Sex-Related Differences in Utilization and Outcomes of Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest

Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 ± 16.9 years (mean ± standard deviation) and men's 54.7 ± 14.1 (p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men (p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men (p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.

Racial disparities among patients on venovenous extracorporeal membrane oxygenation in the pre-Coronavirus Disease 2019 and Coronavirus Disease 2019 eras: A retrospective registry review

Objectives

Although many studies have addressed such disparities caused by COVID-19, to our knowledge, no study has focused on the association of race on outcomes for patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation support. The goal of this study was to assess association of race on death and duration on venovenous extracorporeal membrane oxygenation in both the pre-COVID-19 and COVID-19 eras.

Methods

We retrospectively reviewed the Extracorporeal Life Support Organization registry and included adults (≥18 years) who required venovenous extracorporeal membrane oxygenation between January 2019 and April 2021. We performed descriptive statistics and multivariable logistic regression. Our primary outcomes were death and extracorporeal membrane oxygenation duration.

Results

A total of 7477 patients were included after excluding 340 patients (4.3%) who were missing race data. In the COVID-19 era, 1474 of 2777 COVID-19-positive patients (53.1%) died. Our regression model suggested somewhat of a protective effect on death for Black and multiple race patients. Additionally, a diagnosis of COVID-19 and patients in the COVID-19 era in general, irrespective of COVID-19 diagnosis, had higher odds of death. Hispanic patients had the longest average venovenous extracorporeal membrane oxygenation run times.

Conclusions

Our study using data from the international Extracorporeal Life Support Organization Registry provides updated data on patients supported with venovenous extracorporeal membrane oxygenation in the pre-COVID-19 and COVID-19 eras between 2019 and 2021 with a focus on race. Patients in the COVID-19 era group also had higher mortality compared with those in the pre-COVID-19 era even after being adjusted for COVID-19 diagnosis. Black and multiple races appeared somewhat protective in terms of death. Hispanic race was associated with longer venovenous extracorporeal membrane oxygenation duration.

1039 RECEIVING ASSISTANCE FROM DOMESTIC ROBOTS: WHAT ARE ELDERS’ PREFERENCES?

Introduction

Aging leads to decline in physical and functional ability. Strengthening the domestic support enables elders to manage their health and living at home and reduce their need for residential service. Domestic robots can potentially provide a broad range of support to the elders. However, relatively little research attention has investigated elders’ preferences on it. This study aims to investigate elders’ preferences on receiving assistance from domestic robots.

Methods

This cross-sectional descriptive study recruited a convenient sample of 365 robotic inexperienced elders (65-99 years old). It used the Assistance Preference Checklist to assess participants’ preferences on receiving assistance from domestic robots in 48 home-based tasks under six aspects including personal care, leisure activities, health assistance, chores, information management, and manipulating objects. It used t-test and one-way analysis of variance to compare the difference in preferences between participants with different demographic and health characteristics.

Results

Overall, participants preferred domestic robots to assist in tasks under the aspect on chores, information management, and manipulating objects. Specifically, males indicated a higher preference for domestic robots to assist in maintaining lawn or raking leaves than females (p = 0.05). Married participants indicated a higher preference for domestic robots to assist in getting information on weather/news than unmarried participants (p = 0.049). In contrast, participants who were partially dependent and fully dependent indicated a higher preference for domestic robots to assist in tasks under the personal care aspect such as shaving, bathing, washing/combing hair, getting dressed, walking, and brushing teeth (p &lt; 0.001), comparing to participants who were physically independent.

Conclusion

This study provides insight for manufacturers to develop domestic robots with specific capabilities which are important to support elders’ living in the community. Moreover, it helps the care providers to identify domestic robots with the required capabilities that meet elders’ specific preferences.

1040 VALIDATION OF THE CHINESE VERSION OF THE ASSISTANCE PREFERENCE CHECKLIST

Introduction

Domestic robots have great potential to be developed as a useful and supportive device for elders in domestic setting. To achieve the intended purpose, the designs of domestic robots should make reference to elders’ preferences. The Assistance Preference Checklist is developed to assess elders’ preferences on receiving assistance from domestic robots. It comprises of 48 home-based task under six categories including personal care, leisure activities, health assistance, chores, information management, and manipulating objects. Altogether, these tasks are considered important for the elders to fulfil their general health needs and maintain their homes. The Assistance Preference Checklist is valid and reliable. To adapt it in the Chinese population, the Assistance Preference Checklist has been translated from English to Chinese according to the standard translation model. This study aims to validate the Chinese version of the Assistance Preference Checklist (the checklist).

Method

This was a validation study. Semantic and content equivalence of the checklist was evaluated by an expert panel (five academic specialized on instrument validation or translation and 15 nurses specialized on geriatrics). Content validity of the checklist was assessed by another expert panel (one academic specialized on instrument validation and two nurses specialized on geriatrics). Internal consistency of the checklist was determined by Cronbach's method on a convenience sample of 50 Chinese-speaking elders in Hong Kong.

Results

The checklist demonstrated good semantic and content equivalence with the original English version. The experts agreed that it was appropriately translated. The checklist demonstrated good content validity by having a content validity index of 1.00. Additionally, the checklist reported satisfactory internal consistency by having a Cronbach's alpha of 0.95.

Conclusion

The Chinese version of the Assistance Preference Checklist is a useful instrument for assessing elders’ preferences on receiving assistance from domestic robots. Findings provide evidence on its validity and reliability.

1047 VALIDATION OF THE CHINESE VERSION OF THE KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

Introduction

Among the instruments that measure an elder’s functional dependence level, the Katz Index of Independence in Activities of Daily Living has the advantages of being neutral, easy to use, valid, and reliable. It is a six-item instrument rating an elder’s functional dependence level in performing activities of daily living, including bathing, dressing, toileting, transferring, continence, and feeding. Each item can be rated nominally as 1 (does not require assistance to finish the activity) or 0 (requires assistance to finish the activity). By summing the score of the six items, the functional dependence level of an elder can be classified as independent (6 points), partially dependent (3–5 points), or dependent (&lt; 2 points). The instrument has been translated from English to Chinese through forward and backward translation. This study aims to validate the Chinese version of the Katz Index of Independence in Activities of Daily Living (Katz ADL-Chinese).

Method

This was a validation study. The Katz ADL-Chinese was examined by an expert panel (one academic specialized on instrument validation, four academic specialized on translation, fifteen nurses specialized on geriatrics) for its semantic and content equivalence with the original English version. It was evaluated by another expert panel (one academic specialized on instrument validation and two nurses specialized on geriatrics) for its content validity. Moreover, it was tested and re-tested at 1-week interval on 30 Chinese-speaking elders in Hong Kong.

Results

Good result was achieved on the testing for semantic and content equivalence. All experts confirmed that the Katz ADL-Chinese was appropriately translated. Good content validity was observed. The context validity index at item-level and scale-level was 1.00, respectively. Good stability was observed as well. The test–retest reliability coefficient was 0.85.

Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy

Background

The purpose of the study was to characterize changes in waitlist and post-transplant outcomes of extracorporeal membrane oxygenation (ECMO) patients bridged to heart transplantation under the 2018 adult heart allocation policy.

Methods

All adult patients listed for isolated heart transplantation from August 2016 to December 2020 were identified using the United Network for Organ Sharing database. Patients were stratified into Eras (Era 1 and Era 2) centered around the policy change on October 18, 2018. Competing risk regression was used to evaluate waitlist death or deterioration across Eras. Cox proportional hazards models were used to determine associations between use of ECMO and 1-year post-transplant mortality within each Era.

