Dual Antithrombotic Therapy Versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

OBJECTIVE

Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOAC) are standard for stroke prevention in atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy - an antiplatelet agent used in conjunction with a DOAC - versus DOAC alone (DOAC monotherapy) are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies.

METHODS

Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALE), ischaemic stroke/systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years.

RESULTS

A total of 1470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with higher risks of MALE than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% CI 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with higher risks of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy.

CONCLUSION

In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with lower risks of MALE and bleeding events than dual antithrombotic therapy.

Corrected QT Interval and Outcomes of Dialysis Patients with Symptomatic Peripheral Artery Disease: A Prospective Cohort Study

BACKGROUND

Peripheral artery disease (PAD) is common and associated with a higher risk of cardiovascular morbidity and mortality in dialysis patients. A longer corrected QT (QTc) interval has been associated with adverse cardiovascular events and mortality in the general population and patients with end-stage kidney disease. However, little evidence is available on the predictive value of QTc in dialysis patients with PAD.

METHODS

We conducted a prospective cohort study of 356 dialysis patients with symptomatic PAD undergoing endovascular therapy. We performed the resting 12-lead electrocardiogram (ECG) at baseline. Cox regression analyses were used to assess the association of QTc with all-cause mortality and major adverse cardiovascular events (MACEs), defined as non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death.

RESULTS

The mean age was 67.3 ± 11.5 years; 41.6% of participants were women. The median QTc was 471 (interquartile ranges 448-491) milliseconds (ms). During a median follow-up of 2.2 years, 188 (52.8%) patients died, and MACEs occurred in 119 (33.4%) patients. In multivariable-adjusted models, patients in tertile 3 of QTc levels had a significantly greater risk of all-cause mortality (hazard ratio [HR] 2.41, 95% confidence intervals [CI] 1.58-3.69) and MACEs (HR 1.90, 95% CI 1.15-3.13) than those in tertile 1. Similarly, each 10-ms increase in the baseline QTc predicted a higher risk of all-cause death (HR 1.15, 95% CI 1.09-1.21) and MACEs (HR 1.15, 95% CI 1.07-1.23).

CONCLUSIONS

QTc prolongation was independently associated with adverse outcomes among dialysis patients with symptomatic PAD.

2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases

The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.

[Comparison of formulas for intraocular lens power calculation after corneal refractive surgery]

Objective: To evaluate the accuracy of five intraocular lens (IOL) power calculation formulas for calculating IOL power in patients with previous myopia-corrected corneal refractive surgery. Methods: In this case series study, a total of 30 eyes of 30 patients who had excimer laser corneal refractive surgery for myopia and subsequent cataract surgery in Qingdao Eye Hospital from April 2020 to October 2022 were included. The Pentacam anterior segment analysis system and IOLMaster were used to measure ocular parameters, including axial length, anterior chamber depth, keratometry, lens thickness, and mean true net power (mTNP). Five formulas were used for IOL power calculation: Shammas formula, Olsen formula, SRK/T (mTNP) formula, Haigis-L formula, and Barrett True-K formula. After cataract extraction, we obtained the actual postoperative refraction by measuring the objective refraction. The prediction error was determined as the difference between the actual postoperative refraction and the predicted refraction, and the absolute value of the prediction error was the absolute error. The differences in the calculation errors of the 5 formulas were compared. Results: Regarding the prediction errors, the results of the SRK/T (mTNP) and Olsen formulas were better than those of Shammas and Haigis-L, and the differences were statistically significant (all P<0.05). The proportion of eyes with an absolute error of 0.50 D for Barrett True-K was highest (70%, 21/30), followed by the SRK/T (mTNP) formula (67%, 20/30). The proportions of eyes with an absolute error within 1.00 D for Barrett True-K, SRK/T (mTNP), and Olsen were all over 80%, with 24 eyes, 24 eyes, and 25 eyes, respectively. Conclusions: The Barrett True-K formula showed high accuracy in predicting the refraction after cataract extraction in patients with a history of corneal refractive surgery for myopia. The calculation result of the Haigis-L formula was highly unstable.

Validation of the Framingham General Cardiovascular Risk Score and Pooled Cohort Equations in a Community-Based Population: A Prospective Cohort Study Analysis 2006-2017

Background

The 10-year atherosclerotic cardiovascular disease (ASCVD) risk - as assessed using the Framingham general cardiovascular risk score (FRS-CVD) or pooled cohort equations (PCE) - is commonly used in Western cohorts for the primary prevention of cardiovascular disease (CVD). However, the FRS-CVD and PCE have not been validated in Taiwanese cohorts.

Objectives

We aimed to validate the FRS-CVD and PCE for assessing the 10-year ASCVD risk using a Taiwanese community-based population.

Methods

We extracted patient data from the Landseed Integrated Outreaching Neighborhood Screening registry, a community-based prospective cohort study established in 2006. Cardiovascular events from 2006 to 2017 were determined from electronic medical records. The discriminative power and calibration of the FRS-CVD and PCE were evaluated.

Results

Overall, 5,139 subjects were analyzed; the 10-year follow-up rate was 99.6%. The mean age at baseline was 52.8 ± 13.1 years, and 44.6% of the subjects were male. In total, 430 of 4,631 (9.3%) and 227 of 4,022 (5.6%) of the FRS-CVD- and PCE-like cohorts, respectively, had ASCVD events. The calibration χ2 of the FRS-CVD was 7.0267 (p = 0.6343) in males and 7.8845 (p = 0.5458) in females; the χ2 of PCE was 13.007 (p = 0.1623) in males and 38.785 (p < 0.001) in females. The area under the receiver operating characteristic curve (AUROC) of the FRS-CVD was 0.76 (0.72-0.79) in males and 0.71 (0.67-0.74) in females; the AUROC of PCE was 0.68 (0.62-0.73) in males and 0.61 (0.56-0.67) in females.

Conclusions

Except for PCE in females, the FRS-CVD and PCE provided good calibration and modest discrimination in statin-naïve Taiwanese individuals without prior CVD.

Association between corrected QT interval and long-term cardiovascular outcomes in elderly patients who had undergone endovascular therapy for lower extremity arterial disease

Background

Population-based studies have reported the association between prolonged corrected QT (QTc) intervals and an increased risk of adverse cardiovascular events. Data regarding the association between longer QTc intervals and incident cardiovascular outcomes in patients with lower extremity arterial disease (LEAD) are scarce.

Objective

To examine the impact of QTc interval on long-term cardiovascular outcomes in elderly patients with symptomatic LEAD.

Methods

This cohort study extracted data from the Tzu-chi Registry of ENDovascular Intervention for Peripheral Artery Disease (TRENDPAD) and enrolled 504 patients aged ≥ 70 treated with endovascular therapy for atherosclerotic LEAD from July 1, 2005, to December 31, 2019. The main outcomes of interest were all-cause mortality and major adverse cardiovascular events (MACE). Multivariate analysis was conducted using the Cox proportional hazard model to determine independent variables. We performed interaction analysis between corrected QT and other covariates and Kaplan-Meier analysis to compare the outcome of interest among the groups stratified by the tercile of QTc intervals.

Results

A total of 504 patients [235 men (46.6%); mean age, 79.9 ± 6.2 years; mean QTc interval, 459 ± 33 msec] entered the final data analysis. We categorized the baseline patient characteristics according to terciles of QTc intervals. During the median follow-up time of 3.15 (interquartile ranges, 1.65-5.42) years, we noted 264 deaths and 145 MACEs. The 5-year rates of freedom from all-cause mortality (71% vs. 57% vs. 31%, P < 0.001) and MACEs (83% vs. 67% vs. 46%, P < 0.001) were significantly different among the tercile groups. Multivariate analysis showed that a 1-SD increase in the QTc interval increased the risk of all-cause mortality [hazard ratio (HR) 1.49, P < 0.001] and MACEs (HR 1.59, P < 0.001) after adjusting for other covariates. The interaction analysis showed that QTc interval and C-reactive protein levels were most strongly associated with death (HR = 4.88, 95% CI 3.09-7.73, interaction P < 0.001) and MACEs (HR = 7.83, 95% CI 4.14-14.79, interaction P < 0.001).

