P1761Distal transradial approach for primary percutaneous coronary intervention for patients with acute myocardial infarction: a multicentre study

Background

The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This technique is expected to decrease the incidence of haemorrhagic complications and improve patient comfort. However, limited data are available regarding the application of this technique in patients with acute myocardial infarction (AMI). This study investigated the feasibility and safety of the dTRA for primary percutaneous coronary intervention (PCI) in patients with AMI.

Methods

This study included patients with AMI who underwent primary PCI via the distal radial artery across 3 Japanese hospitals between January 2018 and January 2019. Patients' background, procedural characteristics, and clinical outcomes including the incidence of haemorrhagic complications were analysed.

Results

This study enrolled 95 consecutive patients with AMI, including 68 patients (71.6%) with ST-segment elevation myocardial infarction (STEMI), in whom distal radial artery puncture was attempted for primary PCI. The patients included 70 men (73.7%), and the mean age was 72.2±12.4 years. Among these patients, cannulation was successfully performed in 89 patients (93.7%). A 5-, 6-, or 7-French sheath (conventional or slender) was used in this study. Cannulation was performed using a forearm radial artery approach in patients in whom dTRA failed.

PCI was successfully performed in all patients. The meantime to achieve haemostasis was 6.3±5.3 hours, and no major bleeding complications occurred. Based on The Early Discharge After Transradial Stenting of Coronary Arteries trial haematoma scale, grade I, II, and III subcutaneous haemorrhages were observed in 16 (16.8%), 4 (4.2%), and 1 patient (1.1%), respectively. No patient developed a haematoma > grade IV.

In patients with STEMI, the mean door-to-balloon time was 39.4±31.9 min, and the mean puncture-to-balloon time was 19.7±14.2 min.

Conclusions

The distal radial approach is feasible and safefor primary PCI in selected patients with AMI.The application of the dTRA may serve as a less invasive strategy for the treatment of patients with AMI.

Surgical outcomes of gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2017

BACKGROUND

The Japanese National Clinical Database (NCD) is a large-scale, nationwide, web-based data entry system that is linked to the surgical board certification system and covers almost all surgical cases carried out in Japan.

AIM

To evaluate outcomes according to the gastroenterological section of the NCD.

METHODS

The 115 surgical procedures stipulated by the "Training Curriculum for Board-Certified Surgeons in Gastroenterology" were registered from 2011 to 2017. The number of surgeries, preoperative comorbidities, and short-term outcomes were compared between registration periods.

RESULTS

In total, 3 818 414 cases have been registered. More than 70% of all surgeries were carried out at certified institutions. The annual number of cases has been increasing year after year, and the aged population has also been increasing. Although the rates of preoperative comorbidities and postoperative complications have been increasing, the postoperative mortality rate has remained relatively low; in 2017, the 30-day mortality rate was 1.0% among those who underwent esophagectomy, 0.7% among those who underwent distal gastrectomy, 1.1% among those who underwent total gastrectomy, 1.3% among those who underwent right hemicolectomy, 0.5% among those who underwent low anterior resection, 1.3% among those who underwent hepatectomy, and 1.3% among those who underwent pancreaticoduodenectomy. The annual rate of endoscopic surgery dramatically increased over 7 years between 2011 and 2017, especially for low anterior resection (29.5%-62.6%) and esophagectomy (31.0%-56.1%).

CONCLUSION

This database is expected to ensure the quality of the board-certification system and surgical outcomes in gastroenterological surgery.

Simulation study on regionalization of esophagectomy using data of 27,576 patients with esophageal malignant tumor

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Background: The culture of evidence-based policy making in the field of cancer surgery is still at a developing stage. Although the volume-outcome relationship with esophagectomy has been recently recognized in Japan, there is no regionalization policy. This study was aimed to simulate regionalization of esophagectomy in Japan using data registered in a nationwide clinical database. Methods: The National Clinical Database (NCD) covers more than 95 per cent of all surgical procedures in Japan. The study used data of 27,476 patients with esophageal malignant tumor registered in the NCD as having undergone esophagectomy at 1040 hospitals between 2012 and 2016. The following four scenarios were tested; in scenario 1, 2, 3, and 4, a minimum volume standard was set as 2, 5, 10 and 15 cases per year. The risk-adjusted operative mortality rates after regionalization and travel distances according to patients’ place of residence were estimated for each scenario. Results: Current operative mortality rates according to hospital volume were < 2 cases: 4.8%, 2-4: 3.7%, 5-9: 2.4%, 10-14: 2.1%, and ≥15: 1.6%. In scenario 1 to 4, 598, 791, 896, and 939 hospitals, and 1,982, 4,740, 7,996, and 10,419 patients were affected by regionalization. The risk-adjusted operative mortality rates after regionalization in target patients were estimated to decrease to 2.7, 2.1, 1.8, and 1.7% in each scenario. The median travel distances after regionalization in metropolitan areas were calculated as 4 kilometer (km) in scenario 1 and 7 km in scenario 4. However, those in provincial cities and depopulated areas were 8 and 36 km in scenario 1, and 28 and 65 km in scenario 4. Conclusions: Regionalization of cancer surgery services could be simulated using the comprehensive clinical database covering almost all surgeries in the nation. The simulation showed that operative mortality rate could decrease to less than 2 % by regionalization but a minimum volume standard should be determined considering regional characteristics.