Results

Of 8,902 heart transplants included in analysis, 339 (3.8%) were bridged with ECMO (Era 2: 6.1% vs Era 1: 1.2%, P<0.001). Patients bridged with ECMO in Era 2 were less frequently female (26.0% vs 42.0%, P = 0.02) and experienced shorter waitlist times (5 vs 11 days, P<0.001) along with a lower likelihood of waitlist death or deterioration (subdistribution hazard ratio, 0.45, 95% confidence interval, CI, 0.30–0.68, P<0.001) compared to those in Era 1. Use of ECMO was associated with increased post-transplant mortality at 1-year compared to all other transplants in Era 1 (hazard ratio 3.78, 95% CI 1.88–7.61, P < 0.001) but not Era 2.

Conclusions

Patients bridged with ECMO in Era 2 experience improved waitlist and post-transplant outcomes compared to Era 1, giving credence to the increased use of ECMO under the new allocation policy.

Heart transplantation strategies in arrhythmogenic right ventricular cardiomyopathy: a tertiary ARVC centre experience

Aims

Methods and results

Conclusions

Neurophysiological Findings and Brain Injury Pattern in Patients on ECMO

Introduction. Brain injury is a major determinant of outcomes in extracorporeal membrane oxygenation (ECMO). Neurologic prognostication in ECMO has not been established. Absent electroencephalogram (EEG) reactivity and absent N20 on somatosensory evoked potential (SSEP) are associated with poor outcome in other types of brain injuries, especially following cardiopulmonary arrest. It is currently known if the same criteria are applicable in patients on ECMO. Methods. Continuous EEG (cEEG) was performed for patients with a Glasgow Coma Scale (GCS) <8 and SSEP data were performed for patients with a motor GCS < 4 in a prospective observational cohort undergoing ECMO at a tertiary center. EEG variables including reactivity were collected. SSEPs were categorized into absence, delay, or presence of N20. Poor outcome was defined as cerebral performance category 3 to 5 at discharge. Results. We present 13 consecutive patients who underwent both cEEG and SSEP. The median time from cannulation to EEG and SSEP were 3 (interquartile range [IQR] = 1-6) and 5 (IQR = 2-7) days, respectively. All patients were in coma and 12 (92%) had poor outcomes. Ten (77%) underwent brain computed tomography, the findings of which explained coma in only 2. Patients (n = 12) with poor outcome had poor variability, absent reactivity, and lack of sleep features with diffusely slow theta-delta background on the EEG. Despite poor outcomes, all had relatively preserved or normal N20 responses. One patient with preserved reactivity and sleep features on the EEG and intact SSEP had a good outcome. Conclusions. Absent EEG reactivity with the preservation of SSEP N20 was associated with poor outcome in comatose ECMO patients. We advise caution in interpreting electrophysiological tests in prognosticating ECMO patients until the patterns and outcomes are better understood.

Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support

OBJECTIVE

There is limited evidence on standardized protocols for optimal neurological monitoring methods in patients receiving extracorporeal membrane oxygenation (ECMO). We previously introduced protocolized noninvasive multimodal neuromonitoring using serial neurological examinations, electroencephalography, transcranial Doppler ultrasound, and somatosensory evoked potentials. The purpose of this study was to examine if standardized neuromonitoring is associated with detection of acute brain injury (ABI) and improved patient outcomes.

METHODS

A retrospective analysis of ECMO patients who received neurocritical care consultation was performed and outcomes were reviewed. The cohort was stratified according to those who did not receive standardized neuromonitoring (era 1: 2016-2017) and those who received standardized neuromonitoring (era 2: 2017-2020). Multivariable logistic regression was used to evaluate the association between standardized neuromonitoring and ABI.

RESULTS

A total of 215 patients (mean age, 54 years; 60% male) underwent ECMO (71% venoarterial-ECMO) in our institution, 70 in era 1 and 145 in era 2. The proportion of patients diagnosed with ABI were 23% in era 1 and 33% in era 2 (P = .12). In multivariable logistic regression, standardized neuromonitoring (odds ratio, 2.24; 95% CI, 1.12-4.48; P = .02) and pre-ECMO cardiac arrest (odds ratio, 2.17; 95% CI, 1.14-4.14; P = .02) were independently associated with ABI. There was a greater proportion of patients with good neurological outcomes when discharged alive in era 2 (54% vs 30%; P = .04).

CONCLUSIONS

Standardized neuromonitoring was associated with increased ABIs in ECMO patients. Although neuromonitoring does not prevent ABI from occurring, it might prevent worsening with timely interventions (eg, anticoagulation management, optimizing oxygen delivery and blood pressure), leading to improved neurological outcomes at discharge.

Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation

OBJECTIVES

To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation.

DESIGN

A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0-3 defined as a good neurologic outcome, and a score of 4-6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes.

SETTING

The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01-1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04-1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06-1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08-1.29; p < 0.001).

CONCLUSIONS

In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.

Multi-Institutional Evaluation of a Debate-Style Journal Club for Cardiothoracic Surgery Trainees

BACKGROUND

Traditional journal clubs address individual articles and are limited in terms of breadth and depth of content covered. The present study describes the outcomes of a novel debate-style journal club in a multi-institutional setting.

METHODS

Participating institutions were recruited through the Thoracic Education Cooperative Group (TECoG). The distributed curriculum included instructions, debate scenarios, suggested article lists, moderator slides, debate scoresheets, exams, and feedback surveys.

RESULTS

Six institutions participated in the study (2015-2019), consisting of a total of 10 years' worth of cumulative debates. Cardiothoracic surgery trainees participated in 10 monthly debates over each academic year. Trainee performance on the written examination in the realm of evidence-based medicine and critical appraisal improved over the course of the academic year (beginning 55.2% vs end 76.3%, p=0.040). Importantly, written examination after debates revealed a significant improvement in scores on questions relating to topics that were debated as compared to those that were not (+27.1% vs +2.5%, p=0.006), emphasizing the importance of the debates as compared to other sources of knowledge gain. Surveys completed by trainees and faculty overall favored the debate-style journal club as compared to the traditional journal club in gaining familiarity with seminal literature in the field, improving upon oral presentation skills, and applying published literature to questions encountered clinically.

CONCLUSIONS

In this multi-institutional prospective study, we demonstrate that the novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to acquire, retain, and gain practice in applying literature-based evidence to case-based scenarios.

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.

The 2018 adult heart allocation policy change benefits low-volume transplant centers

INTRODUCTION

The effect of the 2018 adult heart allocation policy change at an institution-level remains unclear. The present study assessed the impact of the policy change by transplant center volume.

METHODS

The United Network for Organ Sharing database was queried for all adults undergoing isolated heart transplantation from November 2016 to September 2020. Era 1 was defined as the period before the policy change and Era 2 afterwards. Hospitals were divided into low-(LVC) medium-(MVC) and high-volume (HVC) tertiles based on annual transplant center volume. Competing-risks regressions were used to determine changes in waitlist death/deterioration, while post-transplant mortality was assessed using multivariable Cox proportional-hazards models.

RESULTS

A total of 3531 (47.0%) patients underwent heart transplantation in Era 1 and 3988 (53.0%) in Era 2. At LVC, Era 2 patients were less likely to experience death/deterioration on the waitlist (subhazard ratio .74, 95% CI .63-.88), while MVC and HVC patients experienced similar waitlist death/deterioration across eras. After adjustment, transplantation in Era 2 was associated with worse 1-year mortality at MVC (hazard ratio, HR, 1.42 95% CI 1.02-1.96) and HVC (HR 1.42, 95% CI 1.02-1.98) but not at LVC.