Conclusions

In elderly patients with symptomatic atherosclerotic LEAD, a prolonged QTc interval is associated with advanced limb ischemia, multiple medical comorbidities, increased risk of MACEs, and all-cause mortality.

Repetition of Paclitaxel-Coated Devices for the Treatment of Lower Extremity Artery Disease: Mortality Outcomes and Predictors

Background

A recent meta-analysis reported late excess mortality in patients treated with paclitaxel-coated devices (PCDs) for symptomatic femoropopliteal disease. However, this finding is controversial.

Objectives

To investigate the impact on mortality and predictors of repeat exposure to PCDs in patients with lower extremity peripheral arterial disease (LE-PAD).

Methods

We analyzed registry patient-level data from two centers. A total of 214 patients were enrolled, and stratified based on terciles of cumulative dose of paclitaxel. We treated 134 patients with a single PCD exposure and 80 with multiple PCD exposures. We used the follow-up index (FUI) in Kaplan-Meier survival estimates to minimize potential selection bias. We used Cox proportional hazard and splines models to determine the predictors of mortality and assess their relationships with mortality.

Results

The mean cumulative dose of paclitaxel was significantly different among groups (6.40 mg vs. 15.06 mg vs. 38.57 mg, p < 0.001). The 5-year FUI (0.93 ± 0.19 vs. 0.94 ± 0.18 vs. 0.95 ± 0.15, p = 0.836) and survival rates were not different (65.4% vs. 51.9% vs. 72.0%, p = 0.148). There was no dose-response association between paclitaxel dosage and death (p = 0.297). The predictors of death were congestive heart failure, stroke, dialysis dependence, neutrophil-lymphocyte ratio (NLR) > 3, age > 71 years, and body mass index (BMI) < 20 kg/m². Spline model analysis validated the non-linear associations between mortality, age, BMI, and NLR.

Conclusions

Repeated PCD exposure for LE-PAD did not result in excess late mortality. Predictors of mortality might change over time, and continuous variables had non-linear relationships with death.

Referral, Diagnosis, and Pharmacological Management of Peripheral Artery Disease: Perspectives from Taiwan

Peripheral artery disease (PAD) imposes a heavy burden of major adverse cardiovascular events that are associated with considerable mortality and morbidity, and major adverse limb events (e.g., thrombectomy, revascularization, amputation) that can substantially impact patients' daily functioning and quality of life. Global registry data have indicated that PAD is an underdiagnosed disease in Taiwan, and its associated risk factors remain inadequately controlled. This review discusses the burden of PAD in Taiwan, major guidelines on PAD management, and the latest clinical trial outcomes. Practical experience, opinions, and the latest trial data were integrated to derive a series of clinical algorithms - patient referral, PAD diagnosis, and the antithrombotic management of PAD. These algorithms can be adapted not only by physicians in Taiwan involved in the clinical management of patients with PAD but also by general practitioners in local clinics and regional hospital settings, with the ultimate aim of improving the totality of PAD patient care in Taiwan.

[Application of lateral upper arm free flap in the repair of postoperative defects of oral cancer]

Objective: To explore the clinical application and efficacy of lateral upper arm free flap (LUAFF) for one-stage repairing of soft tissue defect after oral cancer surgery. Methods: This article was a retrospective analysis of clinical data of 46 patients receiving treatment of one-stage repairing of soft tissue defect with LUAFF after oral cancer surgery in Hunan Cancer Hospital, from June 2019 to June 2021. Among these cases, 40 were males, and 6 were females. The patients' ages were from 23 to 64 years old. The clinical data of patients were reviewed and outcomes were evaluated. SPSS 23.0 software was used for statistical analysis. Results: In the LUAFF of 46 patients, flap area ranged from 5.0 cm×3.5 cm to 15.0 cm×7.0 cm; the mean pedicle length was 8.15±1.42 cm; the mean artery diameter was 1.20±0.41 mm (range, 1.5 to 2.5 mm); the mean diameter of the largest veins was 2.15±0.52 mm; and the median number of perforators was 2.6 (range, 1 to 4). All donor sites were closed primarily. Two cases had arterial anastomosis thrombosis, but their flaps were successfully saved with urgent re-anastomosis of the vessels. The overall flap survival rate was 93.5%(43/46), with flap necroses after operation in three cases. No patient received tracheotomy. The average hospital stay time of patients after operation was 9.4 days. The follow-up time was 6-24 months, elbow and wrist movements on the operative side were normal, and the upper limb muscle strength was not affected. Conclusions: LUAFF is a suitable choice for the repairs of small-moderate tissue defects in oral cancer surgery, with consistent perforators in the flap, simple harvest method, concealed donor-site scar, and high survival rate.

Malnutrition is Associated with Increased Morbidity and Mortality in Dialysis Patients Undergoing Endovascular Therapy for Peripheral Artery Disease

OBJECTIVES

Revascularization for peripheral artery disease (PAD) is increasingly common in dialysis patients. Patients with PAD who have undergone revascularization are at high risk for subsequent complications. Malnutrition is an important modifiable risk factor for dialysis patients, yet little data exist on the prognostic impact of malnutrition on postprocedure long-term outcomes.

METHODS

A total of 395 consecutive dialysis patients undergoing endovascular revascularization for PAD between 2005 and 2019 were examined for the primary outcome of all-cause mortality. Secondary outcomes included major adverse limb events (MALEs), defined as acute limb ischemia, major amputation, and clinically driven revascularization, and major adverse cardiovascular events (MACEs). Nutritional status was assessed by using the Controlling Nutritional Status (CONUT) score, a screening tool for malnutrition incorporating albumin, cholesterol, and total lymphocyte count.

RESULTS

According to the CONUT score, 40.8% of patients were moderately or severely malnourished. During a median follow-up of 2.2 years, 218 (55.2%) patients died; 211 (53.4%) patients had MALEs, and MACEs occurred in 135 (34.2%) patients. Compared with normal nutritional status, severe malnutrition was associated with a significantly increased risk for all-cause death (adjusted HR, 4.83; 95% CI, 2.56-9.12) and MALEs (adjusted HR, 2.42; 95% CI, 1.23-4.74) but not MACEs (adjusted HR, 1.81; 95% CI, 0.74-4.40). Similar results were observed when the CONUT score was analyzed as a continuous variable.

CONCLUSIONS

Malnutrition is common among dialysis patients with PAD requiring endovascular therapy and is strongly associated with increased mortality and MALEs. Clinical trials are needed to evaluate whether nutritional interventions improve outcomes for dialysis patients after peripheral revascularization.

[Relative factors analysis of visual field defect in advanced primary glaucoma]

Objective: To explore the relative factors of visual field defect in advanced primary glaucoma. Methods: A retrospective case-control study. The data of patients with primary advanced glaucoma who had the central 5 to 10 degrees of the visual field or the temporal peripheral field and were treated at Eye & ENT Hospital of Fudan University from January 2014 to December 2019 were reviewed. The patients were divded into the central visual field group and the temporal peripheral field group according to the type of visual field defect. Statistical analyses of single-factor (Chi square test or independent sample t test) and multivariate logistic regression were performed to analyze the correlation between the remaining visual field and the risk factors including age, gender, left/right eye, type of glaucoma, baseline glaucoma stage, peak intraocular pressure (IOP), mean IOP, number of operations, family history, high myopia, diabetes, hypertension, hypotension and migraine. Results: A total of 287 patients (287 eyes) were included. There were 101 patients [mean age, (61±15) years; 48 males, 53 females] with the central 5 to 10 degrees of the visual field and 186 patients [mean age, (59±17) years; 107 males, 79 females] with the temporal peripheral field. There was no statistically significant difference between the two groups with respect to age, gender, left/right eye, age of onset, number of operations, family history and history of combined systemic diseases (all P>0.05). Primary open-angle glaucoma, chronic primary angle-closure glaucoma (CPACG) and acute primary angle-closure glaucoma were found in 26, 34 and 41 patients, respectively, in the central visual field group, and in 61, 78 and 47 patients, respectively, in the temporal peripheral field group. The baseline glaucoma was in the moderate stage in 30 and 32 patients, and in the advanced stage in 71 and 154 patients, respectively, in the two groups. The peak IOP was (31.94±4.11) mmHg (1 mmHg=0.133 kPa) and (34.58±6.47) mmHg, and the mean IOP was (22.48±3.99) mmHg and (24.01±4.30) mmHg, respectively, in the two groups. High myopia occurred in 5 and 28 patients, respectively, in the two groups. The differences in the type of glaucoma (χ²=7.24), baseline glaucoma stage (χ²=6.04), peak IOP (t=4.22), mean IOP (t=2.96) and high myopia (χ²=6.57) between the two groups were statistically significant (all P<0.05). In the multivariable model, CPACG (OR=2.021, 95%CI: 1.020 to 4.001), higher peak IOP (OR=1.128, 95%CI: 1.038 to 1.226) and high myopia (OR=5.090, 95%CI: 1.556 to 16.651) increased the risks for the progression to the temporal peripheral field. Conclusion: CPACG, higher peak IOP and concurrent high myopia are all relative factors for the progression to the temporal peripheral field in advanced primary glaucoma.

