Takotsubo syndrome and vaccines: a systematic review

AIMS

Takotsubo syndrome (TTS) is a rare complication of vaccination. In this study, we sought to provide insight into the characteristics of reported TTS induced by vaccination.

METHODS AND RESULTS

We did a systematic review, searching PubMed, Embase, Web of Science, Ovid MEDLINE, Journals@Ovid, and Scopus databases up to 26 April 2023 to identify case reports or case series of vaccine-induced TTS. We then extracted and summarized the data from these reports. Eighteen reports were identified, with a total of 19 patients with TTS associated with vaccinations. Of the 19 included patients, the majority were female (n = 13, 68.4%) with a mean age of 56.6 ± 21.9 years. Seventeen patients developed TTS after coronavirus disease 2019 vaccination, 14 of whom received an mRNA vaccination. Two cases of TTS occurred after influenza vaccination. Among the 19 patients, 17 (89.5%) completed transthoracic echocardiography and 16 (84.2%) underwent angiography procedures. Seven patients (36.8%) completed cardiac magnetic resonance imaging. The median time to symptom onset was 2 (inter-quartile range, 1-4) days. The most common symptoms were chest pain (68.4%), dyspnoea (57.9%), and digestive symptoms (31.6%). A total of 57.9% of patients developed nonspecific symptoms such as fatigue, myalgia, diaphoresis, and fever. Among the 16 reported cases of TTS, 15 patients (93.8%) exhibited elevated cardiac troponin levels, while among the nine reported cases, eight patients (88.9%) had elevated natriuretic peptide levels. All patients had electrocardiographic changes: ST-segment change (47.1%), T-wave inversion (58.8%), and prolonged corrected QT interval (35.3%). The most common TTS type was apical ballooning (88.2%). Treatment during hospitalization typically included beta-blockers (44.4%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (33.3%), and diuretics (22.2%). After treatment, 81.3% of patients were discharged with improved symptoms. Among this group, nine patients (56.3%) were reported to have recovered ventricular wall motion during follow-up. Two patients (12.5%) died following vaccination without resuscitation attempts.

CONCLUSIONS

TTS is a rare but potentially life-threatening complication of vaccination. Typical TTS symptoms such as chest pain and dyspnoea should be considered alarming symptoms, though nonspecific symptoms are common. The risks of such rare adverse events should be balanced against the risks of infection.

Technology engagement is associated with higher perceived physical well-being in stroke patients prescribed smartwatches for atrial fibrillation detection

Background

Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection.

Method

We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline.

Results

Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health (β = 5.07, P < 0.05), no differences in anxiety (β = 0.92, P = 0.33), mental health (β = -2.42, P = 0.16), or patient activation (β = 1.86, P = 0.54).

Conclusions

Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

Self-reported efficacy in patient-physician interaction in relation to anxiety, patient activation, and health-related quality of life among stroke survivors

BACKGROUND

Early detection of AF is critical for stroke prevention. Several commercially available smartwatches are FDA cleared for AF detection. However, little is known about how patient-physician relationships affect patients' anxiety, activation, and health-related quality of life when prescribed smartwatch for AF detection.

METHODS

Data were used from the Pulsewatch study (NCT03761394), which randomized adults (>50 years) with no contraindication to anticoagulation and a CHA2DS2-VASc risk score ≥2 to receive a smartwatch-smartphone app dyad for AF monitoring vs. conventional monitoring with an ECG patch (Cardea SoloTM) and monitored participants for up to 45 days. The Perceived Efficacy in Patient-Physician Interactions survey was used to assess patient confidence in physician interaction at baseline with scores ≥45 indicating high perceived efficacy in patient-provider interactions. Generalized Anxiety Disorder-7 Scale, Consumer Health Activation Index, and Short-Form Health Survey were utilized to examine anxiety, patient activation, and physical and mental health status, at baseline, 14, and 44 days, respectively. We used mixed-effects repeated measures linear regression models to assess changes in psychosocial outcomes among smartwatch users in relation to self-reported efficacy in physician interaction over the study period.

RESULTS

A total of 93 participants (average age 64.1 ± 8.9 years; 43.0% female; 88.2% non-Hispanic white) were included in this analysis. At baseline, fifty-six (60%) participants reported high perceived efficacy in patient-physician interaction. In the fully adjusted models, high perceived efficacy (vs. low) at baseline was associated with greater patient activation and perceived mental health (β 12.0, p-value <0.001; β 3.39, p-value <0.05, respectively). High perceived self-efficacy was not associated with anxiety or physical health status (β - 0.61, p-value 0.46; β 0.64, p-value 0.77) among study participants.

CONCLUSIONS

Higher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches. Furthermore, we found no association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction. Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes.KEY MESSAGESHigher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches.No association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction.Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes.

Proton and molecular permeation through the basal plane of monolayer graphene oxide

Two-dimensional (2D) materials offer a prospect of membranes that combine negligible gas permeability with high proton conductivity and could outperform the existing proton exchange membranes used in various applications including fuel cells. Graphene oxide (GO), a well-known 2D material, facilitates rapid proton transport along its basal plane but proton conductivity across it remains unknown. It is also often presumed that individual GO monolayers contain a large density of nanoscale pinholes that lead to considerable gas leakage across the GO basal plane. Here we show that relatively large, micrometer-scale areas of monolayer GO are impermeable to gases, including helium, while exhibiting proton conductivity through the basal plane which is nearly two orders of magnitude higher than that of graphene. These findings provide insights into the key properties of GO and demonstrate that chemical functionalization of 2D crystals can be utilized to enhance their proton transparency without compromising gas impermeability.

Using artificial intelligence to learn optimal regimen plan for Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is a progressive neurological disorder with no specific curative medications. Sophisticated clinical skills are crucial to optimize treatment regimens given the multiple coexisting comorbidities in the patient population.

OBJECTIVE

Here, we propose a study to leverage reinforcement learning (RL) to learn the clinicians' decisions for AD patients based on the longitude data from electronic health records.

METHODS

In this study, we selected 1736 patients from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. We focused on the two most frequent concomitant diseases-depression, and hypertension, thus creating 5 data cohorts (ie, Whole Data, AD, AD-Hypertension, AD-Depression, and AD-Depression-Hypertension). We modeled the treatment learning into an RL problem by defining states, actions, and rewards. We built a regression model and decision tree to generate multiple states, used six combinations of medications (ie, cholinesterase inhibitors, memantine, memantine-cholinesterase inhibitors, hypertension drugs, supplements, or no drugs) as actions, and Mini-Mental State Exam (MMSE) scores as rewards.

RESULTS

Given the proper dataset, the RL model can generate an optimal policy (regimen plan) that outperforms the clinician's treatment regimen. Optimal policies (ie, policy iteration and Q-learning) had lower rewards than the clinician's policy (mean -3.03 and -2.93 vs. -2.93, respectively) for smaller datasets but had higher rewards for larger datasets (mean -4.68 and -2.82 vs. -4.57, respectively).

CONCLUSIONS

Our results highlight the potential of using RL to generate the optimal treatment based on the patients' longitude records. Our work can lead the path towards developing RL-based decision support systems that could help manage AD with comorbidities.

