Utility of cranial MRI in non-traumatic headache patients with prior negative head CT within 1 month

AIM

To investigate the importance of additional cranial magnetic resonance imaging (cMRI) in non-traumatic headache patients with a prior negative head computed tomography (CT) examination within 1 month.

MATERIALS AND METHODS

This retrospective study analysed 162 adult patients with non-traumatic headache who underwent cMRI within 1 month of a negative initial head CT at the emergency department (ED). The diagnostic yield and false-referral rate were analysed according to the revisit duration (early [≤1 week] versus late [>1-4 weeks] revisits), patient care settings (ED versus outpatient clinics [OPC]), and clinical variables. Subsequent patient management change (PMC), such as admission and treatment (AT) or outpatient clinic treatment (OT), were also investigated.

RESULTS

The overall diagnostic yield of cMRI was 17.3% (28/162) and the false-referral rate was 1.2% (2/162). The diagnostic yield of cMRI was significantly different according to the patient care settings (ED, 24.7% [21/85] versus OPC, 9.1% [7/77]; p=0.02). The diagnostic yield was highest in the ED-early-revisit group (25.4% [18/71]), 45% (9/20) in those with systemic signs, and 46.7% (14/30) in those with symptom change. Among patients with positive cMRI findings, 90% (27/30) received AT and 3.3% (1/30) received OT. Among OPC-revisit-negative cMRI patients, PMC occurred in 0% (0/50).

CONCLUSION

The diagnostic yield of cMRI was relatively high for headache patients who revisited the ED earlier, especially in those with systemic signs or symptom change. Most positive cMRI cases experienced PMC. Negative cMRI in OPC-revisit patients might help clarify the benign nature of a condition.

Surgery for severe mitral regurgitation: The etiology matters

BACKGROUND

While surgery has been the standard treatment for patients with severe primary mitral regurgitation (PMR), the role of surgery for severe secondary mitral regurgitation (SMR) remained debated. We therefore investigated the prognostic differences of surgery for patients with either severe PMR or SMR.

METHODS

Subjects hospitalized for heart failure were enrolled from 2002 to 2012. The severity of MR was assessed by continuity equation, and an effective regurgitant orifice area of ≥40 mm 2 was defined as severe. Long-term survival was then identified by the National Death Registry.

RESULTS

A total of 1143 subjects (66.4 ± 16.6 years, 65% men, and 59.7% PMR) with severe MR were analyzed. Compared with PMR, patients with SMR were older, had more comorbidities, greater left atrial and ventricular diameter, and less left ventricular ejection fraction (all p < 0.05). While 47.8% of PMR patients received mitral valve surgery, only 6.9% of SMR patients did. Surgical intervention crudely was associated with 54% reduction of all-cause mortality in PMR (hazard ratio, 0.46; 95% confident interval, 0.32-0.67), and 48% in the subpopulation with SMR (0.52, 0.30-0.91). Propensity score matching analysis demonstrated the survival benefits of mitral valve surgery was observed in patients with PMR (log rank p = 0.024), but not with SMR. Among the unoperated subjects, age, renal function, and right ventricular systolic pressure were common risk factors of mortality, regardless of MR etiology.

CONCLUSION

Mitral valve surgery for patients with heart failure and severe MR was associated with better survival in patients with PMR, but not in those with SMR.

Association between spirometry pattern, left ventricular diastolic function, and mortality

BACKGROUND

Spirometric abnormalities have been related to incident heart failure in general population, who generally have preserved left ventricular ejection fraction (LVEF). We aimed to investigate the association between spirometric indices, cardiac functions and clinical outcomes.

METHODS

Subjects presenting with exertional dyspnoea and received spirometry and echocardiography were eligible for this study. Forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1)/FVC ratio were measured to define the spirometry patterns: normal (FEV1/FVC ≥ 70%, FVC ≥ 80%), obstructive (FEV1/FVC < 70%, FVC ≥ 80%), restrictive pattern (FEV1/FVC ≥ 70%, FVC < 80%) and mixed (FEV1/FVC < 70%, FVC < 80%). The diastolic dysfunction index (DDi) was the counts of the indicators, including septal e' velocity <7 cm/s, septal E/e' > 15, pulmonary artery systolic pressure > 35 mmHg and left atrial dimension >40 mm.

RESULTS

Among a total of 8669 participants (65.8 ± 16.3 years, 56% men), 3739 (43.1%), 829 (9.6%), 3050 (35.2%) and 1051 (12.1%) had normal, obstructive, restrictive and mixed spirometry pattern, respectively. Subjects with restrictive or mixed spirometry pattern had higher DDi and worse long-term survival than those with obstructive or normal ventilation. FVC but not FEV1/FVC was predictive of 5-year mortality, independent of age, sex, renal function, LVEF, DDi, body mass index, and comorbidities (hazard ratio, 95% confidence intervals: .981, .977-.985). Furthermore, there was an inverse nonlinear relationship between FVC and DDi, suggesting the declined FVC may mediate 43% of the prognostic hazard of left ventricular diastolic dysfunction.

CONCLUSIONS

The restrictive spirometry pattern or the declined FVC was associated with left ventricular diastolic dysfunction, which aggravated the long-term mortality in the ambulatory dyspnoeic subjects.

Intravascular ultrasound-guided optimization for chronic total occlusion-percutaneous coronary intervention with multiple drug-eluting stents

Background

Multiple stenting in the chronic total occlusion (CTO) lesions is frequently required, however associated with poorer clinical outcomes. It is demonstrated that intravascular ultrasound (IVUS)-guided CTO-percutaneous coronary intervention (PCI) is related to a lower risk of adverse clinical events.

Purpose

We aimed to evaluate the clinical impact of stent optimization under IVUS guidance for multiple stenting, comparing with single stenting.

Methods

A total of 916 patients receiving drug-eluting stent (DES) under IVUS guidance were classified into two groups (stent optimization and non-optimization) according to optimization criteria (an absolute expansion criteria; minimal stent area ≥4.9 mm2 and a relative expansion criteria; 80% of mean reference lumen area). Of total population, 314 patients (34.3%) were treated with single stent and 575 patients (62.7%) were treated with multiple stents, respectively. Ischemic-driven target-lesion revascularization (TLR)/reocclusion was evaluated.

