Prediction of poor exposure in endoscopic mitral valve surgery using computed tomography

OBJECTIVES

In endoscopic mitral valve surgery, optimal exposure is crucial. This study aims to develop a predictive model for poor mitral valve exposure in endoscopic surgery, utilizing preoperative body profiles and computed tomography images.

METHODS

We enrolled patients undergoing endoscopic mitral valve surgery with available operative video and preoperative computed tomography. The degree of valve exposure was graded into 0 (excellent), 1 (fair), 2 (poor) and 3 (very poor). Intrathoracic dimensions-anteroposterior width (chest anteroposterior) and left-to-right width (chest width) of the thorax, height of right hemi-thorax (chest height), angle between the left ventricular axis and the horizontal plane (left ventricle apex angle), heart width, level of diaphragm in midline, and vertical distance between the midline diaphragm level and the highest top of the right diaphragm (Δdiaphragm) were measured.

RESULTS

Among 263 patients, mitral valve exposure was graded as 0 in 131 (49.8%), 1 in 72 (27.4%), 2 in 46 (17.5%) and 3 in 14 (5.3%). Body mass index, chest width, left ventricle apex angle, heart width and Δdiaphragm were identified as independent predictors of grades 2 and 3 exposure by stepwise logistic regression analysis, with an area under the receiver operating characteristic curve of 0.822 (P < 0.001). Univariate logistic regression for grade 3 exposure prediction revealed that Δdiaphragm had the largest area under the curve (0.826, P < 0.001).

CONCLUSIONS

Poor mitral valve exposure occurred in approximately one-fourth of the endoscopic surgery series and might be predicted preoperatively using body mass index and computed tomography measurements to help determine the surgical approach.

Simulation-based training for endoscopic mitral valve repair: the impact on basic surgical skills for placement of sutures at mitral valve annulus during 2-h training workshop

OBJECTIVES

The aim of this study was to evaluate the impact of simulation-based training on surgical skills during 2-h learning labs during surgical annual meeting.

METHODS

During the 36th European Association of Cardiothoracic Surgery annual meeting a learning drylab for simulation-based training for endoscopic mitral valve repair was set up. For this purpose, a validated high-fidelity endoscopic mitral valve surgery simulator and a validated suturing map were used. The training lasted 2 h. Technical pre- and post-assessment were carried out based on time and accuracy to place a suture at the posterior mitral valve annulus. The suture had to be placed within 60 s. The suture was considered anatomically correct if it entered and exited the annulus at the designated place (on the posterior annulus) and accurate if placed within the right width (8-12 mm).

RESULTS

In total, 46 participants were included in this study, of whom 18 (38%) were experienced/staff surgeons, 23 (51%) fellows and 5 (11%) residents. Before the training, 48% of the participants failed to place any suture for pre-assessment. After completing the training, 100% of the participants succeeded in placing an anatomically correct suture. There was a significant improvement in the time taken [pre-assessment mean 45 (standard deviation: 25) s vs post-assessment mean 18 (standard deviation: 12) s, P < 0.001] and the accuracy to place a suture in the mitral valve annulus after completing the training (pre-assessment 32.6% vs post-assessment 65.2%, P < 0.001).

CONCLUSIONS

This study shows a significant improvement in endoscopic skills for mitral valve surgery after completing a 2-h training with a high-fidelity endoscopic mitral valve surgery simulator. This suggests that simulation trainings during scientific annual meetings are effective on surgical skills.

Multivariable model of postoperative delirium in cardiac surgery patients: proteomic and demographic contributions

Background

Delirium following cardiac surgery is common, morbid, and costly, but may be prevented with risk stratification and targeted intervention. Preoperative protein signatures may identify patients at increased risk for worse postoperative outcomes, including delirium. In this study, we aimed to identify plasma protein biomarkers and develop a predictive model for postoperative delirium in older patients undergoing cardiac surgery, while also uncovering possible pathophysiological mechanisms.

Methods

SOMAscan analysis of 1,305 proteins in the plasma from 57 older adults undergoing cardiac surgery requiring cardiopulmonary bypass was conducted to define delirium-specific protein signatures at baseline (PREOP) and postoperative day 2 (POD2). Selected proteins were validated in 115 patients using the ELLA multiplex immunoassay platform. Proteins were combined with clinical and demographic variables to build multivariable models that estimate the risk of postoperative delirium and bring light to the underlying pathophysiology.

Results

A total of 115 and 85 proteins from SOMAscan analyses were found altered in delirious patients at PREOP and POD2, respectively (p<0.05). Using four criteria including associations with surgery, delirium, and biological plausibility, 12 biomarker candidates (Tukey's fold change (|tFC|)>1.4, Benjamini-Hochberg (BH)-p<0.01) were selected for ELLA multiplex validation. Eight proteins were significantly altered at PREOP, and seven proteins at POD2 (p<0.05), in patients who developed postoperative delirium compared to non-delirious patients. Statistical analyses of model fit resulted in the selection of a combination of age, sex, and three proteins (angiopoietin-2 (ANGPT2); C-C motif chemokine 5 (CCL5); and metalloproteinase inhibitor 1 (TIMP1); AUC=0.829) as the best performing predictive model for delirium at PREOP. The delirium-associated proteins identified as biomarker candidates are involved with inflammation, glial dysfunction, vascularization, and hemostasis, highlighting the multifactorial pathophysiology of delirium.

Conclusion

Our study proposes a model of postoperative delirium that includes a combination of older age, female sex, and altered levels of three proteins. Our results support the identification of patients at higher risk of developing postoperative delirium after cardiac surgery and provide insights on the underlying pathophysiology. ClinicalTrials.gov ( NCT02546765 ).

