Ultrasound-guided genitofemoral nerve block for femoral arterial access gain and closure: a randomized controlled trial

OBJECTIVES

This study aimed to compare the analgesic efficacy and safety of the femoral branch block of the genitofemoral nerve (FBB) versus local infiltration anesthesia (LIA) for femoral arterial access gain and closure.

METHODS

Eighty-two patients (age, 64.8 ± 10.9 years; female, 30.5%) undergoing endovascular procedures using 5-Fr femoral sheath were assigned to either FBB (n = 41) or LIA (n = 41). In both groups, 2% lidocaine HCL with 1:100,000 epinephrine was used as an anesthetic solution. Pain scores during access gain and closure were evaluated using a visual analog scale (score 0-10), patient satisfaction levels with the quality of anesthesia were scored on a 7-point Likert scale, and adverse events were recorded.

RESULTS

The primary endpoint, pain scores during access closure, was significantly lower in the FBB group than in the LIA group (0.1 ± 0.37 vs 1.73 ± 0.92; p < 0.001). The FBB group also had significantly lower pain scores during access gain compared to the LIA group (0.83 ± 0.83 vs 2.78 ± 1.26; p < 0.001). There was an inverse relationship between pain scores and FBB after adjustment for age, gender, and body mass index (p < 0.001). FBB group reported significantly higher satisfaction with anesthesia quality compared to the LIA group (6.49 ± 0.64 vs 4.05 ± 1.05; p < 0.001). No complications were recognized in either group.

CONCLUSIONS

Ultrasound-guided genitofemoral nerve blocks offered better acute pain relief and higher patient satisfaction than LIA during femoral arterial access gain and closure.

CLINICAL RELEVANCE STATEMENT

In this prospective randomized controlled trial, ultrasound-guided genitofemoral nerve blocks offered better acute pain relief than local infiltration anesthesia, resulting in enhanced patient satisfaction.

KEY POINTS

• FBB provided better pain relief during access gain and closure than LIA. • FBB offered higher patient satisfaction with the quality of anesthesia than LIA. • No anesthesia-related or access site complications were recognized in either treatment group.

Development and validation of an updated PICC length prediction formula based on anteroposterior chest radiographs for the ultrasound-guided bedside placement

Bedside peripherally inserted central catheter (PICC) placement is sometimes required when the patient's intrahospital transport is restricted, and the ideal catheter length prediction is needed. This study aimed to develop an updated formula that predicts the optimal length of a PICC based on anteroposterior chest radiographs (AP-CXRs). This retrospective study collected PICC procedure data as the training and validation sets in three hospitals, including cubital crease-puncture point distance (CP), the actual PICC length (aCL), and the approach side. Horizontal and vertical measurement variables were set on the AP-CXRs. Two dependent variables were ipsilateral upper arm length (AL) and ideal truncal catheter length (iTCL). Simple and multiple regression analyses were used for formula development, and it was applied to the test set to evaluate the length prediction performance. The study included 309 patients in the training and validation sets and 91 intensive care patients in the test set. The final derived formula was: (AL + iTCL = CP + estimated PICC length, cm) = 19.831 - 0.062 × (contralateral clavicle length, cm) + 0.255 × (2nd ribs horizontal distance, cm) + 0.720 × (humero-vertebral distance, cm) + 0.761 × (thoraco-carinal distance, cm) + 1.024 × (the vertical distance of two vertebral body units, cm). (If approaching from the left, add 2.843cm, and if female, subtract 0.821cm.) In the test set, there was no case of length prediction failure. Moreover, the catheter tip position was evaluated as optimal in 82 cases (90.1%). This study's results suggest an updated formula to predict the ideal PICC length using only AP-CXRs for bedside placement.

Brachial plexus block using only 1% lidocaine to reduce pain during the endovascular treatment of dysfunctional arteriovenous access

BACKGROUND

Interventional endovascular treatments of dysfunctional arteriovenous (AV) access for hemodialysis can cause pain and discomfort to the patients. Ultrasound-guided brachial plexus block (BPB) is an alternative regional anesthesia method, but conventional BPB using ropivacaine or bupivacaine may cause long-lasting motor power loss, significantly reducing patient satisfaction. This study aimed to introduce BPB using only 1% lidocaine, which induces sensory loss while minimizing motor block, and evaluate the efficacy and safety of this procedure.

METHODS

This retrospective study was conducted on 277 consecutive patients with dysfunctional AV access requiring percutaneous transluminal angioplasty (PTA). Of these, 174 patients underwent the BPB procedure using 1% lidocaine. Time data were recorded, and the motor strength grade (MRC scale, grade 0-5) was evaluated. Numeric rating pain score (NRPS, grade 0-10) was asked during every PTA, and overall NRPS and satisfaction scores (scale 1-3) were asked after the procedure was completed.