Results

Under IVUS guidance, 316 patients (34.5%) met IVUS criteria for stent optimization The achieving rates were 53% in the single stent group and 24% in the multiple stents group, respectively, (p&lt;0.001). During a median of 4.7 years, the multiple stent group showed a significantly higher TLR/reocclusion rate, compared with the single stent group (12.8% vs. 5.2%, adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.20–5.25, p=0.01). (Figure 1) Meeting both the absolute and relative expansion criteria was associated with a significantly low rate of TLR/reocclusion rate (12.5% vs. 5.2%, adjusted HR 0.34, 95% CI: 0.15–0.79, p=0.01). Under IVUS-guidance, there was no significant difference between multiple stenting and single stenting in case of achieving the optimization criteria (6.5% vs. 4.2%, p=0.11), whereas non-optimization group in the patients with multiple stenting showed a significantly higher rate of TLR/reocclusion, compared with IVUS-optimization group in the patients with single stenting (14.5% vs. 4.2%, p=0.002). (Figure 2)

Conclusions

In CTO-PCI with DES, multiple stenting significantly increased the risk of TLR/reocclusion. IVUS-guided optimization for multiple stenting showed a comparable long-term risk of TLR/reocclusion to single stenting with IVUS optimization. Hence, achieving IVUS expansion criteria may help to reduce the risk of TLR/reocclusion in CTO-PCI with multiple DES overlapping.

Funding Acknowledgement

Type of funding sources: None.

Impaired renal function and mortalities in acute heart failure with different phenotypes

AIMS

Impaired renal function (IRF) prevails in patients with acute heart failure. The study aimed to investigate the prevalence of on-admission IRF and its association with short-term and long-term mortalities in patients hospitalized for HF with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) left ventricular ejection fraction (LVEF).

METHODS

Patients hospitalized for acute heart failure were enrolled and stratified by LVEF into three phenotypes as HFpEF (≥50%), HFmrEF (40-49%), and HFrEF (<40%). IRF was defined as an estimated glomerular filtration rate of ≤60 mL/min/1.73m² on admission. National Death Registry was linked for the identification of mortality.

RESULTS

Of 2613 patients enrolled, 673 (25.7%) had HFrEF, 367 (14.0%) had HFmrEF, and 1573 (60.1%) had HFpEF, whereas IRF was prevalent among 63.7, 68.6, and 67.5% of them, respectively. IRF significantly correlated with higher long-term mortality in each phenotype of HF. However, IRF was associated with 90-day and 1-year mortality in subjects with HFrEF and HFmrEF, but not HFpEF. After accounting for age, gender, hypertension, diabetes, coronary artery disease, atrial fibrillation, stroke, serum sodium, de novo heart failure, date of enrolment, and systolic blood pressure <90 mmHg or use of inotropic agents, IRF remained related to 5-year mortality in patients with HFrEF (hazard ratio and 95% confidence interval: 1.346, 1.034-1.751), HFmrEF (2.210, 1.435-3.404), and HFpEF (1.493, 1.237-1.801).

CONCLUSIONS

On-admission IRF was independently predictive of long-term mortality in patients hospitalized for HF, irrespective of HF phenotypes. Furthermore, IRF was also associated with short-term mortality in HFrEF and HFmrEF, but not in HFpEF.

Low Intake of Choline Is Associated with Diminished Strength and Lean Mass Gains in Older Adults

OBJECTIVES

Choline is an essential micronutrient for many physiological processes related to exercise training including biosynthesis of acetylcholine. Though dietary choline intake has been studied in relation to endurance training and performance, none have studied it during resistance exercise training (RET) in older adults. The objective of the study was to examine the relationship between choline intake and muscle responses to RET in older adults.

METHODS

Forty-six, 60-69-year-old individuals (M=19, F=27) underwent 12 weeks of RET (3x/week, 3 sets, 8-12 reps, 75% of maximum strength [1RM], 8 exercises). Body composition (DEXA) and 1RM tests were performed before and after training. After analyzing 1,656 diet logs (3x/week, 46 participants, 12 weeks), participants' mean choline intakes were categorized into three groups: Low (2.9-5.5 mg/kg lean/d), Med-Low (5.6-8.0 mg/kg lean/d), or Adequate (8.1-10.6 mg/kg lean/d). These correspond to <50%, ~63%, and ~85% of Adequate Intake (AI) for choline, respectively.

RESULTS

Gains in composite strength (leg press + chest press 1RM) were significantly lower in the Low group compared with the other groups (Low: 30.9 ± 15.1%, Med-Low: 70.3 ± 48.5%, Adequate: 81.9 ± 68.4%; p=0.004). ANCOVA with cholesterol, protein, or other nutrients did not alter this result. Reduced gains in lean mass were also observed in the Low group, compared with higher choline intake of 5.6-10.6 mg/kg lean/d (1.3 ± 0.6% vs. 3.2 ± 0.6%, p<0.05).

CONCLUSION

These data suggest that this population of older adults does not consume adequate choline and lower choline intake is negatively and independently associated with muscle responses to RET.

70 Availability of Personal Protective Equipment in NHS Hospitals During COVID-19: A National Survey

Introduction

The continuous supply of personal protective equipment (PPE) in the National Health Service (NHS) is paramount in order to sustain a safe level of staffing and to reduce transmission of COVID-19 to patients, public and staff.

Method

A 16-question survey was created to assess the availability and personal thoughts of healthcare professionals regarding PPE supply in England. The survey was distributed via social media (Facebook © and Twitter ©) to all UK COVID-19 healthcare professional groups, with responses collected over 3 weeks in March 2020 during the beginning of the pandemic.

Results

A total of 121 responses from physicians in 35 different hospitals were collected (105 inpatient wards, 16 from intensive care units). In inpatient wards, eye and face protection were unavailable to 19.1% of respondents. Masks were available to 97.7% of respondents and gloves in all respondents (100%). Body protection was available primarily as a plastic apron (83.8%). All of respondents working in intensive care had access to full-body PPE, except FFP3 respirator masks (available in 87.5%). PPE is ‘Always’ available for 29.8% of all respondents, and ‘Never’ or ‘Almost Never’ in 11.6%. There was a statistically significant difference between London and non-London responders that ‘Always’ had PPE available (43.9% versus 19.0%, p = 0.003).

Conclusions

This is the first survey to evaluate PPE supply in England during the COVID-19 pandemic. Our survey demonstrated an overall lack of PPE volume supply in the UK, with preferential distribution in London. Eye and full body protection are in most lack of supply.

Schwannoma of the sinonasal tract: case report with review of the literature

Schwannomas of the sinonasal tract are rare, accounting for <4% of head and neck schwannomas. We report the case of a 61-year-old male who presented with unilateral nasal symptoms. Examination and imaging revealed a unilateral polyp at the level of the middle turbinate, with an initial biopsy suggestive of an inflammatory polyp. Due to the persistence of the patient's symptoms and his polyp despite medical therapy, endoscopic nasal polypectomy was performed. The histology surprisingly showed a schwannoma. No further interventions were carried out, and the patient remains disease-free 6 months postoperatively. A review of the literature comprising 60 cases is included. An optimal clinical approach to the investigation and management of schwannomas of the sinonasal tract is subsequently discussed.

