin D supplementation on muscle mass could be mediated by indirect effect of serum vitamin D restoration and by VDR.

A systematic review of autologous adipose-derived stromal vascular fraction (SVF) for the treatment of acute cutaneous wounds

BACKGROUND

Stromal vascular fraction (SVF), derived enzymatically or mechanically from adipose tissue, contains a heterogenous population of cells and stroma, including multipotent stem cells. The regenerative capacity of SVF may potentially be adapted for a broad range of clinical applications, including the healing of acute cutaneous wounds.

OBJECTIVE

To evaluate the available literature on the efficacy and safety of autologous adipose-derived stromal vascular fraction (SVF) for the treatment of acute cutaneous wounds in humans.

METHODS

A systematic review of the literature utilizing MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed to identify published clinical trials of autologous adipose-derived SVF or similar ADSC-containing derivatives for patients with acute cutaneous wounds. This was supplemented by searches for ongoing clinical trials through ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform.

RESULTS

872 records were initially retrieved. Application of inclusion and exclusion criteria yielded 10 relevant studies: two completed non-randomized controlled trials and eight ongoing clinical trials. Both completed studies reported a statistically significant benefit in percentage re-epithelialization and time to healing for the SVF treatment arms. Safety information for SVF was not provided. Ongoing clinical trials were assessing outcomes such as safety, patient and observer reported scar appearance, wound healing rate, and wound epithelization.

CONCLUSION

In the context of substantial limitations in the quantity and quality of available evidence, the existing literature suggests that SVF may be a useful treatment for acute cutaneous wounds in humans. More clinical trials with improved outcome measures and safety assessment are needed.

Antiarrhythmic drug responders among patients with recurrent atrial fibrillation after catheter ablation

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The Ministry of Health and Welfare The National Research Foundation of Korea (NRF)

Backgroud

Sinus rhythm (SR) can be maintained with antiarrhythmic drugs (AADs) in a considerable number of patients with recurrent atrial fibrillation (AF) after AF catheter ablation (AFCA).

Purpose

We explored the characteristics and long-term outcomes of patients who maintained clinically acceptable rhythm control with AADs for 2 years.

Methods

Among 2,935 consecutive AAD-resistant patients who underwent a de novo AFCA, we included 512 recurrent patients (73.0% men, 59.2 ± 10.5 years old, 56.4% paroxysmal AF) who were followed up for over 2 years under AAD medications.

Results

In total, 218 patients remained in SR (AAD-responders[2-yrs], 42.6%) and 294 had recurrent AF among whom, 162 underwent repeat procedures (redo-AFCA[AAD failure-2-yrs]). We also compared the AAD-responders[2-yrs] with 40 patients who underwent AFCA before AADs (redo-AFCA[Before AAD]). AAD-responders[2-yrs] were independently associated with an old age (odds ratio [OR] 1.02 [1.00-1.04] p = 0.037), paroxysmal AF (OR 1.51 [1.04-2.19] p = 0.003), and a delayed recurrence timing of &gt; 18 months (OR 1.52 [1.04-2.22] p = 0.032). When comparing the AAD-responder[2-yrs] and redo-AFCA[AAD failure-2-yrs] groups, the recurrence pattern showed a convergence after 7 years. The overall rhythm outcome was better in the redo-AFCA[Before AAD] group than AAD group (log rank p = 0.013).

Conclusion

Among the patients with recurrent AF after AFCA, over 40% remained in SR with AADs for 2 years, especially those who were old, those with a paroxysmal type, and those who had a delayed recurrence timing of &gt;18 months after the de novo procedure. UnivariateMultivariateOdds Ratio(95% CI)p valueOdds Ratio(95% CI)p valueAge1.02 (1.00-1.04)0.0231.02 (1.00-1.04)0.037Female1.64 (1.11-2.42)0.0141.29 (0.85-1.95)0.236PAF1.58 (1.11-2.26)0.0121.51 (1.04-2.19)0.030Time to recurrence after the initial AFCA &gt;18mo*1.59 (1.11-2.30)0.0131.52 (1.04-2.22)0.032LA dimension, mm0.99 (0.96-1.02)0.360LV ejection fraction, %1.03 (1.01-1.06)0.0111.02 (0.997-1.046)0.081Heart failure0.65 (0.34-1.24)0.192Hypertension1.18 (0.83-1.67)0.358Diabetes1.01 (0.65-1.71)0.844Stroke or TIA0.96 (0.56-1.66)0.879Vascular disease1.43 (0.88-2.31)0.151Logistic regression analysis for AAD responders Abstract Figure. K-M analysis of AF-free survival rate

Malnutrition and risk of procedural complication in patients with atrial fibrillation undergoing catheter ablation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and Welfare of Korea Ministry of Science, ICT & Future Planning of Korea

Background

Malnutrition is common in the elderly, even in developed countries, and increases mortality.

Purpose

 To investigate the prevalence and prognostic value of malnutrition among patients with atrial fibrillation (AF) which is a type of metabolic disease.

Methods

We included 3,239 patients (age 58.5 ± 10.8 years, 73.2% male, 67.7% paroxysmal type) undergoing de novo AF catheter ablation (AFCA) between 2009 and 2020. Nutritional status was assessed using controlling nutritional status (CONUT) score. The associations between malnutrition and the risk of AFCA complications or long-term rhythm outcome were evaluated by multivariable logistic regression.