[Research progress of cirrhotic portal hypertension in diagnostic imaging methods]

Hepatic venous pressure gradient measurement via jugular vein catheterization is still currently the gold standard for evaluating portal hypertension. However, how to accurately and reproducibly assess whether there is portal hypertension has always been a concern in patients with liver cirrhosis. In recent years, imaging methods have made significant progress in the non-invasive diagnosis of portal hypertension. This paper reviews the current different diagnostic value of imaging methods and related research progress in an attempt to evaluate patients with cirrhotic portal hypertension.

In situ X-ray absorption spectroscopic studies of TiO2 photocatalytic active sites for degradation of trace CHCl3 in drinking water

Toxic disinfection byproducts such as trihalomethanes (e.g. CHCl₃) are often found after chlorination of drinking water. It has been found that photocatalytic degradation of trace CHCl₃ in drinking water generally lacks an expected relationship with the crystalline phase, band-gap energy or the particle sizes of the TiO₂-based photocatalysts used such as nano TiO₂ on SBA-15 (Santa Barbara amorphous-15), TiO₂ clusters (TiO₂-SiO₂) and atomic dispersed Ti [Ti-MCM-41 (Mobil Composition of Matter)]. To engineer capable TiO₂ photocatalysts, a better understanding of their photoactive sites is of great importance and interest. Using in situ X-ray absorption near-edge structure (XANES) spectroscopy, the A₁ (4969 eV), A₂ (4971 eV) and A₃ (4972 eV) sites in TiO₂ can be distinguished as four-, five- and six- coordinated Ti species, respectively. Notably, the A₂ Ti sites that are the main photocatalytic species of TiO₂ are shown to be accountable for about 95% of the photocatalytic degradation of trace CHCl₃ in drinking water (7.2 p.p.m. CHCl₃ gTiO₂^-1 h^-1). This work reveals that the A₂ Ti species of a TiO₂-based photocatalyst are mainly responsible for the photocatalytic reactivity, especially in photocatalytic degradation of CHCl₃ in drinking water.

Risk of major bleeding associated with concomitant use of anticancer drugs and direct oral anticoagulant in patients with cancer and atrial fibrillation

This study evaluated the risk of major bleeding associated with concomitant use of direct oral anticoagulant (DOAC) and anticancer drugs (ACDs), which share metabolic pathways, in patients with atrial fibrillation (AF) and cancer. We performed a retrospective cohort study using Taiwan's National Health Insurance database and included patients with AF and cancer who received DOAC prescriptions from 1 to 2012 to 31 December 2017. The incidence of major bleeding in person-quarters with concomitant use of DOAC and any of 15 ACDs with inhibitory or competitive effects of CYP3A4 or P-gp activity (docetaxel, vinorelbine, methotrexate, irinotecan, etoposide, doxorubicin, cyclophosphamide, imatinib, nilotinib, abiraterone, bicalutamide, tamoxifen, anastrozole, cyclosporine, tacrolimus) was compared with that in person-quarters with DOAC alone. Adjusted incidence-rate differences between DOAC use with and without concurrent ACDs were estimated using Poisson regression models weighted by the inverse probability of treatment. In 13,158 patients with AF and cancer (76.9 ± 8.9 years; male 60%), 1545 major bleeding events occurred during 90,540 DOAC-exposed person-quarters. Concurrent use of DOAC and any of 15 ACDs occurred in only 18% of patients. Compared with use of DOAC alone, concomitant use of DOAC and these ACDs was not associated with an increased risk of major bleeding. Co-medication with DOAC and ACDs with inhibitory or competitive effects on CYP3A4 or P-gp activity was not associated with a higher risk of major bleeding than DOAC alone. Our findings may provide clinicians with confidence regarding the safety of concurrent use of DOAC and ACDs in patients with AF and cancer.

[Analysis of genetic abnormalities and clinical outcome of fetus with ultrasonic nonstructural abnormality]

Objective: To analysis the incidence of abnormal genetics and the clinical outcome of fetuses with ultrasonic nonstructural abnormality. Methods: This study was conducted retrospectively. 631 pregnant women were enrolled in the Prenatal Diagnostic Center of Fujian Maternal and Child Health Hospital due to ultrasonic nonstructural abnormality from January 2016 to January 2019. According to different gestational weeks, amniotic fluid or umbilical cord blood samples were collected for chromosome karyotype analysis and SNP-array. According to the number of nostructural abnormalities, they were divided into 1 nostructural abnormality group, 2 nostructural abnormalities group, and ≥3 nostructural abnormalities group. Chi-square test was used for comparison between groups. Results: Of the 631 cases, 34 cases (5.4%, 34/631) had abnormal karyotypes, including 20 cases with abnormal chromosome number and 14 cases with abnormal chromosome structure. In results of SNP-array, there were 53 abnormal results (8.4%, 53/631), including 32 cases of pathogenic copy number variations (CNV) and 21 cases of variations of uncertain clinical significance (VOUS). The rates of pathogenic CNV were 4.57% (21/260), 4.76% (7/147) and 16.67% (4/24) in the group of 1, 2 and ≥3 nostructural abnormalities, respectively. The rate of the three groups showed a linear trend, and the difference was statistically significant (χ²=7.419,P<0.05). In the single nostructural abnormality group, the rate of pathogenic CNV of nasal bone dysplasia, fetal growth restriction (FGR) and thickened nuchal translucency (NT) were 8.11% (3/37), 7.04% (5/71) and 5.60% (7/125), respectively. Conclusions: Compared with the karyotype analysis, SNP-array can significantly improve the detection rate of genetic abnormalities in ultrasonic nonstructural abnormality. When multiple ultrasonic nonstructural abnormality were combined, the risk of genetic abnormalities showed an upward trend.

Effect of a Novel Macrophage-Regulating Drug on Wound Healing in Patients With Diabetic Foot Ulcers: A Randomized Clinical Trial

IMPORTANCE

Delayed healing of diabetic foot ulcers (DFUs) is known to be caused by dysregulated M1/M2-type macrophages, and restoring the balance between these macrophage types plays a critical role in healing. However, drugs used to regulate M1/M2 macrophages have not yet been studied in large randomized clinical trials.

OBJECTIVE

To compare the topical application of ON101 cream with use of an absorbent dressing (Hydrofiber; ConvaTec Ltd) when treating DFUs.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, evaluator-blinded, phase 3 randomized clinical trial was performed in 21 clinical and medical centers across the US, China, and Taiwan from November 23, 2012, to May 11, 2020. Eligible patients with debrided DFUs of 1 to 25 cm2 present for at least 4 weeks and with Wagner grade 1 or 2 were randomized 1:1 to receive ON101 or control absorbent dressings.

INTERVENTIONS

Twice-daily applications of ON101 or a absorbent dressing changed once daily or 2 to 3 times a week for 16 weeks, with a 12-week follow-up.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of complete healing, defined as complete re-epithelialization at 2 consecutive visits during the treatment period assessed on the full-analysis set (FAS) of all participants with postrandomization data collected. Safety outcomes included assessment of the incidences of adverse events, clinical laboratory values, and vital signs.