Feasibility and rationale of direct current cardioversion immediately after transcatheter percutaneous edge-to-edge mitral valve repair

AIMS

Atrial fibrillation (AF) is a frequent comorbidity among patients with severe mitral regurgitation (MR). Direct current (DC) cardioversion is one of the strategies for rhythm control. However, the safety and feasibility of immediate DC cardioversion after MitraClip are not elucidated.

METHODS AND RESULTS

In this study, patients with symptomatic severe MR who underwent MitraClip were included. After fixing the MR, synchronized DC cardioversion was attempted for those with AF. A total of consecutive 60 patients, 36 subjects (60%), comorbid with AF. DC cardioversion was performed in 30 patients (mean age of 76.0 ± 9.3 years), and the successful conversion was achieved in 15 patients (50%). There was no any adverse event related to the cardioversion. Subjects with sustained conversion to SR experienced significant improvement in 6MWT (failed: 285 ± 110-308 ± 135 m, P = .278; successful: 269 ± 109 m-328 ± 78, P = .047) and reduction in NT-proBNP level (failed: 4411 ± 7401-3296 ± 4299 ng/mL, P = .217; successful: 4094 ± 2735-2353 ± 2856 ng/mL, P = .026) at 1 month.

CONCLUSIONS

Direct current cardioversion seemed to be safe and feasible immediately after the transcatheter edge-to-edge mitral valve repairs. Subjects who maintain SR experienced better functional improvement.

Poultry Professionals' Perception of Participation in Voluntary Disease Mapping and Monitoring Programs in the United States: A Cluster Analysis

The development and implementation of disease mapping and monitoring programs can be useful tools for rapid communication and control of endemic and epidemic infectious diseases affecting the food animal industry. Commercial livestock producers have traditionally been reluctant to share information related to animal health, challenging the large-scale implementation of such monitoring and mapping programs. The main objective of this study was to assess the perception of poultry professionals toward disease mapping and monitoring programs and to identify groups of poultry professionals with similar perceptions and attitudes toward these projects. We conducted a survey to identify the perceived risks and benefits to be able to properly address them and encourage industry participation in the future. An anonymous online survey was developed and distributed to poultry professionals through industry and professional associations. The participant's demographic information and perceptions of risk and benefits from participation on voluntary poultry disease mapping and monitoring programs were collected. Multiple correspondence analysis and hierarchical clustering on principal components were performed to identify groups of professionals with similar characteristics. A total of 63 participants from 21 states filled out the survey. The cluster analysis yielded two distinct groups of respondents, each including approximately 50% of respondents. Cluster 1 subjects could be characterized as optimistic, perceiving major benefits of sharing farm-level poultry disease information. However, they also had major concerns, mostly related to potential accidental data release and providing competitive advantages to rival companies. Cluster 2 subjects were characterized as perceiving a lesser degree of benefits from sharing farm-level poultry disease information. This second cluster mostly included production and service technicians. The roles and perceptions of risk and benefits of the participants contributed significantly to cluster assignment, while the represented commodity and geographic location in the United States did not. Successful development of voluntary poultry disease mapping and monitoring programs in the future will require that different sectors of poultry professionals be approached in different manners in order to highlight the benefits of the programs and to achieve maximum participation.

Risk stratification in patients hospitalized for acute heart failure in Asian population

BACKGROUND

The AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score may be suboptimal in predicting long-term mortality in Asian patients with acute heart failure (AHF). We aimed to propose and validate a risk score incorporating easily available echocardiographic parameters to improve risk stratification in Asian patients with AHF.

METHODS

A total of 3537 patients hospitalized for AHF were enrolled and divided into generation and validation cohorts. Independent predictors of all-cause mortality were identified by Cox regression analysis and scored by hazard ratios to constitute the model. Model performance was validated and evaluated by receiver operating characteristic (ROC) curves and net reclassification improvement (NRI).

RESULTS

In the generation cohort of 1775 patients (74.3±13.0 years, 69.9% men), there were 870 deaths (49.0%) during a mean follow-up of 24.7±13.8 months. Age, anemia, estimated glomerular filtration rate <50 ml/min/1.73 m, hyperuricemia, left ventricular ejection fraction <50% and right ventricular systolic pressure (RVSP) >40 mmHg were independently related to mortality, which constituted "UR-HEARt" (U: uric acid, R: renal function, H: hemoglobin, E: ejection fraction of left ventricle, A: age, Rt: RVSP) score. Model performance was evaluated in the validation cohort (n = 1762), which outperformed AHEAD score by comparison of ROC curves in predicting all-cause mortality (area under curve [AUC] of UR-HEARt vs. AHEAD: 0.66 [95% CI 0.62-0.70] vs. 0.58 [95% CI 0.54-0.62]; p < 0.001), with NRI by 10.9% for all-cause mortality (p < 0.001) and 18.4% for cardiovascular death (p < 0.001).

CONCLUSION

UR-HEARt score, an easily accessible racial-specific risk score with integration of echocardiographic indices, improved risk stratification in Asian patients hospitalized for AHF.

Interstitial lung disease and risk of mortality: 11-year nationwide population-based study

BACKGROUND

Patients with interstitial lung disease (ILD) constitute a substantial disease burden. Although ILD outcomes have been investigated, the risk of death due to ILD has not been studied in the light of confounders and comorbidities. In this nationwide, 11-year longitudinal, population-based study, we aimed to discover if ILD is an independent risk factor for mortality.

DESIGN

Data on 1 031 392 (2.2%) randomly selected subjects from 47 279 373 Korean residents were collected from the 2002 Korean National Health Insurance database. The ILD group comprised patients with an initial diagnosis of ILD between January 2003 and December 2007. Each patient was followed until 2013. We used Cox proportional hazard regression analyses to calculate the risk of death adjusted for comorbidities and confounders.

RESULTS

ILD developed in 783 of the 303 385 subjects during the 5-year period (51 per 100 000 person-years). Death occurred in 157 (23.2%) cases and 272 controls (10.4%). ILD was significantly associated with the risk of death (hazard ratio 2.1, 95% confidence interval [CI] 1.6-2.7) and for those aged 40-59, 60-69 and 70 years. A high proportion of patients with ILD died due to respiratory causes.

CONCLUSION

ILD patients had a significantly higher risk of death than matched controls, after adjustment for potential confounders and comorbidities.

P923Feasibility of the transcatheter mitral valve repair as the rescue therapy for patients with severe mitral regurgitation and endangered heart failure

Background

For those who carry high or prohibitive surgical risk, the transcatheter edge-to edge mitral valve repair using MitraClip has been a safe and effective treatment for severe mitral regurgitation (MR). In patients with severe MR and cardiogenic shock under hemodynamic supporting devices, emergent surgical mitral valve interventions carry extremely high risk for peri-operative morbidities and mortalities. The feasibility and efficacy of emergent MitraClip to rescue patients in critical conditions remains elucidate.

