Retraction: Serological Predictors for the Recurrence of Atrial Fibrillation After Electrical Cardioversion

This corrects the article on p.185 in vol.40, PMID: 20421959.

Efficacy of Silkworm Pupae Extract on Muscle Strength and Mass in Middle-Aged and Older Individuals: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

We investigated the efficacy and safety of silkworm pupae extract (SWP) consumption for 12 weeks on muscle mass and strength in middle-aged and older individuals with relatively low skeletal muscle mass who do regular low-intensity exercise.

DESIGN

A randomized double-blinded placebo-controlled trial.

PARTICIPANTS

The study was conducted with 54 participants with relatively low skeletal muscle mass (SMM) (64.4 ± 6.1 years; body mass index, 23.8 ± 2.4 kg/m2).

INTERVENTION AND MEASUREMENTS

Participants were randomly assigned to one of two groups: 1000 mg of SWP/day plus regular exercise (SWP group, n=27) or placebo plus regular exercise (placebo group, n=27). All participants were required to engage in 30-60 minutes/day of walking for ≥3 days/week for 12 weeks. The primary outcome was knee extension/flexion strength (Nm), measured at the velocity of 60°/s. Secondary outcomes included body composition, biomarkers (creatine kinase and creatinine), handgrip strength, and quality of life questionnaire.

RESULTS

Both the intention-to-treat (ITT) and per-protocol (PP) analyses revealed no significant impact of SWP on knee strength compared to the placebo group over 12 weeks. On the other hand, the SWP group had significantly greater increases in right-handgrip strength by 1.94 kg (95% CI: 0.08-3.79; p = 0.041) and left-handgrip strength by 1.83 kg (0.25-3.41; p = 0.024) compared to the placebo group in the ITT population, after 12 weeks. Moreover, in the PP population, the SWP group revealed an even greater increase in right-handgrip strength by 2.07 kg (0.15-3. 98; p = 0.035) and left-handgrip strength by 2.21 kg (0.60-3.83; p = 0.008) for the 12-week period. However, this study resulted in a failure to detect significant differences in the body composition, biomarkers, quality of life questionnaire, physical activity, and caloric intake between the groups. None of the participants in the SWP group experienced any significant adverse events. In the placebo group, two participants experienced urticaria and allergic side effects, leading to their withdrawal from the study and two exhibited elevated levels of liver enzyme and increased diastolic blood pressure, respectively at 12 weeks.

CONCLUSION

SWP, in addition to low-intensity exercise, may enhance handgrip strengths in middle-aged and older adults with relatively lower SMM. Future studies need to use a large sample size over longer periods to validate our findings. This trial was registered at clinicaltrials.gov as NCT04994054.

Late ventricular potential for risk prediction of sudden cardiac death risk: a valuable tool or an unnecessary step?

Background/Introduction

Signal-averaged electrocardiography (SA-ECG) is a high-resolution electrocardiography that can detect late ventricular potential, which known to be a noninvasive tool for risk stratification of sudden cardiac death (SCD) by predicting reentrant ventricular tachyarrhythmia. There is a paucity of data with SA-ECG on SCD survivors without structural heart disease, whereas majority of previous studies had been focused on post myocardial infarction survivors.

Purpose

This study assessed the clinical utility of SA-ECG as a risk stratification modality for lethal arrhythmic event in patients at risk of SCD without definite structural heart disease.

Methods

Total 629 patients who experienced or had potential risk of SCD were studied with SA-ECG. Among them, 48 patients who were found to have significant structural heart disease were excluded, except arrhythmogenic right ventricular cardiomyopathy. Major arrhythmic event (MAE) was defined as composite of all-cause death, aborted SCD, and sustained VT during any time either before visit of clinic or during follow up period. Syncope and non-sustained VT was defined as non-major arrhythmic event. SA-ECG was defined positive when fulfilling three or more criterion: (1) unfiltered QRS duration ≥114ms, (2) filtered QRS duration ≥114ms, (3) duration of terminal QRS <40uV exceeding 40ms, and (4) root mean square voltage in the terminal 40ms of ≤20ms.

Results

Among total 581 patients, 145 patients with positive SA-ECG showed higher incidence of MAE compared to patients with negative SA-ECG (21.4% vs. 6.7%, OR 3.816 [95% CI 2.208–6.597], p<0.001, Table). As the number of positive SA-ECG criteria increases, incidence of MAE tended to increase sequentially, which was markedly noted from 2 positive to 3 positive criteria (10.7% to 20.8%, p<0.001, Figure). In particular, patient with inherited arrhythmia showed higher rate of positive late potential compared to those with non-inherited arrhythmia (51.0% vs. 19.3%, p<0.001).

Conclusion

This study showed that at least 3 out of 4 diagnostic criteria in SA-ECG can independently predict lethal arrhythmic events and the positive late potential was associated with lethal arrhythmic event that leads to SCD, suggesting risk prediction for SCD using SA-ECG in patients even without structural heart disease including inherited arrhythmias.

Funding Acknowledgement

Type of funding sources: None.

Clinical role of genetic testing for overlapping between Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy

Background/Introduction

Brugada syndrome (BrS) and arrhythmogenic right ventricular cardiomyopathy (ARVC) are inherited arrhythmias that may predispose to sudden cardiac arrest. Although its pathogenetic mechanisms differ, overlapping features between BrS and ARVC have been demonstrated previously. However, it remains to be determined whether genetic testing for ARVC-related gene is needed in patients with BrS.