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: A meta-analysis

INTRODUCTION

Left bundle branch area pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure with reduced ejection fraction (HFrEF). We conduted this meta-analysis and systemic review to review current data comparing BVP and LBBP in patients with HFrEF and indications for CRT.

METHODS

We searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications for CRT were included. Two reviewers performed study selection, data abstraction, and risk of bias assessment. We calculated risk ratios (RRs) with the Mantel-Haenszel method and mean difference (MD) with inverse variance using random effect models. We assessed heterogeneity using the I2 index, with I2  > 50% indicating significant heterogeneity.

RESULTS

Ten studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time (MD: 9.68, 95% confidence interval [CI]: 4.49-14.87, I2  = 95%, p < .01, minutes) as well as a shorter procedural time (MD 33.68, 95% CI: 17.80-49.55, I2  = 73%, p < .01, minutes) during the implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRS duration (MD 25.13, 95% CI: 20.06-30.20, I2  = 51%, p < .01, milliseconds), a greater left ventricular ejection fraction improvement (MD: 5.80, 95% CI: 4.81-6.78, I2  = 0%, p < .01, percentage), and a greater left ventricular end-diastolic diameter reduction (MD: 2.11, 95% CI: 0.12-4.10, I2  = 18%, p = .04, millimeter). There was a greater improvement in New York Heart Association function class with LBBP (MD: 0.37, 95% CI: 0.05-0.68, I2  = 61%, p = .02). LBBP was also associated with a lower risk of a composite of heart failure hospitalizations (HFH) and all-cause mortality (RR: 0.48, 95% CI: 0.25-0.90, I2  = 0%, p = .02) driven by reduced HFH (RR: 0.39, 95% CI: 0.19-0.82, I2  = 0%, p = .01). However, all-cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR: 0.98, 95% CI: 0.21-4.68, I2  = 0%, p = .87).

CONCLUSION

This meta-analysis of primarily nonrandomized studies suggests that LBBP is associated with a greater improvement in left ventricular systolic function and a lower rate of HFH compared to BVP. There was uniformity of these findings in all of the included studies. However, it would be premature to conclude based solely on the current meta-analysis alone, given the limitations stated. Dedicated, well-designed, randomized controlled trials and observational studies are needed to elucidate better the comparative long-term efficacy and safety of LBBP CRT versus BIV CRT.

[Exploration of functional reconstruction and rehabilitation strategies for patients with destructive electric burns]

Electric burn is a kind of three-dimensional destructive damage. It is necessary to attach great importance to the functional reconstruction and rehabilitation of patients with destructive electric burns. Wound repair and limb salvage are not the end of the treatment of destructive electric burns, but functional rehabilitation and reintegration into society of patients are the goals of treatment. This paper systematically discusses the early wound repair, late functional reconstruction and rehabilitation, limb salvage and amputation, minimized damage of donor area, psychological rehabilitation, and multi-disciplinary cooperation of destructive electric burns. Only by attaching great importance to the functional reconstruction and rehabilitation, and embedding these concepts in people's brains, perfect repair and rehabilitation of destructive electric burns can be realized.

Artificial Intelligence-based Efficacy Prediction of Phase 3 Clinical Trial for Repurposing Heart Failure Therapies

Introduction

Drug repurposing involves finding new therapeutic uses for already approved drugs, which can save costs as their pharmacokinetics and pharmacodynamics are already known. Predicting efficacy based on clinical endpoints is valuable for designing phase 3 trials and making Go/No-Go decisions, given the potential for confounding effects in phase 2.

Objectives

This study aims to predict the efficacy of the repurposed Heart Failure (HF) drugs for the Phase 3 Clinical Trial.

Methods

Our study presents a comprehensive framework for predicting drug efficacy in phase 3 trials, which combines drug-target prediction using biomedical knowledgebases with statistical analysis of real-world data. We developed a novel drug-target prediction model that uses low-dimensional representations of drug chemical structures and gene sequences, and biomedical knowledgebase. Furthermore, we conducted statistical analyses of electronic health records to assess the effectiveness of repurposed drugs in relation to clinical measurements (e.g., NT-proBNP).

Results

We identified 24 repurposed drugs (9 with a positive effect and 15 with a non-positive) for heart failure from 266 phase 3 clinical trials. We used 25 genes related to heart failure for drug-target prediction, as well as electronic health records (EHR) from the Mayo Clinic for screening, which contained over 58,000 heart failure patients treated with various drugs and categorized by heart failure subtypes. Our proposed drug-target predictive model performed exceptionally well in all seven tests in the BETA benchmark compared to the six cutting-edge baseline methods (i.e., best performed in 266 out of 404 tasks). For the overall prediction of the 24 drugs, our model achieved an AUCROC of 82.59% and PRAUC (average precision) of 73.39%.

Conclusion

The study demonstrated exceptional results in predicting the efficacy of repurposed drugs for phase 3 clinical trials, highlighting the potential of this method to facilitate computational drug repurposing.

ScRNA-Seq Reveals a Distinct Osteogenic Progenitor of Alveolar Bone

The metabolism and remodeling of alveolar bone are the most active among the whole skeletal system, which is related to the biological characteristics and heterogeneity of the bone mesenchymal stromal cells (MSCs). However, there is a lack of systematic description of the heterogeneity of MSC-derived osteoblastic lineage cells as well as their distinct osteogenic differentiation trajectory of alveolar bone. In this study, we constructed a single-cell atlas of the mouse alveolar bone cells through single-cell RNA sequencing (scRNA-seq). Remarkably, by comparing the cell compositions between the alveolar bone and long bone, we uncovered a previously undescribed cell population that exhibits a high expression of protocadherin Fat4 (Fat4⁺ cells) and is specifically enriched around alveolar bone marrow cavities. ScRNA-seq analysis indicated that Fat4⁺ cells may initiate a distinct osteogenic differentiation trajectory in the alveolar bone. By isolating and cultivating Fat4⁺ cells in vitro, we demonstrated that they possess colony-forming, osteogenic, and adipogenic capabilities. Moreover, FAT4 knockdown could significantly inhibit the osteogenic differentiation of alveolar bone MSCs. Furthermore, we revealed that the Fat4⁺ cells exhibit a core transcriptional signature consisting of several key transcription factors, such as SOX6, which are involved in osteogenesis, and further demonstrated that SOX6 is required for the efficient osteogenic differentiation of the Fat4⁺ cells. Collectively, our high-resolution single-cell atlas of the alveolar bone reveals a distinct osteogenic progenitor that may contribute to the unique physiological characteristics of alveolar bone.