RESULTS

Of the 174 patients who received BPB, the success rate was 100%, and there were no significant complications related to BPB. The MRC scale measured at the time when the complete sensory loss was achieved was 1.99 ± 0.63, and that at the point of sensory recovery when the block effect expired was 3.93 ± 0.62, indicating a good grade of motor strength. The average NRPS during PTA in the BPB group was significantly lower than that of the control group without BPB (1.04 ± 2.04vs 6.30 ± 2.71, p < 0.001). The overall satisfaction score was significantly higher in the BPB group than in the control group (2.79 ± 0.50vs 2.00 ± 0.81, p < 0.001).

CONCLUSIONS

BPB using only 1% lidocaine can induce a sensory block while minimizing the effect on motor function. It can be applied safely in an outpatient clinic setting with relatively higher satisfaction.

Single-Session Percutaneous Mechanical Thrombectomy for Acute and Subacute Deep Vein Thrombosis: Clinical Outcomes and Predictive Factors of Recurrence

Objectives

To evaluate the efficacy and safety of single-session percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis (DVT), to compare clinical outcomes and recurrences between acute and subacute DVT, and to identify factors predicting recurrence.

Materials and Methods

From January 2018 to March 2021, 100 consecutive patients (age: 64.64 ± 17.28 years; male, 42%) with symptomatic DVT who underwent single-session PMT were enrolled for this study. These patients were divided into an acute DVT group (< 14 days, n = 75) and a subacute DVT group (15-28 days, n = 25).

Results

A large-bore aspiration thrombectomy was used in 80 (80%) cases, Angiojet (Boston Scientific, Marlborough, MA, USA) device in one (1%) case, and a combination of both techniques in 19 (19%) cases. The anatomic success rate was 97% and the clinical success rate was 95%. There were no major complications. Clinical outcomes were not different between the two groups. The recurrence-free survival rate in the acute DVT group was significantly (p = 0.015) better than that in the subacute DVT group. The anatomic success (HR, 52.3; 95% CI, 3.82-715.21; p = 0.003) and symptom duration (HR, 17.58; 95% CI, 1.89-163.34; p = 0.012) were predictive factors associated with recurrence.

Conclusions

Single-session PMT is safe and effective for immediate symptom relief in acute and subacute DVT patients. However, recurrence occurred more frequently in patients with subacute DVT than in those with acute DVT. Anatomic success of the procedure and duration of symptoms were independent predictors of DVT recurrence.

Double-Pigtail Drainage Catheter: A New Design for Efficient Pleural Drainage

Background and Objectives: The novel double-pigtail catheter (DPC) has an additional pigtail coiling at the mid-shaft with multiple centripetal side holes. The present study aimed to investigate the advantages and efficacy of DPC in overcoming the complications of conventional single-pigtail catheters (SPC) used to drain pleural effusion. Materials and Methods: Between July 2018 and December 2019, 382 pleural effusion drainage procedures were reviewed retrospectively (DPC, n = 156; SPC without multiple side holes, n = 110; SPC with multiple side holes (SPC + M), n = 116). All patients showed shifting pleural effusions in the decubitus view of the chest radiography. All catheters were 10.2 Fr in diameter. One interventional radiologist performed all procedures and used the same anchoring technique. Complications (dysfunctional retraction, complete dislodgement, blockage, and atraumatic pneumothorax) were compared among the catheters using chi-square and Fisher's exact tests. Clinical success was defined as an improvement in pleural effusion within three days without additional procedures. Survival analysis was performed to calculate the indwelling time. Results: The dysfunctional retraction rate of DPC was significantly lower than that of the other catheters (p < 0.001). Complete dislodgement did not occur in any of the DPC cases. The clinical success rate of DPC (90.1%) was the highest. The estimated indwelling times were nine (95% confidence interval (CI): 7.3-10.7), eight (95% CI: 6.6-9.4), and seven (95% CI: 6.3-7.7) days for SPC, SPC + M, and DPC, respectively, with DPC showing a significant difference (p < 0.05). Conclusions: DPC had a lower dysfunctional retraction rate compared to conventional drainage catheters. Furthermore, DPC was efficient for pleural effusion drainage with a shorter indwelling time.

Efficacy and Technical Feasibility of Plug-Assisted Retrograde Transvenous Obliteration of Gastric Varices via Pathways Other than the Gastrorenal Shunt

PURPOSE

To evaluate the efficacy and technical feasibility of plug-assisted retrograde transvenous obliteration of gastric varices via pathways different from the typical gastrorenal shunt.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 130 patients who underwent plug-assisted retrograde transvenous obliteration for gastric varices between 2013 and 2022. Eight patients underwent plug-assisted retrograde transvenous obliteration via different pathways. We evaluated the types of portosystemic shunts in these patients, the procedure technical and clinical success rates, and clinical outcomes.