Purpose

This study is aimed to analyze genetic profiles of BrS patients using next generation sequencing (NGS) based multigene panel including ARVC related genes.

Methods

Patients who were confirmed as BrS or clinically suspected as BrS with type 2 or 3 Brugada pattern electrocardiography were studied. Genetic testing using NGS panels (Illumina Inc., San Diego, CA, USA) included 30 genetic variants associated with inherited arrhythmia and genetic cardiomyopathy.

Results

Among the total 119 patients from BrS registry, 63 patients were confirmed as BrS and 56 patients were clinically suspected as BrS without fulfilling diagnostic criteria. One-hundred-fourteen patients (95.8%) were male, and mean age of onset was 43.6 year-old. Genetic variants were identified in 25 of 42 patients who received genetic testing. Six out of 25 patients (24.0%) showed ARVC-related genotypes (2 PKP2, 1 DSG2, 1 TMEM43, 1 JUP, and 1 DSP) (Figure 1 and Table 1). None of the patients showed structural or electrocardiographic features that fulfill diagnostic criteria of ARVC. It is notable that ARVC-related genotypes were mostly frequently accounted for BrS patients, following SCN5A and SCN10A.

Conclusion

In the clinic setting, ARVC-related genetic variants were identified in significant proportion of BrS patients, supporting that genetic testing of ARVC-overlapping is needed. This study suggests that follow-up including imaging study should be considered in BrS patients with ARVC-related genotypes to monitor disease progression as ARVC.

Funding Acknowledgement

Type of funding sources: None.

Machine Learning-Predicted Progression to Permanent Atrial Fibrillation After Catheter Ablation

Introduction

We developed a prediction model for atrial fibrillation (AF) progression and tested whether machine learning (ML) could reproduce the prediction power in an independent cohort using pre-procedural non-invasive variables alone.

Methods

Cohort 1 included 1,214 patients and cohort 2, 658, and all underwent AF catheter ablation (AFCA). AF progression to permanent AF was defined as sustained AF despite repeat AFCA or cardioversion under antiarrhythmic drugs. We developed a risk stratification model for AF progression (STAAR score) and stratified cohort 1 into three groups. We also developed an ML-prediction model to classify three STAAR risk groups without invasive parameters and validated the risk score in cohort 2.

Results

The STAAR score consisted of a stroke (2 points, p = 0.003), persistent AF (1 point, p = 0.049), left atrial (LA) dimension ≥43 mm (1 point, p = 0.010), LA voltage <1.109 mV (2 points, p = 0.004), and PR interval ≥196 ms (1 point, p = 0.001), based on multivariate Cox analyses, and it had a good discriminative power for progression to permanent AF [area under curve (AUC) 0.796, 95% confidence interval (CI): 0.753–0.838]. The ML prediction model calculated the risk for AF progression without invasive variables and achieved excellent risk stratification: AUC 0.935 for low-risk groups (score = 0), AUC 0.855 for intermediate-risk groups (score 1–3), and AUC 0.965 for high-risk groups (score ≥ 4) in cohort 1. The ML model successfully predicted the high-risk group for AF progression in cohort 2 (log-rank p < 0.001).

Conclusions

The ML-prediction model successfully classified the high-risk patients who will progress to permanent AF after AFCA without invasive variables but has a limited discrimination power for the intermediate-risk group.

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.

The Effects of Single Nucleotide Polymorphisms in Korean Patients with Early-onset Atrial Fibrillation after Catheter Ablation

BACKGROUND

This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early-onset (< 40 years old) atrial fibrillation (AF) and their effects on the outcome after catheter ablation.

METHODS

A total of 89 patients (35.7 ± 3.7 years, 81 males) with drug-refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included in this study. Sixteen SNPs, including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543, and rs3825214, were genotyped. Serial 48-hour Holter monitoring was conducted to detect AF recurrences during long-term follow up.

RESULTS

Wild-type genotypes of rs11047543 (GG; 26/69 [37.7%] vs. GA; 13/18 [72.2%] vs. AA; 0/0 [0%], P = 0.009) and rs7193343 (CC; 0/7 [0%] vs. CT; 22/40 [55.0%] vs. TT; 18/41 [43.9%], P = 0.025) and the homozygous variant of rs3825214 (AA; 16/31 [51.6%] vs. AG; 22/43 [51.2%] vs. GG; 2/13 [15.4%], P = 0.056) were significantly associated with a lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n = 0-3), there were significant differences in recurrence rate (n = 0; 0/3 vs. n = 1; 2/13 [15.4%] vs. n = 2; 24/52 [46.2%] vs. n = 3; 13/17 [76.5%], P = 0.003). When correcting for multiple variables, rs11047543 (hazard ratio [HR], 2.723; 95% confidence interval [CI], 1.358-5.461; P = 0.005) and the number of risk alleles (HR, 2.901; 95% CI, 1.612-5.219; P < 0.001) were significantly associated with recurrence of AF after catheter ablation.