RESULTS

In the FAS, 236 eligible patients (175 men [74.2%]; mean [SD] age, 57.0 [10.9] years; mean [SD] glycated hemoglobin level, 8.1% [1.6%]) with DFUs classified as Wagner grade 1 or 2 (mean [SD] ulcer area, 4.8 [4.4] cm2) were randomized to receive either the ON101 cream (n = 122) or the absorbent dressing (n = 114) for as long as 16 weeks. The incidence of complete healing in the FAS included 74 patients (60.7%) in the ON101 group and 40 (35.1%) in the comparator group during the 16-week treatment period (difference, 25.6 percentage points; odds ratio, 2.84; 95% CI, 1.66-4.84; P < .001). A total of 7 (5.7%) treatment-emergent adverse events occurred in the ON101 group vs 5 (4.4%) in the comparator group. No treatment-related serious adverse events occurred in the ON101 group vs 1 (0.9%) in the comparator group.

CONCLUSIONS AND RELEVANCE

In this multicenter randomized clinical trial, ON101 exhibited better healing efficacy than absorbent dressing alone in the treatment of DFUs and showed consistent efficacy among all patients, including those with DFU-related risk factors (glycated hemoglobin level, ≥9%; ulcer area, >5 cm2; and DFU duration, ≥6 months).

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01898923.

In situ X-ray absorption spectroscopic studies of photocatalytic oxidation of As(III) to less toxic As(V) by TiO2 nanotubes

Arsenic in groundwater caused the black-foot disease (BFD) in many countries in the 1950-1960s. It is of great importance to develop a feasible method for removal of arsenic from contaminated groundwater in BFD endemic areas. Photocatalytic oxidation of As(III) to less toxic As(V) is, therefore, of significance for preventing any arsenic-related disease that may occur. By in situ synchrotron X-ray absorption spectroscopy, the formation of As(V) is related to the expense of As(III) disappearance during photocatalysis by TiO₂ nanotubes (TNTs). Under UV/Vis light irradiation, the apparent first-order rate constant for the photocatalytic oxidation of As(III) to As(V) is 0.0148 min^-1. It seems that As(III) can be oxidized with photo-excited holes while the not-recombined electrons may be scavenged with O₂ in the channels of the well defined TNTs (an opening of 7 nm in diameter). In the absence of O₂, on the contrary, As(III) can be reduced to As(0), to some extent. Cu(II) (CuO), as an electron acceptor, was impregnated on the TNTs surfaces in order to gain a better understanding of electron transfer during photocatalysis. It appears that As(III) can be oxidized to As(V) while Cu(II) is reduced to Cu(I) and Cu(0). The molecular-scale data are very useful in revealing the oxidation states and interconversions of arsenic during the photocatalytic reactions. This work has implications in that the toxicity of arsenic in contaminated groundwater or wastewater can be effectively decreased via solar-driven photocatalysis, which may facilitate further treatments by coagulation.

Association Rule Mining and Prognostic Stratification of 2-Year Longevity in Octogenarians Undergoing Endovascular Therapy for Lower Extremity Arterial Disease: Observational Cohort Study

Background

Two-year longevity is a crucial consideration in revascularization strategies for patients with symptomatic lower extremity arterial disease (LEAD). However, factors associated with 2-year longevity and risk stratification in octogenarians or nonagenarians have been underreported.

Objective

This paper aims to investigate the associated variables and stratify the 2-year prognosis in older patients with LEAD.

Methods

We performed logistic regression and association rule mining based on the Apriori algorithm to discover independent variables and validate their associations with 2-year longevity. Malnutrition, inflammation, and stroke factors were identified. C statistics and Kaplan-Meier analysis were used to assess the impact of different numbers of malnutrition, inflammation, and stroke factors on 2-year longevity.

Results

We recruited a total of 232 octogenarians or nonagenarians (mean age 85 years, SD 4.2 years) treated with endovascular therapy. During the study period, 81 patients died, and 27 of those (33%) died from a cardiac origin within 2 years. Association rules analysis showed the interrelationships between 2-year longevity and the neutrophil-lymphocyte ratio (NLR) and nutritional status as determined by the Controlling Nutritional Status (CONUT) score or Geriatric Nutritional Risk Index (GNRI). The cut-off values of NLR, GNRI, and CONUT were ≥3.89, ≤90.3, and >3, respectively. The C statistics for the predictive power for 2-year longevity were similar between the CONUT score and the GNRI-based models (0.773 vs 0.760; P=.57). The Kaplan-Meier analysis showed that 2-year longevity was worse as the number of malnutrition, inflammation, and stroke factors increased from 0 to 3 in both the GNRI-based model (92% vs 68% vs 46% vs 12%, respectively; P<.001) and the CONUT score model (87% vs 75% vs 49% vs 10%, respectively; P<.001). The hazard ratio between those with 3 factors and those without was 18.2 (95% CI 7.0-47.2; P<.001) in the GNRI and 13.6 (95% CI 5.9-31.5; P<.001) in the CONUT score model.

Conclusions

This study demonstrated the association and crucial role of malnutrition, inflammation, and stroke factors in assessing 2-year longevity in older patients with LEAD. Using this simple risk score might assist clinicians in selecting the appropriate treatment.

Indoxyl Sulfate and Incident Peripheral Artery Disease in Hemodialysis Patients

Peripheral artery disease (PAD) is highly prevalent among patients with chronic kidney disease (CKD) and portends a very poor prognosis. Indoxyl sulfate has been shown to induce atherothrombosis and impaired neovascularization in uremic mice. However, there is no clinical evidence regarding the role of indoxyl sulfate in PAD associated with CKD. We examined associations between indoxyl sulfate and incident symptomatic lower extremity PAD events as well as major adverse cardiovascular events (MACE) and all-cause mortality using Cox proportional hazards models in a prospective cohort of 200 hemodialysis patients free of PAD at baseline. Patients were considered as having PAD if they developed PAD symptoms confirmed by an ankle-brachial index with waveforms, duplex ultrasound or angiography, and/or major adverse limb events including revascularization and amputation. During a median follow-up of 6.5 years, 37 patients (18.5%) experienced incident symptomatic PAD. MACE occurred in 52 patients, and a total of 85 patients died. After adjusting for traditional risk factors for PAD, including age, current smoking, diabetes, and cardiovascular disease, indoxyl sulfate was significantly associated with the risk of PAD (hazard ratio (HR), 1.19 for every 10-μg/mL increase in indoxyl sulfate; 95% confidence interval (CI), 1.05–1.35). However, indoxyl sulfate was not associated with risk of MACE (HR, 1.00; 95% CI, 0.90–1.12) or death from any cause (HR, 0.98; 95% CI, 0.90–1.07). Indoxyl sulfate was associated with incident symptomatic PAD but not with MACE or all-cause mortality, suggesting that indoxyl sulfate toxicity may be unique to PAD among hemodialysis patients.

Correction to: Nuclear medicine services after COVID-19: gearing up back to normality

The authors P. Orellana and N. El-Haj were inadvertently deleted in the original paper.

Inhibition of heat shock protein 90 suppresses Bombyx mori nucleopolyhedrovirus replication in B. mori

Heat shock protein 90 (Hsp90) plays a very important role in facilitating the replication of many viruses. Until now, little has been known about the role of Hsp90 in Bombyx mori virus infection. In this study, we explored the role of BmHsp90 in B. mori nucleopolyhedrovirus (BmNPV) replication. We found that BmHsp90 inhibition by geldanamycin (GA) significantly reduced the BmNPV titre, the protein expression level of BmNPV nucleocapsid protein 39 (VP39) and the transcript level of BmNPV genes. Silencing the hsp90 gene in BmN cells by small interfering RNA suppressed BmNPV replication whereas overexpression of hsp90 promoted the replication of BmNPV. After inhibition of Hsp90, the expression of three key genes [signal transducing activator of transcription (stat), suppressor of cytokine signalling protein 2 (socs2), socs6] involved in the Janus kinase/STAT pathway significantly changed, with up-regulation of stat and down-regulation of socs2 and socs6. In addition, the expression of two antiapoptosis genes, BmNPV inhibitor of apoptosis protein1 (BmNPV-iap1) and Bmiap2, was greatly decreased in GA-treated cells, whereas their expression was significantly increased in hsp90-overexpressed silkworm larvae. Our results indicated that inhibition of Hsp90 can suppress BmNPV proliferation in B. mori. Our findings may provide new clues to elucidate the molecular mechanisms of silkworm-virus interactions.

