P4791Performance of the HAS-BLED, ATRIA, and PRECISE-DAPT Bleeding Risk Scores in Atrial Fibrillation Patients Using Antiplatelet Agents or Oral Anticoagulants

Background

Various bleeding risk scores have been proposed to assess the risk of bleeding in atrial fibrillation (AF) patients undergoing anticoagulation. PRECISE DAPT score has been developed to assess the out-of hospital bleeding risk in patients receiving dual antiplatelet therapy (DAPT). Our objective was to compare the predictive performance between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet therapy) score in AF patients using antiplatelet agents or anticoagulants

Methods

We recruited 1,114 consecutive AF patients (51% male; median age, 71 years) receiving antiplatelet agents or oral anticoagulants from January 2014 through December 2018. Major bleeding was defined as according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥3 g, and intracranial, intraocular or fatal bleeding). The performance of risk scores were assessed by C-statistic.

Results

Bleeding events occurred in 135 patients (12.1%) during 30 days, and 72 patients (6.5%) from 30 days till 1-year follow-up. Based on the C-statistic, PRECISE-DAPT score (AUC: 0.72, 95% CI: 0.69–0.75) had a good performance, significantly better than HAS-BLED (AUC: 0.64, 95% CI: 0.61–0.67) (p=0.008) or ATRIA scores (AUC: 0.57, 95% CI: 0.54–0.60) (p<0.001) for 30-days bleeding prediction. Also, PRECISE-DAPT score had a good C-statistic (AUC: 0.72, 95% CI: 0.69–0.75) for 1-year bleeding events compared with HAS-BLED (AUC: 0.64, 95% CI: 0.60–0.67) (p=0.02) or ATRIA (AUC: 0.61, 95% CI: 0.58–0.65) (p=0.01).

ROC curve for bleeding

Conclusions

The PRECISE-DAPT score has been used for assessing bleeding events during DAPT. Also, the PRECISE-DAPT score predicted bleedings better than HAS-BLED or ATRIA scores in AF patients. So, the PRECISE-DAPT score may be considered as bleeding risk score during DAPT or oral anticoagulation in clinical practice.

Clinical Usefulness of the Korean Developmental Screening Test (K-DST) for Developmental Delays

Objective

To evaluate the clinical usefulness of the Korean Developmental Screening Test (K-DST) via comparison with Korean Ages and Stages Questionnaire (K-ASQ) for the diagnosis of developmental delay in pediatric patients.

Methods

The K-DST and K-ASQ were used to screen pediatric patients who visited the hospital for evaluation and diagnosis of delayed development. Korean Bayley Scales of Infant Development-II (K-BSID-II) or Korean Wechsler Preschool and Primary Scale of Intelligence III (K-WPPSI-III) were used for the standardized assessment. Moreover, the final clinical diagnosis was confirmed by three expert physicians (rehabilitation doctor, psychiatrist, and neurologist). The sensitivity and specificity of each screening tool for the final diagnosis were investigated and correlated with standardized assessments.

Results

A total of 145 pediatric consultations were conducted, which included 123 developmental disorders (40 autism spectrum disorders, 46 global developmental delay/intellectual disability, and 37 developmental language disorders) and another 22 that were not associated with any such disorders. The sensitivity and specificity of K-DST based on the final clinical diagnosis were 82.9% and 90.9%, respectively, which were not significantly different from that of K-ASQ (83.7% and 77.3%). Both K-DST and K-ASQ showed good correlation with K-BSID-II and K-WPPSI-III. No significant difference was found between the K-DST and K-ASQ measures.

Conclusion

K-DST is an excellent screening tool and is expected to replace K-ASQ with high validity.

Severe Ulnar Nerve Injury After Bee Venom Acupuncture at a Traditional Korean Medicine Clinic: A Case Report

This case report describes a severe nerve injury to the right ulnar nerve, caused by bee venom acupuncture. A 52-year-old right-handed man received bee venom acupuncture on the medial side of his right elbow and forearm, at a Traditional Korean Medicine (TKM) clinic. Immediately after acupuncture, the patient experienced pain and swelling on the right elbow. There was further development of weakness of the right little finger, and sensory changes on the ulnar dermatome of the right hand. The patient visited our clinic 7 days after acupuncture. Electrodiagnostic studies 2 weeks after the acupuncture showed ulnar nerve damage. The patient underwent steroid pulse and rehabilitation treatments. However, his condition did not improve completely, even 4 months after acupuncture.