CONCLUSION

Polymorphisms on rs7193343 closest to ZFHX3 (16q22), rs3825214 near to TBX5 (12q24), and rs11047543 near to SOX5 (12p12) modulate the risk for AF recurrence after catheter ablation. The number of risk alleles of these 3 SNPs was an independent predictor of recurrence during long-term follow up in Korean patients with early-onset AF.

Evaluation of Left Atrial Appendage Isolation Using Cardiac MRI after Catheter Ablation of Atrial Fibrillation: Paradox of Appendage Reservoir

Objective

To assess the effect of left atrial appendage (LAA) isolation on LAA emptying and left atrial (LA) function using cardiac MRI in patients who underwent successful catheter ablation of atrial fibrillation (AF).

Materials and Methods

This retrospective study included 84 patients (mean age, 59 ± 10 years; 67 males) who underwent cardiac MRI after successful catheter ablation of AF. According to the electrical activity of LAA after catheter ablation, patients showed either LAA isolation or LAA normal activity. The LAA emptying phase (LAA-EP, in the systolic phase [SP] or diastolic phase), LAA emptying flux (LAA-EF, mL/s), and LA ejection fraction (LAEF, %) were evaluated by cardiac MRI.

Results

Of the 84 patients, 61 (73%) and 23 (27%) patients showed LAA normal activity and LAA isolation, respectively. Incidence of LAA emptying in SP was significantly higher in LAA isolation (91% vs. 0%, p < 0.001) than in LAA normal activation. LAA-EF was significantly lower in LAA isolation (40.1 ± 16.2 mL/s vs. 80.2 ± 25.1 mL/s, p < 0.001) than in LAA normal activity. Furthermore, LAEF was significantly lower in LAA isolation (23.7% ± 11.2% vs. 31.1% ± 16.6%, p = 0.04) than in LAA normal activity. Multivariate analysis demonstrated that the LAA-EP was independent from LAEF (p = 0.01).

Conclusion

LAA emptying in SP may be a critical characteristic of LAA isolation, and it may adversely affect the LAEF after catheter ablation of AF.

Use of Cardiac Computed Tomography and Magnetic Resonance Imaging in Case Management of Atrial Fibrillation with Catheter Ablation

Atrial fibrillation (AF) is the most common arrhythmia associated with the risk of morbidity and mortality in clinical patients. AF is considered as an arrhythmia type that develops and progresses through close connection with cardiac structural arrhythmogenic substrates. Since the introduction of catheter ablation-mediated electrical isolation of arrhythmogenic substrates, cardiac imaging indicates improved treatment outcome and prognosis with appropriate candidate selection, ablation catheter guidance, and post-ablation follow-up. Currently, cardiac computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging are essential in the case management of AF at both pre-and post-procedural stages of catheter ablation. In this review, we discuss the roles and technical considerations of CCT and CMR imaging in the management of patients with AF undergoing catheter ablation.

Usefulness of an Implantable Loop Recorder in Diagnosing Unexplained Syncope and Predictors for Pacemaker Implantation

BACKGROUND

An implantable loop recorder (ILR) is an effective tool for diagnosing unexplained syncope (US). We examined the diagnostic utility of an ILR in detecting arrhythmic causes of US and determining which clinical factors are associated with pacemaker (PM) implantation.

METHODS

This retrospective, multicenter, observational study was conducted from February 2006 to April 2018 at 11 hospitals in Korea. Eligible patients with recurrent US received an ILR to diagnose recurrent syncope and document arrhythmia.

RESULTS

A total of 173 US patients (mean age, 67.6 ± 16.5 years; 107 men [61.8%]) who received an ILR after a negative conventional workup were enrolled. During a mean follow-up of 9.4 ± 11.1 months, 52 patients (30.1%) had recurrent syncope, and syncope-correlated arrhythmia was confirmed in 34 patients (19.7%). The ILR analysis showed sinus node dysfunction in 24 patients (70.6%), supraventricular tachyarrhythmia in 4 (11.8%), ventricular arrhythmia in 4 (11.8%), and sudden atrioventricular block in 2 (5.9%). Overall, ILR detected significant arrhythmia in 99 patients (57.2%) irrespective of syncope. Among patients with clinically relevant arrhythmia detected by ILR, PM implantation was performed in 60 (34.7%), an intra-cardiac defibrillator in 5 (2.9%), and catheter ablation in 4 (2.3%). In a Cox regression analysis, history of paroxysmal atrial fibrillation (PAF) (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.33-4.12; P < 0.01) and any bundle branch block (BBB) (HR, 2.52; 95% CI, 1.09-5.85; P = 0.03) were significantly associated with PM implantation.

CONCLUSION

ILR is useful for detecting syncope-correlated arrhythmia in patients with US. The risk of PM is high in US patients with a history of PAF and any BBB.