Spontaneously Resolved Systolic Anterior Motion of Native Mitral Valve Leaflet After Transcatheter Mitral Valve Replacement

Systolic anterior motion of a mitral leaflet can occur by various mechanisms and it is one of the causes of left ventricular outflow tract obstruction after transcatheter mitral valve replacement. We present a case of systolic anterior motion that resolved spontaneously as the anterior mitral leaflet adhered to the prosthesis. (Level of Difficulty: Intermediate.).

Development of reference material for quality control of uranium analysis in marine sediments

Environmental radioactivity monitoring is strengthening due to public concerns over radioactive contamination since the Fukushima nuclear power plant accident. Therefore, various research laboratories, institutes, and universities have been conducting environmental radioactivity surveys around nuclear power plants (NPPs). However, the reliability of the results continues to trigger controversy in society. This study was conducted to develop reference material (RM) for the quality control of 238U and 234U analyses in marine sediments. The RM was prepared according to ISO Guides 31, 34, and 35. A homogeneity test of the marine sediment RM was implemented by analyzing two batch samples from ten bottles using multiple acid digestion and alkali fusion, respectively. We found that the 238U and 234U reference values of the RM were 43.0 ± 1.7 Bq kg-1(k=1) and 41.5 ± 1.9 Bq kg-1(k=1), respectively. This marine sediment RM will be useful for the quality control of analytical methods for similar samples and proficiency tests.

Development of metal radioactive liquid reference material for proficiency test

This study developed liquid reference materials containing various metals, to be used for quality assurance of radiation measurements of the most common metallic wastes generated during the operation or decommissioning of nuclear power plants. The liquid reference materials were prepared by assuming the dissolution of stainless-steel using acid and melting of the major metals present in the stainless steel, namely Fe, Ni, Cr, and Mn, along with the standard sources (134Cs, 137Cs, 60Co, 90Sr). The theoretical massic activity of the standard sources added to the samples and the measured reference values of the gamma and beta emitters in the samples were compared, and they showed good agreement within a one-sigma confidence interval (k = 1). Using the developed reference materials, a proficiency test was conducted on three domestic labs, and the results were evaluated using Z-score. While the evaluation results showed good agreement between the reference values and the reported values for 137Cs and 60Co, all participating labs reported lower values than the reference value for 134Cs. For 90Sr, two out of the three labs reported significantly higher values than the reference value. Based on the results of this study, the developed metal radioactive liquid reference material is expected to be registered as certified reference material (CRM) in the future. They will be used as the CRM for measuring and ensuring the quality of radioactive metal waste.

Aortic Valve Replacement by Subannular Endomyocardial Implantation of Valve Prosthesis in Behçet's Disease

The novel anastomosis technique, "subannular endomyocardial implantation of valve prosthesis (SEIV)," focuses on excluding aortic annular tissue from suture line to avoid vascular inflammation in Behçet's disease (BD). We aimed to validate that SEIV could prevent prosthetic valve detachment (PVD) after aortic valve replacement (AVR) in BD patients and retrospectively analyzed the medical records of five BD patients who underwent AVR. There was no operative death. Two complete atrioventricular blocks occurred; in one of them, a permanent pacemaker (PPM) was inserted before discharge. The other one was discharged without a PPM; however, he died suddenly 32 days postoperatively. The median follow-up period was 3.3 years. There was a case of PVD with newly developed Valsalva sinus aneurysm requiring the Bentall operation at 3.6 years postoperatively. In conclusion, SEIV might prevent PVD in BD patients who underwent AVR. However, aortic root pathology related to BD activity and resulting PVD may occur later.

Long-Term Outcomes of the Maze Procedure Combined with Endoatriectomy for Patients with Calcified Left Atria

PURPOSE

Left atrial calcification (LAC) is found in long-lasting rheumatic valvular disease and is almost always accompanied by atrial fibrillation (AF). In the presence of LAC, endoatriectomy is required when performing the maze procedure. However, the technical feasibility of endoatriectomy and the long-term outcomes of the maze procedure in patients with LAC are uncertain.

METHODS

The medical records of 18 consecutive patients who underwent combined endoatriectomy and maze procedure were analyzed retrospectively.

RESULTS

Accompanying operations were mitral valve replacement (n = 16) and commissurotomy (n = 2). There was 1 operative death from sepsis following mediastinitis. When patients were divided into "broad" (n = 11) and "limited" (n = 7) groups, with the extent of LAC either greater or less than half of the left atrium, respectively, there was no intergroup difference in postoperative complications. During follow-up (median, 11.4 years), AF recurred in 11 patients. At the last follow-up visits, electrocardiography revealed significantly fewer patients in the broad group maintaining sinus rhythm (1/11 vs 4/6, P = 0.03). The 10-year AF recurrence-free survival rates were 13.9% and 66.7% in the broad and limited groups, respectively (P = 0.01).

CONCLUSIONS

The maze procedure combined with endoatriectomy seems technically feasible with acceptable long-term rhythm outcomes if the LAC extent is limited.