Methods

Patients with severe MR were evaluated by the heart team and those with high or prohibitive surgical risks were referred to receive MitraClip procedures. Emergent MitraClip were conducted in patients with unstable hemodynamics and under mechanical or inotropic support. The hemodynamic measures, transthoracic echocardiography, transesophageal echocardiography, and blood tests were performed before MitraClip procedures. Procedural success was defined as having mild mitral regurgitation immediately after MitraClip, and patients were free from in-hospital mortality. Clinical and echocardiographic outcomes were followed by telephones and clinics.

Results

Among 50 consecutive patients (74.7±11.2 years, 74% male), 8 emergent MitraClip procedures were conducted to rescue patients with cardiogenic shock. Extracorporeal membrane oxygenation were used in 2 patients and intra-aortic balloon pump were applied in 4 patients (50%). The rest of 4 patients received continuous inotropic agent administration. Compare to those who underwent elective procedures, patients underwent emergent MitraClip had higher surgical risk profile (Euroscore II 34.8% vs 5.1% and STS score 19.7% vs 5.1%), poorer renal function and higher right atrial pressure. There was no peri-procedural death, myocardial infarction, stroke or any adverse events requiring emergent cardiac surgery in both groups. Mild mitral regurgitation was achieved in 87.5% patients from the emergent group and 95.2% patients in the elective group (P=0.514). In follow up, there were 5 deaths (three in the emergent group), including 2 non-cardiovascular deaths. The Kaplan-Meier analysis showed patients who underwent emergent procedures have poorer long-term survival rate as compare to those who received elective procedures. (P value = 0.008).

Conclusions

When open-heart surgery is not feasible and deferred due to excessive risk, trans-catheter mitral valve repair is an alternative way to rescue patients in cardiogenic shock status. The emergent MitraClip procedure may provide comparable safety and efficacy in treating patients with severe MR and unstable hemodynamics.

P4733Risk of myocardial infarction with coronary artery bypass grafting versus percutaneous coronary intervention: a systematic review and meta-analysis of fifteen randomised trials

Background

It remains controversial whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is more effective in the prevention of myocardial infarction (MI). MI has been evaluated only as a secondary endpoint without a focused systematic review in multiple meta-analyses.

Purpose

To compare the risk of MI at the latest follow-up available between CABG versus PCI with stents in patients with multivessel or left main coronary artery disease in a pairwise meta-analysis of randomised controlled trials (RCT).

Methods

We searched EMBASE, Cochrane, and Pubmed databases for articles comparing CABG versus PCI for the treatment of multivessel or left main disease. We utilised random-effects model to calculate pooled risk ratio (RR) and 95% confidence interval (CI). Fifteen trials with a total of 13,592 patients treated with either CABG (n=6,596) or PCI (n=6,996) were eligible and included. A multivariable random-effects meta-regression model, including variables such as age, sex, diabetes mellitus, publication year, follow-up duration, type of stent used, and type of coronary artery disease, was used to explore the source of potential heterogeneity of the primary result.

Results

After a weighted follow-up of 4.3 years, patients treated with CABG had a significantly lower risk of MI than patients treated with PCI (RR 0.75, 95% CI 0.58–0.96, P=0.024, I2=66%). The lower risk of MI with CABG as compared to PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52–0.91, P=0.008; ≥5 years, RR 0.64, 95% CI 0.48–0.86, P=0.003) and in diabetic population (RR 0.55, 95% CI 0.44–0.70, P<0.001). There was a statistically meaningful trend toward fewer MIs with CABG with a similar magnitude of risk reduction across patients with left main disease (RR 0.74, 95% CI 0.47–1.15) and multivessel disease (RR 0.72, 95% CI 0.53–0.99). Moderate inter-study heterogeneity could not be explained by the clinical and trial-based variables tested in meta-regression, and is likely because of differences in definitions of MI, risk profile of enrolled patients, and procedural specifics.

Forest plots

Conclusions

In patients undergoing revascularization for multivessel or left main disease, the risk of MI was lower with CABG compared to PCI. The quality assurance for MI definition and treatment-specific procedures should be emphasized for future RCTs.

Cognitive functions and jugular venous reflux in severe mitral regurgitation: A pilot study

Cardiac diseases with elevated central venous pressure have higher frequency of jugular venous reflux (JVR), which is associated with decreased cerebral blood flow and white matter hyperintensities. Whether patients with severe mitral-regurgitation (SMR) have poorer cognitive functions and whether JVR is involved were determined in this pilot study. Patients with SMR and age/sex-matched controls were prospectively recruited. Neuropsychological tests such as global cognitive (Mini-Mental State Examination, MMSE), verbal memory, executive, and visuospatial domains were performed. Cardiac parameters by cardiac catheterisation and echocardiography, and the frequency of JVR by colour-coded duplex ultrasonography were obtained. Forty patients with SMR and 40 controls (71.1±12.2, 38-89 years; 75% men) were included. Compared with the controls, patients with SMR had lower scores in all neuropsychological tests but only MMSE and visuospatial test scores were statistically significant after adjusting for age, sex, and educational level. We further adjusted for cardiovascular risk factors; the significance remained in the visuospatial test but diminished in MMSE. Multivariate linear regression analyses adjusted for age, sex, and educational level showed that JVR combined with high right-atrial-pressure (RAP > 50th-percentile, 12 mmHg) was significantly associated with poorer performances in both MMSE [right JVR: B coefficient(95% confidence interval,p) = -2.83(-5.46-0.20, 0.036); left JVR: -2.77(-5.52-0.02, 0.048)] and visuospatial test [right JVR: -4.52(-8.89-0.16, 0.043); left JVR: -4.56(-8.81-0.30, 0.037)], with significances that remained after further adjusting for cardiovascular risk factors. Our pilot results suggest that retrogradely-transmitted venous pressure might be involved in the mechanisms mediating the relationship between cardiac diseases and brain functions.

Clipping Barlow&rsquo;s mitral valve to rescue a patient with acute biventricular failure

Percutaneous edge-to-edge mitral repair with the MitraClip device is an alternative therapy for patients with severe mitral regurgitation. Given that Barlow's disease is characterised by multiple prolapsed segments and multiple regurgitant jets, the MitraClip is not recommended. Herein, we present the case of a 42-year-old gentleman who suffered acute biventricular failure due to a primary chordae rupture of Barlow's mitral valve. Because of prohibitive surgical risk, he was successfully rescued using transcatheter edge-to-edge mitral repair. Our critical case may demonstrate the feasibility of MitraClip use as a rescue therapy for patients with acute severe mitral regurgitation.