CONCLUSION

Early analysis shows that LVC may be benefitting under the new allocation scheme.

Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)?

PURPOSE

Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest.

METHODS

We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data.

RESULTS

We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR (P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) (P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time.

CONCLUSIONS

Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.

Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation

OBJECTIVE

As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST.

DESIGN

Retrospective cohort study.

SETTING

Single academic hospital center.

PARTICIPANTS

Adult ECMO patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, 150 patients (mean age 54.8 ± 15.9 y, 43.3% female) underwent ECMO (80% venoarterial ECMO and 20% venovenous ECMO). Seventy-three (48.7%) had WLST from ECMO support (median five days), and 33 of those (45.2%) had early WLST (≤five days). Patients who underwent WLST were older (60.3 ± 15.3 y v 49.6 ± 14.7 y; p < 0.001) than those who did not undergo WLST and had greater body mass index (31.7 ± 7.6 kg/m²v 28.3 ± 5.5 kg/m²; p = 0.002), longer ECMO duration (six v four days; p = 0.01), and higher Acute Physiology and Chronic Health Evaluation (25 v 21; p < 0.001) and Sequential Organ Failure Assessment (12 v 11; p = 0.037) scores. Family request frequently (91.7%) was cited as part of the WLST decision. WLST patients experienced more chaplaincy (89% v 65%; p < 0.001), palliative care consults (53.4% v 29.9%; p = 0.003), and code status change (do not resuscitate: 83.6% v 7.8%; p < 0.001).

CONCLUSIONS

Nearly 50% of ECMO patients underwent WLST, with approximately 25% occurring in the first 72 hours. These patients were older, sicker, and experienced a different clinical context. Unlike with other critical illnesses, neurologic injury was not a primary reason for WLST in ECMO patients.

A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke

The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.

Decreased Nutritional Risk Index is associated with mortality after heart transplantation

INTRODUCTION

Validated scoring tools, such as the Nutritional Risk Index (NRI), can aid clinicians in quantifying the degree of malnourishment in patients prior to an operation. We evaluated the association between NRI and outcomes after heart transplantation.

METHODS

The United Network for Organ Sharing (UNOS) database was used to identify adult patients (age > 18) undergoing heart transplantation between 1987 and 2016. NRI was calculated and categorized into previously established groupings representing severity of malnutrition. Multivariate Cox proportional hazards modeling were used to assess the primary outcome of all-cause mortality.

RESULTS

A total of 25,236 patients were included in the analysis. Most patients (75.4%) were male. Malnourishment was absent (NRI ≥ 100) in 11,022 (44%) patients, while 2,898 (12%) were mildly malnourished (97.5 ≤ NRI < 100), 8,685 (34%) were moderately malnourished (83.5 ≤ NRI < 97.5), and 2,631 (10%) were severely malnourished (NRI < 83.5). Moderate-to-severe malnutrition was associated with increased mortality (HR = 1.18, p < .001, 95%CI: 1.13-1.24), and post-transplant renal failure requiring dialysis (OR: 1.13, p < .001, 95%CI: 1.03-1.23).

CONCLUSION

Malnourishment determined by NRI is independently associated with mortality and post-transplant dialysis after heart transplant. This is the largest study of NRI in heart transplant recipients.

Time-Resolved Echo-Particle Image/Tracking Velocimetry Measurement of Interactions Between Native Cardiac Output and Veno-Arterial ECMO Flows

Determination of optimal hemodynamic and pressure-volume loading conditions for patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) would benefit from understanding the impact of ECMO flow rates (QE) on the native cardiac output in the admixing zone, i.e., aortic root. This study characterizes the flow in the aortic root of a pig with severe myocardial ischemia using contrast-enhanced ultrasound particle image/tracking velocimetry (echo-PIV/PTV). New methods for data preprocessing are introduced, including autocontouring to remove surrounding tissues, followed by blind deconvolution to identify the centers of elongated bubble traces in images with low signal to noise ratio. Calibrations based on synthetic images show that this procedure increases the number of detected bubbles and reduces the error in their locations by 50%. Then, an optimized echo-PIV/PTV procedure, which integrates image enhancement with velocity measurements, is used for characterizing the time-resolved two-dimensional (2D) velocity distributions. Phase-averaged and instantaneous flow fields show that the ECMO flow rate influences the velocity and acceleration of the cardiac output during systole, and secondary flows during diastole. When QE is 3.0 L/min or higher, the cardiac ejection velocity, phase interval with open aortic valve, velocity-time integral (VTI), and mean arterial pressure (MAP) increase with decreasing QE, all indicating sufficient support. For lower QE, the MAP and VTI decrease as QE is reduced, and the deceleration during transition to diastole becomes milder. Hence, for this specific case, the optimal ECMO flow rate is 3.0 L/min.

Risk Factors of Ischemic and Hemorrhagic Strokes During Venovenous Extracorporeal Membrane Oxygenation: Analysis of Data From the Extracorporeal Life Support Organization Registry

OBJECTIVES

Stroke is commonly reported in patients receiving venovenous extracorporeal membrane oxygenation, but risk factors are not well described. We sought to determine preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors for both ischemic and hemorrhagic strokes in patients with venovenous extracorporeal membrane oxygenation support.

DESIGN

Retrospective analysis.

SETTING

Data reported to the Extracorporeal Life Support Organization by 366 extracorporeal membrane oxygenation centers from 2013 to 2019.

PATIENTS

Patients older than 18 years supported with a single run of venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 15,872 venovenous extracorporeal membrane oxygenation patients, 812 (5.1%) had at least one type of acute brain injury, defined as ischemic stroke, hemorrhagic stroke, or brain death. Overall, 215 (1.4%) experienced ischemic stroke and 484 (3.1%) experienced hemorrhagic stroke. Overall inhospital mortality was 36%, but rates were higher in those with ischemic or hemorrhagic stroke (68% and 73%, respectively). In multivariable analysis, preextracorporeal membrane oxygenation pH (adjusted odds ratio = 0.10; 95% CI, 0.03-0.35; p < 0.001), hemolysis (adjusted odds ratio = 2.27; 95% CI, 1.22-4.24; p = 0.010), gastrointestinal hemorrhage (adjusted odds ratio = 2.01; 95% CI 1.12-3.59; p = 0.019), and disseminated intravascular coagulation (adjusted odds ratio = 3.61; 95% CI, 1.51-8.66; p = 0.004) were independently associated with ischemic stroke. Pre-extracorporeal membrane oxygenation pH (adjusted odds ratio = 0.28; 95% CI, 0.12-0.65; p = 0.003), preextracorporeal membrane oxygenation Po2 (adjusted odds ratio = 0.96; 95% CI, 0.93-0.99; p = 0.021), gastrointestinal hemorrhage (adjusted odds ratio = 1.70; 95% CI, 1.15-2.51; p = 0.008), and renal replacement therapy (adjusted odds ratio=1.57; 95% CI, 1.22-2.02; p < 0.001) were independently associated with hemorrhagic stroke.

CONCLUSIONS

Among venovenous extracorporeal membrane oxygenation patients in the Extracorporeal Life Support Organization registry, approximately 5% had acute brain injury. Mortality rates increased two-fold when ischemic or hemorrhagic strokes occurred. Risk factors such as lower pH and hypoxemia during the pericannulation period and markers of coagulation disturbances were associated with acute brain injury. Further research on understanding preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors and the timing of acute brain injury is necessary to develop appropriate prevention and management strategies.