RESULTS

In these eight patients (6 males, 2 females; mean age = 60 ± 6 years), the most common type of portosystemic shunt was a gastrocaval shunt (n = 7). Five patients had a gastrocaval shunt only; two had coexisting gastrocaval and gastrorenal shunts. One patient had a pericardiacophrenic shunt without a gastrorenal or gastrocaval shunt. The mean procedure time was 55 min. For patients with a gastrocaval shunt alone (n = 5), the mean procedure time was 40.8 min. The technical and clinical success rates were 100%. No major complication related to the procedure occurred. An initial follow-up computed tomography was performed within 2-3 weeks in all patients and revealed complete thrombosis of the gastric varices. Subsequent follow-up computed tomography (interval: 2-6 months) was performed in seven patients and showed complete disappearance of the gastric varices in all patients. During the follow-up period (range: 42 days-6.25 years), no patients experienced rebleeding or recurrence of gastric varices.

CONCLUSION

Plug-assisted retrograde transvenous obliteration via alternative portosystemic shunts is effective and technically feasible in the treatment of gastric varices.

SUPERA stent placement for salvaging early recurrent arteriovenous graft thrombosis after percutaneous transluminal angioplasty: A single-center study

BACKGROUND

The aim of this study was to evaluate the patency of the helical interwoven SUPERA stent for salvaging prosthetic arteriovenous (AV) grafts with rapidly recurrent thrombotic occlusion developed within a short time period after successful percutaneous transluminal angioplasty.

METHODS

From December 2019 to September 2021, the data of 20 patients with AV graft who had the SUPERA stent inserted satisfying the following conditions were consecutively collected. (1) More than 1 year has passed since the AV access operation; (2) Thrombotic re-occlusion of AV graft occurred within 3 months after previous successful endovascular treatment; (3) Residual stenosis is greater than 30% after full effacement of balloon angioplasty in the primary lesion. Post-interventional target lesion primary patency (TLPP), access circuit primary patency (ACPP), and secondary patency (SP) were calculated.

RESULTS

Primary lesions of early recurrent arteriovenous graft thrombosis were found in 13 patients with graft-vein anastomosis, six patients with intra-graft stenosis, and one patient with outflow vein complications. The lesions showed residual stenosis in 47.4% (interquartile range: 44.1%-55.3%) of patients despite full-effacement balloon angioplasty. Clinical success was achieved in all patients with full-expansion of the stents at the 1-month follow-up. The TLPP was 70.7% and 32% at 6 and 12 months, respectively, and ACPP was 47.5% and 6.8% at 6 and 12 months, respectively. The SP was 76.1% and 57.1% at 6 and 12 months, respectively. No cannulation complications occurred in the six patients with installation inside the graft. No hemodialysis or stent fracture occurred in any patient during the follow-up period.

CONCLUSIONS

The SUPERA stent may have a role in salvaging AV grafts with early recurrent thrombosis due to its greater radial force and its conformability and can be useful in treating stenosis involving the elbow or axilla, with fair patency and low complication rates.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Isolated Gastric Varix Bleeding Caused by Splenic Vein Obstruction: Two Case Reports

Isolated left-sided portal hypertension is a rare clinical syndrome caused by splenic veno-occlusive disease. Splenic vein thrombosis and extrinsic compression causes proximal splenic vein hypertension, and the splenic blood flows into the superior mesenteric or portal vein through the upper stomach's collateral vessels, such as the short gastric, coronary, and gastroepiploic veins. Open splenectomy is recommended to treat gastrointestinal bleeding caused by isolated left-sided portal hypertension. Interventional management could be a clinically useful option for selected patients who want to avoid surgical corrections. The report presents two cases of left-sided portal hypertension with gastric variceal bleeding.

Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal bleeding in absence of gastrorenal or gastrocaval shunt: A case report

RATINALE

Plug-assisted retrograde tansvenous obliteration (PARTO) is commonly used to treat gastric variceal bleeding. PARTO is typically performed via the gastrorenal shunt or gastrocaval shunt and there have been no reports of PARTO performed through the pericardial vein in cases of gastric varices in which there is no gastrorenal or gastrocaval shunt. Herein, we report a case of PARTO was performed to treat gastric variceal bleeding in a patient with a gastric varix without a gastrorenal or gastrocaval shunt.

PATIENT CONCERNS

A 54-year-old man with alcoholic liver cirrhosis presented to the emergency room with hematemesis and melena. At presentation, the patient's blood pressure was 130/70 mm Hg and hemoglobin level was 10.1 g/dL.