Application of Eye Tracker in Lie Detection

Objective To investigate the application value of eye tracking in lie detection. Methods The 40 subjects were randomly divided into two groups. The pupil diameter, fixation duration, points of fixation and blink frequency of the subjects in the experimental group in observing target stimulation and non-target stimulation were recorded with eye tracker after they accomplished the mock crime. The eye movement parameters of subjects in the control group were directly collected. The differences in eye movement parameters of the experimental group and the control group in observing target stimulation and non-target stimulation were analyzed by t-test. Pearson coefficient analysis of correlation between eye movement parameters that had differences was conducted. The effectiveness of eye movement parameters to distinguish between the experimental group and the control group was calculated by the receiver operator characteristic （ROC） curve. Results Participants from the experimental group had shorter average pupil diameter, longer average fixation duration and fewer fixation points （P<0.05）, but the differences in blink frequency had no statistical significance. The differences in the above indicators of the control group in observing target stimulation and non-target stimulation had no statistical significance. The average fixation duration showed a negative correlation with fixation points （r=-0.255, P<0.05）; the average fixation duration showed a negative correlation with average pupil diameter （r=-0.218, P<0.05）; the fixation points showed a positive correlation with average pupil diameter （r=0.09, P<0.05）. The area under the curve of average pupil diameter, average fixation duration and fixation points was 0.603, 0.621 and 0.580, respectively. Conclusion The average pupil diameter, average fixation duration and fixation points obtained by the eye tracker under laboratory conditions can be used to detect lies.

[The mid-term outcomes of minimally invasive plasty for severe tricuspid regurgitation after cardiac surgery]

Objectives: To evaluate the efficacy of minimally invasive surgery in patients with late severe tricuspid regurgitation after cardiac surgery, and to evaluate the role of leaflets augmentation technique in tricuspid valvuloplasty. Methods: From January 2015 to June 2019, 85 patients undergoing tricuspid valve repair procedure with minimally invasive approach at Department of Cardiovascular Surgery, Guangdong provincial People's Hospital were enrolled. There were 22 males and 63 females, aging of (53.6±12.4) years (range: 15 to 75 years). The interval between the prior and current operations was (16.0±7.3) years (range: 0.2 to 35.0 years). The diameter of right atrium and right ventricle was (77.3±17.2) mm and (61.0±8.4) mm, respectively. Tricuspid regurgitation was severe or extremely severe, the tricuspid regurgitation area was (19.0±10.3) cm(2). All patients underwent minimally invasive tricuspid valvuloplasty or tricuspid valve replacement on beating-heart with totally endoscopic technique and port-access approach through right chest wall. The operations included tricuspid valve replacement and tricuspid valvuloplasty, the technique of tricuspid valvuloplasty including leaflets augmentation with patch, ring implantation, chordae tendineaes reconstruction, release of papillary muscle, edge to edge method, etc. Postoperative hospitalization days, the time of ICU stay, blood transfusion rate, ventilator time and the results of echocardiography were recorded. Follow-up was completed regularly by WeChat, telephone and outpatient visit. Results: Sixty-five patients underwent tricuspid valve repair, and 20 patients underwent tricuspid valve replacement because of prosthetic failure and plasty failure. Five patients died during hospitalization, with mortality rate 5.9%. One patient was transferred to local hospital for anti-infection treatment, the other 79 patients were discharged from hospital in well condition and followed-up. The postoperative hospitalization time was 7.0 (5.5) days (M(Q(R))) days, the mean ventilator time was 18.0 (16.2) hours, and the mean ICU stay time was 68.0 (75.5) hours. There were 35 patients without blood conduction transfusion, the transfusion rate was only 58.9% (50/85). Four cases of severe, 9 cases of moderate and 67 cases of mild to zero tricuspid regurgitation were examined before being discharged, with tricuspid regurgitation area of (2.8±3.5) cm(2) (range: 0 to 19.1 cm(2)). The follow-up time was 1 to 38 months. Two patients died during follow-up, one patient died from infective endocarditis and mitral perivalvular leakage, the other one died of intractable right heart failure. One patient was implanted with permanent pacemaker due to Ⅲ atrioventricular block. Valvular re-replacement was performed in 2 patients who were re-admitted for the artificial valve infection and mechanical valve obstruction. No re-operation of tricuspid valve. Conclusions: Totally endoscopic minimally invasive technique provided satisfactory surgical outcomes for critically sick patients with severe tricuspid regurgitation following cardiac surgery. The application of leaflets augmentation technique achieved ideal repair effect for previously unrepairable lesions.

Contemporary cardiovascular outcomes in Taiwanese patients undergoing endovascular therapy for symptomatic lower extremity peripheral arterial disease

BACKGROUND/PURPOSE

To investigate contemporary cardiovascular (CV) outcomes in Taiwanese patients with symptomatic low extremity peripheral artery disease treated with endovascular therapy.

METHODS

An observational cohort study with up to 155 months of follow-up was conducted using a single-center registry database between July 2005 and June 2017. Long-term outcomes and predictors of future CV events were analyzed in 936 patients with 1246 affected legs.

RESULTS

This study cohort comprised 21% claudicants and 79% critical limb ischemia (CLI) patients. Compared with claudicants, CLI patients had higher rates of medical comorbidities, tissue inflammation, and lesion complexities. During the study period, 349 patients died (130 CV deaths and 219 non-CV deaths), 306 had non-fatal CV events. The rates of 5-year freedom from all-cause mortality, major CV events (MACEs), and non-fatal CV events were 54.9%, 67.1%, and 56.6% respectively. For CLI patients, independent factors for all-cause mortality were age (odds ratio [OR] 1.03), atrial fibrillation (OR 1.79), albumin (OR 0.62), hematocrit (OR 0.96), body mass index (OR 0.94), C-reactive protein (OR 1.18), dialysis (OR 2.16), and non-ambulance (OR 2.05). Congestive heart failure, dialysis, and non-ambulance independently predicted the MACEs (OR 2.04, 1.93, and 1.67, respectively). For claudicants, coronary artery disease (CAD) was the essential factor for all-cause mortality (OR 2.24), MACE (OR 2.76) and non-fatal CV events (OR 1.82).

CONCLUSION

Long-term survival and MACE-free rates were significantly worse in CLI patients than in claudicants. Malnutrition and inflammation were associated with long-term survival. CAD, low hematocrit, dialysis, CHF, and ambulatory status predicted future CV events.

Risk stratification for low extremity amputation in critical limb ischemia patients who have undergone endovascular revascularization: A survival tree analysis

Patients with peripheral artery disease (PAD) are a heterogeneous population and differ in risk of mortality and low extremity amputation (LEA), which complicates clinical decision-making. This study aimed to develop a simple risk scale using decision tree methodology to guide physicians in managing critical limb ischemia (CLI) patients who will benefit from endovascular therapy (EVT).A total of 736 patients with CLI, Rutherford classification (RC) stage ≥4, and prior successful EVT were included. Variables significantly associated with LEA by univariate analysis (P < .05) were selected and put into classification tree analysis using the Classification and Regression Tree (CART) model with a dependent variable, amputation, and depth of tree = 3. Four risk groups were generated according to the order of amputation rate. The amputation-free survival (AFS) times between groups were compared using the Kaplan-Meier curve with the log-rank test.Patients were classified as high risk for amputation (G4) (WBC counts ≥10,000/μl, and platelet-lymphocyte ratio (PLR) ≥130.337); intermediate risk group 1 (G3) (WBC < 10,000/μl and RC stage before EVT > 5); intermediate risk group 2 (G2) (WBC count ≥ 10,000/μl, and PLR < 130.337) and low-risk group (G1) (WBC < 10,000/μl, RC before EVT ≤ 5). G2, G3, and G4 risk groups had shorter AFS time (range, 58.7 to 65.5 months) than the G1 risk group (100 months) (P < .05). Risk of LEA was significantly higher in the G4, G3, and G2 groups than in the G1 group (P ≤ .05). The G4 group had the highest risk of amputation (odds ratio = 6.84, P < .001).This simple risk scale model can help healthcare professionals more easily identify and appropriately treat patients with CLI who are at different levels of risk for LEA following endovascular revascularization.