Sterile Neutrino Search at the NEOS Experiment

An experiment to search for light sterile neutrinos is conducted at a reactor with a thermal power of 2.8 GW located at the Hanbit nuclear power complex. The search is done with a detector consisting of a ton of Gd-loaded liquid scintillator in a tendon gallery approximately 24 m from the reactor core. The measured antineutrino event rate is 1976 per day with a signal to background ratio of about 22. The shape of the antineutrino energy spectrum obtained from the eight-month data-taking period is compared with a hypothesis of oscillations due to active-sterile antineutrino mixing. No strong evidence of 3+1 neutrino oscillation is found. An excess around the 5 MeV prompt energy range is observed as seen in existing longer-baseline experiments. The mixing parameter sin^{2}2θ_{14} is limited up to less than 0.1 for Δm_{41}^{2} ranging from 0.2 to 2.3 eV^{2} with a 90% confidence level.

Use of magnetic resonance imaging to identify outcome predictors of caudal epidural steroid injections for lower lumbar radicular pain caused by a herniated disc

Objective

We used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD).

Methods

Ninety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half ), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure-clear nucleus and height of intervertebral disc).

Results

A centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical.

Conclusion

The HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.

The relationship between postoperative intravenous patient-controlled fentanyl analgesic requirements and severity of liver disease

PURPOSE

Decreased inhalational anesthetic requirements during orthotopic liver transplantation (OLT) have been reported according to the severity of the pre-existent disease as well as decreased opioid requirements thereafter. The aim of the present study was to determine the relationship between postoperative opioid requirements and severity of liver disease among OLT patients.

METHODS

We retrospectively reviewed 44 recipients who used intravenous fentanyl-based patient-controlled analgesia (PCA) after OLT from November 2009 to May 2010. The severity of liver disease was assessed using the model for end-stage liver disease (MELD) score. Recipients were divided into a low-MELD group (<20; n=30) and a high-MELD group (≥20; n=14). The amounts of PCA infusion and rescue opioid up to 3 postoperative days (POD) were compared between the 2 groups. The intensity of pain at rest and when coughing was assessed using visual analog scale (VAS) scores.

RESULTS

The cumulative opioid requirements via PCA on POD 1, 2, and 3 were significantly lower in the high-MELD than the low-MELD group. The amounts of rescue opioid were similar between the 2 groups. However, the intensity of pain at both rest and when coughing on POD 1, 2, and 3 were significantly less severe in the high-MELD than the low-MELD group.

CONCLUSIONS

OLT patients with high MELD scores required less postoperative opioids and experienced less pain than those with low scores. Therefore, postoperative pain control after OLT should be carefully titrated according to the severity of the liver disease.

Characteristics of InGaN-based concentrator solar cells operating under 150X solar concentration

InGaN/sapphire-based photovoltaic (PV) cells with blue-band GaN/InGaN multiple-quantum-well absorption layers grown on patterned sapphire substrates were characterized under high concentrations up to 150-sun AM1.5G testing conditions. When the concentration ratio increased from 1 to 150 suns, the open-circuit voltage of the PV cells increased from 2.28 to 2.50 V. The peak power conversion efficiency (PCE) occurred at the 100-sun conditions, where the PV cells maintained the fill factor as high as 0.70 and exhibited a PCE of 2.23%. The results showed great potential of InGaN alloys for future high concentration photovoltaic applications.

Endoscopy-aided laser therapy for intractable granular myringitis

Objective: We report our technique and results for endoscopy-aided CO2 laser therapy for the treatment of intractable granular myringitis, as an out-patient office procedure.

Materials and methods: A total of 21 patients (14 women and seven men; mean age 32.6 years) were retrospectively reviewed, all of whom suffered from intractable granular myringitis and had undergone endoscopy-aided laser treatment. Granulation tissue was vaporized for one to two seconds with a CO2 laser (spot size 0.5–1 mm with a power setting of 5–10 W in continuous mode). The mean follow-up period was 11 months.

