[Analysis of factors associated with futile recanalization after endovascular treatment for acute ischemic stroke with large vessels occlusion in anterior intracranial circulation]

Objective: To analyze the related factors of futile recanalization (FR) after emergency endovascular treatment of large artery occlusion in anterior circulation. Methods: Three studies on endovascular treatment of acute anterior circulation large vessels occlusion stroke were selected, and their data were merged for retrospective analysis. Patients were divided into the FR group and favorable prognosis group according to the functional prognosis. Risk factor analysis was conducted using multivariate logistic regression. Results: A total of 1 581 patients were finally included, with 858 (48.9%) patients in favorable prognosis group and 926 (51.91%) patients in FR group. Among them, there were 939 males and 642 females, with a mean age of (65±12) years. Multivariate logistic regression analysis showed that National Institute of Health Stroke Scale (NIHSS) score (OR=1.089,95%CI:1.066-1.113), puncture to recanalization time (OR=0.756, 95%CI:0.586-0.971), age (OR=1.04,95%CI:1.029-1.051), serum glucose (OR=1.101,95%CI:1.062-1.143), systolic blood pressure (OR=1.005,95%CI:1.001-1.010), passes≥3(OR=1.941,95%CI:1.294-2.941)Alberta stroke program early CT (ASPECT) score (OR=0.919,95%CI:0.847-0.996), occlusion site (M1 segment of middle cerebral artery, OR=0.744,95%CI:0.565-0.980) and collateral circulation [(2 points, OR=0.757, 95%CI:0.581-0.985); (3-4 points, adjusted OR=0.640, 95%CI: 0.472-0.866)] were independent factors of FR. Conclusion: The incidence of FR in patients with large artery occlusion in anterior circulation who achieve satisfied reperfusion after endovascular treatment is high. Higher NIHSS score, longer puncture to recanalization time, older age, higher serum glucose and systolic blood pressure are risk factors, while lower ASPECTS, occlusion in cerebral middle M1 segment, better collateral circulation are protective factors.

Angiography alone versus angiography plus intracoronary imaging to guide emergency percutaneous coronary intervention: outcomes from a single-centre retrospective analysis

Funding Acknowledgements

Type of funding sources: None.

Background

There is emerging evidence showing improvement in clinical outcomes with optical coherence tomography (OCT) and intravascular ultrasound (IVUS)-guided elective percutaneous coronary intervention (PCI). Yet data supporting their use in emergency setting are still conflicting.

Purpose

We aim to compare the immediate angiographic outcomes, short and long-term clinical outcomes in patients undergoing emergency PCI with intracoronary imaging to those with angiography guidance only.

Methods

We included 426 patients from May 2012 to December 2020 who presented with ST-elevation myocardial infarction (STEMI) and underwent emergency PCI within 24 hours of hospital admission. Intracoronary imaging was used in 196 of them to guide PCI. Immediate angiographic outcomes in terms of TIMI flow grade (TFG), myocardial blush grade (MBG) and corrected TIMI frame count (CTFC) are compared. Clinical outcomes including major adverse cardiac events (MACE), target vessel revascularization (TVR), hospitalization for heart failure and all-cause mortality were also compared.

Results

196 patients (46%) underwent intracoronary imaging-guided PCI. Use of imaging was associated with a higher post procedural CTFC (27.0 vs. 25.8, p=0.11), yet it failed to reach statistical significance. Comparing with angiography-guided PCI, imaging-guided PCI was associated with significantly larger proportion of high CTFC post procedure (slow coronary flow) (OR, 0.62; 95% CI: 0.38-1.0, P=0.05), and this result was consistent after adjustment of variables (adjusted OR, 0.57; 95% CI 0.34-0.98, P=0.04). Subjective measures of TIMI flow grade and MBG, however, were not different between the 2 groups. In the subgroup of patients with high Syntax score and American Heart Association (AHA)/American College of Cardiology (ACC) type C culprit lesion morphology, imaging guided PCI was associated with significantly worse post procedural MBG (OR, 0.36; 95% CI 0.17-0.78, P=0.01 vs. OR, 0.40; 95% CI 0.18-0.94, P=0.04), and the results were consistent after adjusting for variables. In the subgroup of patients with high Syntax score, imaging guided PCI was associated with significantly worse post procedural TIMI flow grade (adjusted OR, 0.35; 95% CI 0.12-0.95, P=0.05) and a trend towards higher CTFC (adjusted OR, 0.26; 95% CI: 0.06-0.94, P=0.05) after adjusting for variables. The cumulative incidences of all clinical outcome measures were not significantly different between the 2 groups before and after adjusting for confounders.