Trotter and Gleser's (1958) equations outperform Trotter and Gleser's (1952) equations in stature estimation of the US White males

Trotter and Gleser presented two sets of stature estimation equations for the US White males in their 1952 and 1958 studies. Following Trotter's suggestion favouring the 1952 equations simply due to the smaller standard errors, the 1958 equations have been seldom used and have gone without additional systematic validation tests. This study aims to assess the performance of the Trotter and Gleser 1952, Trotter and Gleser 1958, and FORDISC equations for the White males in a quantitative and systematic way, particularly when applied to the WWII and Korean War casualties. In sum, 27 equations (7 from the 1952 study, 10 from the 1958 study, and 10 from FORDISC) were applied to the osteometric data of 240 accounted-for White male casualties of the WWII and Korean War. Then, the bias, accuracy, and Bayes factor for each set of stature estimates were calculated. The results show that, overall, Trotter and Gleser's 1958 equations outperform the 1952 and FORDISC equations in terms of all three measures. Particularly, the equations with higher Bayes factors produced stature estimates where distributions were closer to that of the reported statures than those with lower Bayes factors. When considering Bayes factors, the best performing equation was the "Radius" equation from the 1958 study (BF = 15.34) followed by the "Humerus+Radius" equation from FORDISC (BF = 14.42) and the "Fibula" equation from the 1958 study (BF = 13.82). The results of this study will provide researchers and practitioners applying the Trotter and Gleser stature estimation method with a practical guide for equation selection.

Key Points

The performance of three stature estimation methods was compared quantitatively.Trotter and Gleser's (1952, 1958) and FORDISC White male equations were included.Overall, Trotter and Gleser's 1958 method outperformed the other methods.This study provides a practical guide for stature estimation equation selection.

Routine Mediastinal Drainage Fluid Culture for Early Diagnosis of Poststernotomy Mediastinitis

BACKGROUND

Early diagnosis of poststernotomy mediastinitis (PSM) is challenging. Since 2016, we have routinely performed mediastinal drainage fluid culture (MDFC) in patients undergoing sternotomy. This study aimed to determine the utility of MDFC for early diagnosis of PSM.

METHODS

Between November 2016 and April 2020, we conducted MDFC in 1,012 patients on the third postoperative day and prospectively observed for PSM occurrence for 3 months. If bacteria were identified, additional MDFC or blood culture was performed to reduce the possibility of false positives. Based on MDFC results, the decision for early treatment for PSM was at the attending physician's discretion.

RESULTS

Bacteria were identified in MDFC of 29 patients, eight of whom subsequently developed PSM. Among 983 patients with negative MDFC, only 15 developed PSM. In multivariate analysis, previous sternotomy history and positive MDFC were predictors of PSM. Positive MDFC was regarded as true positive if (1) PSM occurred subsequently, and/or (2) the same bacteria were identified in additional MDFC/blood culture. Non-occurrence of PSM in the absence of antibiotic treatment was regarded as false-positive MDFC. The sensitivity, specificity, and positive and negative predictive values of routine MDFC for diagnosis of mediastinal infection were 46.4, 99.0, 56.5, and 98.5%, respectively. When categorizing cases with positive MDFC based on the identified bacteria, the positive predictive value was highest (76.9%) when Staphylococci were identified.

CONCLUSION

Routine MDFC after sternotomy can facilitate early diagnosis of PSM. Early treatment for PSM may be indicated in patients in whom Staphylococci are identified in the MDFC.

Development of concrete reference material for quality assurance/quality control of gamma radioactivity measurement for nuclear power plant decommissioning waste

The Korea Research Institute of Standards and Science has developed a new concrete reference material (RM) for measuring gamma-emitting radionuclides, such as 134Cs, 137Cs, 65Zn, 241Am, and 60Co, to improve and maintain the quality assurance and quality control of the radioactivity measurement in radioactive waste generated during the decommissioning of nuclear power plants. In this study, cement, SiO2, and bentonite, which are the main components of concrete, were mixed in an appropriate ratio with radionuclides. For certification and homogeneity assessment, 10 bottles were randomly selected, two sub-samples were collected from each bottle, and radionuclides were measured via HPGe gamma spectrometry. The results of the homogeneity tests using a one-way analysis of variance on 241Am, 134Cs, 137Cs, 65Zn, and 60Co in the concrete RM fulfilled the requirements of ISO Guide 35. Coincidence summing and self-absorption correction were performed on measurement results by introducing the Monte Carlo efficiency transfer code and Monte Carlo N-Particle transport code. The reference values for five radionuclides (60Co, 65Zn, 241Am, 134Cs, and 137Cs) in the RM were in the range of 15-40 Bq/kg, and the expanded uncertainty was within 10% (k = 2). To the best of our knowledge, this was the first study to develop concrete RM for measuring gamma-emitting radionuclides.

Minimally Invasive Surgical Treatment of Hepatic Hydrothorax Complicated by Empyema: A Case Report

Hepatic hydrothorax complicated by empyema is difficult to manage. A 53-year-old man with liver cirrhosis was admitted for refractory right pleural effusion. He had a pleural catheter inserted 2 months prior. Pleural fluid appeared as exudate, and bacteria were identified in the pleural fluid culture. After confirming full ipsilateral lung expansion, minimally invasive surgery was performed. A diaphragmatic defect found by creating a pneumoperitoneum was closed, followed by talc pleurodesis. Postoperatively, overnight positive-pressure ventilation and 5-day peritoneal drainage were performed; chest tube drainage dramatically reduced over this time. At the 10-month follow-up, no recurrence of pleural effusion or signs of infection were observed.

POS1060 CHANGES IN DISEASE ACTIVITY AND PATIENT-REPORTED OUTCOMES IN PSORIATIC ARTHRITIS PATIENTS TREATED WITH IXEKIZUMAB IN A REAL-WORLD US COHORT

Background

Ixekizumab (IXE), an IL-17A inhibitor, has demonstrated efficacy in clinical trials1-3 but real-world effectiveness (RWE) data are limited.4

Objectives

To describe changes in disease activity and patient-reported outcomes (PROs) at 6 and 12 months follow-up among psoriatic arthritis (PsA) patients initiating IXE in a routine clinical setting.