Results: Eighteen of the 21 patients (85 per cent) were cured after a single treatment. Three patients with the diffuse form of the disease required repeat laser treatments coupled with self-irrigation with a diluted vinegar solution. We noted no perforations of patients' tympanic membranes after laser vaporization. We also observed no recurrences over follow-up periods ranging from three months to 2.6 years. Our laser procedure produced no adverse effect on hearing thresholds, nor were any other complications observed.

Conclusion: Our results suggest that endoscopy-aided CO2 laser ablation is a reliable and minimally invasive method associated with low rates of recurrence and a low incidence of complications. It can be conducted as an office procedure.

Emergence of ciprofloxacin-resistant pseudomonas in chronic suppurative otitis media

The most frequently isolated organism in chronic suppurative otitis media (CSOM) is Pseudomonas aeruginosa. Ototopical ciprofloxacin has proven effectiveness against P. aeruginosa. The purpose of this study is to evaluate the patients with recurrent otorrhoea caused by CSOM that was unresponsive to topical ciprofloxacin. Eighty-eight patients (18-77 years of age) with otorrhoea due to CSOM were reviewed retrospectively. All of them were initially treated with ciprofloxacin eardrops but the otorrhoea failed to resolve. Bacteriological specimens were processed and identified with standard cultures. In vitro antimicrobial susceptibility of these bacterial isolates was assessed by an agar disc diffusion method. Isolates were tested against 16 antibiotics. Ciprofloxacin-resistant P. aeruginosa were isolated in all cases. Imipenem was the most sensitive antibiotic agent with an overall susceptibility rate of 96.5%, followed by amikacin (55.6%), piperacillin/tazobactam (37.5%) and ceftazidime (31.8%). In our series, ciprofloxacin-resistant P. aeruginosa is increasing recently. Continuous surveillance is necessary to monitor antimicrobial resistance and to guide antibacterial therapy.

Changes in external ear resonance after mastoidectomy: open cavity mastoid versus obliterated mastoid cavity

The creation of an open mastoid cavity changes the acoustic characteristics of the external ear. The aim of this study was to ascertain the acoustic change in the external auditory canal caused by an open mastoid cavity and to compare it with mastoid obliteration. The external ear resonance characteristics were measured in 40 normal adult ears, 20 ears with an open mastoid cavity and 40 ears with an obliterated mastoid. The measurement of resonance characteristics was performed using a real ear analyser. An open mastoid cavity changed the mean peak resonant frequency of the external ear from 2.1 kHz to 2.3 kHz (P < 0.02), with a mean attenuation of 8 dB SPL at 4 kHz. An obliterated mastoid produced higher resonance frequencies from 2.5 kHz to 2.8 kHz. The sound pressure gain of the external auditory canal with an open mastoid cavity was higher than with an obliterated mastoid. The author concludes that an open mastoid cavity can affect the resonance frequency, and that this effect is reduced by mastoid obliteration. Therefore, mastoid obliteration results in a more normal ear canal both anatomically and functionally.

Inhibitory effect of immunoglobulin E production by jin-deuk-chal (Siegesbeckia orientalis)

Elevated levels of immunoglobulin (Ig) E are associated with immediate-type allergic reactions. Jin-deuk-chal is the whole plant of Siegesbeckia orientalis (SO) sL Immunization of mice with small amounts of protein antigens on alum results in several fold increases in total plasma IgE, much of it specific for the immunizing antigen. In the present study, we investigated the effect of Siegesbeckia orientalis (SO) on IgE production. SO inhibited the plasma levels of IgE induced by antigens. The effects of SO on the interleukin (IL)-4-dependent IgE response by mouse whole spleen cells were studied. IL-4 dependent IgE production of lipopolysaccharide (LPS)-stimulated whole spleen cells was inhibited by SO. In addition, using U266B I human IgE-bearing B cells, we found that SO inhibited the production of IgE activated by LPS plus IL-4. These results suggest that SO have antiallergic activity by inhibition of IgE production from B cells.