Conclusions

Imaging-guided PCI was not associated with improved angiographic or clinical outcomes in patients with STEMI who underwent emergency PCI. Use of intracoronary imaging in emergency PCI may associate with worse immediate angiographic outcomes.

[Surgical management of nipple areola complex in central breast cancer]

Objective: To explore the surgical strategy of nipple areola complex (NAC) management in central breast cancer. Methods: A retrospective analysis was conducted on 164 cases of central breast cancer who underwent surgery treatment from December 2017 to December 2020 in the Breast Center of Beijing Tongren Hospital, Capital Medical University. Prior to the surgery, the tumor-nipple distance (TND) and the maximum diameter of the tumor were measured by magnetic resonance imaging (MRI). The presence of nipple invagination, nipple discharge, and nipple ulceration (including nipple Paget's disease) were recorded accordingly. NAC was preserved in patients with TND≥0.5 cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative intraoperative frozen pathological margin. All patients with signs of NAC involvement, TND<0.5 cm or positive NAC basal resection margin confirmed by intraoperative frozen pathology underwent NAC removal. χ(2) test or Fisher exact test was used to analyze the influencing factors. Results: Of the 164 cases of central breast cancer, 73 cases underwent breast-conserving surgery, 43 cases underwent nipple-areola complex sparing mastectomy (NSM), 34 cases underwent total mastectomy, and the remaining 14 cases underwent skin sparing mastectomy (SSM). Among the 58 cases of NAC resection (including 34 cases of total mastectomy, 14 cases of SSM, and 10 cases of breast-conserving surgery), 25 cases were confirmed tumor involving NAC (total mastectomy in 12 cases, SSM in 9 cases, and breast-conserving surgery in 4 cases). The related factors of NAC involvement included TND (P=0.040) and nipple invagination (P=0.031). There were no correlations between tumor size (P=0.519), lymph node metastasis (P=0.847), bloody nipple discharge (P=0.742) and NAC involvement. During the follow-up period of 12 to 48 months, there was 1 case of local recurrence and 3 cases of distant metastasis. Conclusions: For central breast cancer, data suggest that patients with TND≥0.5cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative NAC margin in intraoperative frozen pathology should be treated with NAC preservation surgery, whereas for those with TND<0.5 cm or accompanied by signs of NAC invasion, NAC should be removed. In addition, nipple reconstruction can be selected to further improve the postoperative appearance of patients with central breast cancer.

Pulmonary pressure-to-longitudinal strain ratio by echocardiography: a rapid surrogate to magnetic resonance for right ventricular failure assessment

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): United Christian Hospital Ruttonjee and Tang Siu Kin Hospitals

Background

Better risk stratification in pulmonary hypertension (PH) by echocardiography (echo) to detect ventricular vascular uncoupling may act as gate-keeper for downstream management, such as MRI and expensive therapies. Studies showed modest correlation found between RV peak global longitudinal strain (RVGLS), which is afterload dependent, and right ventricular ejection fraction (RVEF)

Purpose

To test the accuracy and optimal cut-off of echo derived mean PA pressure-to-RVGLS ratio against MRI detected severe RV dysfunction (defined as RVEF&lt; 35%), RV dilatation (defined as RVEDVi &gt;87ml), and correlate native T1-values (nT1)