Peak systolic velocity ratio derived from quantitative vessel analysis for restenosis after femoropopliteal intervention: a multidisciplinary review from Endovascular Asia

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.

Osteoprotegerin and osteopontin levels, but not gene polymorphisms, predict mortality in cardiovascular diseases

Aim: This study aims to investigate whether osteoprotegerin (OPG) or osteopontin (OPN) single nucleotide polymorphisms (SNPs) will predict survival. Materials & methods: This study enrolled 617 participants undergoing health examination, 536 coronary artery disease (CAD) patients and 86 peripheral artery disease (PAD) patients. Genotypes of OPG SNP rs2073618 and OPN SNP rs11730582 were determined. OPG and OPN levels were measured. Results: In both CAD and PAD populations, high OPG and OPN levels were strong predictors of all-cause death. The OPG rs2073618 CC genotype and the OPN rs11730582 TT genotype did not predict mortality. Conclusion: High OPG and high OPN levels, but not OPG rs2073618 CC genotype or OPN rs11730582 TT genotype, were strong predictors of mortality in both CAD and PAD patients.

[Expression and significance of Survivin and Bcl-2 in nasal aquamous cell carcinoma]

Objective:To investigate the expression and it's clinical significance of Survivin and Bcl-2 in nasal squamous cell carcinoma (SNSCC). Method:The immunohistochemical Envision two step method was used to measure the expression of Survivin and Bcl-2 in 35 cases of SNSCC, 20 cases of normal inferior concha tissues. Result:The expression of Survivin in SNSCC was 88.6%, significantly higher than the normal inferior turbinate mucosal tissue expression of 0% (P<0.01). The expression of Bcl-2 in SNSCC was 71.4%, significantly higher than the normal inferior turbinate mucosal tissue expression of 25% (P<0.01). Expression of Bcl-2 was significantly higher in SNSCC than in normal tissue. The expression of Survivin was positively correlated with Bcl-2 expression (P<0.01). The higher the grade of tumor, the lower expressions of Survivin and Bcl-2. Conclusion:Survivin and Bcl-2 may play an promoting role in the development and progression process of SNSCC. Survivin may become a target spot of SNSCC gene therapy.

Failure mode and bimodal restenosis of drug-coated balloon in femoropopliteal intervention

BACKGROUND

Pattern of DCB restenosis and associated outcomes in facing complex femoropopliteal lesions remain uncertain.

METHODS

Data were retrospectively collected from dual centers in Taiwan on patients who underwent treatment with DCBs for femoropopliteal lesions between 2013 and 2016. The restenosis pattern was categorized by the index-treated length. Clinical outcomes and time to DCB restenosis were retrospectively analyzed. Cox proportional hazards model identified restenosis predictors.

RESULTS

We recruited a total of 164 patients (91 men; median age 73 years) into the final analysis. The mean lesion length was 204.0 ± 109.2 mm. Of them, 45% total occlusions, 28% severe calcification and 15% in-stent restenosis were treated. Fifty-five patients have DCB restenosis (28 focal and 27 diffuse-occlusive patterns) over a 55-month follow-up. The median restenosis time emerged as a bimodal pattern with a significant difference between the diffuse-occlusive and focal restenosis group (225 vs. 484 days, P = 0.01). The 1-year patency rate after reintervention for DCB restenosis also was different between both restenosis group (29% vs. 65%, P = 0.017). The anticipated timing of escape for diffuse-occlusive or focal restenosis was 687 and 1068 days, respectively. Independent factors were lesion length (P = 0.049) for diffuse-occlusive restenosis and lumen gain of the popliteal artery for focal restenosis (P = 0.034).

CONCLUSIONS

This study demonstrated time to DCB failure emerged as a bimodal pattern of distribution and associations of restenosis pattern to subsequent outcomes after the repeated intervention. Exemption from late catchup restenosis required 3-year observation instead of the 1-year mark for conventional treatment.

Comparison of automatic and manual reposition treatment for horizontal semicircular canal benign paroxysmal positional vertigo

The purpose of this investigation was to compare the efficacy of automatic to manual reposition treatment for patients with horizontal semicircular canal paroxysmal positional vertigo (BPPV). Sixty patients diagnosed with BPPV were equally and randomly divided into either a manual reposition treatment group or an automatic reposition treatment group. The groups were compared regarding difference in pain [visual analog scale (VAS)], extent of vertigo disorder [dizziness handicap inventory (DHI)], quality of life (SF-36), and therapeutic effect. Improved VAS, DHI and SF-36 were observed in both groups, however the efficacious rate of the automatic reposition group (96.7%) was 13.4% higher than that of the manual reposition group, reaching a statistical significance (p less than 0.05). In conclusion, in the treatment of BPPV patients, automatic reposition is more effective than manual reposition and can improve the patient’s quality of life.

Drug-Coated Balloon vs. Conventional Balloon Angioplasty in Dialysis Patients With Symptomatic Femoropopliteal Disease - A Matched Comparison

BACKGROUND

Recent randomized trials have shown the treatment benefits of use of a drug-coated balloon (DCB) over conventional percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal disease. However, the effectiveness and safety of DCB for dialysis patients remain unclear.Methods and Results:Consecutive dialysis patients, who underwent PTA or DCB for femoropopliteal disease, were assessed retrospectively via 2:1 propensity score matching. Effectiveness and safety endpoints, including binary restenosis, clinically driven target lesion revascularization (CD-TLR), amputations, major adverse cardiac events (MACE), and deaths, were compared between groups. A total of 278 dialysis patients with 339 limbs were eligible for matching: 84 limbs from 77 patients treated with PTA and 46 limbs from 37 patients treated with DCB were compared after matching. Baseline patient and lesion characteristics were not different between groups. Patients treated with DCB had significantly higher rates of freedom from binary restenosis (52.4% vs. 18.6%, P<0.001) and CD-TLR (56.4% vs. 25.9%, P=0.001) at 2 years compared with patients treated with PTA. Both groups had similar outcomes for amputation, MACE, and death. Cox proportional analysis showed that treatment with DCB was independently associated with a reduction of binary restenosis (hazard ratio [HR] 0.368, P=0.001) and CD-TLR (HR 0.390, P=0.004).

CONCLUSIONS

This study suggested superior 2-year outcomes using DCB compared with PTA and similar safety profiles in dialysis patients with femoropopliteal disease.

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Clinical Outcomes of Repetition of Drug-Coated Balloon for Femoropopliteal Restenosis After Drug-Coated Balloon Treatment

BACKGROUND

To compare the clinical outcomes of patients undergoing repeated drug-coated balloon (DCB) treatment for femoropopliteal (FP) DCB restenosis with those of patients without repetition-DCB.Methods and Results:From March 2013 to September 2014, 102 patients (118 affected legs) underwent DCB for symptomatic FP disease; 47 patients had restenosis, and 37 underwent reintervention over a 45-month follow-up. We compared the outcomes of repetition-DCB for DCB restenosis with those of patients without repetition. The baseline patient and lesion characteristics were similar between groups. The mean lesion length was 200.8±113.1 and 195.2±134.6 mm, P=0.894, respectively. In addition, the procedural and follow-up outcomes were not different. The rates of freedom from binary restenosis (70% vs. 14%, P=0.001) and clinically driven target lesion revascularization (CD-TLR) (78% vs. 38%, P=0.026) at 1 year were statistically different between groups. Cox regression analysis showed that repetition of DCB was the only predictor for freedom from binary restenosis (hazard ratio [HR]: 6.15, 95% confidence interval (CI) 1.60 to 23.6, P=0.008) and CD-TLR (HR: 5.37, 95% CI 1.32-22.0, P=0.019).

CONCLUSIONS

For FP DCB restenosis, repetition of DCB can potentially improve vessel patency and significantly reduce the need for reintervention compared with conventional treatment. However, these observations require further confirmation in larger scale studies.

[The multicenter study on the registration and follow-up of low anticoagulation therapy for the heart valve operation in China]

OBJECTIVE

To investigate the optimal anticoagulation methods and monitoring strategy for Chinese patients undergoing heart valve replacement, which is potentially quite different from western populations.