Osteoblastic RAR Inhibition Causes VAD-Like Craniofacial Skeletal Deformity

Retinoid signaling disorders cause craniofacial deformity, among which infants with maternal vitamin A deficiency (VAD) exhibited malformation of the eye, nose, palate, and parietal and jaw bone. Previous research uncovered the pathogenesis of eye defect and cleft palate of VAD in mice, but the studies on craniofacial skeletal deformity met obstacles, and the cell/lineage and underlying mechanism remain unclear. The retinoic acid receptor (RAR) is the key transcription factor in retinoid signaling, but individual knockout cannot simulate pathway inhibition. Here, we conditionally expressed dominant-negative RARα mutation (dnRARα) in osteoblasts to specifically inhibit the transcription activity of RAR in mice, which mimics the craniofacial deformities caused by VAD in clinical cases: hypomineralization of cranial bones, mandibular deformity, and clavicular hypoplasia. Furthermore, we performed 3-dimensional reconstruction based on micro-computed tomography and confirmed the abnormalities in the shape, size, and ossification of craniofacial bones due to osteoblastic RAR inhibition. Histological analysis indicated that inhibition of RAR in osteoblasts impaired both bone formation and bone resorption, which was confirmed by transcriptome sequencing of the calvaria. Furthermore, mechanism investigation showed that inhibition of RAR in osteoblasts directly decreased osteoblast differentiation in a cell-autonomous manner by impairing osteogenic gene transcription and also inhibited osteoclast differentiation via osteoblast-osteoclast crosstalk by impairing Rankl transcription. In summary, osteoblastic RAR activity is critical to craniofacial skeletal development, and its dysfunction leads to skeletal deformities mimicking VAD craniofacial defects, providing a new insight for VAD pathogenesis.

False Atrial Fibrillation Alerts from Smartwatches are Associated with Decreased Perceived Physical Well-being and Confidence in Chronic Symptoms Management

Wrist-based wearables have been FDA approved for AF detection. However, the health behavior impact of false AF alerts from wearables on older patients at high risk for AF are not known. In this work, we analyzed data from the Pulsewatch (NCT03761394) study, which randomized patients (≥50 years) with history of stroke or transient ischemic attack to wear a patch monitor and a smartwatch linked to a smartphone running the Pulsewatch application vs to only the cardiac patch monitor over 14 days. At baseline and 14 days, participants completed validated instruments to assess for anxiety, patient activation, perceived mental and physical health, chronic symptom management self-efficacy, and medicine adherence. We employed linear regression to examine associations between false AF alerts with change in patient-reported outcomes. Receipt of false AF alerts was related to a dose-dependent decline in self-perceived physical health and levels of disease self-management. We developed a novel convolutional denoising autoencoder (CDA) to remove motion and noise artifacts in photoplethysmography (PPG) segments to optimize AF detection, which substantially reduced the number of false alerts. A promising approach to avoid negative impact of false alerts is to employ artificial intelligence driven algorithms to improve accuracy.

Association of atrial fibrillation burden with in-hospital outcomes in patients with Takotsubo cardiomyopathy

BACKGROUND

The effects of atrial fibrillation (AF) and its burden on in-hospital mortality in patients with Takotsubo cardiomyopathy (TCM) are unclear. Here, we examined the effect of AF and paroxysmal AF on in-hospital outcomes in patients with TCM.

METHODS

We used ICD-10 codes to retrospectively identify patients with a primary diagnosis of TCM in the National Inpatient Sample database 2016-2018. We compared in-hospital outcomes in TCM patients with and without AF before and after propensity score matching. The effect of AF burden on outcomes was assessed in patients with paroxysmal AF and no AF.

RESULTS

Of the 4,733 patients with a primary diagnosis of TCM, 650 (13.7%) had AF, and 4,083 (86.3%) did not. Of TCM patients with AF, 368 (56.6%) had paroxysmal AF. In-hospital mortality was higher in patients with AF before (3.4% vs 1.2%, P <  0.001) and after propensity matching (3.4% vs 1.7%, P = 0.021) but did not differ between the paroxysmal AF and the no AF groups (P = 0.205). In the matched cohorts, both AF and paroxysmal AF groups were associated with a higher rate of cardiogenic shock (AF, P < 0.001; paroxysmal AF, P < 0.001), ventricular arrhythmia (AF, P = 0.002; paroxysmal AF, P = 0.02), acute kidney injury (AF, P = 0.007; paroxysmal AF, P = 0.008), and acute respiratory failure (AF, P < 0.001; paroxysmal AF, P < 0.001) compared with the no AF group.

CONCLUSIONS

Although AF was associated with increased in-hospital mortality, paroxysmal AF did not affect in-hospital mortality, suggesting a higher AF burden is associated with worse clinical outcome in patients with TCM.

Accounting for the High Enrollment of African Americans on Winship Cancer Institute's Myeloma Clinical Trials

Background

Thirty-four percent of Multiple Myeloma (MM) clinical trial participants at Winship Cancer Institute (Winship) are African American (AA); however, AAs make up only 4.5 percent of myeloma clinical trial participants in the United States. Given our high enrollment, we aimed to measure AAs' trust in providers and identify if clinical trial enrollment barriers exist.

Methodology

A member of the ethics research team surveyed AA patients who had consented to a MM clinical trial at Winship. Three validated surveys were used: Trust in Medical Research (TMR); Human Connection (THC) which measures how much patients feel they are heard and valued by their physicians; and the Duke Intrinsic Religiosity Scale (DUREL) which measures strength of religious engagement and belief. The survey also included questions about the impact of side effects, distance to the trial center and trial related costs on the decision to participate in clinical trial.

Results

Ninety-two percent (61/67) of patients approached consented. The mean TMR score and the mean THC score were significantly higher (P-value < 0.001) than the results obtained in key national surveys (TMR 14.9 compared to 11.65; THC 57.7 compared to 54.6). These two surveys were significantly correlated, meaning trust and human connection increase or decrease in tandem. The 3 religiosity subscale results showed high religiosity (3.84, 4.36, and 4.35 with 5 being the highest score). The mean scores of the importance of the investigational agent's side effects, trial costs, and distance to trial center on the decision to enroll in a clinical trial were also high (8.5, 7.8, and 6.5, respectively, with 10 being the most important).

Conclusion

In our study population, high trust and human connection overcame other trial participation barriers: strong religious beliefs and concerns about side effects, costs, and travel distance. We present a roadmap to guide investigators to increase human connection, and hopefully trust.

Salvage endoscopic surgery for skull base osteoradionecrosis in nasopharyngeal carcinoma patients: A prospective, observational, single-arm clinical study

BACKGROUND

Postradiation skull base osteoradionecrosis (ORN) is a severe complication that occurs after radiotherapy in patients with nasopharyngeal carcinoma (NPC) that can severely affect quality of life (QOL) and be life threatening. Only 13.4% - 28.6% of patients can be cured by traditional repeated endoscopic debridement. Here, we introduced salvage endoscopic surgery for skull base ORN patients and evaluated its clinical efficacy.

METHODS

This was a prospective, observational, single-arm clinical study. Clinical data from 18 skull base ORN patients who underwent radical endoscopic necrectomy followed by reconstruction using a septal pedicled mucosal flap or temporal muscle flap were included in the study. The endpoint was an overall survival (OS) of 2 years. The numeric rating scale (NRS) scores for pain and foul odor were analyzed to determine the efficacy and safety of this surgery.