Anaesthetic Management of Planned or Emergency Endovascular Stent Graft Surgery for Thoracic Aneurysms and Dissections

We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.

High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance Spectroscopy for the Metabolic Assessment of Acute Rejection After Cardiac Transplantation in Rats

PURPOSE

To evaluate the potential of high-resolution magic angle spinning (HR-MAS) ¹H nuclear magnetic resonance (NMR) spectroscopy for metabolite characterization and the differentiation of acute rejection after heart transplantation in rat models.

METHODS

We transplanted syngeneic heart grafts from Lewis rats (n = 4) and allogeneic heart grafts from F344 rats (n = 4) heterotopically into Lewis recipients. On day 7 postoperatively, the transplanted hearts were harvested for ex vivo ¹H NMR spectroscopy and HR-MAS ¹H NMR spectroscopy. ¹H NMR spectroscopy and HR-MAS ¹H NMR spectroscopy were performed at 4.7 T and 11.7 T, respectively. Metabolomic profiles contributing to the differentiation of allogeneic and syngeneic graft groups were statistically assessed by orthogonal partial least squares discriminant analysis (OPLS/O2PLS-DA). Metabolite concentrations were normalized by total spectral intensities and were compared using Mann-Whitney U tests.

RESULTS

One allogeneic graft that showed extensive necrotic change suggesting graft failure was excluded from the statistical analysis of the NMR spectroscopy. In the 4.7-T ¹H NMR spectroscopy, the creatine peak was decreased in the allogeneic group. The PLS-DA and OPLS/O2PLS-DA score plot demonstrated good discrimination of the allogeneic graft group from syngeneic graft group. The concentrations of creatine, myo-inositol, glucose, niacinamide, hypoxanthine, inosine, and glutamine were significantly decreased in the allogeneic graft group, whereas the concentrations of glycine, phosphoethanolamine, xanthine, sn-glycero-3-phosphocholine, leucine, valine, and tyrosine were significantly increased (P < .05).

CONCLUSIONS

HR-MAS ¹H NMR spectroscopy can metabolically characterize the acute rejection of heart transplantation.

Initial experience with percutaneous edge-to-edge transcatheter mitral valve repair in a tertiary medical center in Taiwan

BACKGROUND

The transcatheter edge-to-edge mitral valve repair, using MitraClip, has been a safe and effective treatment for severe mitral regurgitation (SMR) in the westerners. However, the therapeutic results of the MitralClip in Taiwan remained elucidated.

METHODS

Patients with symptomatic SMR were evaluated by the heart team. For those with high or prohibitive surgical risks, transcatheter mitral valve repair was performed in hybrid operation room. During procedure, continuous hemodynamic monitoring was conducted. Transthoracic echocardiography (TTE), blood tests, and six-minute walk test (6MWT) were performed before and 1-month after surgery.

RESULTS

A total of 20 patients (73.4 ± 11.1 years, 85% male) with a mean Euroscore II of 13.2 ± 17.7% and a mean STS score of 8.7 ± 9.0% for mortality were enrolled. After a mean procedural time of 239 ± 95 min, an average of 1.8 ± 0.7 clips were used in each procedure. The procedural successful rate was 95% to achieve mild residual mitral regurgitation. Cardiac output was increased from 3.6 ± 0.9 to 4.6 ± 1.4 (p = 0.008) and V-wave of left atrial pressure declined from 24.4 ± 9.8 to 19.3 ± 7.1 (p = 0.030) immediately during the index procedure. There was no peri-procedural death, myocardial infarction, stroke or any events requiring emergent cardiac surgery. All patients experienced significant improvement in heart failure symptoms. The 6-min walk distance increased from 219.6 ± 118.4 m to 279.1 ± 111.6 (p = 0.04) at 1 month. The echocardiogram further showed significant improvements of mitral regurgitation, pulmonary artery systolic pressure, and the left ventricular end-diastolic volume.

CONCLUSION

Trans-catheter edge-to-edge mitral valve repairs are safe and effective in Asians with symptomatic SMR, regarding the improvements of clinical symptoms and exercise capacities. MitraClips is also associated with reverse remodeling of pulmonary hypertension and left ventricular size in patients with SMR.

Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder

Background: There is room for improvement regarding the treatment of severe post-traumatic stress disorder (PTSD). Intensifying treatment to increase patient retention is a promising development. Objective: The aim of this study was to determine the effectiveness of an intensive trauma-focused treatment programme over 8 days for individuals suffering from severe PTSD. Method: Treatment was provided for 347 PTSD patients (70% women; mean age = 38.32 years, SD = 11.69) and consisted of daily sessions of prolonged exposure and eye movement desensitization and reprocessing (EMDR) therapy (16 sessions in total), physical activity, and psycho-education. All participants had experienced multiple traumas, including sexual abuse (74.4%), and suffered from multiple comorbidities (e.g. 87.5% had a mood disorder). Suicidal ideation was frequent (73.9%). PTSD symptom severity was assessed by both clinician-rated [Clinician Administered PTSD Scale (CAPS)] and self-report [PTSD Symptom Scale Self Report (PSS-SR) and Impact of Event Scale (IES)] inventories. For a subsample (n = 109), follow-up data at 6 months were available. Results: A significant decline in symptom severity was found (e.g. CAPS intention-to-treat sample Cohen's d = 1.64). At post-treatment, 82.9% showed a clinically meaningful response and 54.9% a loss of diagnosis. Dropout was very low (2.3%). Conclusions: Intensive trauma-focused treatment programmes including prolonged exposure, EMDR therapy, and physical activity can be effective for patients suffering from severe PTSD and are associated with low dropout rates.

Hemographic indices are associated with mortality in acute heart failure

Hemographic indices have been associated with clinical outcomes in patients with chronic heart failure. We therefore investigated the prognostic values of hemographic indices in patients hospitalized for acute heart failure (AHF). Patients hospitalized primarily for AHF were drawn from an intramural registry. Hemographic indices, including white blood cell counts, neutrophil counts, neutrophil-to-lymphocyte ratio, reciprocal of lymphocyte (RL) and platelet-to-lymphocyte ratio were recorded. Among a total of 1923 participants (mean age 76 ± 12 years, 68% men), 875 patients died during a mean follow-up of 28.6 ± 20.7 months. Except for white blood cell counts, all the other hemographic indices were related to mortality, independently. In a forward stepwise Cox regression analysis among hemographic indices, RL was the strongest predictor (HR and 95% CI per-1SD:1.166,1.097-1.240) for mortality, after accounting for confounders. However, conditioned on the survivals, the hemographic indices were independently related to mortality within 3 years of follow-up, rather than beyond. Hemographic indices were independent risk factors of mortality in patients hospitalized for AHF, especially in patients with impaired left ventricular systolic function. As an acute presentation of inflammation, hemographic indices might be useful to identify subjects at risk of mortality soon after the index hospitalization.