DIAGNOSES

Computed tomography (CT) scan and endoscopic examination revealed a gastric varix at the gastric fundus.

INTERVENTIONS

PARTO was performed to treatment of gastric variceal bleeding via the pericardial vein.

OUTCOMES

The patient did not show any signs of variceal bleeding after the procedure, and follow-up CT at 3 weeks showed complete resolution of the gastric varix.

LESSONS

Although PARTO is technically difficult to perform through pathways other than the gastrorenal or gastrocaval shunt, it can be a beneficial alternative in cases in which other treatments fail or are not feasible.

Imaging-Guided Deployment of a Balloon-Based Vascular Closure Device in Routine Clinical Practice

This study evaluated the feasibility and safety of imaging-guided deployment of a Mynx Control device (Cordis, Miami Lakes, Florida) at the femoral access. A total of 201 Mynx devices were used under imaging guidance in 137 patients (mean age, 64.18 years ± 13.8; male, 68.6%) between June 2020 and February 2022. A 5-F sheath was used in 176 (87.6%) procedures, a 6-F sheath was used in 17 (8.5%) procedures, and a 7-F sheath was used in 8 (4%) procedures. Indicator errors occurred in 9 (4.5%) procedures. However, technical success was achieved via manipulation under imaging guidance in all procedures. The mean time to hemostasis was 3.3 minutes ± 0.5, and the clinical success rate was 100%. The mean length of hospital stay was 7 days ± 7.5. After 4 (2%) procedures, small hematomas reabsorbed spontaneously. Imaging-guided deployment of a Mynx Control device is a feasible and safe option for access site closure. Even after an indicator error, successful hemostasis was achieved via real-time interaction.

[Case Reports of Intravascular Treatment for Gastrointestinal Bleeding Associated with Pancreatitis: Hemosuccus Pancreaticus and Pancreaticocolic Fistula]

Elderly patients with a history of chronic alcoholism presented to our hospital with episodes of melena, abdominal pain, and anemia. During admission, hemorrhagic cystic lesion at the pancreas was observed on abdominal CT. Transcatheter angiography confirmed active bleeding foci and arterial embolization was performed. After the procedure, the bleeding was resolved. The authors report two cases of hemosuccus pancreaticus and pancreaticocolic fistula associated with pancreatitis, a rare cause of gastrointestinal bleeding, treated with vascular intervention.

Prediction of atrial fibrillation in patients with embolic stroke with undetermined source using electrocardiogram deep learning algorithm and clinical risk factors

Background

Combining the artificial intelligence algorithm with the known clinical risk factors may provide enhanced accuracy for prediction of the hidden atrial fibrillation (AF) in patients with embolic stroke with undetermined source (ESUS).

Purpose

We aimed to develop enhanced prediction models for AF with deep learning algorithm (DLA) and clinical predictors in patients with ESUS. The DLA was created to identify the patients with paroxysmal AF based on their electrocardiograms (ECG) during sinus rhythm.

Methods

We analyzed the 221 patients who underwent insertable cardiac monitor (ICM) for AF detection following ESUS. The DLA was previously developed with sinus rhythm ECGs of 10,605 paroxysmal AF patients and 50,522 non-AF patients. The convolutional neural network was used for the DLA. The primary endpoint was defined as any AF episode lasting over 5 min by ICM. The atrial ectopic burden (AEB) was calculated as the percentage of the number of conducted QRS by atrial ectopy on Holter monitoring.

Results

AF (≥5 min) was detected by ICM in 32 patients (14.5%) during follow-up period of 15.1±8.6 months. AF patients had higher AEB (0.199% vs 0.023%, p&lt;0.001), larger left atrial diameters (LAD, 41.2 mm vs 35.7 mm, p&lt;0.001), and larger left atrial volume index (LAVI, 46.4 ml/m2 vs 32.3 ml/m2, p&lt;0.001) than those without AF. The means of calculated probabilities of AF by DLA were higher in patients with AF than those without AF (63.8% vs 40.2%, p&lt;0.001). In the receiver operating characteristic curve analysis, the areas under the curve (AUC) were the highest in DLA (0.824) followed by AEB (0.784), LAVI (0.780), and LAD (0.768). The multivariable model with AEB, LAVI, and DLA demonstrated excellent prediction accuracy for paroxysmal AF (AUC: 0.902, Figure 1)

Conclusions

In patients with ESUS, the DLA outperformed other clinical risk factors for prediction of AF. Combining DLA with AEB, LAD and LAVI could is a potential useful tool to predict AF in ESUS patients.

Funding Acknowledgement

Type of funding sources: None.