RESULTS

A total of 21 patients were recruited, 18 of whom completed the study and were analyzed. All surgeries were successfully performed. During the 2-year study, the OS rate of the entire cohort was 75%. The median NRS score for pain decreased from 6.44 +- 2.62 to 0.50 +- 0.71, and the NRS score for foul odor decreased from 1.89±1.08 to 1 after surgery.

CONCLUSIONS

Salvage endoscopic necrectomy followed by construction using a septal pedicled mucosal flap or temporal muscle flap is a novel, safe, and effective treatment for ORN in patients with NPC.

CLINICAL TRIAL REGISTRATION

This study was approved by the independent ethics committee of the Eye, Ear, Nose and Throat Hospital of Fudan University (IEC No. 2019095-1). Written informed consent was obtained from all patients. The study was registered with the Chinese Clinical Trial registry (ChiCTR2000029327).

Predicting Physiological Response in Heart Failure Management: A Graph Representation Learning Approach using Electronic Health Records

Heart failure management is challenging due to the complex and heterogenous nature of its pathophysiology which makes the conventional treatments based on the "one size fits all" ideology not suitable. Coupling the longitudinal medical data with novel deep learning and network-based analytics will enable identifying the distinct patient phenotypic characteristics to help individualize the treatment regimen through the accurate prediction of the physiological response. In this study, we develop a graph representation learning framework that integrates the heterogeneous clinical events in the electronic health records (EHR) as graph format data, in which the patient-specific patterns and features are naturally infused for personalized predictions of lab test response. The framework includes a novel Graph Transformer Network that is equipped with a self-attention mechanism to model the underlying spatial interdependencies among the clinical events characterizing the cardiac physiological interactions in the heart failure treatment and a graph neural network (GNN) layer to incorporate the explicit temporality of each clinical event, that would help summarize the therapeutic effects induced on the physiological variables, and subsequently on the patient's health status as the heart failure condition progresses over time. We introduce a global attention mask that is computed based on event co-occurrences and is aggregated across all patient records to enhance the guidance of neighbor selection in graph representation learning. We test the feasibility of our model through detailed quantitative and qualitative evaluations on observational EHR data.

Using Artificial Intelligence to Learn Optimal Regimen Plan for Alzheimer's Disease

Background

Alzheimer's Disease (AD) is a progressive neurological disorder with no specific curative medications. While only a few medications are approved by FDA (i.e., donepezil, galantamine, rivastigmine, and memantine) to relieve symptoms (e.g., cognitive decline), sophisticated clinical skills are crucial to optimize the appropriate regimens given the multiple coexisting comorbidities in this patient population.

Objective

Here, we propose a study to leverage reinforcement learning (RL) to learn the clinicians' decisions for AD patients based on the longitude records from Electronic Health Records (EHR).

Methods

In this study, we withdraw 1,736 patients fulfilling our criteria, from the Alzheimer's Disease Neuroimaging Initiative(ADNI) database. We focused on the two most frequent concomitant diseases, depression, and hypertension, thus resulting in five main cohorts, 1) whole data, 2) AD-only, 3) AD-hypertension, 4) AD-depression, and 5) AD-hypertension-depression. We modeled the treatment learning into an RL problem by defining the three factors (i.e., states, action, and reward) in RL in multiple strategies, where a regression model and a decision tree are developed to generate states, six main medications extracted (i.e., no drugs, cholinesterase inhibitors, memantine, hypertension drugs, a combination of cholinesterase inhibitors and memantine, and supplements or other drugs) are for action, and Mini-Mental State Exam (MMSE) scores are for reward.

Results

Given the proper dataset, the RL model can generate an optimal policy (regimen plan) that outperforms the clinician's treatment regimen. With the smallest data samples, the optimal-policy (i.e., policy iteration and Q-learning) gained a lesser reward than the clinician's policy (mean -2.68 and -2.76 vs . -2.66, respectively), but it gained more reward once the data size increased (mean -3.56 and -2.48 vs . -3.57, respectively).

Conclusions

Our results highlight the potential of using RL to generate the optimal treatment based on the patients' longitude records. Our work can lead the path toward the development of RL-based decision support systems which could facilitate the daily practice to manage Alzheimer's disease with comorbidities.

Association of Circulating Caprylic Acid with Risk of Mild Cognitive Impairment and Alzheimer's Disease in the Alzheimer's Disease Neuroimaging Initiative (ADNI) Cohort

OBJECTIVE

Medium-chain fatty acids (MCFAs) can rapidly cross the blood-brain barrier and provide an alternative energy source for the brain. This study aims to determine 1) whether plasma caprylic acid (C8:0) is associated with risk of incident mild cognitive impairment (MCI) among baseline cognitively normal (CN) participants, and incident Alzheimer's Disease (AD) among baseline MCI participants; and 2) whether these associations differ by sex, comorbidity of cardiometabolic diseases, apolipoprotein E (APOE) ε4 alleles, and ADAS-Cog 13.

METHODS

Within the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort, plasma C8:0 was measured at baseline in 618 AD-free participants aged 55 to 91. Logistic regression models were used to estimate odds ratios (ORs) and 95% CIs with incident MCI and AD as dependent variables, separately.

RESULTS

The inverse association between circulating C8:0 and risk of incident MCI was of borderline significance. The inverse association between circulating levels of C8:0 and risk of incident MCI was significant among CN participants with ≥1 cardiometabolic diseases [OR (95% CI): 0.75 (0.58-0.98) (P=0.03)], those with one copy of APOE ε4 alleles [OR (95% CI): 0.43 (0.21-0.89) (P=0.02)], female [OR (95% CI): 0.60 (0.38-0.94) (P=0.02)], and ADAS-Cog 13 above the median [OR (95%CI): 0.69 (0.50-0.97)(P=0.03)] after adjusting for all covariates.

CONCLUSION

The inverse associations were present only among subgroups of CN participants, including female individuals, those with one or more cardiometabolic diseases, or one APOE ε4 allele, or higher ADAS-Cog 13 scores. If confirmed, this finding will facilitate precision prevention of MCI, in turn, AD among CN older adults.

Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation

Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.

Machine learning predicting mortality in sarcoidosis patients admitted for acute heart failure

Background

Sarcoidosis with cardiac involvement, although rare, has a worse prognosis than sarcoidosis involving other organ systems.

Objective

We used a large dataset to train machine learning models to predict in-hospital mortality among sarcoidosis patients admitted with heart failure (HF).

Method

Utilizing the National Inpatient Sample, we identified 4659 patients hospitalized with a primary diagnosis of HF. In this cohort, we identified patients with a secondary diagnosis of sarcoidosis using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes. Patients were separated into a training group and a testing group in a 7:3 ratio. Least absolute shrinkage and selection operator regression was used to select variables to prevent model overfitting or underfitting. For machine learning models, logistic regression, random forest, and XGBoosting were applied in the training group. Parameters in each of the models were tuned using the GridSearchCV function. After training, all models were further validated in the testing group. Models were then evaluated using the area under curve (AUC) score, sensitivity, and specificity.