Effect of allergina on mast cell-mediated allergic reactions

The herbal formulation ALLERGINA has been used against allergic inflammation disease for generations, and still occupies an important place in traditional medicine in Korea. In this study, we investigated the effect of ALLERGINA by oral administration in mast cell-mediated anaphylaxis responses. ALLERGINA dose-dependently inhibited compound 48/48-induced systemic anaphylaxis with doses of 10(-2) to 5 g/kg 1 h before orally administered. Of special note, ALLERGINA inhibited systemic anaphylaxis completely with doses of 1 g/kg and 5 g/kg. ALLERGINA (1 g/kg) also inhibited passive cutaneous anaphylaxis by 84%. ALLERGINA dose-dependently inhibited histamine release from rat peritoneal mast cells. When ALLERGINA (0.01 mg/ ml) was added, ALLERGINA inhibited the production of tumor necrosis factor-alpha and interleukin-6, 80% and 26%, respectively in anti-dinitrophenyl IgE antibody-stimulated mast cells. Our studies provide evidence that ALLERGINA may be beneficial in the treatment of allergic inflammation diseases.

Efficacy of tympanomastoid surgery for control of infection in active chronic otitis media

The efficacy of surgery in controlling infection in 272 tympanomastoidectomy procedures for chronic otitis media (COM) was assessed by means of a four-point rating scale that incorporated both symptoms and signs, such as the presence or absence of otorrhea and granulation tissue. Of the 272 procedures, 170 were performed for COM with cholesteatoma and 102 were for active COM with granulation tissue but no cholesteatoma. Forty-seven percent were primary procedures, and 53% were revisions. Minimum follow-up was 12 months for all cases, with a mean of 30 months. Adequate control of infection occurred in 248 (91%) of the 272 cases. Of the 24 cases (9%) that developed persistent infection, 10 were controlled with a combination of oral and topical antibiotics and/or delayed skin grafting in the office. Thus overall satisfactory control of infection was achieved in 258 of 272 cases (95%). The outcome was influenced by the diagnostic category of COM: COM with cholesteatoma did significantly better than COM with granulation tissue (P = 0.02). The outcome was not influenced by the following variables: primary versus revision surgery, canal wall-up versus canal wall-down surgery, and extent of disease. The results suggest that active COM with granulation tissue may be more difficult to control than COM with cholesteatoma.

Histopathology of labyrinthine fistulae in chronic otitis media with clinical implications

The objective of this study was to describe the light microscopic pathology of labyrinthine fistulae in chronic otitis media (COM) in seven temporal bones and to discuss clinical and surgical implications. In COM, labyrinthine fistulae are usually caused by cholesteatoma, with the lateral semicircular canal being the most commonly affected site. Some fistulae are asymptomatic, whereas, others affect the auditory and vestibular systems to varying degrees. Surgical removal of cholesteatoma matrix over a fistula carries a risk of sensorineural hearing loss. Knowledge of the pathology of fistulae may provide a better understanding of their clinical manifestations and may allow a more rational approach to surgical management. The Massachusetts Eye and Ear Infirmary temporal bone collection contains 115 specimens with COM, of which seven specimens show pathologic fistulization of the bony labyrinth. Histologic sections from these seven bones were evaluated with respect to type of COM, location and size of fistula, changes in the inner ear adjacent to the fistula, middle ear and mastoid disease, and pathology in the vestibular and cochlear sense organs. The following conclusions are presented (a) Labyrinthine fistulae can be caused not only by cholesteatoma, but also by granulomatous COM without cholesteatoma and even by localized infection within a canal-down mastoid cavity. (b) Cholesteatoma matrix or inflammatory tissue usually becomes apposed to the endosteum or membranous labyrinth within the fistula. In most cases, reactive inner ear changes do not occur at the fistula site. Occasionally, there is thickening of the endosteum or chronic localized labyrinthitis. (c) Most bones do not show any alterations of the vestibular and cochlear sense organs. Occasionally, there is serous labyrinthitis, which might lead to partial sensorineural hearing loss. (d) A protective "walling-off" phenomenon in the labyrinth is not common. Therefore, if overwhelming infection or surgical trauma breaches the natural barriers of the endosteum/membranous labyrinth, then the fistula may allow rapid dissemination of infection throughout the inner ear.