Methods

This retrospective cohort study included patients from the OM1 PsA Registry (OM1, Boston, MA), a linked electronic medical record and administrative claims dataset with over 50,000 patients. Eligible patients had ≥1 prescription for IXE (first = index), were ≥18 years old at index, had ≥1 diagnosis code for PsA in the 12 months before or on index, and had ≥12 months of baseline and ≥6 months of follow-up data as of June 2021. For patients with baseline and follow-up measures available, changes in Clinical Disease Activity Index (CDAI), PROs, and other clinical outcomes from baseline to 6 and 12 months were described. For patients on IXE monotherapy, change in CDAI score from baseline to 6 and 12 months was assessed using mixed effects linear models adjusted for age, sex, and baseline CDAI score.

Results

The study population included 1,812 patients with a mean age of 53.7 years (Table 1). Psoriasis was present in 82% and enthesitis in 28%. Over 60% of patients were obese, and the mean Charlson Comorbidity Index was 1.3. Most patients (84%) had prior treatment with a biologic disease-modifying antirheumatic drug (bDMARD) and 40% with a targeted synthetic DMARD (tsDMARD). The mean number of bDMARDs and tsDMARDs used during all available prior history was 2.3 and 1.1, respectively. The most common prior bDMARDs were secukinumab (n=428, 24%) and adalimumab (n=245, 14%).

Table 1.

Demographic and Clinical Characteristics by Therapy Status

All Patients(N=1,812)Monotherapy(N=1,485)Combination Therapy(N=327)Age (years)Mean (s.d.)53.7 (12.2)53.9 (12.3)52.9 (11.7)Median (Q1-Q3)55 (46-62)55 (46-62)54 (45-61)SexFemale1,108 (61.1%)909 (61.2%)199 (60.9%)Male704 (38.9%)576 (38.8%)128 (39.1%)Charlson Comorbidity IndexMean (s.d.)1.3 (1.6)1.3 (1.6)1.5 (1.7)Median (Q1-Q3)1 (0-2)1 (0-2)1 (0-2)BMIUnderweight: <18.510 (0.6%)10 (0.7%)0 (0.0%)Normal weight: 18.5-24.9210 (12.2%)172 (12.2%)38 (12.1%)Overweight: 25-29.9455 (26.5%)379 (27.0%)76 (24.2%)Obese: >= 301,045 (60.8%)845 (60.1%)200 (63.7%)Missing927913Domains of PsA: PsoriasisYes1,490 (82.2%)1,222 (82.3%)268 (82.0%)No322 (17.8%)263 (17.7%)59 (18.0%)Domains of PsA: EnthesitisYes510 (28.1%)409 (27.5%)101 (30.9%)No1,302 (71.9%)1,076 (72.5%)226 (69.1%)

Of patients with a baseline CDAI score, 61% had moderate or severe disease activity. For all patients, CDAI scores improved (decreased) by an average of 3.4 and 3.7 points at 6 and 12 months, respectively, from a baseline mean of 15.4. All disease activity measures and PROs improved from baseline to 6 and 12 months (Figure 1). In patients persistent with IXE, 35.3% and 33.7% were in CDAI remission or low disease activity at 6 and 12 months after initiation, respectively. For IXE monotherapy users (82% of patients), at baseline, patients had a mean CDAI of 14.3 (n=131) and 15.1 (n=105) for the 6 and 12 month analyses, respectively. Adjusted mean changes in CDAI from baseline to 6 months (-3.6 points, p < 0.0001) and 12 months (-4.9 points, p < 0.0001) were statistically significant.

Conclusion

In this cohort of PsA patients with multiple prior b/tsDMARD failures, improvements in disease activity and PROs were observed at 6 and 12 months after initiating treatment with IXE. Improvements were observed in patients overall and in the monotherapy subgroup. More real-world research on IXE and other bDMARDs are important to understand the effect of treatment choices on clinical and PROs in both bDMARD-naive and experienced PsA patients.

References

[1]Mease PJ. Ann. Rheum. Dis. 2017;76(1):79-87

[2]Nash P. Lancet. 2017;389(10086):2317-2327

[3]Mease PJ. Ann. Rheum. Dis. 2020;79(1):123-131

[4]Berman J. Biologics. 2021 Nov 18;15:463-470

Disclosure of Interests

Julie Birt Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis,, Pfizer, UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, UCB, Cristi Cavanaugh: None declared, Yoojin Jung: None declared, Aisha Vadhariya Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Sarah Ross Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Jess Paulus: None declared, Aubrey Trevelin Sprabery Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Ennio Lubrano: None declared

Case Report: Intravascular Ultrasound-guided Intervention for Anastomosis Stenosis of the Left Main Coronary Artery Post-Cabrol Technique

Introduction

Some cases of percutaneous coronary intervention (PCI) for the anastomotic site between the Cabrol-type conduit and the left main coronary artery (LMCA) have been reported. Nevertheless, the combination of PCI with a detailed description of lesion appearance using virtual histology-intravascular ultrasound (VH-IVUS) has never been reported. In this study, we present a case of acute myocardial infarction that was successfully treated with intravascular ultrasound (IVUS)-guided PCI for focal stenosis at the anastomotic site, and the plaque composition was studied in detail.