Results

Among 3,239 patients, 1,005 (31.0%) patients had malnutrition; 991 (30.6%) with mild (CONUT scores 2-4) and 14 (0.4%) with moderate-to-severe (CONUT scores ≥5) malnutrition. Overall complication rates after AFCA were 3.3% in normal nutrition, 4.2% in mild malnutrition, and 21.4% in moderate to severe malnutrition, respectively (P for trend = 0.031). Major complication rates were 1.9%, 2.6%, and 14.3% in normal nutrition, mild malnutrition, and moderate to severe malnutrition (P for trend = 0.042). After multivariable adjustment, moderate-to-severe malnutrition status was associated with increased risks of overall (OR 8.215 [2.199-30.691], P = 0.002) and major (OR 7.392 [1.568-34.837], P = 0.011) complications compared with normal nutrition. However, CONUT score did not affect the long-term rhythm outcome during the mean follow-up of 40 (interquartile range 18-74) months (log-rank P = 0.760).

Conclusion

Malnutrition is common in patients undergoing AFCA. Those with moderate-to-severe malnutrition status were at substantially higher risk of complications after AFCA. Abstract Figure. Overall and major complication rates

Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures.

Methods

Among 3,282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5 ± 10.3 years old, 61.5% paroxysmal AF) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications, and long-term clinical recurrences after propensity score matching.

Results

The LA volume index (43.1 ± 18.6 vs. 35.8 ± 11.6 ml/m2, p &lt; 0.001) was higher, but LA dimension (40.0 ± 6.8 vs. 41.6 ± 6.3mm, p = 0.018), LA voltage (0.94 ± 0.55 vs. 1.20 ± 0.68 mV, p = 0.002), and pericardial fat volume (89.5 ± 43.1 vs. 122.1 ± 53.9 cm3, p &lt; 0.001) lower in women with a repeat ablation than in their male counterparts. The pulmonary vein (PV) reconnections were lower (58.7% vs. 74.9%, p = 0.001), but the proportion of extra-PV triggers (27.5% vs. 17.0%, p = 0.026) and elevated LA pulse pressures (79.7% vs. 63.7%, p = 0.019) was significantly higher in women than men. There was no significant sex difference in the procedure-related complication rate (4.6% vs. 4.2%, p = 0.791). During a 31(8∼60) month median follow-up, clinical recurrences were significantly higher in women after both the de novo procedure (log rank p = 0.039, antiarrhythmic drug [AAD]-free log rank p &lt; 0.001) and second procedure (log rank p = 0.006, AAD-free log rank p = 0.093). A female sex (HR 1.51 [1.06-2.15], p = 0.023), non-paroxysmal AF (HR 1.78 [1.30-2.34], p &lt; 0.010), and extra-PV triggers (HR 1.88 [1.28-2.75], p = 0.001) were independently associated with clinical recurrences after repeat procedures.

Conclusions

During the repeat AFCA procedures, PV reconnections were lower in women than men, and the existence of extra-PV triggers and an LA pressure elevation was more significant, which resulted in poor rhythm outcomes.

Artificial intelligence-predicted poor responders to catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although atrial fibrillation (AF) catheter ablation is effective for rhythm control, in some patients it is hard to maintain sinus rhythm in spite of repeated AF catheter ablation (AFCA) procedures and anti-arrhythmic drugs (AADs). We explored the pre-procedural predictors for poor responders to AFCA and tested whether artificial intelligence (AI) assists the prediction of poor responders in the independent cohort by determining the invasive parameters.

Methods

Among 1,214 patients who underwent AFCA and regular rhythm follow-up for 56.2 ± 33.8 months (59 ± 11 years, 73.5% male, 68.6% paroxysmal AF), we differentiated 92 poor responders defined as those with sustained AF despite repeat AFCAs, AADs, or electrical cardioversion. Using the Youden index, we identified advanced LA remodeling with lower LA voltage under 1.109mV. AI model, which was derived from development cohort using medical record, was applied to predict LA voltage &lt;1.109mV in the independent cohort (n = 634, poor responders = 24) using a grad-cam score.

Results

The patients with lower LA voltage under 1.109mV showed significantly poorer rhythm outcomes (Log-rank p &lt; 0.001). We determined invasive parameter LA voltage by using the multiple variables (age, female sex, AF type, CHA2DS2VASc score, LA dimension, E/em, hemoglobin, PR interval) and achieved relatively good prediction power of AI for LA voltage &lt;1.109mV (AUC = 0.734, sensitivity 0.729, specificity 0.643) in the test cohort. In the independent cohort, the AI model showed good discrimination power for poor responders (AUC 0.751, p &lt; 0.001) by estimating LA voltage, which is an invasive variable. The patients with predicted lower LA voltage (grad-cam score &lt;0) showed poorer rhythm outcome after active rhythm control (Log-rank p &lt; 0.001)

Conclusions

The patients with advanced atrial remodeling with low LA voltage, which can be predicted by an AI, showed significantly higher recurrence of AF after AFCA with AADs or cardioversion. AI may assist to select these poor responder patients before the AFCA procedure. Abstract Figure.