Epipericardial Fat Necrosis in a Pediatric Patient Diagnosed Using Contrast-Enhanced MRI Findings: A Case Report and Literature Review

Epipericardial fat necrosis (EPFN) is a relatively rare cause of acute chest pain, with only five pediatric cases having been reported in the English-language medical literature to date. EPFN can be diagnosed based on the clinical symptoms of acute pleuritic chest pain and classic CT features of typically ovoid fatty lesions surrounded by a rim or capsule in the mediastinal or pericardial areas. Previous studies have reported that contrast-enhanced MRI can detect typical fat signal changes in adults with EPFN. We report a pediatric EPFN case diagnosed using gadolinium-enhanced MRI. Thus, contrast-enhanced MRI may be used to confirm EPFN in the differential diagnoses of the causes of acute chest pain.

Spacecraft sample collection and subsurface excavation of asteroid (101955) Bennu

Carbonaceous asteroids, such as (101955) Bennu, preserve material from the early Solar System, including volatile compounds and organic molecules. We report spacecraft imaging and spectral data collected during and after retrieval of a sample from Bennu’s surface. The sampling event mobilized rocks and dust into a debris plume, excavating a 9-m-long elliptical crater. This exposed material that is darker, spectrally redder, and more abundant in fine particulates than the original surface. The bulk density of the displaced subsurface material was 500–700 kg per cubic meter, about half that of the whole asteroid. Particulates that landed on instrument optics spectrally resemble aqueously altered carbonaceous meteorites. The spacecraft stored 250 ± 101 g of material, which will be delivered to Earth in 2023.

Pebbles and sand on asteroid (162173) Ryugu: In situ observation and particles returned to Earth

The Hayabusa2 spacecraft investigated the C-type (carbonaceous) asteroid (162173) Ryugu. The mission performed two landing operations to collect samples of surface and subsurface material, the latter exposed by an artificial impact. We present images of the second touchdown site, finding that ejecta from the impact crater was present at the sample location. Surface pebbles at both landing sites show morphological variations ranging from rugged to smooth, similar to Ryugu's boulders, and shapes from quasi-spherical to flattened. The samples were returned to Earth on 6 December 2020. We describe the morphology of >5 grams of returned pebbles and sand. Their diverse color, shape, and structure are consistent with the observed materials of Ryugu; we conclude that they are a representative sample of the asteroid.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients

BACKGROUND

There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay.

PURPOSE

To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding.

MATERIAL AND METHODS

The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32).

RESULTS

The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding.

CONCLUSION

In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Gastrointestinal bleeding after failed endoscopic hemostasis: diagnostic efficacy of angiography compared with computed tomography and treatment outcomes of transcatheter arterial embolization

PURPOSE

This study compared the detection sensitivity of catheter angiography to that of contrast-enhanced multi-detector computed tomography (MDCT) for detecting acute non-variceal gastrointestinal bleeding (GIB) to elucidate the diagnostic efficacy of catheter angiography. We also determined GIB outcomes of transcatheter arterial embolization after failed endoscopic hemostasis.

MATERIALS AND METHODS

Data were collected retrospectively from 63 patients managed at four institutions who met the following criteria during a 3-year period: (1) ongoing non-variceal GIB confirmed during endoscopy; (2) failed endoscopic hemostasis; and (3) endoscopy, MDCT, and catheter angiography performed within 24 h. The diagnostic efficacies of MDCT, selective angiography with a 5-Fr catheter (5Fr-angiography), and super-selective angiography with a microcatheter (micro-angiography) were compared using endoscopic diagnosis as the reference method. The rates of technical success, clinical success, and complications were analyzed when arterial embolization was performed.

RESULTS

All transcatheter angiographies were performed after MDCT. Micro-angiography had a significantly higher GIB detection rate (73.0%) than MDCT (57.1%) and 5Fr-angiography (39.7%) (micro-angiography vs. MDCT, P = 0.021; MDCT vs. 5Fr-angiography, P = 0.043). Arterial embolization was attempted in 55 of 63 patients, with technical success achieved in 53 of 55 patients (96.4%) and clinical success in 38 of 42 patients (90.5%). Eleven patients were lost to follow-up. Three patients experienced complications, including bowel infarction (two patients) and common bile duct stricture (one patient).

CONCLUSION

In cases of endoscopic hemostasis failure, angiography can be performed even if MDCT yields negative results but should include micro-angiography; moreover, embolization can be performed safely and effectively.

TRIAL REGISTRATION

None.