Case Presentation

A 35-year-old Korean male with Behçet's disease was diagnosed with acute myocardial infarction. He had previously undergone three cardiothoracic surgeries including two aortic replacements, followed by modified Bentall operation with a Cabrol-type aortocoronary anastomosis. Coronary angiogram (CAG) showed focal critical stenosis at the anastomosis site between the conduit and the LMCA, and VH-IVUS showed fibrotic plaque with mainly fibrous tissue but without a confluent necrotic core. PCI was performed using a drug-eluting stent (4.5 × 12 mm, Synergy^TM, Boston Scientific, Marlborough, MA, USA). Since a repeat CAG and IVUS post-surgery showed an under-expanded stent strut, post-dilation ballooning was additionally performed. Subsequently, the repeat IVUS revealed wellapposed and optimized deployment of the drug-eluting stent with full lesion coverage. Final CAG showed optimal angiographic results. After successful PCI, the patient's anginal symptoms improved dramatically, and he was successfully discharged from our hospital.

Conclusion

This study presents an IVUS-guided PCI case for an anastomotic site between the conduit and the LMCA. It is the first to investigate the characteristics of this lesion through VH-IVUS, which demonstrated the presence of fibrous plaques at the anastomotic site. IVUS radiofrequency data allow for a detailed assessment of plaque composition and provide new insights into the histopathological nature of stenotic lesions at the anastomotic site, especially in patients with chronic inflammatory diseases like Behçet's disease.

Open surgical treatment of subclavian artery pseudoaneurysm after endovascular repair: a case report

Background

Subclavian artery aneurysms are rare but may cause life-threatening complications. Surgical repair has been performed as a treatment of choice, but recently, with the development of endovascular treatment, many endovascular repairs have been performed to prevent surgical complications.

Case presentation

A patient undergoing endovascular repair with a subclavian artery aneurysm was diagnosed with a type II endoleak with an enlarged aneurysmal sac. Surgical repair was performed to remove the aneurysmal sac compressing the adjacent organs.

Conclusions

The highly mobile subclavian artery has abundant collaterals. Therefore, regular follow-up is essential for endovascular repair. Surgical repair is effective when adjacent organs are compressed by the aneurysm sac.

Differentiation of multiple visceral artery aneurysm rupture from major bleeding after coronary artery bypass grafting

BACKGROUND

Visceral artery aneurysm is a very rare disease, but it is clinically important because of the high risk of rupture involved. These ruptures must be differentiated from those that occur during hospitalization after extra-abdominal surgery.

METHODS

During hospitalization after off-pump coronary artery bypass grafting, a 77-year-old woman developed hypovolemic symptoms and had decreased hemoglobin. There was no obvious bleeding, but while screening for possible complications after cardiac surgery, abdominal computed tomographic angiography showed multiple visceral artery aneurysms of the gastroduodenal and pancreaticoduodenal arteries along with hemoperitoneum.

RESULTS

The patient underwent coil embolization of the visceral artery aneurysm and was discharged without any complications.

CONCLUSIONS

In patients with coronary artery disease with risk factors for atherosclerosis, if anemia occurs without apparent bleeding after surgery, visceral artery aneurysm should be considered as a differential diagnosis.

Successful subclavian transcatheter aortic valve replacement in a nonagenarian patient: Case report and review of literature

RATIONALE

In super-aged patients with severe symptomatic aortic stenosis, transcatheter aortic valve replacement (TAVR) is a good treatment option, and the number of TAVR-eligible elderly patients is expected to grow exponentially. We present the case of a nonagenarian woman with severe aortic stenosis who underwent successful subclavian TAVR.

PATIENT CONCERNS

A 90-year-old Korean woman was brought to our department with dyspnea. On physical examination, a grade IV systolic murmur was auscultated in both the upper sternal borders and the left lower sternal border.

DIAGNOSIS

A transthoracic echocardiogram showed heavy calcification of the aortic valve with an increase in both peak velocity (4.36 m/s) and mean pressure (44.8 mm Hg), indicating severe symptomatic aortic stenosis.

INTERVENTIONS

After a heart team conference involving interventional cardiologists, cardiac surgeons, and anesthesiologists, subclavian TAVR was performed. Using the left subclavian artery, we successfully deployed a self-expandable valve prosthesis (CoreValveTM Evolut RTM, Medtronic Inc., Minneapolis, MN).

OUTCOMES

After TAVR, transthoracic echocardiogram showed a decline in both peak velocity (2.06-2.14 m/s) and mean pressure (7.42-7.95 mm Hg) with an increase in the aortic valve area (1.12 cm2). The patient's dyspnea symptoms improved dramatically.

LESSONS

In addition to femoral TAVR, subclavian TAVR may be feasible and safe in super-aged patients.

Acute biological mitral valve thrombosis after the left atrial venting in a patient with a venoarterial extracorporeal membrane oxygenator

BACKGROUND

Left atrial venting through atrial septotomy in patients with decreased left ventricular (LV) contractility after venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a simple and effective method for treating LV decompression.

MATERIALS & METHODS

We report a case of prosthetic mitral valve thrombosis after left atrial venting in a patient with VA-ECMO.

RESULTS

In patients undergoing mitral valve replacement, left atrial venting reduces the flow through the mitral valve and forms a prosthetic thrombosis.

DISCUSSION

Therefore, excessive left atrial venting should be avoided. Other venting methods that can maintain the flow through the mitral valve should be considered after mitral valve replacement.

High spatial-density, cladding-pumped 6-mode 7-core fiber amplifier for C-band operation

We present a C-band 6-mode 7-core fiber amplifier in an all-fiberized cladding-pumped configuration for space division multiplexed transmission supporting a record 42 spatial channels. With optimized fiber components (e.g. passively cooled pump laser diode, pump coupler, pump stripper), high power multimode pump light is coupled to the active fiber without any noticeable thermal degradation and an average gain of 18 dB and noise figure of 5.4 dB are obtained with an average differential modal gain of 3.4 dB.