P2523Hand grip strength as a predictor of exercise capacity in coronary heart disease

A recent study has shown that quadriceps strength can be used to predict the level of exercise capacity in patients with coronary heart disease (CHD). We investigated whether the relationship between muscular strength and exercise capacity is also observed with hand grip strength (HGS). We studied 443 participants (age, 61.8±11.2 y; 77.7% male) who underwent coronary intervention and participated in cardiac rehabilitation between 2015 and 2018. Participants were assessed for grip strength, measured using a Jamar dynamometer. Logistic regression was used to assess the relationship between various clinical measures (HGS, age, sex, etc) with the distance walked on a 6-minute walk test (6MWT) and maximal oxygen uptake (VO2max). HGS was significantly related to distance walked on the 6MWT (r=0.435, p<0.001). It was the only predictor of all exercise capacity categories, and one of the strongest predictors of each exercise capacity category. A HGS of 25.5% of body weight predicted an achievement of a 200 m walk on the 6MWT (positive predictive value = 0.95). However, HGS less than 35.5% of body weight predicted that 500m could not be done in 6 minutes (negative predictive value = 0.97). This trend was also observed in the subgroups in which VO2max was measured. This study demonstrates that HGS is associated with exercise capacity in CHD and can be used to predict the level of exercise capacity. These findings may contribute to setting the recommended level of daily activity as well as the level of cardiac rehabilitation in CHD.

Logistic regression models for different levels of exercise capacity Level of exercise capacity B±S.E p-value Odd ratio 95% CI Distance of 6MWT   200 m Grip strength 0.054±0.014 <0.001 1.056 1.027–1.086   300 m Grip strength 0.042±0.009 <0.001 1.042 1.024–1.062   400 m Grip strength 0.047±0.011 <0.001 1.048 1.026–1.070   500 m Grip strength 0.051±0.016 0.001 1.053 1.021–1.086 VO2max level   4 METs Grip strength 0.054±0.010 <0.001 1.056 1.036–1.076   6 METs Grip strength 0.059±0.011 <0.001 1.061 1.039–1.083   8 METs Grip strength 0.081±0.015 <0.001 1.085 1.053–1.117   10 METs Grip strength 0.113±0.049 0.019 1.12 1.019–3.232 Data are presented as mean ± standard deviation (SD). 6MWT, 6-minute walk test; STEMI, ST-Elevation Myocardial Infarction; SE, standard error; CI, confidence interval; VO2max, Maximal Oxygen uptake; METs, Metabolic equivalents.

Abstract P2-11-09: Excellent acute toxicity outcomes with proton therapy for partial breast irradiation in early stage breast cancer: Initial results of a multi-institutional phase II trial

Background and Purpose: Partial breast irradiation (PBI) with proton therapy after lumpectomy for early stage invasive breast cancer is an area of active investigation. Advantages of this technique include a shorter treatment course and the potential for decreased morbidity versus external beam photon radiation therapy given superior sparing of the surrounding normal breast tissue. To date, multiple single-institutional studies have reported conflicting results on the acute toxicity of PBI. This prospective phase II trial investigates the feasibility, safety, and efficacy of delivering PBI with proton therapy in a multi-institutional setting.

Methods: Patients over the age of 50 years with ER-positive nonlobular invasive breast cancer or ductal carcinoma in situ ≤3 cm in size who had undergone lumpectomy with at least 2 mm negative surgical margins were treated with proton therapy to a dose of 40 Gy delivered over 10 daily fractions. In this initial analysis, we assess early toxicity and treatment efficacy of proton PBI. Patients were followed up at 4 weeks post-treatment and annually thereafter, along with annual mammograms. Patient-reported quality of life and physician-reported cosmesis assessments including photographs were obtained at 1 and 3 years post-treatment.

Results: Forty patients were enrolled, of which 38 were evaluable. At a median follow-up of 17.8 months (range 2-36 months), all patients had overall breast cosmesis that was scored “good” or “excellent”. Of 6 grade 2 acute adverse events that occurred, only 1 was radiation dermatitis, with others including lymphedema, hot flashes, and fatigue. One grade 3 acute toxicity occurred 3 weeks after radiation completion in the form of vascular disease requiring stent placement, highly unlikely to be attributable to radiation effects. Patient-reported quality of life outcomes were recorded using the standardized Breast Cancer Treatment Outcome Scale (BCTOS) scored from 1-4 (1: none; 2: mild; 3: moderate; 4: large), with endpoints receiving a score of 3 or 4 most frequently involving change in breast size, breast texture, nipple appearance, or scar tissue. Patients assigned a score of 4 for change in nipple appearance (n=2), breast shape (n=2), and scar tissue formation (n=2). To date, local, locoregional, and distant disease control are 100%, although one patient has developed a new hormone receptor-negative invasive ductal carcinoma of the contralateral breast.

Conclusion: Proton PBI provides excellent early cancer control with acceptable cosmetic outcomes and minimal adverse effects as per patient- and physician-reported assessments. On continued follow-up, late toxicity and cosmesis, as well as long-term disease control outcomes, will be assessed.

Citation Format: Choi JI, Chang AL. Excellent acute toxicity outcomes with proton therapy for partial breast irradiation in early stage breast cancer: Initial results of a multi-institutional phase II trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-09.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation

Background and Objectives

Previous studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias.

Methods

The clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women).

Results

Total 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m²; p<0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027).

Conclusions

The clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.

Aortic Injury during Transforaminal Lumbar Interbody Fusion

Aortic injury during transforaminal lumbar interbody fusion (TLIF) is a rare but severe complication. We experienced aortic injury during TLIF at L3–4 with a 59-year-old woman diagnosed with an adjacent segment disease at L3–4. Severe bleeding occurred during disc space expansion, and the blood pressure dropped to 60/40 mmHg. The patient’s vital sign stabilized after compression with gauze and Gelfoam in addition to blood transfusion. The patient was treated with endovascular repair using a percutaneous technique after intertransverse fusion at L3–4 was completed. She recovered and is being followed-up in the outpatient department.