Results

A total of 2.3% of sarcoidosis patients died in HF admission. Our machine learning model analysis found the RF model to have the highest AUC score and sensitivity. Feature analysis found that comorbid arrhythmias and fluid electrolyte disorders were the strongest factors in predicting in-hospital mortality.

Conclusion

Machine learning methods can be useful in identifying predictors of in-hospital mortality in a given dataset.

Mortality in Stable Coronary Disease in Patients With Intermediate- or High-Risk Myocardial Perfusion Imaging

The management of patients with stable coronary disease and intermediate- or high-risk features on single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) continues to be controversial as to whether they should be treated with an initial invasive strategy (catheterization and revascularization when feasible) or medical therapy alone to improve mortality. We performed a retrospective observational study of 1,946 patients with intermediate- or high-risk SPECT MPI scans performed over a 6-year period (from 2014 to 2019). Each patient was followed from the time of SPECT MPI to 16 months after the last patient was enrolled. The primary end point was all-cause mortality and the secondary end point cardiovascular mortality. Of the eligible 1,697 patients, 1,144 had an intermediate-risk scan, 553 a high-risk scan, 915 had medical therapy alone, and 782 went on an initial invasive strategy. All patients were divided into the following three groups: combined SPECT MPI (both intermediate- and high-risk), high-risk SPECT MPI, and intermediate-risk SPECT MPI groups. After propensity score matching, there was a statistically significant difference in cardiovascular death (5.9% vs 2.7%; p = 0.038) in the medical therapy cohort compared with initial invasive cohort in the combined SPECT MPI group, but no difference in all-cause death (15.7% vs 13%; p = 0.318). On subgroup analysis, in intermediate-risk SPECT MPI group, there was no significant difference in either all-cause death (13.8 vs 11.7%; p = 0.583) or cardiac death (5.4% vs 2.5%; p = 0.16) in conservative cohort compared with invasive strategy cohort. In high-risk SPECT MPI group, conservative therapy cohort had higher cardiac death (11.7% vs 2.5%; p = 0.002) compared with initial invasive strategy cohort, but there was no significant difference in all-cause death (24.5% vs 15.3%; p = 0.052). In conclusion, this study supports that patients with intermediate- or high-risk SPECT MPI scans when considered together or only with high-risk features, derive a cardiovascular mortality benefit with an initial invasive strategy. Patients who had undergone intermediate-risk SPECT MPI had similar outcomes with either medical therapy alone or initial invasive evaluation.

Takotsubo syndrome and respiratory diseases: a systematic review

Takotsubo syndrome (TTS) is a rare cardiovascular condition characterized by reversible ventricular dysfunction and a presentation resembling that of acute myocardial infarction. An increasing number of studies has shown the association of respiratory diseases with TTS. Here, we comprehensively reviewed the literature and examined the available evidence for this association. After searching PubMed, EMBASE, and Cochrane Library databases, two investigators independently reviewed 3117 studies published through May 2021. Of these studies, 99 met the inclusion criteria (n = 108 patients). In patients with coexisting respiratory disease and TTS, the most common TTS symptom was dyspnoea (70.48%), followed by chest pain (24.76%) and syncope (2.86%). The most common type of TTS was apical, accounting for 81.13% of cases, followed by the midventricular (8.49%), basal (8.49%), and biventricular (1.89%) types. Among the TTS cases, 39.82% were associated with obstructive lung disease and 38.89% were associated with pneumonia. Coronavirus disease 2019 (COVID-19), which has been increasingly reported in patients with TTS, was identified in 29 of 42 (69.05%) patients with pneumonia. The overall mortality rate for patients admitted for respiratory disease complicated by TTS was 12.50%. Obstructive lung disease and pneumonia are the most frequently identified respiratory triggers of TTS. Medications and invasive procedures utilized in managing respiratory diseases may also contribute to the development of TTS. Furthermore, the diagnosis of TTS triggered by these conditions can be challenging due to its atypical presentation. Future prospective studies are needed to establish appropriate guidelines for managing respiratory disease with concurrent TTS.

Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk

Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) after cryptogenic stroke; however, the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials comparing ILR with usual care after any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1,233 participants). Cryptogenic stroke and underlying AF included cryptogenic stroke only, stroke of known cause and underlying-AF included small or large vessel stroke only, and post embolic rhythm detection with implantable vs external monitoring included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared with usual care (OR 5.8, 95% confidence interval 3.2 to 10.2). Stroke or transient ischemic attack occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% confidence interval 0.5 to 1.2). In patients with detected AF, 97% and 100% were started on OAC in cryptogenic stroke and underlying AF and post embolic rhythm detection with implantable vs external monitoring, respectively, compared with 68% in stroke of known cause and underlying-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the nondifferential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.

Clinical phenotypes of cardiac sarcoidosis by latent class analysis

Background

Sarcoidosis is a systemic granulomatous disease with cardiac involvement reported in 20–27% of patients [1]. Cardiac sarcoidosis (CS) can lead to atrial or ventricular arrhythmias, various conduction system disorders, heart failure or sudden cardiac death, depending on the location of myocardial involvement [2]. Previous studies have investigated the possible types of CS based on the distribution of myocardial involvement on imaging as well as the role of genetic factors [3,4]. However, there are no studies describing the clinical heterogeneity of CS patients.

Purpose

In order to determine if clinical clusters exist in CS, we carried out a latent class analysis (LCA) to explore potential phenotypes in a large sample of CS patients from the National Inpatient Sample (NIS).

Methods

We identified 848 patients with a diagnosis of CS from the NIS in 2016–2018. A LCA was performed based on comorbidities. Utilizing the Bayesian information criterion and Akaike's information criterion we divided our study population into 3 cohorts. We subsequently applied the LCA model for our study population to fit each patient into one of the 3 cohorts. Finally, we compared the clinical outcomes among the 3 groups.

Results

Following LCA, patients in cohort 3 were strongly associated with a cardiometabolic syndrome profile with the highest prevalence of congestive heart failure (CHF, 95.1%), chronic kidney disease (CKD, 69.7%), diabetes mellitus (68.9%), hyperlipidemia (52.5%) and obesity (45.1%). Patients in cohort 2 had an intermediate prevalence of cardiometabolic syndrome with a universal diagnosis of hypertension (100%) but with the lowest number of CHF (32.5%) patients and none with CKD. Finally, patients in cohort 1 had the least comorbidities in comparison to the other groups but there was a higher prevalence of CHF (71.7%). There was no significant difference in mortality among the 3 groups, but acute respiratory failure was the highest in cohort 3. However, ventricular arrhythmias were more prevalent in cohort 1 patients (Table).

Conclusion

We identified 3 different types of CS based on their clinical phenotype. The clinical outcomes varied among the cohorts with ventricular arrhythmias being the most prevalent in patients with the least cardiometabolic comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Smoking and incidence of insomnia: a systematic review and meta-analysis of cohort studies

OBJECTIVE

This study investigated the impact of smoking on the incidence of insomnia.

STUDY DESIGN

Systematic review and meta-analysis of cohort studies.