Current status of projects for developing cancer-related clinical practice guidelines in Japan and recommendations for the future

Background

The current status and adoption of cancer-related clinical practice guidelines in Japan has not been elucidated yet. The purpose of this study was to propose roles and suggestions to develop future cancer-related clinical guidelines.

Methods

A questionnaire consisting of four domains with a total of 17 questions was developed. We distributed the questionnaire to 28 specific academic organizations in Japan which have developed any cancer-related clinical practice guidelines and which were funded by the Ministry of Health, Labor, and Welfare.

Results

Most organizations have investigated nationwide dissemination and adoption of clinical practice guidelines. The rate of adoption in clinical practice was estimated at approximately ≥ 70%. However, organizations with smaller budgets reported surveying approximately 60% of the time, whereas the ones with larger budgets reported approximately 100% success in surveying about their guidelines. The presidents of the organizations agreed that a new organization operated directly by the national government was necessary.

Conclusion

In Japan, to develop cancer-related clinical practice guidelines, a study of clinical validation is necessary. Sufficient funds must be available to support the project to maintain and revise the guidelines. Furthermore, legal and ethical issues should be solved before establishing any registry system.

Evaluating the quality of data from the Japanese National Clinical Database 2011 via a comparison with regional government report data and medical charts

PURPOSE

The aim of this study was to examine the quality of data from the National Clinical Database (NCD) via a comparison with regional government report data and medical charts.

METHODS

A total of 1,165,790 surgical cases from 3007 hospitals were registered in the NCD in 2011. To evaluate the NCD's data coverage, we retrieved regional government report data for specified lung and esophageal surgeries and compared the number with registered cases in the NCD for corresponding procedures. We also randomly selected 21 sites for on-site data verification of eight demographic and surgical data components to assess the accuracy of data entry.

RESULTS

The numbers of patients registered in the NCD and regional government report were 46,143 and 48,716, respectively, for lung surgeries and 7494 and 8399, respectively, for esophageal surgeries, leading to estimated coverages of 94.7% for lung surgeries and 89.2% for esophageal surgeries. According to on-site verification of 609 cases at 18 sites, the overall agreement between the NCD data components and medical charts was 97.8%.

CONCLUSION

Approximately, 90-95% of the specified lung surgeries and esophageal surgeries performed in Japan were registered in the NCD in 2011. The NCD data were accurate relative to medical charts.

Vascular endothelial growth factors C and D and lymphangiogenesis at the early stage of esophageal squamous cell carcinoma progression

We conducted a detailed study of lymphangiogenesis and subsequent lymph node metastasis in early-stage esophageal squamous cell carcinoma (ESCC) using immunostaining for D2-40 and vascular endothelial growth factor (VEGF)-C and D. The study materials included 13 samples of normal squamous epithelium, 6 samples of low-grade intraepithelial neoplasia (LGIN), and 60 samples of superficial ESCC (M1 and M2 cancer 24; M3 or deeper cancer 36). We assessed lymphatic vessel density (LVD) using D2-40 and immunoreactivity for VEGF-C and D in relation to histological type, lymphatic invasion, and lymph node metastasis. LVD in M1 and M2 lesions and M3 or deeper lesions was significantly higher than in normal squamous epithelium (P < 0.001). High expression of VEGF-C and D was observed in M1 and M2 cancer and in M3 or deeper cancer, but not in normal squamous epithelium or LGIN. LVD in VEGF-C- and D-positive cases was significantly higher than in negative cases (P < 0.001). In M3 or deeper cancer, the correlation between VEGF-C or D status and lymphatic invasion or lymph node metastasis was not significant. LVD in cases with positive lymphatic invasion and those with lymph node metastasis was significantly higher than in cases lacking either (P = 0.02 and 0.03, respectively). ESCC cells produce VEGF-C and D from the very early stage of progression. VEGF-C and D activate lymphangiogenesis, and this increase of lymphatic vessels leads to lymphatic invasion and subsequent lymph node metastasis.

The fate of Osterix-expressing mesenchymal cells in dental root formation and maintenance

OBJECTIVES

Osterix (Osx)-expressing mesenchymal cells are progenitors for tooth root forming cells. The aim of this study was to reveal the fates of Osx-expressing cells during and after root formation using a lineage tracing experiment.