METHODS

In this multicenter prospective cohort study, the anticoagulation and monitoring strategy data was acquired from 25 773 in-hospital patients in 35 medical centers and 20 519 patients in outpatient clinic in 11 medical centers from January 1st, 2011 to December 31th, 2015.

RESULTS

As for in-hospital patients, mean age of study population was (48.6±11.2) years old; main etiology of valve pathology was rheumatic (87.5%) origin among study cohort; 94.8% of study population received mechanical valve implantation; international normalized ratio (INR) monitoring (in all the study centers) and low-intensity anticoagulation strategy (31 hospitals chose target INR range of 1.5-2.5, and actual values of INR among 89.2% of 100 069 in-hospital monitoring samples were 1.5-2.5), with mean actual INR values of 1.84±0.53, and warfarin dosage of (2.82±0.93) mg/d were widely adopted among the study centers; strategies of in-hospital warfarin administration were similar in all the study centers; complication rates of low-intensity anticoagulation strategy were low in severe hemorrhage (0.02%), thrombosis (0.05%), and thromboembolism (0.05%) events, without anticoagulation-related death.As for 18 974 outpatient clinic patients, the follow-up rate was 92.47%, with a total of 30 012 patient-years (Pty). Anticoagulation-related morbidity and mortality rates were 0.67% and 0.15% Pty; major hemorrhage morbidity and mortality rates were 0.25% and 0.13% Pty; thromboembolism morbidity and mortality rates were 0.45% and 0.03% Pty.The mean dosage of warfarin daily dosage was (2.85±1.23) mg/d and INR value was 1.82±0.57.No significant regional difference in the intensity of anticoagulation therapy was noted during the study.

CONCLUSIONS

INR can be used as a normalized indicator for intensity of anticoagulation therapy in China.The optimal anticoagulation intensity with INR range from 1.5 to 2.5 is safe and effective for Chinese patients with heart valve replacement, and there is no significant regional difference in the intensity of anticoagulation therapy.

[Comparison and application of two risk assessment methods for occupational lead exposure risk classification in a lead-acid battery enterprise]

Objective: To apply and compare two risk assessment methods for occupational lead exposure risk classification in a lead-acid battery enterprise. Methods: In April 2013, an occupational health survey was carried out in a lead-acid battery enterprise. Lead smoke and lead dust were tested in the workplace. The risk assessment index system for occupational chemical hazards that was established and optimized by the research group (referred to as "optimized index system" ) , as well as the Singapore semi-quantitative risk assessment model, was used for occupational lead exposure risk classification in the lead-acid battery enterprise. The two risk classification results were analyzed and compared. Results: In the lead smoke risk classification results, the optimized index system classified the raw material group and foundry group workshops as Class I hazardous and the assembling group workshop as Class II hazardous. The Singapore semi-quantitative risk assessment model classified the raw material group workshop as high risk and foundry group and assembling group workshops as extremely high risk. In the lead dust risk classification results, the optimized index system classified the raw material group workshop as Class I hazardous, while the plate painting group, plate cutting group, and assembling group workshops were classified as Class II hazardous. The Singapore semi-quantitative risk assessment model classified the raw material group workshop as medium risk, the plate painting group and plate cutting group workshops as high risk, and the assembling group workshop as extremely high risk. Conclusion: There are some differences in risk assessment of occupational lead exposure between the two risk assessment methods. The optimized index system is comparably more reasonable and feasible, and is highly operable.

Severe Coronary Artery Spasm with Anaphylactoid Shock Caused by Contrast Medium

This study reports 2 cases of severe coronary artery spasm with anaphylactoid shock caused by contrast medium. The first patient had anaphylactoid shock in response to contrast medium and severe coronary spasms of both the left anterior descending coronary artery and the left circumflex coronary artery. The patient developed ventricular arrhythmia and complete atrioventricular block following the severe coronary spasm. The second patient had a totally occluded right coronary artery, owing to a spasm after anaphylactoid shock. Anaphylactoid shock should always be considered when persistent shock is noted after the coronary artery spasm has been relieved.

[Clinical experience of 60 patients underwent three-dimensional video assisted thoracoscopic mitral valvuloplasty]

OBJECTIVE

To summarize the clinical experience of 60 patients underwent three-dimensional video assisted thoracoscopic mitral valvuloplasty.

METHODS

Sixty patients were enrolled retrospectively from March 2014 to January 2016 in Department of Cardiacvascular Surgery, Guangdong Cardiovascular Institute. They underwent three-dimensional video assisted thoracoscopic mitral valvuloplasty. There were 37 male and 23 female patients. The range of age was 15 to 78 years (the median age was 47 years). The techniques of mitral valvuloplasty included chordae tendineae transplantation (53 patients), annuloplasty (58 patients), posterior leaflet resection (13 patients), anterior leaflet resection (2 patients), commissure resection (1 patient). Their information from charts were collected. The follow-up time was lasting 3 to 25 months by telephone or outpatient department interview. The data was analyzed via paired t test or Wilcoxon signed-rank test.

RESULTS

Conversions to mitral valve replacement were performed for two patients. No patients underwent thoracotomy. The operation time was (213±37) minutes, cardiopulmonary bypass time was (129±31) minutes, aortic cross clamping time was (81±21) minutes. Postoperative hospital stay was (7±3) days. During follow-up period, there were no re-operation and no death. Mitral regurgitation level and New York Heart Association class were both improved (Z=-6.286, P=0.000, Z=-6.237, P=0.000), respectively. Besides, there was also no new atrial fibrillation patients.

CONCLUSIONS

Not only does three-dimensional video assisted thoracoscopic mitral valvuloplasty maintain the advantages of 2-Dimensional thoracoscopy, but also have the similar view of median thoracotomy. This technique showed promising clinical value in the future.

Activin A Predicts Left Ventricular Remodeling and Mortality in Patients with ST-Elevation Myocardial Infarction

BACKGROUND

Activin A levels increase in a variety of heart diseases including ST-elevation myocardial infarction (STEMI). The aim of this study is to investigate whether the level of activin A can be beneficial in predicting left ventricular remodeling, heart failure, and death in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We enrolled 278 patients with STEMI who had their activin A levels measured on day 2 of hospitalization. Echocardiographic studies were performed at baseline and were repeated 6 months later. Thereafter, the clinical events of these patients were followed for a maximum of 3 years, including all-cause death and readmission for heart failure.

RESULTS

During hospitalization, higher activin A level was associated with higher triglyceride level, lower left ventricular ejection fraction (LVEF), and lower left ventricular end diastolic ventricular volume index (LVEDVI) in multivariable linear regression model. During follow-up, patients with activin A levels > 129 pg/ml had significantly lower LVEF, and higher LVEDVI at 6 months. Kaplan-Meier survival curves showed that activin A level > 129 pg/ml was a predictor of all-cause death (p = 0.022), but not a predictor of heart failure (p = 0.767).

CONCLUSIONS

Activin A level > 129 pg/ml predicts worse left ventricular remodeling and all-cause death in STEMI.

[Prenatal diagnosis of Thailand deletion of α-thalassemia 1 families]

OBJECTIVE

To conduct analysis and prenatal diagnosis on 11 couples carrying Thailand deletion (--(THΑI)) α-thalassemia 1, so as to provide information for clinical genetic counseling on α-thalassemia 1.

METHODS

Altogether 11 Thailand deletion (--(THΑI)) α-thalassemia 1 families were collected from Fujian Maternal and Children Health Hospital from May 2009 to September 2015. Gap-polymerase chain reaction (gap-PCR) and reverse dot blot (RDB) technology were used to detect the thalassemia mutations in the couples and fetuses.

RESULTS

In one family, Thailand deletion α-thalassemia 1 was detected in both the pregnant woman and her husband. In 10 families, Thailand deletion α-thalassemia 1 was detected in either the pregnant women or the husband, while the spouses had α-thalassemia heterozygote (1 combined with β thalassemia heterozygote). Thailand deletion α-thalassemia 1 family members all had lower mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH). In prenatal diagnosis of the 12 fetuses, 4 fetuses were found with hemoglobin(Hb) Bart's hydrops fetalis syndrome, 5 were with α-thalassemia heterozygote, and 3 were normal.