METHODS

PubMed, EMBASE, Web of Science, Cochrane Library, and OVID were searched through March 2020. Cohort studies reporting the effect of smoking on the incidence of insomnia were included. We quantitatively analyzed the basic framework and study characteristics and then pooled estimate effects with 95% confidence intervals (CIs) of outcomes of each included study using fixed-effects meta-analyses.

RESULTS

This systematic review included six cohort studies involving 12,445 participants. Quantitatively summarized results suggested that smoking could significantly increase the incidence of insomnia (odds ratio [OR]: 1.07, 95% CI: 1.02, 1.13). Regular smoking was significantly associated with the incidence of insomnia (OR = 1.07, 95% CI: 1.01, 1.13). As for occasional smokers and ex-smokers, the pooled analysis did not indicate a significant association (occasional smoker: OR = 2.09, 95% CI: 0.44, 9.95; ex-smoker; OR = 1.02, 95% CI: 0.67, 1.54). Subgroup analysis by age, gender ratio, and region showed a statistically significant relationship between smoking and the incidence of insomnia in specific groups.

CONCLUSIONS

Integrated longitudinal observational evidence identified smoking as a significant risk factor of insomnia. Considering the limited amount of available studies, more high-quality and prospective cohort studies of large sample sizes are needed to explore details of this association.

The association between the vaginal microenvironment and fecundability: a register-based cohort study among Chinese women

OBJECTIVE

To evaluate the association between the vaginal microenvironment and fecundability among women.

DESIGN

Register-based nationwide cohort study.

SETTING

Chinese National Free Pre-conception Check-up Project from 2015 to 2018.

POPULATION

Our study included a total of 3 388 554 eligible women who were attempting to become pregnant.

METHOD

We assessed the vaginal microenvironment at baseline by considering four indices: vaginal pH, clue cell examination, whiff test and vaginal cleanliness grading. If any of these indicators was abnormal, the vaginal microenvironment was defined as poor. Propensity score matching was used to control for potential confounders and reduce bias. Logistic models were used to estimate the fecundability odds ratios (FORs) after adjustment for covariates.

MAIN OUTCOME MEASURES

Achievement of a pregnancy within 1 year.

RESULTS

Of the total study population, 379 718 women (11.2%) had a poor vaginal microenvironment and their pregnancy rate after 1 year was significantly lower than the group with a normal microenvironment (71.8% versus 76.1%, P < 0.001). After adjusting for potential confounders, the women with a poor vaginal microenvironment were associated with a 9% reduction in fecundability compared with the normal microenvironment group (FOR 0.91, 95% CI 0.90-0.92). The adverse effects of a poor vaginal microenvironment were stronger among multipara (FOR 0.89, 95% CI 0.87-0.90) or women with irregular menstruation (FOR 0.86, 95% CI 0.84-0.89).

CONCLUSION

There was a negative association between a poor vaginal microenvironment and the fecundability of women. These findings highlight the significance of assessing the vaginal microenvironment during pre-pregnancy health examinations.

TWEETABLE ABSTRACT

Women with a poor vaginal microenvironment were associated with a reduction in fecundability.

FOXO3 Mediates Tooth Movement by Regulating Force-Induced Osteogenesis

The high prevalence of malocclusion and dentofacial malformations means that the demand for orthodontic treatments has been increasing rapidly. As the biological basis of orthodontic treatment, the mechanism of mechanical force-induced alveolar bone remodeling during orthodontic tooth movement (OTM) has become the key scientific issue of orthodontics. It has been demonstrated that bone mesenchymal stem cells (BMSCs) are crucial for bone remodeling and exhibit mechanical sensing properties. Mechanical force can promote osteoblastic differentiation of BMSCs and osteogenesis, but the key factor that mediates mechanical force-induced osteogenesis during OTM remains unclear. In this study, by performing reverse-phase protein arrays on BMSCs exposed to mechanical force, we found that the expression level of forkhead box O3 (FOXO3) was significantly upregulated during the mechanical force-induced osteoblastic differentiation of BMSCs. The number of FOXO3-positive cells was consistently higher on the OTM side as compared with the control side and accompanied by the enhancement of osteogenesis. Remarkably, inhibiting FOXO3 with repaglinide delayed OTM by severely impairing mechanical force-induced bone formation in vivo. Moreover, knockdown of FOXO3 effectively inhibited the mechanical force-induced osteoblastic differentiation of BMSCs, whereas the overexpression of FOXO3 enhanced this effect. Mechanistically, we revealed a novel regulatory model in which FOXO3 promoted osteocalcin transcription by activating its promoter in cooperation with runt-related transcription factor 2 (RUNX2). We collectively obtained the first evidence that FOXO3 is critical for OTM, where it responds to mechanical force and directly regulates downstream osteoblastic differentiation in an efficient manner.

MiR-802 inhibits the malignant biological behavior of oral squamous cell carcinoma by targeting proto-oncogene MET

OBJECTIVE

Oral squamous cell carcinoma (OSCC) is one of the frequently occurring malignancies, but effective treatments are lacking. It is believed that exploring new molecular targets could help us to improve the treatment of OSCC. Therefore, we hope to find a new miRNA target to control OSCC.

PATIENTS AND METHODS

qPCR and Western blots were used to test the expressions of miR-802 and target gene in OSCC tissues and cell lines. Luciferase reporter assay was performed to check whether miR-802 could directly target MET. CCK-8, wound healing, cell invasion, colony formation, and tumor growth assays were used to determine the functions of miR-802 and MET in the malignant biological behavior of OSCC.

RESULTS

The results suggested that miR-802 was low expressed in OSCC tissues and cell lines. Overexpression of miR-802 inhibited the cell viability, colony formation, migration and invasion of Tca8113 and SCC9 cells, and tumor growth in vivo. It was predicted that miR-802 might target the mRNA of proto-oncogene MET. Overexpressing miR-802 suppressed the expression of wild-type MET at both protein and mRNA levels in Tca8113 and SCC9 cells. Moreover, the expression of MET was high and significantly correlated with the low expression of miR-802 in OSCC tissues. Overexpression of MET in Tca8113 and SCC9 cells reduced the tumor-suppressive effects, which was induced by miR-802 overexpression.

CONCLUSIONS

MiR-802 suppresses the malignant biological behavior of OSCC by targeting proto-oncogene MET. This work provides a new potential molecular target for treating OSCC.

The Association Between Hyperlipidemia and In-Hospital Outcomes in Takotsubo Cardiomyopathy

PURPOSE

Hyperlipidemia (HLD) is one of the most common cardiovascular risk factors and is prevalent in patients with takotsubo cardiomyopathy (TCM), but the association between HLD and TCM patients' outcomes is unclear. We investigated the impact of HLD on the in-hospital outcomes of TCM patients.

PATIENTS AND METHODS

Our retrospective cohort study used the latest available data from the National Inpatient Sample (2016-2017). Using the ICD-10 code, we identified 3139 patients with a primary diagnosis of TCM, 1530 of whom had HLD. We compared in-hospital outcomes between HLD and non-HLD groups before and after propensity score matching.