Uterine Artery Embolization as an Effective Management and Diagnostic Tool for Puerperal Uterine Inversion with Severe Postpartum Bleeding: A Case Report

Acute puerperal uterine inversion is a rare postpartum obstetric complication; however, without rapid diagnosis and appropriate management, it is life-threatening. Substantial bleeding hinders the verification of a partially inverted uterus, possibly delaying the treatment. Herein, we present the report of a 32-year-old female presenting with massive postpartum bleeding managed by uterine artery embolization. The peculiar course of the uterine artery bowing inferiorly along the inverted fundus during embolization could uncover the uterine inversion, which was not diagnosed by physical examination and CT. In conclusion, uterine artery embolization is not only an effective therapeutic strategy for postpartum hemorrhage but also a valuable tool for diagnosing uterine inversion.

Engineered ionizable lipid nanoparticles for targeted delivery of RNA therapeutics into different types of cells in the liver

Ionizable lipid nanoparticles (LNPs) have been widely used for in vivo delivery of RNA therapeutics into the liver. However, a main challenge remains to develop LNP formulations for selective delivery of RNA into certain types of liver cells, such as hepatocytes and liver sinusoidal endothelial cells (LSECs). Here, we report the engineered LNPs for the targeted delivery of RNA into hepatocytes and LSECs. The effects of particle size and polyethylene glycol-lipid content in the LNPs were evaluated for the hepatocyte-specific delivery of mRNA by ApoE-mediated cellular uptake through low-density lipoprotein receptors. Targeted delivery of RNA to LSECs was further investigated using active ligands. Incorporation of mannose allowed the selective delivery of RNA to LSECs, while minimizing the unwanted cellular uptake by hepatocytes. These results demonstrate that engineered LNPs have great potential for the cell type-specific delivery of RNA into the liver and other tissues.

Developing a predictive model for distinguishing invasive nail unit melanoma from nail unit melanoma in situ

BACKGROUND

Clinical information that distinguishes invasive nail unit melanoma from nail unit melanoma in situ before surgery would aid physicians in the decision-making process and estimating prognosis. However, limited information is available on the detailed demographic and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ for differential diagnosis.

OBJECTIVE

This study aimed to investigate the demographic data and dermoscopic features of invasive nail unit melanoma and nail unit melanoma in situ and establish a predictive model for differentiating these two forms of nail unit melanoma.

METHODS

A retrospective observational study of ninety-seven patients diagnosed with nail unit melanoma (59 in situ and 38 invasive cases) in four healthcare centres in South Korea (three tertiary referral hospitals and one second referral hospital) from March 2014 to December 2019.

RESULTS

A multivariable analysis revealed that ulcer (odds ratio = 21.6, confidence interval = 2.1-219.8, P = 0.009), total melanonychia (odds ratio = 17.6, confidence interval = 3.0-104.0, P = 0.002), nail plate destruction (odds ratio = 10.9, confidence interval = 2.0-59.4, P = 0.006) and polychromia (odds ratio = 5.3, confidence interval = 1.36-20.57, P = 0.016) were distinctive dermoscopic features of invasive nail unit melanoma. A predictive model with scores ranging from 0 to 6 points demonstrated a reliable diagnostic value (C-statistic = 0.902) in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

CONCLUSIONS

Invasive nail unit melanoma and nail unit melanoma in situ have different dermoscopic features. A predictive model based on morphologic dermoscopic features could aid in differentiating invasive nail unit melanoma from nail unit melanoma in situ.

OP0202 STRESS-ACTIVATED MIR-204 GOVERNS SENESCENT PHENOTYPES OF CHONDROCYTES TO PROMOTE OSTEOARTHRITIS DEVELOPMENT

Background:

A progressive loss of cartilage matrix leads to the development of osteoarthritis (OA). Matrix homeostasis is disturbed in OA cartilage as the result of reduced production of cartilage-specific matrix and increased secretion of catabolic mediators by chondrocytes. Chondrocyte senescence is a crucial cellular event contributing to such imbalance in matrix metabolism during OA development.

Objectives:

We sought to identify a previously unknown, senescence-associated signaling pathway in chondrocytes linked to major OA cartilage manifestations such as PG loss and cartilage degeneration.

Methods:

We particularly aimed to screen miRNAs whose inhibition could effectively modulate senescent phenotypes of chondrocytes to treat OA. We investigated the regulatory mechanisms of miR-204 under various stress-eliciting stimuli in primary cultured human and mouse chondrocytes. We examined the in vivo effects of miR-204 overexpression and its antagonism in surgically induced OA mouse models. DMM surgery was used to induce posttraumatic OA in 12-week-old mice. Small RNAs were delivered to mouse knee joints by intra-articular injection. Various OA manifestations including cartilage destruction, subchondral bone sclerosis, osteophyte maturity, and synovial inflammation in mice were histologically inspected.