Rapid enlargement of endometrial stromal sarcoma after uterine fibroid embolization for presumed adenomyosis: a case report and literature review

Uterine sarcomas have rarely been diagnosed after uterine artery embolization. It remains unclear whether the diagnostic work-up is required prior to such embolization to prevent a missed diagnosis of sarcomas and a delay in providing definitive treatment. Because of the rarity and heterogeneity of endometrial stromal neoplasms, little is known about their epidemiology, pathogenesis, and molecular pathology. The authors report a case of low-grade endometrial stromal sarcoma (ESS) diagnosed after uterine fibroid embolization. Although they performed laparoscopic biopsy of the rapidly growing uterine mass, they could not detect the ESS. Although rare, ESS should be considered in the differential diagnosis of uterine fibroid enlargement. It is essential to assess the risk of malignancy by taking into account the patient's clinical symptoms, results of the physical exam, and imaging findings prior to uterine artery embolization. Pathologic diagnosis should include an adequate biopsy sample and the use of molecular genetic testing.

Management of otogenic brain abscess using the transmastoid approach

Despite significant advances in the treatment of all forms of chronic otitis media (COM), complications still can and do occur, with intracranial complications representing the most life-threatening cases, often requiring immediate therapeutic intervention. Herein, we present a rare case of rapidly progressing facial paralysis with concomitant severe headache and ipsilateral hearing loss secondary to an otogenic brain abscess, treated with the transmastoid approach, drainage, and facial nerve decompression.

Isorhamnetin inhibits Prevotella intermedia lipopolysaccharide-induced production of interleukin-6 in murine macrophages via anti-inflammatory heme oxygenase-1 induction and inhibition of nuclear factor-κB and signal transducer and activator of transcription 1 activation

BACKGROUND AND OBJECTIVE

Interleukin-6 (IL-6) is a key proinflammatory cytokine that has been considered to be important in the pathogenesis of periodontal disease. Therefore, host-modulatory agents directed at inhibiting IL-6 appear to be beneficial in terms of attenuating periodontal disease progression and potentially improving disease susceptibility. In the current study, we investigated the effect of the flavonoid isorhamnetin on the production of IL-6 in murine macrophages stimulated with lipopolysaccharide (LPS) from Prevotella intermedia, a pathogen implicated in inflammatory periodontal disease, and its mechanisms of action.

MATERIAL AND METHODS

Lipopolysaccharide from P. intermedia ATCC 25611 was isolated using the standard hot phenol-water method. Culture supernatants were collected and assayed for IL-6. We used real-time PCR to quantify IL-6 and heme oxygenase-1 (HO-1) mRNA expression. The expression of HO-1 protein and the levels of signaling proteins were monitored using immunoblot analyses. The DNA-binding activity of nuclear factor-κB (NF-κB) was analyzed using ELISA-based assay kits.

RESULTS

Isorhamnetin significantly down-regulated P. intermedia LPS-induced production of IL-6 as well as its mRNA expression in RAW264.7 cells. Isorhamnetin up-regulated the expression of HO-1 at both gene transcription and translation levels in cells stimulated with P. intermedia LPS. In addition, inhibition of HO-1 activity by tin protoporphyrin IX blocked the inhibitory effect of isorhamnetin on IL-6 production. Isorhamnetin failed to prevent LPS from activating either c-Jun N-terminal kinase or p38 pathways. Isorhamnetin did not inhibit NF-κB transcriptional activity at the level of inhibitory κB-α degradation. Isorhamnetin suppressed NF-κB signaling through inhibition of nuclear translocation and DNA binding activity of NF-κB p50 subunit and attenuated signal transducer and activator of transcription 1 signaling.

CONCLUSION

Although further research is required to clarify the detailed mechanism of action, we propose that isorhamnetin may contribute to blockade of the host-destructive processes mediated by IL-6 and could be a highly efficient modulator of the host response in the treatment of inflammatory periodontal disease. Further research in animal models of periodontitis is required to better evaluate, the potential of isorhamnetin as a novel agent for treating periodontal disease.

Circadian and seasonal variations of ventricular tachyarrhythmias in patients with early repolarization syndrome and Brugada syndrome: analysis of patients with implantable cardioverter defibrillator

INTRODUCTION

The circadian and seasonal patterns of ventricular tachyarrhythmia (VTA) in patients with early repolarization syndrome (ERS) have not been determined. We compared the timing of VTAs in patients with ERS and Brugada syndrome (BS).

METHODS AND RESULTS

We enrolled patients with ERS (n = 14) and BS (n = 53) who underwent implantable cardioverter defibrillator (ICD) implantation. The timing of VTAs, including cardiac arrest and appropriate shocks, was determined. During follow up of 6.4 ± 3.6 years in the ERS group and 5.0 ± 3.3 years in the BS group, 5 of 14 (36%) ERS and 10 of 53 (19%) BS patients experienced appropriate shocks (P = 0.37). Cardiac arrest showed a trend of nocturnal distribution peaking from midnight to early morning (P = 0.14 in ERS, P = 0.16 in BS). Circadian distribution of appropriate shocks showed a significant nocturnal peak in patients with ERS (P < 0.0001) but a trend toward a nocturnal peak in patients with BS (P = 0.08). There were no seasonal differences in cardiac arrest in patients with ERS and BS. However, patients with ERS showed a seasonal peak in appropriate shocks from spring to summer (P < 0.0001). There was no significant seasonal peak in patients with BS. The timing of VTAs (cardiac arrest plus appropriate shock) showed significant nocturnal distributions in patients with ERS and BS (P < 0.01, respectively). A significant clustering of VTAs was noted from spring to summer (P < 0.01) in patients with ERS, but not in patients with BS (P = 0.42).