RESULTS

In the unmatched cohort, the HLD group had lower incidences of cardiac arrest, cardiogenic shock, and acute respiratory failure (ARF); shorter length of stay (LOS); and lower total charges (All p<0.05). In-hospital mortality (p=0.102) and ventricular arrhythmia (p=0.235) rates did not differ. After propensity score matching, the HLD group had lower rates of in-hospital mortality (1.1% vs 2.4%, p=0.027), ARF (9.1% vs 12.1%, p = 0.022) and cardiogenic shock (3.4% vs 5.6%, p=0.012), shorter LOS (3.20 ± 3.27 days vs 3.57 ± 3.14 days, p=0.005), and lower total charges (p=0.013). The matched groups did not differ significantly regarding cardiac arrest (p=0.141), ventricular arrhythmia (p=0.662) or acute kidney injury (AKI) (p = 0.167).

CONCLUSION

Counterintuitively, HLD was associated with better in-hospital outcomes in both the unmatched and propensity-matched cohorts of hospitalized TCM patients. Further studies are needed to investigate the mechanisms that may contribute to the association in TCM patients with HLD.

Identifying different phenotypes in takotsubo cardiomyopathy by latent class analysis

Aims

This study sought to determine whether clinical clusters exist in takotsubo cardiomyopathy. Takotsubo cardiomyopathy (TCM) is a heterogeneous disorder with a complex, poorly understood pathogenesis. To better understand the heterogeneity of TCM, we identified different clinical phenotypes in a large sample of TCM patients by using latent class analysis (LCA).

Methods and results

Using the National Inpatient Sample (NIS) database, we identified 3139 patients admitted to hospitals in 2016–2017 with a primary diagnosis of TCM. We performed LCA based on several patient demographics and comorbidities: age, sex, hypertension, hyperlipidaemia, diabetes mellitus, obesity, current smoking, asthma, chronic obstructive pulmonary disease (COPD), and anxiety and depressive disorders. We then repeated LCA separately with the NIS 2016 and 2017 data sets and performed a robust test to validate our results. We also compared in‐hospital outcomes among the different clusters identified by LCA. Four patient clusters were identified. C1 (n = 1228, 39.4%) had the highest prevalence of hyperlipidaemia (93.4%), hypertension (61.6%), and diabetes (34.3%). In C2 (n = 440, 14.0%), all patients had COPD, and many were smokers (45.8%). C3 (n = 376, 11.8%) largely comprised patients with anxiety disorders (98.4%) and depressive disorders (80.1%). C4 (n = 1097, 34.8%) comprised patients with isolated TCM and few comorbidities. Among all clusters, C1 had the lowest in‐hospital mortality (1.0%) and the shortest length of stay (3.2 ± 3.1 days), whereas C2 had the highest in‐hospital mortality (3.4%).

Conclusions

Using LCA, we identified four clinical phenotypes of TCM. These may reflect different pathophysiological processes in TCM. Our findings may help identify treatment targets and select patients for future clinical trials.

The Impact of COPD on in-Hospital Outcomes in Patients with Takotsubo Cardiomyopathy

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a known comorbidity of takotsubo cardiomyopathy (TCM), and COPD exacerbation is a potential triggering factor of TCM. The association between COPD and in-hospital outcomes and complications among TCM patients is not well established. We sought to assess the effect of COPD on hospitalized patients with a primary diagnosis of TCM.

METHODS

We conducted a retrospective cohort study in patients with a primary diagnosis of TCM with or without COPD using the latest National Inpatient Sample from 2016-2017. We identified 3139 patients admitted with a primary diagnosis of TCM by the ICD-10-CM coding system; 684 of those patients also had a diagnosis of COPD. We performed propensity score matching in a 1:2 ratio (n=678 patients, matched COPD group; n=1070, matched non-COPD group) and compared in-hospital outcomes and complications between TCM patients with and without a COPD diagnosis.

RESULTS

Before matching, the COPD group had worse outcomes compared with the non-COPD group in inpatient death (2.9% vs 1.3%, p=0.006), length of stay (LOS) (4.02±2.99 days vs 3.27±3.39 days, p<0.001), hospitalization charges ($55,242.68±47,637.40 vs $48,316.97±47,939.84, p=0.001), and acute respiratory failure (ARF) (22.5% vs 7.7%, p<0.001), respectively. After propensity score matching, the matched COPD group, compared with the matched non-COPD group, had a higher inpatient mortality rate (2.9% vs1.0%, p=0.005), longer LOS (4.02±3.00 days vs 3.40±3.54 days, p<0.001), higher hospitalization charges ($55,409.23±47,809.13 vs $46,469.60±42,209.10, p<0.001), and a higher incidence of ARF (22.6% vs 8.2%, p<0.001) and cardiogenic shock (5.6% vs 3.3%, p=0.024), respectively.

CONCLUSION

Patients with COPD who are hospitalized for TCM have higher rates of inpatient mortality, ARF, cardiogenic shock, as well as a longer LOS, and higher charges of stay than those without COPD. Prospective studies are warranted to examine the effect of early intervention or treatment of COPD on short- and long-term outcomes of TCM.

Impact of Bariatric Surgery on Inpatient Complication, Cost, and Length of Stay Following Total Hip or Knee Arthroplasty

BACKGROUND

Morbid obesity is an important risk factor for arthroplasty and also closely associated with worse postoperative outcomes. Bariatric surgery is effective in losing weight and decreasing comorbidities associated with obesity. However, no study had demonstrated the influence of bariatric surgery on the outcome of arthroplasty in a large population.

METHODS

We used 2006-2014 discharge records from the Nationwide Inpatient Sample, and identified study population and inpatient complications by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis/procedure codes. Propensity score analysis was used to match total hip arthroplasty (THA) or total knee arthroplasty (TKA) patients with morbid obesity and THA or TKA patients with bariatric surgery.

RESULTS

Proportion of morbid obesity in both TKA and THA patients demonstrated a rising trend, while proportion of bariatric surgery in morbidly obese TKA and THA patients remains steady after 2007. For THA patients, there was fewer pulmonary embolism, more blood transfusion and anemia, and shorter length of stay in bariatric surgery group. For TKA patients, bariatric surgery group had a lower risk of pulmonary embolism, respiratory complications, death, and shorter length of stay, but bariatric surgery group had a higher risk of blood transfusion and anemia.

CONCLUSION

There is evidence that bariatric surgery prior to arthroplasty, especially THA, appears to reduce rates of pulmonary complications and length of stay. But anemia and blood transfusion seem to be more common in patients with prior bariatric surgery.