Minimally invasive surgical strategy for refractory hepatic hydrothorax

OBJECTIVES

Treatment of refractory hepatic hydrothorax, a complication of liver cirrhosis, is complex. We aimed to investigate the usefulness of the '4-step approach', which is a minimally invasive surgical strategy combining 4 therapeutic modalities: (i) pneumoperitoneum to localize diaphragmatic defects; (ii) thoracoscopic pleurodesis; (iii) postoperative positive-pressure ventilation; and (iv) peritoneal drainage for abdominal decompression.

METHODS

We retrospectively analysed the medical records of 12 patients with hepatic hydrothorax who underwent surgical treatment using the 4-step approach from January 2013 to December 2017. Nine of them (75.0%) were Child C cases; the median model for end-stage liver disease score was 20.5. The diaphragmatic defects localized after forming a pneumoperitoneum were treated with primary closure followed by thoracoscopic pleurodesis, postoperative positive-pressure ventilation and peritoneal drainage.

RESULTS

Diaphragmatic defects were localized in all patients except one. The median postoperative positive-pressure ventilation duration was 20.1 h. Peritoneal drainage was performed for a median duration of 5 days; the peritoneal drains were removed at a median of 8 postoperative days. The median duration of postoperative hospital stay until discharge/transfer was 9.5 days. No operative mortalities occurred. The median duration of follow-up was 10.9 months. Eight deaths (66.7%) occurred during the follow-up period; however, no deaths were surgery-associated. Ipsilateral pleural effusion recurred in 3 patients (25%), among whom reoperation was performed in 1 without recurrence at the 13-month follow-up.

CONCLUSIONS

The 4-step approach seems to be a safe and effective minimally invasive surgical strategy for treating refractory hepatic hydrothorax.

Risk factors for the delayed diagnosis of extrapulmonary TB

BACKGROUND: Extrapulmonary TB (EPTB) is more difficult to diagnose than pulmonary TB. The delayed management of EPTB can lead to complications and increase the socio-economic burden.METHODS: Patients newly diagnosed with EPTB were retrospectively enrolled from 11 general hospitals in South Korea from January 2017 to December 2018. The basic characteristics of patients were described. Univariable and multivariable analyses were performed between early and delayed diagnosis groups to identify risk factors for delayed diagnosis and treatment in EPTB.RESULTS: In total, 594 patients were enrolled. Lymph node TB (28.3%) was the predominant form, followed by abdominal (18.4%) and disseminated TB (14.5%). Concurrent lung involvement was 17.8%. The positivity of diagnostic tests showed no significant difference between the two groups. Acute clinical manifestations in disseminated, pericardial and meningeal TB, and immunosuppression were associated with early diagnosis. Delayed diagnosis was associated with outpatient clinic visits, delayed sample acquisition and diagnostic departments other than infection or pulmonology.CONCLUSION: The delay in diagnosis and treatment of EPTB was not related to differences in microbiological characteristics of Mycobacterium tuberculosis itself; rather, it was due to the indolent clinical manifestations that cause referral to non-TB-specialised departments in the outpatient clinic and delay the suspicion of TB and diagnostic testing.

MULTIPHYSICS MODELING OF PRECURSORS IN MOLTEN SALT FAST REACTORS USING PROTEUS AND Nek5000

The goal of this work was to calculate the impact of the delayed neutron precursor drift in fast spectrum Molten Salt Reactors (MSRs) using coupled solutions from the neutronics code PROTEUS and the computational fluid dynamics code Nek5000. Specifically, using a multiphysics approach to solve the effective delayed neutron fraction (βeff) or delayed neutron precursor distribution for reactors with flowing fuel salts would provide valuable information for transient simulations and safety assessments. Given the multiple options for the flux solution and geometric resolution/fidelity in PROTEUS, two approaches were developed and applied to various test cases: PROTEUS-NODAL/Nek5000 and PROTEUS-SN/Nek5000. For the former, the precursors are tracked in the built-in precursor drift model in PROTEUS-NODAL, whereas in the latter, Nek5000 directly tracks the precursors. Both approaches were used to solve a single test channel problem and showed excellent agreement in the calculated βeff. Separately, a 3D hourglass-shaped core was modeled using the PROTEUS-SN/Nek5000 approach. This problem was designed to demonstrate the capability of the discrete ordinates (SN) solver and Nek5000 to model complex core designs with axially varying geometries and the ability for Nek5000 to track the precursors and calculate the resulting βeff. In addition, the Nek5000 calculations revealed the presence of recirculation zones in the hourglass design, which could lead to significant temperatures in the fuel salt and surrounding materials. These first coupled solutions show why these approaches may be necessary for not only predicting the precursor drift effect in fast MSRs but also for reactor design and performance assessments.

Advances in Mechanical Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion

Acute ischemic stroke (AIS) is a significant cause of global morbidity and mortality, with functional implications for quality of life and long-term disability. The limitations of intravenous thrombolytic therapy for the treatment of AIS, especially for emergent large vessel occlusion (ELVO), have paved the way for alternative therapies and the rapidly evolving landscape of endovascular therapy (EVT). Here, we summarize the major landmark trials that have advanced the field largely due to ongoing biomedical engineering device development that have translated into significantly improved clinical outcomes. Our review describes the clinical success of EVT, and current and future trends.