Method

Strain analyses by echo and volumetric assessment by 1.5 tesla MRI were performed in all patients. Contoured MRI short axis images provided RVEF. In a subgroup of pulmonary arterial hypertension (PAH), right heart catheterization and MRI non-contrast native T1 mapping were performed (Figure 1). Using previous study data, to identify a difference of 1.8 pressure-to-strain ratio between mild and severe PH with a variance  of 2.2 , power of 80% and a significance level of 0.05, a total of 11 participants per group were needed

Result

Thirty-one PH patients (13 female, age 60 ± 14y, 13 had PAH) were recruited prospectively. Strong correlation was demonstrated between the mean PA pressure-to-RVGLS ratio to MRI derived RVEF (r = 0.80, p &lt; 0.01), and to catheterization derived pulmonary vascular resistance and indexed cardiac output (r = -0.80, p= 0.001; r= -0.75, p = 0.003 respectively). The cut-off value of -2.5 had best accuracy in ROC analyses (Table 1)

In PAH patients, this ratio correlated with global nT1 at basal short-axis level (r= -0.91, p = 0.004), but not at the mid short-axis level. Their basal posterior interventricular insertion regions had significantly higher nT1 than those of age-matched normal controls at the same region on the same scanner (1256 ± 217 ms vs. 932 ± 25 ms, p = 0.04)

Conclusion

In terms of detection of severe right ventricular dysfunction by echocardiography, mean PA pressure-to-RVGLS ratio performed better than RVGLS alone, and a ratio cutoff of -2.5 predicts MRI determined ventricular vascular uncoupling in pulmonary hypertension

Table 1 Echo detect MRI AUC standard error 95% CI sens (%) spec (%) p Mean PA pressure -to-RVGLS ratio RVEF &lt; 35% 0.86 0.073 0.71-1.00 72 83 0.007 RVEDVi &gt; 87ml 0.81 0.081 0.65-0.97 83 70 0.004 RVGLS RVEF &lt; 35% 0.76 0.100 0.57-0.96 60 83 0.048 RVEDVi &gt; 87ml 0.73 0.090 0.55-0.91 67 70 0.032 PA pulmonary artery; RVGLS: RV global longitudinal strain; RVEDVi: indexed RV end-diastolic volume Abstract Figure 1

Therapeutic efficacy of percutaneous microwave coagulation versus liver resection for single hepatocellular carcinoma ≤3 cm with Child-Pugh A cirrhosis

AIMS

This study aimed to compare the therapeutic efficacy of liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) for single hepatocellular carcinoma ≤3 cm (HCC) in cirrhotic livers.

METHODS

In this study, 190 patients with single HCC ≤3 cm and Child-Pugh A cirrhosis were retrospectively reviewed. Among these patients, 122 patients underwent LR, and 68 patients received PMCT. The therapeutic efficacy and complications were compared between the two procedures.

RESULTS

There was no treatment-related hospital mortality in either group. Major complications were significantly more frequent in the LR group compared to the PMCT group (22.1% vs 5.9%, p = 0.004). The 1-, 3-, and 5-year OS rates for the LR group and PMCT group were 98.4%, 93.6%, 55.2% and 97.1%, 87.7%, 51%, respectively. There was no significant difference in OS rates between the LR group and PMCT group (p = 0.153). The 1-, 3-, and 5-year DFS rates were 96.7%, 70.5% and 43.7%, respectively, in the LR group, which were significantly higher compared to the PMCT group (92.6%, 50.5% and 26.3%, p = 0.006). Subgroup analyses revealed that HCC patients with portal hypertension (PH), OS and DFS were similar between the two groups.

CONCLUSIONS

LR may provide better DFS and lower recurrence rates than PMCT for single HCC ≤3 cm and Child-Pugh A cirrhosis. For HCC patients with PH, PMCT may provide therapeutic effects that are similar to LR.