Dynamic Internet-Mediated Team-Based Case Management of High-Frequency Emergency Department Users

Introduction

We assessed whether a strategy using dynamic, internet-mediated, team-based case management could reduce the number of subsequent emergency department (ED) visits by frequent ED users.

Methods

Patients who attended the ED three or more times within 72 hours in June 2010 were identified. These cases were divided into the pain management or chronic disease group according to their chief complaint. Patients were assessed by expert panels, and initial care plans were developed and posted on an internal website. Thereafter, each emergency physician could follow or adjust the care plans dynamically via the internal website according to the patient's condition and use the website to communicate results. Care plans were revised by the team according to the patient's clinical situation as it changed. Patient ED visits over the subsequent six months were monitored.

Results

Fourteen cases were enrolled in the study, seven in each group. The mean number of visits per patient per month in the pain management and chronic disease groups decreased from 14.9 to 5.79 (p=0.031) and 6.1 to 2.9 (p<0.001) visits per month after the intervention, respectively. The overall mean number of visits per patient per month decreased from 10.5 to 4.36 (p=0.004), a decrease of 6.14 visits (58.27%).

Conclusions

Dynamic internet-mediated team-based case management may help to reduce subsequent visits in patients who frequently visit the ED. (Hong Kong j.emerg.med. 2014;21:161-166)

[Percutaneous Edge-to-Edge Mitral Valve Repair: New Transcatheter Approach and Nursing Experience in Patients With Severe Mitral Regurgitation and Prohibitive Surgical Risk]

Open-heart surgery and conservative medical treatments have been the traditional, mainstay treatments for patients with severe mitral regurgitation (MR). Transcatheter edge-to-edge mitral repair is a novel technique. Using the transcatheter approach allows delivery of the clip into the left ventricle and the clipping of the orifice of the MR. The heart failure symptoms and outcomes of patients improve after this procedure. Compared to open-heart surgery, the mitral clip achieves similar MR reduction results with a significantly lower rate of complications. Since 2016, MitraClip has been available for clinical use in Taiwan. The aim of this report is to introduce this new treatment with a focus on nursing care in order to provide a reference for clinical care.

Clinical judgement perplexed by initially undisclosed use of herbal medicine and unexpected cross-reactivity of immunoassay

We report a case of symptomatic bradycardia caused by consumption of a Chinese herbal medicine which was initially undisclosed to the attending emergency physician. The scientific name of the herb is Panax japonicus. Electrocardiogram revealed sinus bradycardia. Laboratory tests were normal except for the detection of a high serum digoxin level. Further interrogation of the patient eventually disclosed ingestion of the herb which, however, did not contain any digoxin. Other active ingredients in the herb include various types of ginsenoside. These are digoxin-like substances that had caused the observed false-positive detection of digoxin by fluorescence polarization immunoassay due to cross-reactivity. Our case-report provides an important insight about a blind-spot in the field of laboratory medicine (clinical pathology), namely, the false positive detection of digoxin due to crossreactivity in the immunoassay when we come across digoxin-like substances in clinical scenarios, which has barely received attention in the medical literature. It also conveys a clear educational message that with full understanding of the laboratory methodology and its mechanistic rationale there are actually some tricks-of-the-trade that allow us to optimize the specificity of the biochemical tests and the treatment of digoxin-like substances overdose.

Rapid manufacturing techniques in the development of an axial blood pump impeller

This paper presents a comparison of manufacturing techniques used in the development of an axial blood pump impeller. In this development process the impeller was designed and its performance was evaluated with the aid of computational fluid dynamics (CFD). Prototypes of those designs where the CFD results show promise were needed in sufficient quantities at a low cost for experimental validation of the CFD results. As the impeller is less than 16 mm in diameter with a maximum blade thickness of about 1.5 mm, innovative manufacturing techniques are explored in this paper to determine the best process for quick fabrication of prototypes that are dimensionally accurate, structurally robust and low in cost. Four rapid prototyping techniques were explored. The completed parts were compared on the basis of manufacturing time, quality and strength of parts obtained, manufacturing cost and also in vitro performances. Based on these studies, it was concluded that selective laser sintering (SLS) is the most appropriate method for the quick production of prototype parts for evaluation of pump performance.

Antibiotic resistance and plasmid profiling of Vibrio spp. in tropical waters of Peninsular Malaysia

Vibrio species isolated from four different sampling stations in the west coast of Peninsular Malaysia were screened for their antimicrobial resistance and plasmid profiles. A total of 138 isolates belonging to 15 different species were identified. Vibrio campbellii, V. parahaemolyticus, V. harveyi, and V. tubiashii were found to predominance species at all stations. High incidence of erythromycin, ampicillin, and mecillinam resistance was observed among the Vibrio isolates. In contrast, resistance against aztreonam, cefepime, streptomycin, sulfamethoxazole, and sulfonamides was low. All the Vibrio isolates in this study were found to be susceptible to imipenem, norfloxacin, ofloxacin, chloramphenicol, trimethoprim/sulfamethoxazole, and oxytetracycline. Ninety-five percent of the Vibrio isolates were resistant to one or more different classes of antibiotic, and 20 different resistance antibiograms were identified. Thirty-two distinct plasmid profiles with molecular weight ranging from 2.2 to 24.8 kb were detected among the resistance isolates. This study showed that multidrug-resistant Vibrio spp. were common in the aquatic environments of west coast of Peninsular Malaysia.

Incidence of idiopathic pulmonary fibrosis in Korea based on the 2011 ATS/ERS/JRS/ALAT statement

OBJECTIVE

To estimate the annual incidence rate of interstitial lung disease (ILD) and idiopathic pulmonary fibrosis (IPF) in Korea.

DESIGN

A retrospective cohort design using the Korean Health Insurance Review and Assessment Service (HIRA) database spanned the period from January 2008 to December 2012. Patients with ILD and IPF were identified based on the International Classification of Disease-10 (ICD-10) diagnosis and procedure codes. Definition 1 is code J84 (ILD); Definition 2 is code J84 plus high-resolution computed tomography (HRCT), bronchoalveolar lavage (BAL) or lung biopsy; Definition 3 is code J84.1 (ILD with fibrosis); Definition 4 is code J84.1 and HRCT, BAL or lung biopsy; and Definition 5 is code J84.1A (IPF), and was specifically implemented for IPF.

RESULTS

The incidence rates of ILD per 100,000 population based on Definitions 1-5 were respectively 48.5, 32.2, 16.2, 11.4 and 1.7.