Post-partum spontaneous coronary artery dissection refractory to conservative management

This case report describes a 31-year-old female who was diagnosed with a spontaneous coronary artery dissection (SCAD) of her left anterior descending artery during the post-partum period. She failed nonoperative management and was found to have extensive propagation of the dissected vessel associated with recurrent chest pain. She ultimately underwent coronary artery bypass grafting which restored perfusion and cardiac wall motion. A brief discussion of the presentation, diagnosis, and management of SCAD follows.

Therapeutic drug monitoring of valproic acid in extracorporeal membrane oxygenation

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for those in cardiopulmonary failure, including post-cardiac arrest. Despite a high volume of ECMO patients using anti-seizure medication, there is a paucity of data concerning the dosing, levels, and clinical scenarios for their use.

CASE REPORT

We present three cases of ECMO patients post-PEA arrest who were on valproic acid (VPA) for treatment of seizure and/or myoclonus. The total and free levels of VPA are reported.

DISCUSSION

The trough levels are consistent throughout therapy, suggesting VPA is not significantly removed by the ECMO circuitry. Although the total serum levels remained below the toxic range, the free level was elevated in two patients. These patients did not develop signs of toxicity.

CONCLUSION

VPA may be an effective anti-seizure medication in ECMO patients. Free VPA levels should be more readily available to better quantify efficacy or toxicity, especially in ECMO patients.

Brain magnetic resonance imaging in adult survivors of extracorporeal membrane oxygenation

Despite the common occurrence of neurologic complications in patients with extracorporeal membrane oxygenation (ECMO), data on magnetic resonance imaging (MRI) findings in adult ECMO are limited. We aimed to describe the MRI findings of patients after ECMO cannulation. Records of patients who underwent ECMO from September 2017 to June 2019 were reviewed. MRI studies were performed using multiplanar sequences consisting of T1-, T2-weighted, fluid attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and susceptibility weighted images (SWI). Of the 78 adult patients who underwent ECMO, 26 (33%) survived. Of 26, eight patients (31%) had MRI studies, with a median age of 47 years (interquartile range [IQR]: 25-57). The median ECMO support time was 8 days (IQR: 4-25) and the median time from decannulation to MRI was 12 days (IQR: 1-34). Five (63%) of eight patients had ischemic infarcts; 4 (50%) had cerebral microhemorrhage; 2 (25%) had intracranial hemorrhage; and 1 (13%) had thoracic cord ischemic infarct. There were no patients with normal MRI. All patients underwent transcranial Doppler (TCD). Four of 8 (50%) showed presence of microemboli with TCD; 3 of 4 (75%) had ischemic infarcts; and 1 of 4 (25%) had presence of multiple cerebral microhemorrhages on MRI. All ischemic infarcts had diffuse pattern of punctate to small lesions for ECMO survivors. The location of cerebral microhemorrhages included lobar (n = 4, 100%), deep (n = 2, 50%), and both (n = 2, 50%). Of the MRI studies, cerebrovascular related lesions were the most frequent, with punctate ischemic infarct being the most common type that may be associated with TCD microemboli. The results of the study suggest that subclinical cerebral lesions are commonly found in patients with ECMO support. Further research is needed to understand long-term effect of these cerebral lesions.

The Ethics of Extracorporeal Membrane Oxygenation: Revisiting the Principles of Clinical Bioethics

BACKGROUND

Extracorporeal life support has become accepted as a rescue therapy for cardiopulmonary shock, and there have been over 100,000 extracorporeal membrane oxygenation (ECMO) cases since 1987. Rapid growth has presented ethical challenges and concerns. Here, we discuss core principles of bioethics in an attempt to more thoroughly appreciate the ethical concerns and considerations raised by use of this technology.

METHODS

An extensive literature review was performed on current papers on ECMO and ethics. In this paper, we utilized 3 case studies to highlight 4 major tenets of bioethics as they relate to use of ECMO: autonomy, beneficence, nonmaleficence, and justice.

RESULTS

Case studies presented involved unique perspectives on utilization of ECMO and a careful balance of benefits and harms as they relate to autonomy, beneficence, nonmaleficence and justice. We present nuanced interpretations of autonomy (eg, physician autonomy) and justice (eg, various providers interpret and offer ECMO differently). An additional challenge includes contending with potentially prolonged clinical courses and/or complications that either result directly from cannulation for ECMO or indirectly from being subject to ensuing extreme conditions and prolongation of life that medical science has yet to fully understand.

CONCLUSIONS

ECMO programs continue to grow in number and capacity. A deep appreciation of the bioethical dimensions of this technology and its application must be pursued, understood and applied to individual patient scenarios.

The Use of Cerebral NIRS Monitoring to Identify Acute Brain Injury in Patients With VA-ECMO

Acute brain injury (ABI) increases morbidity and mortality in patients with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Optimal neurologic monitoring methods have not been well-explicated. We studied the use of Near-infrared Spectroscopy (NIRS) to monitor cerebral regional oxygenation tissue saturation (rSO2) and its relation to ABI in VA-ECMO. In this prospective, observational cohort study of 39 consecutive patients, we analyzed the ability of rSO2 values from continuous bedside NIRS monitoring to predict ABI during VA-ECMO support. ABI occurred in 24 (61.5%) patients. Those with ABI had a lower pre-ECMO Glasgow Coma Scale, more blood product transfusions of pRBCs and FFP, and higher APACHEII score. Baseline rSO2 values were not significantly different between cohorts (54.25 vs 58.50, p = 0.260), while the minimum rSO2 value was lower for patients who experienced an ABI than those who did not (39.75 vs 44.50, p = 0.039). In patients with ABI, 21 (87.5%) had a drop in rSO2 of 25% from baseline, compared to only 7 (46.7%) patients without ABI (p = 0.017). By ROC analysis, we found that desaturations with >25% drop from the baseline rSO2 on VA-ECMO exhibited 86% sensitivity and 55% specificity to predict ABI, with an area under the curve of 0.68. Patients with ABI were more likely to have withdrawal of life sustaining therapy (17 vs 5, p = 0.049), while neurologic outcome and mortality were not statistically different between patients with or without ABI. Our results support that cerebral NIRS is a useful, real-time bedside neuromonitoring tool to detect ABI in VA-ECMO patients. A >25% drop from the baseline was sensitive in predicting ABI occurrence. Further research is needed to assess how to implement this knowledge to utilize NIRS in developing appropriate intervention strategy in VA-ECMO patients.

Effects of a Mindfulness-based Intervention on diurnal cortisol pattern in disadvantaged families: A randomized controlled trial

OBJECTIVE

The present study examined the psychophysiological effects of Family-based Mindfulness Intervention (FBMI) on children and parents from disadvantaged families.

METHODS

This randomized controlled trial recruited parents and their children from 51 disadvantaged families in Hong Kong and randomized them into FBMI (n = 26) and waitlist control (n = 25) groups. The parent intervention included 6 sessions and the child intervention included 8 sessions with 2 half-hour joint programs. Both interventions lasted 9 hours in total each. All participants completed four salivary cortisol measures after wakeup, before lunchtime, late-afternoon, and before sleep at baseline and end of the intervention. The diurnal cortisol pattern was summarized by the morning cortisol, evening cortisol, mean cortisol, and diurnal cortisol slope.

RESULTS

Compared to the control group, children in the FBMI group showed significant increases in morning cortisol (d = 0.50, p =  0.03) and significant decreases in diurnal cortisol slopes (d = 0.50, p =  0.04) at the end of intervention. Parents in the FBMI group displayed significant decreases in evening cortisol (d = 0.50, p =  0.04) compared to the control group at the end of intervention. No significant treatment effects were found on the mean cortisol.