CONCLUSIONS

Incidence of VTAs showed marked circadian variations with night-time peaks in patients with ERS and BS.

Increase of paradoxical excitement response during propofol-induced sedation in hazardous and harmful alcohol drinkers

BACKGROUND

Paradoxical excitement response during sedation consists of loss of affective control and abnormal movements. Chronic alcohol abuse has been proposed as a predisposing factor despite lack of supporting evidence. Because alcohol and propofol have a common site of action, we postulated that paradoxical excitement responses during propofol-induced sedation occur more frequently in hazardous and harmful alcohol drinkers than in social or non-drinkers.

METHODS

One hundred and ninety patients undergoing orthopaedic knee joint surgery were enrolled in this prospective and observational study. Subjects were divided into Group HD (hazardous and harmful drinkers) or Group NHD (no hazardous drinkers) according to the alcohol use disorder identification test (AUDIT). In study 1, propofol infusion was adjusted to achieve the bispectral index at 70-80 using target-controlled infusion. In study 2, the target concentration of propofol was fixed at 0.8 (study 2/Low) or 1.4 μg ml(-1) (study 2/High). Paradoxical excitement responses were categorized by intensity into mild, moderate, or severe.

RESULTS

The overall incidence of paradoxical excitement response was higher in Group HD than in Group NHD in study 1 (71.4% vs 43.8%; P=0.022) and study 2/High (70.0% vs 34.5%; P=0.006) but not in study 2/Low. The incidence of moderate-to-severe response was significantly higher in Group HD of study 1 (28.6% vs 3.1%; P=0.0005) and study 2/High (23.3% vs 3.4%; P=0.029) with no difference in study 2/Low. Severe excitement response occurred only in Group HD of study 1 and study 2/High.

CONCLUSIONS

Paradoxical excitement occurred more frequently and severely in hazardous and harmful alcohol drinkers than in social drinkers during propofol-induced moderate-to-deep sedation, but not during light sedation.

Total and interatrial epicardial adipose tissues are independently associated with left atrial remodeling in patients with atrial fibrillation

INTRODUCTION

As epicardial adipose tissue (EAT) is a metabolically active visceral fat, potential interaction between EAT and myocardium is strongly suggested. The aims of this study were to determine whether the amount and regional distribution of EAT are related to the chronicity of atrial fibrillation (AF) and left atrial (LA) remodeling.

METHODS AND RESULTS

This study consisted of 40 subjects with paroxysmal AF (PAF) and 40 with persistent AF (PeAF). Eighty subjects with no history of AF were enrolled as controls. Total volume of EAT (EAT(total)), regional thickness of EAT, and LA volume (LAV) were measured by multislice computed tomography. In the AF group, blood samples were drawn from coronary sinus for analysis of inflammatory cytokines including adiponectin.

RESULTS

Compared with controls, AF subjects had larger LAV, EAT(total), and the thicknesses of periatrial EAT including interatrial septum (IAS). However, the thicknesses of periventricular EAT were not different between the groups. The PeAF subjects had larger LAV, EAT(total), and periatrial EAT thicknesses, higher levels of inflammatory cytokines, and lower level of adiponectin than did the PAF subjects. Adiponection level was significantly associated with EAT(total) and IAS thickness. Multivariate analysis revealed that EAT(total) (P = 0.004) and IAS thickness (P = 0.016) were independently associated with LAV.

CONCLUSION

EAT(total) and thickness of periatrial EAT were significantly larger in AF subjects compared to those of the matched controls and were closely related to the chronicity of AF. Moreover, EAT(total) and IAS thickness were independently associated with LAV in subjects with AF.

Improved endothelial function in patients with atrial fibrillation through maintenance of sinus rhythm by successful catheter ablation

BACKGROUND

Although atrial fibrillation (AF) is a risk factor for endothelial dysfunction (ED), the effect of catheter ablation (CA) on AF-associated ED has not been evaluated. The aims of this study are to determine if the degree of ED predicts the outcome of AF ablation and to evaluate whether ED can be improved through restoring sinus rhythm (SR) by successful CA.

METHODS

This study prospectively enrolled 80 subjects who underwent CA for AF (paroxysmal AF = 61, persistent AF = 19). Eighty subjects with no history of AF were enrolled as controls, all of whom were matched by age, gender, body mass index, and atherosclerotic risk factor distribution. Brachial artery flow-mediated dilatation (FMD) was measured at baseline, and at 1 month and 6 months post CA in AF subjects who remained in SR. Among controls, FMD was measured at baseline and at 6 months. We used high sensitivity C-reactive protein (hs-CRP), interleukin-6, soluble E- or P-selectin, and endothelin-1 as biomarker indices for inflammation and/or ED.