Oxytocin receptor expression in stallion testes and epididymides

Endocrine, paracrine, and autocrine factors orchestrate the development and physiology of the stallion reproductive system. Oxytocin (OXT) is one of the critical endocrine, paracrine, and autocrine factors for the male reproductive system. Previous studies have investigated OXT receptor (OXTR) expression in testes and epididymides, including humans, marmosets, macaques, swine, and sheep. This study aimed to explore (1) OXTR localization in the testes and epididymides and (2) the seasonal modification of OXTR expression in the testes. Adult stallion testis and epididymis samples were prepared using routine castration procedures. Reverse-transcription PCR was performed to detect the presence of OXTR messenger RNA (mRNA) in the testes. Western blot procedure was performed to confirm the cross-reactivity of OXTR antibody to horse OXTR. Immunohistochemistry was performed to detect OXTR protein expression in the testes and epididymides. Oxytocin receptor mRNA was detected in the stallion testes. The OXTR protein band was observed at 55 kDa. Interestingly, the relative intensity of the OXTR protein band varied between nonbreeding and breeding season. The OXTR protein level in the testes collected during the breeding season was higher than that during the nonbreeding season. Oxytocin receptor localization was observed in the cytoplasm of Type A spermatogonia and spermatid. Oxytocin receptor protein expression was also observed in the cytoplasmic area of Leydig cells and the membrane of the seminiferous tubules. The cytoplasm of principal and basal cells in the caput, corpus, and cauda was also immunolabeled with OXTR antibody. In conclusion, based on the expression of OXTR in tissues of testes and epididymides, OXT-OXTR system may be a critical factor for stallion testicular and epididymal function. In addition, according to the seasonal alteration of intensity, the OXT-OXTR system may be associated with seasonal changes in the reproductive system in stallions.

Bayes factor: A useful tool to quantitatively evaluate and compare performance of multiple stature estimation equations

When stature estimation of incomplete skeletal remains is necessary, researchers select an estimation equation which will produce the most accurate estimates. The purpose of this study is to propose that, given prior information of a target sample, the Bayes factor can be a useful tool to quantitatively evaluate and compare performance of multiple equations in this regard. This study also explores the best-performing equations to reconstruct statures of Korean War casualties with a demonstration of equation comparisons by the Bayes factor. Thirty-three sets of stature estimates were generated using different equations based on the osteometric data of the Korean War casualties. The distribution of each set was compared to that of the population (i.e., Korean servicemen during the Korean War) using the Bayes factors and posterior probabilities generated by the R codes in the LearnBayes package. A higher Bayes factor indicates a closer similarity between the two distributions under comparison. The equation with the highest Bayes factor in this study was Choi et al.'s (1997) humerus equation (bf=9.84), followed by the femur equation of the same authors (bf=5.3). The Bayesian approach has advantages over the traditional frequentist approach primarily based on the p-value. Particularly, the Bayes factor can provide practical interpretations on the models under comparison, which allows for a quantitative prioritization of different models. Researchers can obtain more accurate stature estimates of a target sample by using the equation of the highest Bayes factor.

Cerebral Ketones Detected by 3T MR Spectroscopy in Patients with High-Grade Glioma on an Atkins-Based Diet

BACKGROUND AND PURPOSE

Ketogenic diets are being explored as a possible treatment for several neurological diseases, but the physiologic impact on the brain is unknown. The objective of this study was to evaluate the feasibility of 3T MR spectroscopy to monitor brain ketone levels in patients with high-grade gliomas who were on a ketogenic diet (a modified Atkins diet) for 8 weeks.

MATERIALS AND METHODS

Paired pre- and post-ketogenic diet MR spectroscopy data from both the lesion and contralateral hemisphere were analyzed using LCModel software in 10 patients.

RESULTS

At baseline, the ketone bodies acetone and β-hydroxybutyrate were nearly undetectable, but by week 8, they increased in the lesion for both acetone (0.06 ± 0.03 ≥ 0.27 ± 0.06 IU, P = .005) and β-hydroxybutyrate (0.07 ± 0.07 ≥ 0.79 ± 0.32 IU, P = .046). In the contralateral brain, acetone was also significantly increased (0.041 ± 0.01 ≥ 0.16 ± 0.04 IU, P = .004), but not β-hydroxybutyrate. Acetone was detected in 9/10 patients at week 8, and β-hydroxybutyrate, in 5/10. Acetone concentrations in the contralateral brain correlated strongly with higher urine ketones (r = 0.87, P = .001) and lower fasting glucose (r = -0.67, P = .03). Acetoacetate was largely undetectable. Small-but-statistically significant decreases in NAA were also observed in the contralateral hemisphere at 8 weeks.

CONCLUSIONS

This study suggests that 3T MR spectroscopy is feasible for detecting small cerebral metabolic changes associated with a ketogenic diet, provided that appropriate methodology is used.

Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

PURPOSE

Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage.

MATERIALS AND METHODS

Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled.

RESULTS

The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index <19 kg/m², refractory hepatic hydrothorax not managed with liver transplantation, Child-Turcotte-Pugh score >10, and history of severe encephalopathy (grade >2) were associated with poor survival.

CONCLUSION

Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

CXCR3 ligands in pleural fluid as markers for the diagnosis of tuberculous pleural effusion

SETTING

A tertiary care academic medical centre.

OBJECTIVE

To evaluate the clinical usefulness of C-X-C motif chemokine receptor 3 (CXCR3) ligands in tuberculous pleural effusion (TPE).

DESIGN

We recruited 336 patients with pleural effusion due to various causes. Concentrations of interferon-gamma (IFN-γ) and the CXCR3 ligands CXCL9 and CXCL11 were determined using enzyme immunoassays; adenosine deaminase (ADA) activity was measured in pleural fluid and serum.