DISCUSSION

The present findings suggest that FBMI could improve the diurnal cortisol slope and cortisol levels of the children and parents from disadvantaged families, respectively. Future studies should elucidate its potential benefits on neuroendocrine functioning.

The relationship between clinical characteristics including presence of exposed lesions and health-related quality of life (HRQoL) in patients with psoriasis: analysis from the nationwide epidemiologic study for psoriasis in Korea (EPI-PSODE study)

BACKGROUND

Psychological aspect and quality of life should be considered in treating patients with psoriasis.

OBJECTIVE

We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis.

METHODS

The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ).

RESULTS

Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental).

CONCLUSION

The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

Minimal residual disease-based effect and long-term outcome of first-line dasatinib combined with chemotherapy for adult Philadelphia chromosome-positive acute lymphoblastic leukemia

BACKGROUND

The use of imatinib combined with chemotherapy has demonstrated improved outcome in adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-positive ALL). However, a substantial proportion of patients continue to die as a result of disease progression.

PATIENTS AND METHODS

We assessed the minimal residual disease (MRD)-based effect and long-term outcome of first-line incorporation of dasatinib (100 mg once daily) into chemotherapy alternatively for adults with Ph-positive ALL. The primary end point was the major molecular response (MMR) rate by the end of the second dasatinib cycle. Patients with a donor proceeded to allogeneic stem cell transplantation (SCT) as early as possible. MRD monitoring was centrally evaluated by real-time quantitative polymerase chain reaction (4.5-log sensitivity) using bone marrow samples.

RESULTS

Fifty-one patients (median age, 46 years) were enrolled and treated with this strategy. After the first dasatinib cycle, 50 patients (98.0%) achieved complete remission (CR). By the end of the second dasatinib cycle, 46 (93.9%) of 49 assessable patients had persistent CR, and 38 (77.6%) had MMR (32.7%) or undetectable MRD (44.9%). On the basis of the MRD kinetics by this time point, the numbers of early-stable, late, and poor molecular responders were 23 (46.9%), 15 (30.7%), and 11 (22.4%), respectively. Thirty-nine patients (76.5%) underwent allogeneic SCT in CR1. After a median follow-up of 54 months, the 4-year cumulative incidence of relapse and disease-free survival (DFS) rate for all patients were 30.0% and 52.0%, respectively, and the corresponding outcomes among those receiving allogeneic SCT in CR1 were 20.5% and 64.1%, respectively. Poor molecular responders had a higher risk of relapse and DFS than those of early-stable molecular responders.

CONCLUSION

This dasatinib-based protocol was effective for achieving a good quality molecular response and durable DFS in adults with Ph-positive ALL.

TRIAL REGISTRATION

clinicaltrials.gov, NCT01004497.

Retinoic Acid as a Radiosensitizer on the Head and Neck Squamous Cell Carcinoma Cell Lines

PURPOSE

Retinoic acid is a substance that has previously been reported to increase radiosensitivity, but at concentrations likely to inhibit cell growth or to induce celluar differentiation. We choose head and neck cancer cell lines to investigate the role of retinoic acid as a radiosensitizer and to elucidate the mechanism through the changes in the expression of retinoid receptors and squamous cell differentiation marker.

MATERIALS AND METHODS

Three cell lines (PCI-50, SqCC/ Y1 and UMSCC-11B) were used. 7-AAD staining for apoptosis and Western blot analysis for RAR-alpha, beta, gamma, RXR-alpha, beta, gamma and involucrin were performed after various treatments (control, beta-all-trans-retinoic acid (t-RA) only (10 6 M), radiation only (3 Gy), radiation with t-RA).

RESULTS

The synergistic radiosensitivity effect of t-RA was seen only radioresistant UMSCC-11B cell line. Expression of RAR-beta was induced by t-RA in maily UMSCC- 11B cell line. RAR-alpha,gamma, and RXR-alpha, beta, gamma expression were not changed in all cell lines tested. Expression of involucrin was inhibited by t-RA in PCI-50 cell line but other two cell lines were not changed by t-RA treatment.

CONCLUSION

We found that only radioresistant cell line (UMSCC-11B) showed synergistic radiosensitivity effect by t-RA and this mechanism may be through RAR-beta expression induction.

AMPKα, C/EBPβ, CPT1β, GPR43, PPARγ, and SCD Gene Expression in Single- and Co-cultured Bovine Satellite Cells and Intramuscular Preadipocytes Treated with Palmitic, Stearic, Oleic, and Linoleic Acid

We previously demonstrated that bovine subcutaneous preadipocytes promote adipogenic gene expression in muscle satellite cells in a co-culture system. Herein we hypothesize that saturated fatty acids would promote adipogenic/lipogenic gene expression, whereas mono- and polyunsaturated fatty acids would have the opposite effect. Bovine semimembranosus satellite cells (BSC) and intramuscular preadipocytes (IPA) were isolated from crossbred steers and cultured with 10% fetal bovine serum (FBS)/Dulbecco’s Modified Eagle Medium (DMEM) and 1% antibiotics during the 3-d proliferation period. After proliferation, cells were treated for 3 d with 3% horse serum/DMEM (BSC) or 5% FBS/DMEM (IPA) with antibiotics. Media also contained 10 μg/mL insulin and 10 μg/mL pioglitazone. Subsequently, differentiating BSC and IPA were cultured in their respective media with 40 μM palmitic, stearic, oleic, or linoleic acid for 4 d. Finally, BSC and IPA were single- or co-cultured for an additional 2 h. All fatty acid treatments increased (p = 0.001) carnitine palmitoyltransferase-1 beta (CPT1β) gene expression, but the increase in CPT1β gene expression was especially pronounced in IPA incubated with palmitic and stearic acid (6- to 17- fold increases). Oleic and linoleic acid decreased (p = 0.001) stearoyl-CoA desaturase (SCD) gene expression over 80% in both BSC and IPA. Conversely, palmitic and stearic acid increased SCD gene expression three fold in co-cultured in IPA, and stearic acid increased AMPKα gene expression in single- and co-cultured BSC and IPA. Consistent with our hypothesis, saturated fatty acids, especially stearic acid, promoted adipogenic and lipogenic gene expression, whereas unsaturated fatty acids decreased expression of those genes associated with fatty acid metabolism.

Investigation on antibacterial and antioxidant activities, phenolic and flavonoid contents of some thai edible plants as an alternative for antibiotics

This study was aimed to examine the antibacterial and antioxidative properties of seven edible plants from Thailand to develop alternative antibiotics as feed additives. The plants include Citrus aurantifolia Swingle (Lime) fruits and its leaves, Sesbania grandiflora L. (Agati sesbania) leaves, Piper sarmentosum Roxb (Wild betal) leaves, Curcuma domestica Valeton (Turmeric) roots, Morinda citrifolia L. (Beach mulberry) leaves, Cassia siamea britt (Siamea cassia) leaves, and Cocos nucifera L. (Coconut) peels. The plants were extracted by methanol, n-hexane, chloroform, ethyl acetate, butanol and water. Antibacterial activities with minimum inhibitory concentration (MIC) were determined by agar diffusion assay against Escherichia coli, Burkholderia sp., Haemopilus somnus, Haemopilus parasuis, and Clostridium perfringens that were considered pathogenic strains in livestock infection. Methanol extracts of C. aurantifolia Swingle fruits and leaves showed the broadest spectrum of antibacterial activities except for C. perfringens. Butanol extract of S. grandiflora L. leaves showed the strongest activity against Burkholderia sp. with MIC, 135 μg/mL. P. sarmentosum Roxb leaves showed antibacterial activities against E. coli, Burkholderia sp. and H. parasuis. Ethyl acetate and water extracts from C. domesitca Valeton roots showed MIC of 306 μg/mL and 183 μg/mL, respectively against only C. perfringens. Antioxidative activity was determined by 2-diphenyl-2-picryl hydrazyl photometric assay. The methanol extracts of C. aurantifolia Swingle fruits and P. sarmentosum Roxb leaves showed the highest antioxidant activity among all the extracts with 3.46 mg/mL and 2.70 mg/mL effective concentration 50% (EC₅₀) values, respectively. Total contents of phenolics and flavonoids were measured from the plant extracts. Methanol extracts of S. grandiflora L. and chloroform extracts of C. domestica Valeton were found to have the highest amount of total phenolics, 41.7 and 47.8 μg/mL, respectively. Flavonoid content of methanol extracts in S. grandiflora L. T was 22.5 μg/mL and the highest among plant extracts tested. These results indicated that C. aurantifolia Swingle, S. grandiflora L., P. sarmentosum Roxb, and C. domestica Valeton have antibacterial and antioxidant activities and can be used as alternative antibiotics or potential feed additives for the control of animal pathogenic bacteria.