CONCLUSION

The incidence of ILD with fibrosis was approximately 23% of overall ILD incidence. IPF incidence was approximately 10% of the incidence of ILD with fibrosis. Based on the new ATS/ERS/JRS/ALAT statement published in 2011, the incidence rate of IPF was 1.7/100,000.

Neurovascular Interactions in the Neurologically Compromised Neonatal Brain

Neurological brain injuries such as hypoxic ischaemic encephalopathy (HIE) and associated conditions such as seizures have been associated with poor developmental outcome in neonates. Our limited knowledge of the neurological and cerebrovascular processes underlying seizures limits their diagnosis and timely treatment. Diffuse optical tomography (DOT) provides haemodynamic information in the form of changes in concentration of de/oxygenated haemoglobin, which can improve our understanding of seizures and the relationship between neural and vascular processes. Using simultaneous EEG-DOT, we observed distinct haemodynamic changes which are temporally correlated with electrographic seizures. Here, we present DOT-EEG data from two neonates clinically diagnosed as HIE. Our results highlight the wealth of mutually-informative data that can be obtained using DOT-EEG techniques to understand neurovascular coupling in HIE neonates.

Prevalence of pre-sarcopenia and sarcopenia in Hong Kong Chinese geriatric patients with hip fracture and its correlation with different factors

INTRODUCTION

Sarcopenia and osteoporosis are age-related declines in the quantity of muscle and bone, respectively. Both contribute in disability, fall, and hip fracture in the elderly. This study reported the prevalence of sarcopenia in Chinese geriatric patients with hip fracture, and the correlation between relative appendicular skeletal muscle mass index and other factors.

METHODS

This case series was conducted in Kowloon West Cluster Orthopaedic Rehabilitation Centre in Hong Kong. Data of all geriatric patients with primary hip fracture admitted to the above Centre from June to December 2014 were studied. Isometric grip strength, the maximal handgrip strength, was measured using a JAMAR hand dynamometer. Body composition including appendicular and whole-body lean body mass was measured using dual-energy X-ray absorptiometry. Pearson's correlation was used to examine the correlation between relative appendicular skeletal muscle mass index and other factors.

RESULTS

A total of 239 patients with a mean age of 82 years were included in the study. Stratifying patients as male or female, the mean (± standard deviation) hand grip strength was 20.6 ± 7.3 kg and 13.6 ± 4.5 kg, the mean relative appendicular skeletal muscle mass index was 5.72 ± 0.83 kg/m(2) and 4.87 ± 0.83 kg/m(2), and the mean hip bone mineral density was 0.696 ± 0.13 g/cm(2) and 0.622 ± 0.12 g/cm(2), respectively. The prevalence of sarcopenia based on relative appendicular skeletal muscle mass index and hand grip strength according to the Asian Working Group for Sarcopenia definition was 73.6% in males and 67.7% in females. According to the European Working Group on Sarcopenia definition, the prevalence of pre-sarcopenia was 20.8% in males and 12.4% in females. Relative appendicular skeletal muscle mass index was positively correlated with hand grip strength, body weight, hip bone mineral density, body mass index, and total fat mass in males; and hand grip strength, body weight, body height, body mass index, and total fat mass in females. Except for body height in females, all correlations were statistically significant.

CONCLUSION

The prevalence of sarcopenia was very high in geriatric hip fracture patients, and much higher than that in community-dwelling elderly population. Apart from the need to prescribe osteoporosis medicine, sarcopenia screening and treatment should be offered and is essential to reduce subsequent fall, subsequent fracture, fracture-related complications and economic burden to Hong Kong.

Immunogenicity and protective efficacy of the norovirus P particle-M2e chimeric vaccine in chickens

The ectodomain of the influenza matrix protein 2 (M2e) is highly conserved across strains and has been shown to be a promising candidate for universal influenza vaccine in the mouse model. In this study, we tested immune response and protective efficacy of a chimeric norovirus P particle containing the avian M2e protein against challenges with three avian influenza (AI) viruses (H5N2, H6N2, H7N2) in chickens. Two-week-old specific pathogen free chickens were vaccinated 3 times with an M2e-P particle (M2e-PP) vaccine via the subcutaneous (SQ) route with oil adjuvant, and transmucosal routes (intranasal, IN; eye drop, ED; microspray, MS) without adjuvant. M2e-PP vaccination via the SQ route induced significant IgG antibody responses which were increased by each booster vaccination. In groups vaccinated via IN, ED or MS, neither IgG nor IgA responses were detected from sera or nasal washes of immunized birds. The M2e-PP vaccination via the SQ route significantly reduced the virus shedding in the trachea and the cloaca for all three challenge viruses. Despite the absence of detectable IgG and IgA responses in birds vaccinated with the M2e-PP via intranasal routes, a similar level of reduction in virus shedding was observed in the IN group compared to the SQ group. Our results supports that the universal vaccine approach using M2e-based vaccine can provide cross-protection against challenge viruses among different HA subtypes although the efficacy of the vaccine should be enhanced further to be practical. Better understanding of the protective immune mechanism will be critical for the development of an M2e-based vaccine in chickens.

Fainting After Chest Pain

Variant angina presenting acute chest pain and ST elevation on electrocardiogram accounts for an underdiagnosed scenario in acute coronary syndrome and contributes to syncope as a consequence of ventricular arrhythmia. Here, we report a case of a 48-year-old man with a recent onset of chest pain and palpitations followed by syncope. Holter monitoring documented 2 episodes of evolving ST elevation associated with non-sustained ventricular tachycardia. Emergent cardiac catheterization indicated insignificant coronary narrowing. A non-invasive brachial artery ultrasound, which demonstrated endothelial dysfunction that was salvaged by exogenic nitrate, was used instead of intracoronary provocation. There was no clinical or electrocardiographic recurrence of variant angina after vasodilator treatment. In conclusion, variant angina represents an important but overlooked etiology for syncope. Holter monitoring facilitates the diagnostic and prognostic assessment in patients with syncope precipitated by chest pain.

KEY WORDS

Flow-mediated vasodilation; Holter monitoring; Variant angina; Ventricular arrhythmia.

Genetic diversity and evolution of satellite RNAs associated with the bamboo mosaic virus

Satellite RNAs (satRNAs) are subviral agents that depend on cognate helper viruses for genome replication and encapsidation. Their negative impacts on helper viruses have been exploited to control plant viral diseases. SatBaMV is a commonly found satRNA associated with Bamboo mosaic virus (BaMV) that infects diverse bamboo species in the field. To investigate the genetic diversity and evolution of satRNAs, we examined seven satBaMV populations derived from five bamboo species and cultivars from Taiwan, China, and India and one from the greenhouse. We found 3 distinct clades among the seven populations. Clade I is consisted of all satBaMV isolates, except for those from Dendrocalamus latiflorus in Taiwan and Bambusa vulgaris in India, which belong to Clades II and III, respectively. Interestingly, nucleotide diversity was lower for Clade I than II and III. However, the nucleotide diversity did not seem to depend on bamboo species or geographic location. Our population genetic analyses revealed the presence of excessive low-frequency polymorphic sites, which suggests that the satBaMV population was under purifying selection and/or population expansion. Further analysis of P20, the only satBaMV gene that encodes a non-structural protein involved in the long-distance movement of satBaMV, showed evidence of purifying selection. Taken together, our results suggest that purifying selection against defective P20 protein is responsible at least in part for the evolution of the satBaMV genome.