RESULTS

TPE was diagnosed in 106 patients. Non-TB conditions included lung cancer (n = 95), para-pneumonic effusion (n = 52), non-lung malignancy (n = 30), other exudate (n = 24) and transudate (n = 29) disorders. All marker levels in serum samples and pleural fluid were significantly higher in the TPE group. Analyses of receiver operating characteristic curves for differentiating TPE from non-TB effusions produced the following results for the area under the curve (AUC) for CXCL9, CXCL11, IFN-γ and ADA, respectively: 0.982, 0.952, 0.982, and 0.952. Marker AUCs in lymphocytic exudates were also high. Combining the levels of CXCL9, IFN-γ and ADA in pleural fluid improved the diagnostic performance. Serum levels of CXCL9 had the highest AUC (0.848) for diagnosing TPE.

CONCLUSION

Levels of CXR3 ligands in pleural effusion are useful for diagnosing TPE.

Lysophosphatidylserine receptor P2Y10: A G protein-coupled receptor that mediates eosinophil degranulation

BACKGROUND

P2Y10, along with GPR34 and GPR174, is a G protein-coupled receptor that is activated by an endogenous lipid mediator lysophosphatidylserine (LysoPS). Its expression pattern and its function are completely unknown. We have previously shown that P2Y10 is one of the highly up-regulated genes at the late differentiation stage during in vitro eosinophilopoiesis.

OBJECTIVE

We explored the expression and functions of P2Y10 in human cord blood (CB)-derived and peripheral blood (PB) eosinophils.

METHODS

Real-time PCR, FACS, Western blot, ELISA, and chemotaxis assays were performed to determine the expression and function of P2Y10.

RESULTS

As CB cells differentiated towards eosinophils, P2Y10 mRNA and protein were abundantly expressed. P2Y10 was the most highly expressed in the granulocytes from PB, to a lesser extent in monocytes, and least in lymphocytes. Further fractionation of granulocytes revealed that eosinophils express P2Y10 much more strongly than do neutrophils. PB eosinophils solely expressed P2Y10 among the three LysoPS receptors, while PB neutrophils expressed the three at comparable levels. LysoPS activated both CB and PB eosinophils to induce a robust ERK phosphorylation. Importantly, LysoPS was capable of triggering degranulation of ECP in PB eosinophils. This response was significantly reduced by pharmacological inhibitors of TNF-alpha-converting enzyme (TACE), epidermal growth factor receptor (EGFR), and ERK1/2, which were known to be required in P2Y10-mediated signalling pathways. However, LysoPS had no effect on chemotaxis, differentiation, or eosinophil survival.

CONCLUSIONS AND CLINICAL RELEVANCE

LysoPS provokes eosinophil degranulation through P2Y10. Therefore, P2Y10 is a potential therapeutic target to control eosinophil-associated diseases.

Oral tolerance modulates the skin transcriptome in mice with induced atopic dermatitis

Defective gut immune reactions have been implicated in the development of atopic dermatitis (AD), whereas oral tolerance (OT), that is, the immune unresponsiveness induced by oral antigen administration, protects mice against AD. To investigate this protective role of OT, the transcriptomic profiles of skin were obtained by RNA sequencing from mice that were epicutaneously sensitized, orally tolerized prior to epicutaneous sensitization, or neither (control). Oral tolerance inhibited the upregulation of keratin- and allergic inflammation-associated genes that occurred in the epicutaneously sensitized group. Compared to the controls, mice that were orally tolerized and epicutaneously sensitized showed an upregulation of genes that regulate inflammation or keratinocyte differentiation. Knocking down two of those genes, SCGB1A1 and TSC22D3, upregulated Th2 inflammatory mediators and downregulated a cornified cell envelope-related gene. Based on our findings, OT may protect skin against allergic inflammation by promoting the expression of genes that regulate Th2 inflammatory responses and skin barrier function.

Role of RNA modifications in brain and behavior

Much progress in our understanding of RNA metabolism has been made since the first RNA nucleoside modification was identified in 1957. Many of these modifications are found in noncoding RNAs but recent interest has focused on coding RNAs. Here, we summarize current knowledge of cellular consequences of RNA modifications, with a special emphasis on neuropsychiatric disorders. We present evidence for the existence of an "RNA code," similar to the histone code, that fine-tunes gene expression in the nervous system by using combinations of different RNA modifications. Unlike the relatively stable genetic code, this combinatorial RNA epigenetic code, or epitranscriptome, may be dynamically reprogrammed as a cause or consequence of psychiatric disorders. We discuss potential mechanisms linking disregulation of the epitranscriptome with brain disorders and identify potential new avenues of research.

Point-by-point femtosecond laser micro-processing of independent core-specific fiber Bragg gratings in a multi-core fiber

Four 3rd order fiber Bragg gratings were inscribed into separate cores of a 7 core multi-core fiber using the point-by-point inscription technique. A 1030 nm, 206 ± 5 fs laser was used, operating at a frequency of 1 kHz and pulse energy of 2.1 ± 0.2 µJ. Independent Bragg resonances at λ_B = 1541.01 ± 0.02, 1547.82 ± 0.02, 1532.66 ± 0.02, and 1537.42 ± 0.02 nm and extinction ratios of 13.97 ± 0.4, 16.02 ± 0.4, 10.08 ± 0.4 and 13.40 ± 0.4 dB were recorded. Our data analysis shows that refractive index changes, Δn, of the order 10^-3 were induced. Core-specific inscription of fiber Bragg gratings in a multi-core fiber can provide a flexible and versatile platform to address the needs of recent space division multiplexed transmission and optical sensor networks.