CONCLUSIONS

For couples with positive hematological phenotype but normal results in routine genetic examination of α-thalassemia, attention should be paid especially for with a history of having babies of hydrops fetalis syndrome or hemoglobin H disease. It is necessary to consider the possibility of the rare Thailand deletion (--(THΑI)) α-thalassemia 1. Prenatal diagnosis for high-risk families plays an important role.

Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases

Purpose

To investigate the clinical outcomes of endovascular therapy (EVT) in octogenarians and nonoctogenarians with peripheral arterial disease.

Methods

A retrospective analysis of 511 patients (654 affected legs) who underwent EVT between July 2005 and December 2013 was conducted in a prospectively maintained database. Immediate results and long-term vascular outcomes were analyzed and compared between octogenarians and nonoctogenarians.

Results

Octogenarians were more likely to be female and have atrial fibrillation (AF), whereas nonoctogenarians had higher rates of obesity, claudication, and medical comorbidities. There were no differences in the rates of EVT success, 30-day major adverse vascular events, and 6-month functional improvement between groups. Over the 10-year follow-up period, the rates of 3-year limb salvage, sustained clinical success, freedom from major cerebrovascular and cardiovascular events, and composite vascular events were similar between groups, but the survival rate was better in nonoctogenarians than in octogenarians (73% vs 63%, respectively, P=0.004). In Cox regression analysis, dependence on dialysis and AF were significant predictors of death (odds ratio [OR] 4.44 in dialyzed and 2.83 in AF patients), major cerebrovascular and cardiovascular events (OR 3.49 and 2.45), and composite vascular events (OR 3.14 and 2.25).

Conclusion

EVT in octogenarians was feasible, without an increased risk of periprocedural complications. The rates of limb salvage, sustained clinical success, and long-term vascular events were comparable between groups. Dialysis dependence and AF are independent predictors for poor prognosis in patients with peripheral arterial disease. However, these observations require further confirmation in larger scale studies.

Impact of routine coronary catheterization in low extremity artery disease undergoing percutaneous transluminal angioplasty: study protocol for a multi-center randomized controlled trial

Background

The prevalence of significant obstructive coronary artery disease with complex lesions is high in patients who have low extremity artery disease (LEAD). However, intermediate- or long-term cardiovascular prognosis of LEAD patients undergoing percutaneous transluminal angioplasty (PTA) remains poor. Accordingly, prophylactic coronary revascularization may modify short- and long-term cardiovascular outcomes of LEAD patients receiving PTA. Because myocardial ischemic symptoms are often masked in LEAD and the accuracy of non-invasive stress tests is usually limited, a high-quality randomized controlled trial aimed at the investigation of the prognostic role of coronary evaluation strategies before PTA is warranted.

Methods/Design

The proposed study is designed as a prospective, multi-center, open-label, superiority, randomized controlled trial. The study is conducted in high-volume centers for PTA and coronary revascularization in Taiwan. To meet the inclusion criteria, the patients must be at least 20 years old, have known LEAD, and have been admitted for elective PTA. We plan to enroll 450 participants who are randomly allocated to a routine group (routine coronary angiography without a previous non-invasive stress test before PTA) and a selective group (selective coronary angiography based on the results of non-invasive stress tests before PTA) with 1:1 ratio. Besides, we expect to enroll about 250 additional participants, who are not willing to be randomly assigned, in the registration group. The choice of revascularization procedure depends on the operator’s or cardiovascular team’s suggestion and the patient’s decision. Clinical follow-up will be performed 30 days after PTA and every 6 months until the end of the 1-year follow-up for the last randomly assigned participant. The primary endpoint is the composite major adverse cardiac event on long-term follow-up. Pre-specified secondary and other endpoints are also evaluated. Those assessing biomarkers and clinical endpoints are all blinded after assignment to interventions.

Discussion

The results of the trial will, for the first time, support better decision-making for coronary evaluation before PTA in LEAD. If favorable, routine coronary angiography followed by revascularization will improve cardiovascular outcomes in LEAD patients undergoing PTA.

Trial registration

ClinicalTrials.gov identifier: NCT02169258 (registered on 21 June 2014); registry name: Routine Coronary Catheterization in Low Extremity Artery Disease Undergoing Percutaneous Transluminal Angioplasty (PIROUETTE-PTA).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1237-0) contains supplementary material, which is available to authorized users.

Outcomes of Endovascular Therapy With the Controlled Antegrade Retrograde Subintimal Tracking (CART) or Reverse CART Technique for Long Infrainguinal Occlusions

Purpose: To compare the safety, efficacy, and clinical outcomes associated with the controlled antegrade retrograde subintimal tracking (CART) or reverse CART (r-CART) technique to the conventional retrograde approach in the treatment of patients with long infrainguinal occlusions. Methods: From May 2008 to April 2014, 121 patients failed antegrade recanalization and underwent a retrograde approach to recanalize long infrainguinal occlusions. Patients who underwent successful endovascular therapy (EVT) by the conventional retrograde approach (CRA group) were compared to patients who had successful EVT using the CART/r-CART technique (CART group) after failure of a bidirectional approach. The efficacy, safety, vessel patency, and other clinical outcomes were compared between the groups. Results: Fifty-eight patients (mean age 71.6±12.2 years; 32 men) underwent successful EVT (47.9%, 58/121) using the conventional retrograde approach (CRA group), while 44 patients (mean age 70.8±11.1 years; 31 men) among the 50 patients who underwent the CART/r-CART technique were successfully treated (88.0%, 44/50). Both groups had similar average occlusion lengths and gained 100% immediate hemodynamic success after EVT. There was no significant difference between the groups regarding procedure-related complications. During follow-up, 28 patients died (p=0.380), but there were no differences in the rates of major (p=0.279) or minor amputation (p=0.417) between the groups. There was no difference in the 2-year primary patency (31% vs 24%, p=0.686), assisted primary patency (66% vs 76%, p=0.251), target vessel revascularization (65% vs 54%, p=0.845), or sustained clinical success (52% vs 46%, p=0.995) rates between the CRA and CART groups, respectively. Conclusion: Based on acceptable safety, efficacy, and follow-up results in this study, the CART/r-CART technique can salvage patients with long peripheral occlusions after failure of the conventional antegrade or retrograde approach.

Feasibility and Clinical Outcomes of Peripheral Drug-Coated Balloon in High-Risk Patients with Femoropopliteal Disease

BACKGROUND

Clinical outcomes of the drug-coated balloon (DCB) procedure in high-risk patients with femoropopliteal (FP) disease have not been investigated sufficiently.

METHODS

This retrospective, single-center study analyzed 87 patients (39% dialysis) and 97 affected legs (64% critical limb ischemia [CLI]) that underwent DCB for symptomatic FP disease from March 2013 to September 2014. Risk stratification was based on FeDCLIP (female, diabetes, dialysis, CLI, lesion length >150 mm and poor runoff) score. The DCB outcomes among the different risk groups were compared and factors predicting restenosis were analyzed during follow-up.

RESULTS

Most of study participants (84%) were moderate to high-risk patients. The procedural success rate was 100% and the 30-day major adverse vascular event rate was 2.1%. The mean lesion length was 178 ± 106 mm and the mean follow-up time was 428 ± 145 (range 50-782) days. The binary restenosis-free and clinically driven target lesion revascularization (CD-TLR)-free rates at 12 months were 77.5% and 84.3%, respectively, for all participants. No significant differences were observed in 1-year binary restenosis and CD-TLR rates in the low-, moderate-, and high-risk groups (60%, 84%, and 73%: p = 0.396; 78%, 89%, and 80%: p = 0.635, respectively). In multivariate analysis, lesion length >150 mm (Hazard ratio [HR]: 8.00, 95% confidence interval (CI) 1.12 to 55.6, p = 0.038) and Rutherford class 6 (HR: 7.09, 95% CI, 1.15 to 43.5, p = 0.034) were identified as independent predictors of binary restenosis.

CONCLUSIONS

Despite general comorbidities and advanced limb ischemia, 1-year outcomes of DCB in high-risk patients with FP disease were effective. The DCB procedure holds promise to improve vessel patency; however, lesion length >150 mm and major tissue loss were independent predictors for binary restenosis after the treatment.