Results:

We identify miR-204 as a senescence-associated microRNA (miRNA) which is markedly upregulated in OA cartilage. The upregulated miR-204 simultaneously targets multiple components of the sulfated proteoglycan (PG) biosynthesis pathway, effectively shutting down PG anabolism. Ectopic expression of the miR-204 in joints triggers spontaneous cartilage loss and OA development, whereas inhibition of miR-204 ameliorates experimental OA, with concomitant recovery of PG synthesis and suppression of inflammatory senescence-associated secretory phenotype (SASP) factors in cartilage

Conclusion:

we unravel a stress-activated senescence pathway that underlies disrupted matrix homeostasis in OA cartilage.

References:

[1]O. H. Jeon, C. Kim, R.-M. Laberge, M. Demaria, S. Rathod, A. P. Vasserot, J. W. Chung, D. H. Kim, Y. Poon, N. David, D. J. Baker, J. M. van Deursen, J. Campisi, J. H. Elisseeff, Local clearance of senescent cells attenuates the development of post-traumatic osteoarthritis and creates a pro-regenerative environment. Nat. Med. 23, 775–781 (2017)

Disclosure of Interests:

None declared

AB0080 A SYSTEM-LEVEL APPROACH IDENTIFIES A CRITICAL REGULATOR OF CHONDROSARCOMA PROGRESSION

Background:

Chondrosarcomas are cartilaginous tumors that constitute one-third of skeletal system cancers. Chondrosarcomas are capable of transitioning to highly metastatic and treatment-refractory states, resulting in significant patient mortality. However, the molecular events accompanying this behavior remain unknown.

Objectives:

We aimed to uncover the molecular pathway underlying such tumor progression that confers a higher malignancy to chondrosarcoma.

Methods:

We conducted unsupervised gene co-expression network analyses using transcriptomes of patients with chondrosarcoma and extracted a characteristic transcription network underlying chondrosarcoma malignancy. By implementing a system-level upstream analysis of this gene network, we identified the transcriptional factor as a key regulator governing chondrosarcoma progression. We unraveled the functional roles of the identified factor in promoting tumor growth and metastasis of chondrosarcomas in the context of their unique microenvironments.

Results:

By conducting system-level upstream analysis, we identified a factor as a transcriptional regulator that governs the malignancy gene module. The identified factor was upregulated in chondrosarcoma biopsies associated with a high histological grade and conferred chondrosarcoma cells invasiveness and tumor-initiating capacity. In an orthotopic xenograft mouse model, the identified factor modulated local outgrowth and pulmonary metastasis of chondrosarcoma. Pharmacological inhibition of the identified factor in conjunction with the chemotherapy agents such as cisplatin or doxorubicin synergistically enhanced chondrosarcoma cell apoptosis and abolished malignant phenotypes of chondrosarcoma in mice.

Conclusion:

Our study provides a proof of concept evidence that inhibiting the identified factor suppresses progression of chondrosarcoma and improves the efficacy of chemotherapy in cellular and pre-clinical levels. Taken together, we believe that our findings provide novel molecular insights for the development of new anti-cancer therapies to target chondrosarcomas.

References:

[1]Gelderblom H, et al. The clinical approach towards chondrosarcoma. Oncologist 13, 320-329 (2008)

Disclosure of Interests:

None declared

0622 In-Depth Surveillance of Central Sleep Apnea in Patients with Stable Heart Failure

Introduction

Central sleep apnea (CSA) is unique sleep breathing phenotype in patients with advanced chronic heart failure (HF) and portend poor prognosis. The prevalence of CSA in HF patients under contemporary therapy is uncertain.

Methods

We reviewed consecutive HF patients on optimal medical therapy who underwent clinically indicated diagnostic in-lab polysomnography at a single academic center. Age, sex and BMI matched patients without HF were selected from sleep clinic as a control. Patients with atrial fibrillation were excluded from this study. Apnea subtypes were determined after careful scoring and confirmation by sleep physicians. ‘Any CSA’ was defined by central apnea index (CAI) &gt;5 and &gt;1/hr. ‘True CSA’ was defined if met both CAI≥5/hr and &gt; obstructive apnea index (OAI). Obstructive sleep apnea (OSA) was defined if apnea hypopnea index &gt;15 and OAI&gt;CAI. Multivariate analysis was performed using logistic regression adjusting for age, sex, HF and systolic dysfunction as appropriate.