Pharmacokinetics and potential advantages of a new oral solution of levothyroxine vs. other available dosage forms

To better understand the pharmacokinetics and potential advantages of a levothyroxine oral solution vs. tablets and soft gel capsules.4 randomized, 2-treatment, single-dose (600 mcg levothyroxine), 2-way crossover bioequivalence studies in 84 healthy subjects were analyzed. Samples were collected before dosing and until 48-72 h post-dose to calculate noncompartmental baseline-adjusted pharmacokinetic parameters: maximum concentration, time to maximum concentration, and area-under-the-concentration-time-curve from 0 to 48 h and from 0 to 2 h.Mean pharmacokinetic parameters (±standard deviation) for tablets, capsules and solution, respectively, were: area-under-the-concentration-time-curve from 0 to 2 h (ng*h/mL)=68.4±32.8, 64.4±24.4, 99.1±22.7; area-under-the-concentration-time-curve from 0 to 48 h (ng*h/mL)=1 632±424, 1 752±445, 1 862±439; maximum concentration (ng/mL)=67.6±20.9, 68.0±15.9, 71.4±16.0; time of maximum concentration (hours)=2.25±0.99, 2.38±1.58, 1.96±1.07. Overall rate and extent of exposure were not statistically different between formulations, but a faster onset of absorption for the solution was suggested (greater area-under-the-concentration-time-curve from 0 to 2 h and faster time to maximum concentration by an average of 30 min).Levothyroxine rate and extent of exposure are similar between tested formulations. The solution appears however to reach systemic circulation quicker as dissolution is not needed before absorption starts. The solution's greater early exposure and a faster time to maximal concentration of around 30 min may be of benefit to minimize drug-food interactions and deserves further investigations.

Prognostic value of adenosine stress myocardial perfusion by cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has been intensely researched in recent years, and its high diagnostic accuracy for myocardial ischemia has been demonstrated. However, its prognostic information is very limited.

AIM

We sought to assess the value of adenosine stress myocardial perfusion by CMR in predicting cardiac events in patients with known or suspected coronary artery disease (CAD).

DESIGN

Retrospective study.

METHODS

From January 2003 to December 2008, we retrospectively reviewed consecutive patients with or without history of CAD referred for evaluation of suspected myocardial ischemia who had undergone adenosine stress CMR in our hospital. End points were cardiac death or non-fatal myocardial infarction (MI).

RESULTS

After a mean follow-up of 3.2 ± 1.6 years in 203 patients, 15 (7.4%) cardiac events occurred. The 4-year event-free survival was 96.2% for patients with normal stress CMR perfusion and 71.5% for those with abnormal stress CMR perfusion. Univariate analysis showed that both adenosine-induced reversible perfusion defect and delayed gadolinium enhancement by CMR were significant predictors of cardiac events [Hazard ratio (HR) 9.31; 95% Confidence Interval (95% CI) 3.18-27.3; and HR 9.24; 95% CI 3.27-26.08; P < 0.001, respectively). By multivariate analysis, adenosine-induced reversible perfusion defect remained an independent predictor of cardiac events (HR 7.77; 95% CI 2.50-24.18; P < 0.001). In a stepwise multivariate model (Cox regression), an abnormal stress CMR perfusion result had significant incremental predictive value over clinical risk factors and resting regional wall motion abnormality (RWMA) (P < 0.001).

CONCLUSION

In patients with known or suspected CAD, adenosine stress CMR could be used to identify patients at high risk for subsequent cardiac death or nonfatal MI. A normal CMR perfusion was associated with a very low long-term event rate and excellent long-term prognosis. In addition, stress CMR perfusion provided important incremental prognostic information over clinical risk factors and RWMA.

The first novel influenza A (H1N1) fatality despite antiviral treatment and extracorporeal membrane oxygenation in Hong Kong

We report the first fatality caused by novel influenza A (H1N1) infection despite having the diagnosis confirmed and being given antiviral treatment after hospitalisation. This patient was also the first with influenza A (H1N1) to be supported with extracorporeal membrane oxygenation in Hong Kong. Although extracorporeal membrane oxygenation is an effective means of supporting patients with refractory hypoxaemia on high mechanical ventilatory support, it is labour-intensive and technically demanding. We also discuss the challenges faced when managing this case.