Effects of dietary levels of glycine, threonine and protein on threonine efficiency and threonine dehydrogenase activity in hepatic mitochondria of chicks

This study was carried out to evaluate the relationship between threonine (Thr) efficiency and Thr dehydrogenase (TDG) activity as an indicator of Thr oxidation on chicks fed with levels of diets (CP [17.5% and 21.5%] and Thr [3.8 and 4.7 g/100 g CP]; glycine [Gly][0.64% and 0.98%] and true digestible Thr [dThr] [0.45% and 0.60%]). Calculation of the Thr efficiency was based on N-balance data and an exponential N-utilization model, and TDG activity was determined as accumulation of aminoacetone and Gly during incubation of hepatic mitochondria. This study found that in the liver of chicks who received a diet containing up to 0.79% Thr (4.7 g Thr/100 g of CP) in the 17.5% CP diet, no significant (p>0.05) effect on TDG activity was observed. However, significantly (p = 0.014) increased TDG activity was observed with a diet containing 21.5% CP (4.7 g Thr/100 g of CP) and the efficiency of Thr utilization showed a significant (p = 0.001) decrease, indicating the end of the Thr limiting range. No significant (p>0.05) effect on the total TDG activity and accumulation of Gly was observed with addition of Gly to a diet containing 0.45% dThr. In addition, addition of Gly to a diet containing 0.60% dThr also did not result in a change in accumulation of Gly. Due to an increase in accumulation of aminoacetone, an elevated effect on total TDG activity was also observed. No significant (p>0.05) reduction in the efficiency of Thr utilization was observed after addition of Gly at the level of 0.45% dThr. However, significantly (p<0.001) reduced efficiency of Thr utilization was observed after addition of Gly at the level of 0.60% dThr. Collectively, we found that TDG was stimulated not only by addition of Thr and protein to the diet, but also by addition of Gly, and efficiency of Thr utilization was favorably affected by addition of Gly at the level near to the optimal Thr concentration. In addition, no metabolic requirement of Gly through the TDG pathway was observed with almost the same accumulation of Gly and a slight increase in TDG activity by addition of Gly. Thus, our findings suggest that determination of TDG activity and parameter of efficiency of Thr utilization may be useful for evaluation of dietary Thr level.

A case of prolonged fever and a diagnosis obscured by an opaque sinus

Prolonged fever in patients can be a diagnostic challenge. Clinicians generally consider infectious diseases, malignant diseases and collagen vascular diseases as possible causes of pyrexia of unknown origin (PUO). Even after extensive evaluation as many as 15 percent of patients with prolonged fever may remain undiagnosed. This case report describes subacute thyroiditis as a cause of prolonged fever and documents how that diagnosis was finally made after 40 days of fever.

Transection of the obturator nerve by an electrosurgical instrument and its immediate repair during laparoscopic pelvic lymphadenectomy: a case report

Obturator nerve injury seldom occurs in gynecologic surgery. However, gynecologic oncologic surgery, including pelvic lymph node dissection, increases the risk of this type of injury. Microsurgical techniques are usually performed for the repair of the nerve injury. Herein the authors report a case of obturator nerve injury caused by an electrosurgical instrument during laparoscopic pelvic lymphadenectomy, and its prompt repair by laparoscopic procedure in a 44-year-old patient with cervical cancer.

Randomised, double-blind trial of carboplatin and paclitaxel with daily oral cediranib or placebo in patients with advanced non-small cell lung cancer: NCIC Clinical Trials Group study BR29

INTRODUCTION

This randomised double-blind placebo-controlled study evaluated the addition of cediranib, an inhibitor of vascular endothelial growth factor receptors 1-3, to standard carboplatin/paclitaxel chemotherapy in advanced non-small cell lung cancer.

METHODS

Eligible patients received paclitaxel (200mg/m(2)) and carboplatin (area under the concentration time curve 6) intravenously every 3 weeks. Daily oral cediranib/placebo 20mg was commenced day 1 of cycle 1 and continued as monotherapy after completion of 4-6 cycles of chemotherapy. The primary end-point of the study was overall survival (OS). The trial would continue to full accrual if an interim analysis (IA) for progression-free survival (PFS), performed after 170 events of progression or death in the first 260 randomised patients, revealed a hazard ratio (HR) for PFS of ⩽ 0.70.

RESULTS

The trial was halted for futility at the IA (HR for PFS 0.89, 95% confidence interval [CI] 0.66-1.20, p = 0.45). A final analysis was performed on all 306 enrolled patients. The addition of cediranib increased response rate ([RR] 52% versus 34%, p = 0.001) but did not significantly improve PFS (HR 0.91, 95% CI 0.71-1.18, p = 0.49) or OS (HR 0.94, 95% CI 0.69-1.30, p=0.72). Cediranib patients had more grade 3 hypertension, diarrhoea and anorexia.

CONCLUSIONS

The addition of cediranib 20mg daily to carboplatin/paclitaxel chemotherapy increased RR and toxicity, but not survival.

The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism

OBJECTIVE

Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE.

METHODS

In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined.

RESULTS

Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01).

CONCLUSION

At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE.

ADVANCES IN KNOWLEDGE

The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE.

Association of KIR genes and HLA-C alleles with HPV-related uterine cervical disease in Korean women

This study investigated whether killer-cell immunoglobulin-like receptor (KIR) genes and human leukocyte antigen (HLA)-C alleles, receptors and ligands of natural killer cells are associated with the development of human papillomavirus (HPV)-related cervical disease in Korean women. Blood samples from 132 women with HPV-related cervical disease and 159 women without HPV infection were collected for genotyping of KIR genes and HLA-C alleles. Although no relationship was found between KIR genes and HPV-related cervical disease, a significant relationship was found between HLA-C alleles as ligands of KIR and HPV-related cervical disease. Women with HPV-related cervical disease were found to be significantly more likely to carry HLA-C*0303, particularly those with HPV 16 or 18 infection, and less likely to carry HLA-C*01 compared to women without HPV infection. HLA-C*0303 was found to confer susceptibility to HPV-related cervical disease, whereas HLA-C*01 was found to confer a protective effect against HPV-related cervical disease.