MATERIAL AND METHODS

To reveal the fates of Osx-expressing dental mesenchymal progenitors, we took advantage of tamoxifen-inducible Cre reporter system. Osx-creER; R26R-tdTomato mice received tamoxifen (0.1 mg/body) at postnatal day 3 (P3). In this system, Osx-expressing at P3 (Osx-P3) cells undergo recombination, and they and their descendants continue to express Tomato red fluorescence protein permanently. Mandibles were dissected at serial time points ranging from P4 to P116 to investigate how Osx-P3 cells participated in root formation. Tomato⁺ cells on frozen sections were imaged under fluorescence microscopy.

RESULTS

Osx-P3 cells and their descendants differentiated into all kinds of cells that contributed to the root and periodontal tissues, such as odontoblasts, cementoblasts, alveolar bone osteoblasts and periodontal ligament (PDL) cells during root formation. Even after root formation was completed, they persisted in dental pulp and PDL to provide progenitor cells for odontoblasts and cementoblasts.

CONCLUSION

Osx-expressing cells play important roles in the entire processes of tooth root formation; their progeny continue to contribute to maintenance of tooth root even after root formation is complete.

Oxygen Transport Capacity and Hemodynamic Effect of Newly Developed Artificial Blood “Neo Red Cells (NRC)”

The purpose of this study was to evaluate liposome-encapsulated hemoglobin, named Neo Red Cells (NRC), on hemodynamics and oxygen-transport capacity in a blood exchange experiment. The experiment was carried out in nine mongrel dogs. Depending on the percentage of blood exchange with NRC, the animals were divided into two groups; Group I (4 animals with an exchange rate less than 88%), and Group II (5 animals with an exchange rate over 88%). After blood exchange, total peripheral vascular resistance index (TPRI) decreased and cardiac index (CI) increased. These changes were more marked in Group II than in Group I, thus showing that NRC relieved the burden on the heart, probably due to the fact that the viscosity of NRC is 2 cp which is less than 1/3 that of whole blood. The oxygen binding capacity per 1g hemoglobin in NRC was 2-4 times as much as red blood cells. Thus, NRC was superior to natural red blood cells in terms of oxygen transport capacity and its effects on the circulatory system.

Verification of Data Accuracy in Japan Congenital Cardiovascular Surgery Database Including Its Postprocedural Complication Reports

Background:

Japan Congenital Cardiovascluar Surgical Database (JCCVSD) is a nationwide registry whose data are used for health quality assessment and clinical research in Japan. We evaluated the completeness of case registration and the accuracy of recorded data components including postprocedural mortality and complications in the database via on-site data adjudication.

Methods:

We validated the records from JCCVSD 2010 to 2012 containing congenital cardiovascular surgery data performed in 111 facilities throughout Japan. We randomly chose nine facilities for site visit by the auditor team and conducted on-site data adjudication. We assessed whether the records in JCCVSD matched the data in the source materials.

Results:

We identified 1,928 cases of eligible surgeries performed at the facilities, of which 1,910 were registered (99.1% completeness), with 6 cases of duplication and 1 inappropriate case registration. Data components including gender, age, and surgery time (hours) were highly accurate with 98% to 100% concordance. Mortality at discharge and at 30 and 90 postoperative days was 100% accurate. Among the five complications studied, reoperation was the most frequently observed, with 16 and 21 cases recorded in the database and source materials, respectively, having a sensitivity of 0.67 and a specificity of 0.99.

Conclusions:

Validation of JCCVSD database showed high registration completeness and high accuracy especially in the categorical data components. Adjudicated mortality was 100% accurate. While limited in numbers, the recorded cases of postoperative complications all had high specificities but had lower sensitivity (0.67-1.00). Continued activities for data quality improvement and assessment are necessary for optimizing the utility of these registries.

Effect of Neo Red Cells on the Canine Hemorrhagic Shock Model

This study evaluated the newly developed artificial red blood cells named Neo Red Cells (NRC) after hemorrhagic shock in mongrel dogs. NRC is prepared as microcapsules by a method in which stroma-free hemoglobin is encapsulated using a bimolecular lipid membrane called liposome. The particle size is 0.2 μm, methemoglobin content is less than 5% and the hemoglobin concentration is 5.6 g/dl.

We analyzed blood gases and hemodynamics and carried out laboratory examinations after 59-88% blood exchange using NRC. The hemodynamic parameters returned to the normal range after NRC. Inhaling normal room air, oxygen carried by NRC was 60.40% at the exchange rate of 88%. Renal and hepatic function and other laboratory findings were normal after administration of NRC. After further study and improvement NRC could be considered suitable as artificial blood for treatment of hemorrhagic shock.