Results

In patients with HF (N=95, mean age 59, female: 50%), CSA was low and was comparable to control group (N=94) (HF vs. Non-HF; CSA: 5.3 vs. 4.3%, P=NS; Any CSA 14.7 vs. 17%, P=NS). Only 3 patients with HF had true CSA. In contrast, OSA was common in both groups regardless of obesity status (52.3 vs. 55.3%). In patients with HF, Cheyne Stokes respiration was more frequent in patients with Any CSA vs. without Any CSA (13.3 vs. 3.8%, p=0.04). In multivariate analysis, presence of OSA, but not HF, was associated with Any CSA in entire cohort (Any CSA OR: 3.1 [1.3, 8.1], p=0.02). In patients with HF, male sex was associated with Any CSA (OR: 5.3 [1.1, 40.8], p=0.05). Exclusion of patients with high BMI did not change the results.

Conclusion

CSA was rare in patients with stable HF on contemporary optimal medical therapy.

Support

None

1052 Continuous Blood Pressure Monitoring In Sleep

Introduction

Abnormal nocturnal blood pressure(BP) such as non-dipping or nocturnal hypertension(reverse-dipping) represents a potent marker for cardiovascular risks. Standard cuff-based ambulatory nocturnal BP measurement yields limited data points potentially resulting in imprecise results, especially compared to continuously recorded BP. We hypothesized nocturnal BP based on periodic measurement would be different from true average beat-to-beat based BP.

Methods

We prospectively enrolled patients undergoing clinically indicated in-lab polysomnography, both CPAP and non-CPAP studies, for sleep apnea evaluation. Nocturnal BP was continuously monitored beat-to-beat by a noninvasive Caretaker™ device, which uses the Pulse Decomposition Analysis(PDA) algorithm. We compared BP recorded at 30-minute intervals with average BP continuously recorded over 30 minutes, both recorded by Caretaker™. We also looked at the differences between recording spot and continuous BP from an awake or sleeping state and BP variability(SD) based on continuously recorded BP. Using first 30 min as a reference, we determined dipping status (dipping: 10-20% reduction, level: 0-10% reduction, riser: any increase) by the two methods.

Results

A total of 18 patients were recruited(male:11, mean age:52.2). Among a total of 261 periodic BP measurements, 60 (30.0%) were obtained while awake. Mean nocturnal SBP by periodic BP measurement was higher compared with beat-to-beat-derived average BP(135.6mmHg[24.2] vs. 131.5[20.3], p&lt;0.0001). The difference between the two methods remained similar when continuous BP was derived from sleep vs. awake period(4.5mmHg[3.1] vs. 7.7[9.9], p=0.202). BP variability was more pronounced during awake compared with sleep period(6.7mmHg[8.1] versus 3.95[7.5], p=0.047). 8 patients were dippers by spot check measurement, but 11 were dippers by continuous BP.

Conclusion

Standard ambulatory periodic nocturnal BP recording may not yield true sleep BP patterns due to its spot-check nature and lack of sleep-awake information, which leads to inaccurate dipping measurements. Incorporation of beat-to-beat continuous BP measurement can provide more accurate and meaningful nocturnal BP information.

Support

N/A

0791 Effects of Low Frequency Electrical Stimulators as Nonpharmacological Treatment in Restless Legs Syndrome

Introduction

Non-pharmacological treatments for restless legs syndrome (RLS) is a treatment option for patients who have not yet started medical treatment, who do not respond to their prescribed medication, or who suffer from adverse effects of medication. This study aims to investigate the clinical effectiveness of low frequency electronic stimulators (LFES) as a non-pharmacological treatment.

Methods

This is a randomized, single-blind study. After screening 64 patients according to the inclusion/exclusion criteria, a total of 46 patients participated in the study. The participants were separated into an active group and a sham group with 22 and 24 members, respectively. The stimulation was administered using the tapping mode (3Hz) present on the machines used, and symptom changes were measured in both groups. The effects of the stimuli were analyzed with repeated measures ANOVA.

Results

Symptom severity was significantly reduced in the active group, and showed significant interaction effects in the time multiple group. Although both the active and sham groups reported improved symptoms upon receiving longer periods of treatment, the effect of the LFES was greater in the active group.

Conclusion

Analyzing the effects of LFES by dividing the active and sham groups revealed that LFES treatment resulted in symptom improvement when using effective stimulation intensity. LFES can be a non-pharmacological treatment option for RLS.

Support

None

Bilateral inferior renal polar arteries with a high origin from the abdominal aorta

Bilateral multiple renal arteries are not-so-rare variations. However, inferior renal polar arteries with a high origin from the abdominal aorta have rarely been reported. We found bilateral inferior renal polar arteries with a high origin from the abdominal aorta in an 84-year-old Korean female cadaver. Two right and three left renal arteries were seen with the lowest as the main renal artery bilaterally. The highest artery crossed the main renal artery and penetrated into the inferior pole of the kidney, respectively. After dissection, each inferior polar artery could be classified as the inferior segmental branch. A further understanding on its embryogenesis might be important since variations in renal arteries are of particular interest to clinicians as well as anatomists.