Effect of indigenous herbs on growth, blood metabolites and carcass characteristics in the late fattening period of hanwoo steers

This study was conducted to evaluate the effects of indigenous herbal supplements on growth, blood metabolites and carcass characteristics in the late fattening period of Hanwoo steers. In a 6 month feeding trial, thirty Hanwoo steers (647±32 kg) were allotted to one of 5 treatment groups, control (basal diet contained lasalocid), licorice, clove, turmeric and silymarin, with six steers per pen. All groups received ad libitum concentrate and 1 kg rice straw/animal/d throughout the feeding trial. Blood samples were collected at the beginning, middle, and the end of the experiment and the steers were slaughtered at the end. Blood glucose, triglyceride, total protein, and albumin concentrations were higher in the turmeric treatment compared with other treatments. Blood urea nitrogen and creatinine concentrations were highest (p<0.003 and p = 0.071, respectively) in steers treated with silymarin. Alanine aminotransferase activity was lower (p<0.06) for licorice and silymarin compared with the control group. There were no alterations in serum aspartate aminotransferase and gamma glutamyltransferase activities as a consequence of herb treatments (p = 0.203 and 0.135, respectively). Final body weight, body weight gain, average dairy gain and dry matter intake were not significantly different among treatments. Yield grade, marbling score and quality grade were higher for silymarin group than those of the control group (p<0.05). Therefore, the results suggest that silymarin can be used an effective dietary supplement as an alternative to antibiotic feed additive and a productivity enhancer, providing safe and more consumer acceptable alternative to synthetic compounds during the late fattening period of steers.

Effect of Oral Administration of Intact Casein on Gastrointestinal Hormone Secretion and Pancreatic α-Amylase Activity in Korean Native Steer

Three Korean native steers (779±24 kg) fitted with duodenal cannulas were used in a 3×3 Latin square design to investigate the influence of oral administration of soluble proteins, intact casein (IC) and acid hydrolyzed casein (AHC), on gastrointestinal hormone (GIH) secretion in the blood and pancreatic α-amylase activity in the duodenum. Oral treatment consisted of a basic diet (control), IC (C+100% protein), or AHC (C+80% amino acid, 20% peptide) for 21 d. Blood and duodenum samples were collected for measurement of serum GI hormones, and pancreatic α-amylase activity was determined at 900, 1030, 1330, 1630, and 1930 h after feeding on d 21 of treatment. The levels of serum cholecystokinin (CCK) and secretin in the IC treatment group were higher compared to the other treatment groups (p<0.05). In addition to the changes in CCK and secretin levels upon IC treatment, the pancreatic α-amylase activity in the duodenum was higher in the IC group compared to the control diet group (p<0.05). The response of serum ghrelin to IC and AHC treatment was in accordance with the response of serum secretin. The level of peptide fragments flowing in the duodenum was higher in the IC treatment group than the other treatment groups (p<0.05). In conclusion, this study demonstrated that an increase in duodenal CCK and secretin upon IC oral administration increased pancreatic α-amylase secretion. In addition, ghrelin may be associated with GI hormone secretion in Korean native steers.

Manual contouring based volumetric evaluation for colorectal cancer with liver limited metastases: a comparison with RECIST

BACKGROUND

To compare response evaluation criteria in solid tumours (RECIST) and volumetric evaluation (VE) for colorectal cancer with liver-limited metastasis.

PATIENTS AND METHODS

VE of liver metastases was performed by manual contouring before and after chemotherapy on 45 pairs of computed tomography (CT) images in 36 patients who suffered from metastatic colorectal cancer (mCRC) with liver metastasis only. Cohen kappa was used to compare the agreement between VE and RECIST. Pearson correlation was performed for their comparison after cubic root transformation of the aggregate tumor volumes. Logistic regression was done to identify clinical and radiographic factors to account for the difference which may be predictive in overall response (OR).

RESULTS

There were 16 partial response (PR), 23 stable disease (SD) and 6 progressive disease (PD) cases with VE, and 14 PR, 23 SD and 8 PD with RECIST. VE demonstrated good agreement with RECIST (κ=0.779). Discordant objective responses were noted in 6 pairs of comparisons (13.3%). Pearson correlation also showed excellent correlation between VE and RECIST (r2=0.966, p<0.001). Subgroup analysis showed that VE was in slightly better agreement with RECIST for enlarging lesions than for shrinking lesions (r2=0.935 and r2=0.780 respectively). No factor was found predictive of the difference in OR between VE and RECIST.

CONCLUSIONS

VE exhibited good agreement with RECIST. It might be more useful than RECIST in evaluation shrinking lesions in cases of numerous and conglomerate liver metastases.

Fatty acid biosynthesis and lipogenic enzyme activities in subcutaneous adipose tissue of feedlot steers fed supplementary palm oil or soybean oil

We hypothesized that supplementing finishing diets with palm oil would promote adipocyte differentiation in subcutaneous adipose tissue of feedlot steers, and that soybean oil supplementation would depress adipocyte differentiation. Twenty-eight Angus steers were assigned randomly to 3 groups of 9 or 10 steers and fed a basal diet without additional fat (control), with 3% palm oil (rich in palmitic acid), or with 3% soybean oil (rich in polyunsaturated fatty acids), for 10 wk, top-dressed daily. Palm oil had no effect (P > 0.05) on ADG, food intake, or G:F, whereas soybean oil depressed ADG (P = 0.02), food intake (P = 0.04), and G:F (P = 0.05). Marbling scores tended (P = 0.09) to be greater in palm oil-fed steers (Modest(09)) than in soybean oil-fed steers (Small(55)). Subcutaneous adipocyte mean volume was greater in palm oil-fed steers (515.9 pL) than in soybean-supplemented cattle (395.6 pL; P = 0.01). Similarly, glucose and acetate incorporation into total lipids in vitro was greater in subcutaneous adipose tissue of palm oil-fed steers (119.9 and 242.8 nmol·3h(-1)·10(5) cells, respectively) than adipose tissue of soybean oil-fed steers in (48.9 and 95.8 nmol·3h(-1)·10(5) cells, respectively). Glucose-6-phosphate dehydrogenase and NADP-malate dehydrogenase activities were greater (P ≤ 0.05) in subcutaneous adipose tissue of palm oil-fed steers than in adipose tissue of control steers. Palm oil did not increase palmitic acid or decrease oleic acid in subcutaneous adipose tissue or LM, but decreased (P ≤ 0.05) myristoleic, palmitoleic, and cis-vaccenic acid in adipose tissue, indicating a depression in stearoyl-coenzyme A desaturase activity. Soybean oil increased the proportion of α-linolenic acid in adipose tissue and muscle and increased linoleic acid and 18:1trans-10 in muscle. We conclude that palm oil supplementation promoted lipid synthesis in adipose tissue without depressing feed efficiency or increasing the palmitic acid content of beef.