Predictive Value of CHA2DS2-VASc Score for Ischemic Events in Patients Undergoing Percutaneous Coronary Intervention

We evaluated the association of preprocedure CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex) score with ischemic events in patients undergoing percutaneous coronary intervention (PCI). The Dryad Digital Repository enrolled 2533 patients between July 2009 and August 2011. We recorded 1-year ischemic events. Univariate and multivariable logistic regression analyses were used to analyze the association between CHA₂DS₂-VASc score and ischemic events. Receiver operating characteristic curves were used to evaluate the accuracy of CHA₂DS₂-VASc score in predicting long-term ischemic events. Long-term death (9.5 vs 2.8%), cardiac death (2.9 vs 1.4%), and nonfatal stroke (1.9 vs 0.7%) were significantly higher in the CHA₂DS₂-VASc score ≥2 group than the CHA₂DS₂-VASc score ≤1 group. The CHA₂DS₂-VASc score was a predictor for all-cause death (odds ratio [95% confidence interval]: 3.71 [1.89-7.30]). The risk factors for all-cause death in CHA₂DS₂-VASc score ≥2 patients included age, diagnosis, heart failure, older myocardial infarction, diabetes, and chronic obstructive pulmonary disease, while the risk factor for CHA₂DS₂-VASc score ≤1 patients was age. In conclusion, the CHA₂DS₂-VASc score is associated with long-term all-cause death, cardiac death, and stroke in patients undergoing PCI, and it may have a potential use for risk stratification for patients who undergo PCI.

Serum-Derived Extracellular Vesicles Protect Against Acute Myocardial Infarction by Regulating miR-21/PDCD4 Signaling Pathway

Acute myocardial infarction (AMI) represents a leading cause of morbidity and mortality worldwide. Extracellular vesicles (EVs) are being recognized as a promising therapeutic approach in protecting against MI. Serum is a rich source of EVs, which transports various microRNAs (miRNAs, miRs). EVs from serum have been shown beneficial for protecting against ischemia-reperfusion injury; however, their roles in AMI are unclear. In addition, whether a miRNA might be responsible for the effects of serum EVs on protecting against AMI is undetermined. Here, we demonstrated that serum EVs significantly reduced cardiomyocytes apoptosis in both cellular and mouse models of AMI, and dramatically attenuated the infarct size in mouse hearts after AMI. Inhibition of miR-21 was shown to reduce the protective effects of serum EVs in inhibiting cardiomyocytes apoptosis. miR-21 was decreased in mouse hearts after AMI, while serum EVs increased that. In addition, the programmed cell death 4 (PDCD4) expression was identified as a target gene of miR-21. Therefore, our study showed the protective effects of serum EVs on AMI, and provided a novel strategy for AMI therapy.

Puerarin Stimulates Osteogenic Differentiation and Bone Formation Through the ERK1/2 and p38-MAPK Signaling Pathways

BACKGROUND

Osteoporosis is a world-wide health problem, which leads to decreased bone strength and increased susceptibility to fractures. Puerarin, a phytoestrogen extracted from Pueraria lobata (Willd.) Ohwi, has been identified as a promising intervention for preventing bone loss and promoting bone regeneration. However, the underlying mechanisms for its anabolic action are still not clear. In the present study, we aimed to investigate the effect of puerarin on the osteogenic differentiation of bone marrow stromal cells (BMSCs) and the possible molecular mechanism mediating its action.

METHODS

Bone marrow stromal cells (BMSCs) and intragastric administration on ovariectomized(OVX) rats were used to study the anti-osteoporotic function of puerarin. The involvement of mitogen-activated protein kinase (MAPK) signaling pathways was determined.

RESULTS

Our results demonstrated that at optimal concentration, puerarin could promote osteogenic differentiation of BMSCs in vitro. This induction was mediated by MAPK signaling pathway. Further detailed study revealed that ERK1/2-Runx2 signaling pathway had more prominent effect than p38 signaling pathway in puerarin-induced differentiation of BMSCs toward the osteogenic phenotype. We also found that puerarin protected against reduction in bone mineral density and improved femur trabecular bone structure in ovariectomized rats.

CONCLUSION

Our findings revealed the functional mechanism of puerarin in promoting osteogenic differentiation which involved ERK1/2 and p38-MAPK pathway and provided experimental evidence for the potential application of puerarin for estrogen replacement therapy of osteoporosis.

Decreased Expression of MYPT1 Contributes to Tumor Angiogenesis and Poor Patient Prognosis in Human Prostate Cancer

BACKGROUND

Our previous study demonstrated that Myosin Phosphatase Targeting subunit 1 (MYPT1) may function as a direct target of microRNA-30d, which promotes tumor angiogenesis and tumor growth of prostate cancer (PCa). Here, we aimed to investigate the clinical significance of MYPT1 expression and its functions in PCa.

METHODS

Roles of MYPT1 deregulation in tumor angiogenesis of PCa was determined in vitro and in vivo experiments. Expression patterns of MYPT1 and CD31 proteins were examined by immunohistochemistry and immunofluorescence, respectively. Associations of MYPT1/CD31 combination with various clinicopathological features and patients' prognosis of PCa were also statistically evaluated.

RESULTS

Through gain- and loss-of-function experiments, MYPT1 inhibited capillary tube formation of endothelial cells and in vivo tumor angiogenesis in a mouse model with the downregulation of VEGF and CD31 expression. In addition, MYPT1 expression was significantly decreased, while CD31 expression was dramatically increased in PCa tissues compared to benign prostate tissues. Notably, MYPT1 expression levels in PCa tissues were negatively correlated with that of CD31. Statistically, MYPT1-low/CD31- high expression was distinctly associated with high Gleason score, positive biochemical recurrence, and reduced overall survival of PCa patients. Moreover, PCa patients with MYPT1-low/CD31-high expression more frequently had shorter overall, biochemical recurrence-free and metastasis-free survivals. MYPT1/CD31 combination was identified as an independent factor to predict biochemical recurrence-free and metastasis-free survivals of PCa patients.

CONCLUSIONS

Our findings indicate that MYPT1 may inhibit angiogenesis and contribute favorable prognosis in PCa patients, implying that MYPT1 might be a potential drug candidate in anticancer therapy.

Rewarding Network Mechanism of Left Orbito-frontal Cortex Transcranial Magnetic Stimulation in Depression

Objective

The difficulties in the clinical antidepressant treatment lead to the pursuing of more effective methods such as transcranial magnetic stimulation (TMS). Mixed findings from DLPFC targeted TMS result in the exploration of optimal stimulation location. Disturbed function of obitofrontal cortex (OFC) has been indicated in depression, which is involving in the remission of depression. However, whether it could be a more specific treating target is not tested. Simultaneously, disturbed reward network (RN) has been confirmed in depression, however, whether this could be improved by TMS treatment remains unclear.

Methods

Fourteen patients with major depressive disorder (MDD) were allocated in a four-week course of OFC targeted TMS. Motivated by the literature, before and after the treatment, the function connectivity of RN with the seed of ventral striatum was conducted. The results were also compared with the data from 33 healthy controls.

Results

The OFC targeted TMS improved the clinical depression significantly and enhanced the function connectivity within the RN effectively. Specifically, lower baseline dorsolateral striatum connectivity predicted strong therapeutic effect of TMS on depression, while lower baseline insula connectivity predicted weak therapeutic effect on depression.

Conclusions

The findings offer the first experimental evidence of the therapeutic effect of OFC targeted TMS on clinical depression, enhanced function connectivity within RN might be the potential neural mechanism (Fig. 1). Lower dorsolateral striatum connection might be a reliable neural biomarker of strong responding for TMS treatment, which helps to identify the patients who will be cured by TMS most effectively.