RESULTS

Compared with controls, AF subjects had lower FMD at baseline (FMD(baseline), P < 0.001). After successful CA, FMD was significantly improved at 1 month and 6 months, nearly approaching control levels. A multivariate analysis revealed that FMD(baseline), hs-CRP, and left atrial volume (LAV) were independent predictors for arrhythmia recurrence after CA. Other biomarkers were not related to rhythm outcome.

CONCLUSION

AF subjects have significantly impaired FMD, which can be reversed through maintenance of SR by successful CA. FMD(baseline), hs-CRP, and LAV are important predictors for AF recurrence after CA.

Serological predictors for the recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND AND OBJECTIVES

Although electrical cardioversion (CV) is effective in restoring sinus rhythm (SR) in patients with atrial fibrillation (AF), AF frequently recurs in spite of antiarrhythmic medications. We investigated the predictors of failed CV and AF recurrence after successful CV.

SUBJECTS AND METHODS

In 81 patients (M:F=63:18, 59.1+/-10.5 years old) with AF who underwent CV, clinical findings and pre-CV serologic markers were evaluated.

RESULTS

During 13.1+/-10.6 months of follow-up, 8.6% (7/81) showed failed CV, 27.16% (22/81) showed early recurrence atrial fibrillation (ERAF; </=2 weeks), 32.1% (26/81) had late recurrence atrial fibrillation (LRAF; >2 weeks), and 32.1% (26/81) remained in SR and had no recurrence (NR). Plasma levels of transforming growth factor beta (TGF)-beta were significantly higher in patients with failed CV than in those with successful CV (p=0.0260). Patients in whom AF recurred were older (60.4+/-9.0 years old vs. 55.3+/-12.5 years old, p=0.0220), and had lower plasma levels of stromal cell derived factor (SDF)-1alpha (p=0.0105). However, there were no significant differences in these parameters between ERAF patients and LRAF patients.

CONCLUSION

Post-CV recurrence commonly occurs in patients aged >60 years and who have low plasma levels of SDF-1alpha. High plasma levels of TGF-beta predict failure of electrical CV.

Clinical and serological predictors for the recurrence of atrial fibrillation after electrical cardioversion

AIMS

Although electrical cardioversion (CV) is effective in restoring sinus rhythm in patients with atrial fibrillation (AF), AF frequently recurs in spite of antiarrhythmic medications. We investigated the predictors of failed CV and AF recurrence after successful CV.

METHODS AND RESULTS

In 81 patients (M:F = 63:18, 59.1 +/- 10.5 years old) with AF who underwent CV, clinical, image, and CV findings (energy requirement, immediate recurrence of AF < 15 min), and pre-CV serological markers were evaluated.

RESULTS

(i) During 13.1 +/- 10.6 months of follow-up, 8.6% (7/81) showed failed CV, 59.26% (48/81) showed AF recurrence, and 32.1% (26/81) remained in sinus rhythm (no recurrence). (ii) Failed CV showed higher plasma levels of transforming growth factor (TGF)-beta (P = 0.0260) than those with successful CV. (iii) Patients with AF recurrence were older (60.4 +/- 9.0 years old vs. 55.3 +/- 12.5 years old, P = 0.0220), had a higher incidence of spontaneous echo contrast (SEC; 68.1 vs. 40.0%, P = 0.0106), a lower prescription rate of angiotensin-converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB; 27.0 vs. 50.0%, P = 0.0248) or spironolactone (0.0 vs. 19.2%, P = 0.0007), and lower plasma levels of stromal cell-derived factor (SDF)-1alpha (P = 0.0105).

CONCLUSION

Post-CV recurrence commonly occurs in patients with age >60 years, SEC, under-utilization of ACE-I/ARB or spironolactone, and low plasma levels of SDF-1alpha. High plasma level of TGF-beta predicts failed CV.

Non-ischaemic titrated cardiac injury caused by radiofrequency catheter ablation of atrial fibrillation mobilizes CD34-positive mononuclear cells by non-stromal cell-derived factor-1alpha mechanism

AIMS

It has been known that myocardial ischaemia mobilizes CD34+ bone marrow-derived cells by the stromal cell-derived factor (SDF)-1alpha pathway. We hypothesized that non-ischaemic titrated cardiac injury caused by radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) recruits CD34+ cells by an alternative mechanism.

METHODS AND RESULTS

Fifty-six patients (39 males, 53.0 +/- 13.5 years old) who underwent electrophysiology study (EPS; n = 10) or RFCA of AF (n = 46) were included. Peripheral blood CD34+ cell count and multiple serologic markers were evaluated before, immediately after, at 24 h, and 10 days after the procedure. The results are as follows: (i) the per cent increase in CD34+ cells (%DeltaCD34+) was significant after RFCA compared with after EPS (P < 0.01), and correlated with RF duration and troponin I, respectively. (ii) In contrast, SDF-1alpha decreased after RFCA and had no correlation with %DeltaCD34+ cells while matrix metalloproteinase (MMP)-9 (P < 0.0001) and GRObeta (P < 0.001) increased after RFCA and had correlations with 24 h %DeltaCD34+ cells.

CONCLUSION

Non-ischaemic titrated cardiac injury caused by AF ablation mobilizes CD34+ cells to the peripheral blood through a non-SDF-1alpha pathway associated with MMP-9 and GRObeta.