Effect of lysine to digestible energy ratio on growth performance and carcass characteristics in finishing pigs

This experiment was performed to investigate the effects of lysine (Lys) to DE ratio on growth performance, and carcass characterics in finishing barrows. Ninety six cross-bred finishing barrows ((Landrace×Yorkshire) ×Duroc, average BW 58.25±0.48 kg) were assigned as a randomized complete block design by 2 energy levels and 4 Lys:DE ratios on the basis of BW to one of 8 treatments with 3 replications with 4 animals per pen. The levels of DE and Lys:DE ratio for each treatment were i) DE 3.35 Mcal/kg, 1.5 g Lys/Mcal DE, ii) DE 3.35 Mcal/kg, 1.8 g Lys/Mcal DE, iii) DE 3.35 Mcal/kg, 2.1 g Lys/Mcal DE, iv) DE 3.35 Mcal/kg, 2.4 g Lys/Mcal DE, v) DE 3.60 Mcal/kg, 1.5 g Lys/Mcal DE, vi) DE 3.60 Mcal/kg, 1.8 g Lys/Mcal DE, vii) DE 3.60 Mcal/kg, 2.1 g Lys/Mcal DE, viii) DE 3.60 Mcal/kg, 2.4 g Lys/Mcal DE. During finishing period from 58 kg to 103 kg of BW, increased energy density in the diet increased (p<0.05) ADG and gain:feed ratio, but did not influence ADFI. As Lys:DE ratio was increased, ADG, ADFI and gain:feed ratio were improved in finishing barrows (p<0.05). There were positive interactions (p<0.05) between carcass weight, grade, and backfat thickness and energy density and Lys level (p<0.05). In conclusion, data from our current study suggest that maximum yields including ADG, gain:feed ratio, carcass weight and grade can be achieved by administrating finishing pigs with an ideal Lys:DE ratio, Lys 2.1 g/DE Mcal.

Soluble Non-ammonia Nitrogen in Ruminal and Omasal Digesta of Korean Native Steers Supplemented with Soluble Proteins

An experiment was conducted to study the effect of soluble protein supplements on concentration of soluble non-ammonia nitrogen (SNAN) in the liquid phase of ruminal (RD) and omasal digesta (OD) of Korean native steers, and to investigate diurnal pattern in SNAN concentration in RD and OD. Three ruminally cannulated Korean native steers in a 3×3 Latin square design consumed a basal diet of rice straw and corn-based concentrate (control), and that supplemented (kg/d DM basis) with intact casein (0.24; IC) or acid hydrolyzed casein (0.46; AHC). Ruminal digesta was sampled using a vacuum pump, whereas OD was collected using an omasal sampling system at 2.0 h intervals after a morning feeding. The SNAN fractions (free amino acid (AA), peptide and soluble protein) in RD and OD were assessed using the ninhydrin assay. Concentrations of free AA and total SNAN in RD were significantly (p<0.05) lower than those in OD. Although free AA concentration was relatively high, mean peptide was quantitatively the most important fraction of total SNAN in both RD and OD, indicating that degradation of peptide to AA rather than hydrolysis of soluble protein to peptide or deamination may be the most limiting step in rumen proteolysis of Korean native steers. Diurnal variation in peptide concentration in OD for the soluble protein supplemented diets during the feeding cycle peaked 2 h post-feeding and decreased thereafter whereas that for the control was relatively constant during the entire feeding cycle. Diurnal variation in peptide concentration was rather similar between RD and OD.

Ultraviolet-induced red fluorescence of patients with acne reflects regional casual sebum level and acne lesion distribution: qualitative and quantitative analyses of facial fluorescence

BACKGROUND

The ultraviolet (UV)-induced red fluorescence of patients with acne has been considered to be caused by Propionibacterium acnes.

OBJECTIVES

To study the correlation of the facial red fluorescence with the casual sebum level and the number of acne lesions and to investigate the difference in clinical features, according to both distribution and proportion of fluorescence.

METHODS

A total of 878 patients clinically diagnosed with acne vulgaris were included. Inflammatory and noninflammatory acne lesions were counted separately. UV fluorescent photography and casual sebum level measurements were performed. UV-induced fluorescence patterns were classified according to the facial distribution. The proportions of UV-induced red fluorescence were calculated.

RESULTS

We identified six different fluorescence distribution patterns in the T-zone (the forehead, nose and chin) and three different patterns in the U-zone (both cheeks). The proportion of fluorescence in the U-zone showed a positive correlation with the casual sebum level and the number of acne lesions. In the T-zone, the fluorescence proportion correlated with the casual sebum level, but not with the number of acne lesions. As the patients' age and the age at onset increased, the distribution of fluorescence changed from the upper part of the T-zone to the lower part, and to the centre of the face in the U-zone.

CONCLUSIONS

Our results support the hypothesis that the origin of facial red fluorescence is sebum. In patients with acne, analyses of the pattern and proportion of UV-induced red fluorescence can be useful for evaluating the sebum secretion and selecting efficient treatment modalities.

Subcutaneous and intramuscular adipose tissue stearoyl-coenzyme A desaturase gene expression and fatty acid composition in calf- and yearling-fed Angus steers

We proposed that stearoyl-CoA desaturase (SCD) activity dictates fatty acid composition of adipose tissue and muscle in beef cattle, regardless of ruminal or hepatic fatty acid hydrogenation or desaturation. Twelve Angus steers were assigned to a calf-fed (CF) group and slaughtered at weaning (8 mo of age; n=4), 12 mo of age (n=4), or 16 mo of age (n=4). Twelve steers were assigned to a yearling-fed (YF) group and slaughtered at 12 mo of age (n=4), 16 mo of age (n=4), and 17.5 mo of age (n=4; 525 kg, market weight). Data were analyzed based on time on the corn-based finishing diet, with terminal age as a covariate, and orthogonal polynomial contrasts were tested on the main effects of treatment group and time on the finishing diet. Fatty acids from duodenal digesta, plasma, liver, LM, and subcutaneous and intramuscular adipose tissue were measured, and SCD gene expression was measured in intramuscular and subcutaneous adipose tissues. In duodenal digesta, palmitic and linoleic acids increased by 100% over the sampling period, α-linolenic acid decreased over the sampling period, and trans-vaccenic acid was greater in YF than in CF steers (all P < 0.01). The proportion of α-linolenic acid decreased over time in all tissues, including liver. The SCD index (ratio of SCD fatty acid products to SCD fatty acid substrates) increased over time in LM and in intramuscular and subcutaneous adipose tissues. The SCD:glyceraldehyde 3-phosphate dehydrogenase mRNA ratio was virtually undetectable at the initial sampling periods in subcutaneous adipose tissue of YF and CF steers, and it increased over time (P < 0.01). The SCD index and SCD:glyceraldehyde 3-phosphate dehydrogenase ratio were greater in intramuscular adipose tissue of CF steers than in that of YF steers. The SCD index did not change over time in liver and decreased over time in duodenal digesta. We conclude that, unlike essential fatty acids, the SFA and MUFA composition of adipose tissue is regulated by adipose tissue fatty acid desaturation, with little contribution from hepatic or duodenal fatty acids.

Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer centre

OBJECTIVE

Delayed presentation is an important obstacle to improving cancer treatment outcomes. We aimed to study the magnitude of this problem in Hong Kong and the factors associated with delayed presentation of patients with symptomatic breast cancers.

DESIGN

Retrospective study using self-administered questionnaires.

SETTING

Clinical Oncology Department in a regional public hospital in Hong Kong.

PATIENTS

A total of 158 Chinese women with breast cancer referred to our hospital between October 2006 and December 2007 consented to participate in this study. Among these, 59 (37%) patients were referred after having surgery in private sector.

RESULTS

The mean total delay (from first symptom to treatment) was 22 weeks. The mean patient delay (from first symptom to first consultation) was 13 weeks, constituting the largest component (60%) of the total delay. After symptom onset, the delay exceeded 12 weeks for consulting a doctor in 29%, and for receipt of treatment in 52% of them. Low family income (<HK$5000 per month; P<0.001) and surgery in public hospitals (P=0.013) were both independent predictors of patient delay. Surgery in public hospitals (P=0.006) and low family income (P=0.005) were the only predictors of doctor/system delay and total delay, respectively.

CONCLUSIONS

Delayed presentation and treatment of symptomatic breast cancer remains an important issue in Hong Kong. Apart from socio-economic factors, limited access to public medical care was likely an important contributing factor in delays related to patients as well as to doctor/system.

Immunoglobulin D multiple myeloma: response to therapy, survival, and prognostic factors in 75 patients

BACKGROUND

To analyze the clinical features, outcomes including efficacy of treatment, and prognostic factors of patients with immunoglobulin D multiple myeloma (IgD MM).

DESIGN AND METHODS

Seventy-five patients diagnosed with IgD MM were selected from the Korean Myeloma Registry database (www.myeloma.or.kr).

RESULTS

Median age was 57 years and the main presenting features were bone pain (77%). Renal function impairment and hypercalcemia were present in 40 (53%) and 20 (27%) patients. Sixty-seven patients (89%) had lambda light chains. Forty-eight patients (64%) were of stage III by International Staging System. Twenty-six patients (53%) had chromosomal abnormalities mostly by conventional cytogenetics. Thirty-nine patients (54%) were treated with vincristine, adriamycin, and dexamethasone chemotherapy; the overall response rate (ORR) of 56%. Sixteen patients (22%) received first-line chemotherapy including new drugs (bortezomib or thalidomide), with an ORR of 81%. At a median follow-up time of 28.6 months, median overall survival (OS) was 18.5 months. Age, extramedullary plasmacytoma, del(13) or hypoploidy, serum β(2) microglobulin level, and platelet count were significant prognostic factors for OS.

CONCLUSIONS

IgD MM is an aggressive disease that is usually detected at an advanced stage. Despite a positive initial response, survival after relapse was dismal. Intensive treatment strategies before and following stem cell transplantation may improve outcomes in younger patients.

Randomized trial of radiotherapy plus concurrent-adjuvant chemotherapy vs radiotherapy alone for regionally advanced nasopharyngeal carcinoma

BACKGROUND

Current practice of adding concurrent-adjuvant chemotherapy to radiotherapy (CRT) for treating advanced nasopharyngeal carcinoma is based on the Intergroup-0099 Study published in 1998. However, the outcome for the radiotherapy-alone (RT) group in that trial was substantially poorer than those in other trials, and there were no data on late toxicities. Verification of the long-term therapeutic index of this regimen is needed.

METHODS

Patients with nonkeratinizing nasopharyngeal carcinoma staged T1-4N2-3M0 were randomly assigned to RT (176 patients) or to CRT (172 patients) using cisplatin (100 mg/m(2)) every 3 weeks for three cycles in concurrence with radiotherapy, followed by cisplatin (80 mg/m(2)) plus fluorouracil (1000 mg per m(2) per day for 4 days) every 4 weeks for three cycles. Primary endpoints included overall failure-free rate (FFR) (the time to first failure at any site) and progression-free survival. Secondary endpoints included overall survival, locoregional FFR, distant FFR, and acute and late toxicity rates. All statistical tests were two-sided.

RESULTS

The two treatment groups were well balanced in all patient characteristics, tumor factors, and radiotherapy parameters. Adding chemotherapy statistically significantly improved the 5-year FFR (CRT vs RT: 67% vs 55%; P = .014) and 5-year progression-free survival (CRT vs RT: 62% vs 53%; P = .035). Cumulative incidence of acute toxicity increased with chemotherapy by 30% (CRT vs RT: 83% vs 53%; P < .001), but the 5-year late toxicity rate did not increase statistically significantly (CRT vs RT: 30% vs 24%; P = .30). Deaths because of disease progression were reduced statistically significantly by 14% (CRT vs RT: 38% vs 24%; P = .008), but 5-year overall survival was similar (CRT vs RT: 68% vs 64%; P = .22; hazard ratio of CRT = 0.81, 95% confidence interval = 0.58 to 1.13) because deaths due to toxicity or incidental causes increased by 7% (CRT vs RT: 1.7% vs 0, and 8.1% vs 3.4%, respectively; P = .015).

CONCLUSIONS

Adding concurrent-adjuvant chemotherapy statistically significantly reduced failure and cancer-specific deaths when compared with radiotherapy alone. Although there was no statistically significant increase in major late toxicity, increase in noncancer deaths narrowed the resultant gain in overall survival.

Should young age be a contra-indication to breast conservation treatment in Chinese women? Twelve-year experience from a public cancer centre in Hong Kong

OBJECTIVE

It has been proposed that young women should not be treated by breast conservation treatment because of a higher risk of local recurrences and worse survival. We therefore examined whether breast conservation treatment in young Chinese women yielded inferior clinical outcomes compared to modified radical mastectomy.

DESIGN

Retrospective study.

SETTING

Clinical oncology department in a public hospital in Hong Kong.

PATIENTS

A total of 258 Chinese women with invasive breast cancer, aged below 40 years, and referred between January 1994 and July 2006.

RESULTS

A total of 124 (48%) and 134 (52%) patients were treated by breast conservation treatment and modified radical mastectomy, respectively. Mastectomy patients tended to have larger primary tumours (P<0.001) and more nodal involvement (P<0.001). At a median follow-up of 6.5 years, there was no significant difference in the local failure-free survival rate (92% vs 93%, P=0.324) and loco-regional failure-free survival rate (89% vs 88%, P=0.721) in patients having breast conservation treatment and mastectomy. Probably due to their earlier presentation with disease, the former actually had better 6-year distant failure-free survival (88% vs 71%, P=0.002) and overall survival (92% vs 81%, P=0.173) rates. Multivariate analyses showed that both the resection margin status (hazard ratio=2.77, P=0.050) and the presence of peritumoural vascular invasion (hazard ratio=3.01, P=0.038) were independent predictors of local recurrence; the nodal status (hazard ratio=3.91, P<0.001) was the only predictive factor for overall survival. The choice of breast conservation treatment (vs modified radical mastectomy) had no apparent adverse impact on all the clinical outcome parameters analysed.

CONCLUSION

Breast conservation treatment is a reasonable option for many suitably selected young Chinese women.

Thyroid dose estimation with potassium iodide (KI) administration in a nuclear emergency

In a breach-of-containment nuclear reactor accident, the near-field exposure is primarily through inhalation of radioiodine. Thyroid blockade by oral potassium iodide (KI) is a practical and effective protective measure for the general public in such an emergency. The retention functions incorporating the thyroid blocking effects by KI have been derived using a standard three-compartment model of iodine metabolism. This allows more accurate estimation of the thyroid dose by calculating the blocking factor.