Important role of cardiac spect imaging in patients undergoing percutaneous transluminal coronary angioplasty

OBJECTIVE

To examine the utilization and contribution of cardiac perfusion scans to patients undergoing percutaneous transluminal coronary angioplasty.

METHODS

From July 1996 to January 1998, 34 patients underwent percutaneous transluminal coronary angioplasty and cardiac SPECT imaging was studied. Twenty-five patients had pre-procedure SPECT scans. The agreement between angioplasty strategies and SPECT findings of ischemia and hypokinesia was examined.

RESULTS

When radionuclide imaging was performed before revascularization procedures, 84% of the patients had intervention strategies guided by scan findings. Perfusion scan findings including extent and severity of ischemia, degree of hypokinesia directed the selection of target vessel for angioplasty in the patient subgroup with multi-vessel disease. Post-angioplasty radionuclide cardiac scans were performed only on symptomatic patients, demonstrating ischemia and hypokinesia in most of them, conceivably reflected the selection bias.

CONCLUSION

We recommend routine pre- and post-angioplasty radionuclide imaging with multigated scans for wall motion assessment for all patients receiving coronary intervention.

Effect of force level on synthesis of type III and type I collagen in mouse interparietal suture

Nine-week-old Swiss male white mice were divided into groups killed after time intervals of force application of six h, and one, three, five, seven, ten, 14, 21, and 28 days. Each group had 45 animals: three control, three sham-operated, and three experimental animals for each of the five force levels: 50 g, 35 g, 25 g, 15 g, and 5 g. The experimental animals had helical springs placed surgically in their calvaria for expansion of the interparietal suture. The sham-operated animals received inactive springs. Control animals were at the same age as the experimental and sham-operated animals. After death, the amount of sutural expansion was measured, and the calvaria with the implanted springs were explanted into Trowell-type organ culture dishes. [14C]-glycine was added for two h after 60 min of culture for all explants. The rate of suture expansion was directly proportional to the force value of the tensile stress, and a maximum 2.0-mm expansion was achieved for all force levels by the 28th day. Sutural collagen was solubilized by limited pepsin digestion, and radiolabeled types I and III alpha-chains were separated by SDS-PAGE, visualized fluorographically, and measured densitometrically. All the experimental and sham-operated animals responded with a rapid rise followed by an almost equally rapid fall in the proportion of newly-synthesized type III collagen before becoming stabilized for the rest of the experimental period at a level that was significantly higher than that of the control and sham-treated animals of the same age.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of sutural growth rate on collagen phenotype synthesis

We determined the ratio of newly-synthesized type III collagen to the total of type I and type III collagen in mouse interparietal sutural tissue at selected ages between birth and adulthood (36 weeks old). We incubated mouse calvaria explants in Trowell-type organ culture dishes for one h and then added [14C]-glycine for two h. We dissected the interparietal sutural tissues for collagen solubilization by limited pepsin digestion. Fluorographic visualization of separated radiolabeled collagens, after SDS-PAGE, found the ratio of collagen type III alpha-chains to the total type I and type III alpha-chains to be age-dependent. The proportion of type III alpha-chains at birth was quite high, but there was a significant drop (p less than 0.05) during the first two days of life, probably because of the sudden environmental change from in utero. The proportion of type III alpha-chains rose significantly from day 2 to day 4, reaching a maximum and then dropping significantly to about the same proportion as at birth by day 7. A further significant drop took place during the second week of life, with the proportion stabilized at around 3.5% at two weeks to ten weeks of age. A final significant drop during the eleventh week of life led to no detectable synthesis of type III collagen after 12 weeks of age. The changes in the collagen phenotype ratio did not relate to changes in body weight during growth and development, which suggests that the interparietal suture may have an independent maturing pattern.(ABSTRACT TRUNCATED AT 250 WORDS)