Comparison of effects of telmisartan and valsartan on late lumen loss and inflammatory markers after sirolimus-eluting stent implantation in hypertensive patients

We compared the effects of telmisartan and valsartan on late lumen loss and inflammatory markers after sirolimus-eluting stent implantation in hypertensive patients. This was a prospective, randomized, single-blinded, 8-month follow-up study that included hypertensive patients with significant coronary artery stenosis treated with telmisartan (n=79) or valsartan (n=80). Risk factors such as diabetes, hyperlipidemia, smoking, and obesity were similar between groups. After 8 months of follow-up, only the telmisartan group showed significant decreases in interleukin-6 and tumor necrosis factor-alpha. The decreases from baseline level in total cholesterol and low-density lipoprotein cholesterol concentrations were significantly greater in the telmisartan group. The increase in adiponectin concentrations from baseline measurements was significantly greater in the telmisartan group than in the valsartan group (1.9+/-2.7 vs 0.4+/-2.0 microg/ml, respectively, p<0.05). Moreover, late lumen loss was significantly lower in the telmisartan group than in the valsartan group (0.1+/-0.4 vs 0.3+/-0.5 mm, respectively, p=0.001). Major adverse cardiac events were similar between groups. In conclusion, compared with valsartan, telmisartan was associated with a significant decrease in late lumen loss and inflammatory markers after sirolimus-eluting stent implantation in hypertensive patients with significant coronary narrowing.

Applications of three-dimensionally scanned models in orthodontics

The purpose of this study was to investigate clinical applications of the three-dimensional reverse engineering technologies for the analysis of orthodontic models. The measuring accuracy and the process of the 3D model scanning technique were evaluated with respect to linear, surface and volumetric parameters. Orthodontically induced dentoalveolar changes, which have been traditionally evaluated by cephalometric analysis, were assessed by the registration function of Rapidform 2002, a 3D-reverse modeling software in scanned maxillary casts. Three-dimensional digital models are valuable alternatives to conventional casts for model analysis and also yield information which could previously be gathered only by cephalometric superimposition.

Synergistic antinociception between zaprinast and morphine in the spinal cord of rats on the formalin test

BACKGROUND AND OBJECTIVE

The cyclic guanosine monophosphate level, which causes an antinociception, is increased in cells as a direct result of phosphodiesterase inhibition. This study used a nociceptive test to examine the nature of the pharmacological interaction between intrathecal zaprinast, a phosphodiesterase inhibitor, and morphine.

METHODS

Catheters were inserted into the intrathecal space through an incision in the atlantooccipital membrane of male Sprague-Dawley rats. As a nociceptive model, 50 microL of a 5% formalin solution was injected into the hind paw. After observing the effect of zaprinast (37, 111, 369 nmol) and morphine (1, 4, 10, 40 nmol) alone, the interactions of their combination were examined by an isobolographic analysis.

RESULTS

Intrathecal zaprinast (P < 0.05) and morphine (P < 0.05) dose-dependently suppressed the flinching observed during phase 1 and phase 2 in the formalin test. The ED50 values (95% confidence intervals) of zaprinast and morphine in phase 1 were 161.9 (87.9-298.3) and 11.6 nmol (4.8-27.9 nmol), respectively. The phase 2 ED50 values (95% confidence intervals) of zaprinast and morphine were 229.9 (142.5-370.9) and 3.9 nmol (1.9-7.6 nmol), respectively. Isobolographic analysis revealed a synergistic interaction after intrathecal delivery a zaprinast-morphine mixture in both phases. The ED50 values of (95% confidence intervals) zaprinast in the combination of zaprinast with morphine in phase 1 and phase 2 were 14.2 (4.9-40.6) and 10.4 nmol (3-35.9 nmol), respectively.

CONCLUSIONS

Intrathecal zaprinast and morphine are effective against acute pain and facilitated pain state. Zaprinast interacts synergistically with morphine.

Antinociception of intrathecal cholinesterase inhibitors and cholinergic receptors in rats

BACKGROUND

Intrathecal cholinesterase inhibitors have been shown to have an antinociceptive effect which is mediated through the spinal cholinergic receptors, mainly muscarinic receptor. Spinal nicotinic receptor also has been involved in the control of nociception. Authors characterized the respective role of muscarinic or nicotinic receptor for the antinociception of cholinesterase inhibitors and further determined the antinociceptive potency of them.

METHODS

Rats were prepared with intrathecal catheters. Formalin-induced flinching response was regarded as a nociceptive behavior.

RESULTS

Intrathecal neostigmine, physostigmine and edrophonium produced a dose-dependent suppression of flinching in both phases. Atropine and the M1 selective antagonist attenuated the effect of them, while the M2 selective antagonist did not affect. M3, M4 selective, and nicotinic receptor antagonists reversed the antinociception induced by edrophonium, but by neither neostigmine nor physostigmine. The ordering of potency was neostigmine > physostigmine > > edrophonium.

CONCLUSION

These data indicate that the nicotinic receptor may be involved, at least in part, in the antinociceptive action of cholinesterase inhibitor at the spinal level, and M1 receptor subtype may be a common pharmacologic site of action. Moreover, neostigmine is more potent than physostigmine and edrophonium.