Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement

BackgroundThere are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR.MethodsEighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet’s disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.ResultsThe operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group.ConclusionsReoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.     

胆汁酸参与结肠炎症和结肠癌发生的研究进展

结直肠癌的发生和发展与多种因素相关,其中胆汁酸因素逐渐引起学者们的重视。人体胆汁酸在相关因子的调解下,形成了具有生理功能并保持无毒作用的胆汁酸池。虽然胆汁酸相关代谢与肠道炎症存在复杂联系,但胆汁酸在结肠癌发生和发展中的确定机制尚未明确,本文主要对胆汁酸与结肠炎症和恶性肿瘤发生的相关性进行综述。     

Colon ischemia: A comprehensive review

The clinical and endoscopic features of colon ischemia (CI) are non-specific. CI is correctly identified at the time of presentation in only 9% of patients is. The true incidence is likely underestimated because many mild cases resolve spontaneously without medical treatment. Furthermore, since most cases of CI are transient, and no specific cause is detected they are often considered to be “idiopathic”. In the setting of severe CI correct diagnosis and prompt recognition and therapy as well as identification of underlying causes are crucial for a favourable outcome. Although less severe, mild cases may present with similar symptoms, the prognosis and management are completely different and managed conservatively rather than with surgery. Unfortunately, data from most studies and current guidelines do not provide recommendations on the long-term management of CI or about the need for endoscopic follow-up to detect the development chronic, recurrent and/or ischemic colonic strictures. In this review, we focus on the definition of CI, its aetiology, and patterns of presentation. We highlight the pharmacological and/or endoscopic management as determined severity of disease that allow for improved outcomes. Prompt recognition and treatment using a multidisciplinary approach are essential for successful management of severe CI because mortality rates are significantly higher when the diagnosis is delayed.     

Impact of revascularization in patients with post‐infarction left ventricular aneurysm and ventricular tachyarrhythmia

BackgroundVentricular arrhythmia is a leading cause of cardiac death among patients with post‐infarction left ventricular aneurysm (PI‐LVA). The effect of coronary revascularization in PI‐LVA patients with ventricular tachyarrhythmia remains unknown. This study aims to investigate the impact of revascularization therapy on clinical outcomes in these patients.MethodsA total of 238 PI‐LVA patients were enrolled, and 59 patients were presented with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Patients were classified into 4 groups by treatment strategies (medical or revascularization) and the presence of VT/VF: group 1 (n = 57): VT/VF− and revascularization−; group 2 (n = 122): VT/VF− and revascularization+; group 3 (n = 34): VT/VF+ and revascularization+; and group 4 (n = 25): VT/VF+ and revascularization‐. The clinical outcomes were compared, and the primary endpoint was cardiac death or heart transplantation.ResultsPatients were followed up for 45 ± 16 months, and 41 patients (17.2%) reached the primary endpoint. Kaplan–Meier analysis showed that in VT/VF− patients, revascularization associated with higher cardiac survival compared with medical therapy (log‐rank p = .002), but in VT/VF+ patients, revascularization did not predict better cardiac outcome (log‐rank p = .901). Cox regression analysis revealed PET‐EF (HR 4.41, 95% CI: 1.72–11.36, p = .002) and moderate/severe mitral regurgitation (HR 2.32, 95% CI: 1.02–5.30, p = .046) as independent predictors of adverse cardiac outcome in patients with VT/VF.ConclusionPI‐LVA patients with VT/VF are at high risk of adverse cardiac outcome, and coronary revascularization does not mitigate this risk, although revascularization was associated with higher cardiac survival in PI‐LVA patients without VT/VF.     

Managing pasireotide-associated hyperglycemia: a randomized,open-label,Phase IV study

Purpose

Pasireotide is an effective treatment for acromegaly and Cushing’s disease, although treatment-emergent hyperglycemia can occur. The objective of this study was to assess incretin-based therapy versus insulin for managing pasireotide-associated hyperglycemia uncontrolled by metformin/other permitted oral antidiabetic drugs.

Methods

Multicenter, randomized, open-label, Phase IV study comprising a core phase (≤?16-week pre-randomization period followed by 16-week randomized treatment period) and optional extension (ClinicalTrials.gov ID: NCT02060383). Adults with acromegaly (n?=?190) or Cushing’s disease (n?=?59) received long-acting (starting 40 mg IM/28 days) or subcutaneous pasireotide (starting 600 µg bid), respectively. Patients with increased fasting plasma glucose (≥?126 mg/dL on three consecutive days) during the 16-week pre-randomization period despite metformin/other oral antidiabetic drugs were randomized 1:1 to open-label incretin-based therapy (sitagliptin followed by liraglutide) or insulin for another 16 weeks. The primary objective was to evaluate the difference in mean change in HbA_1c from randomization to end of core phase between incretin-based therapy and insulin treatment arms.

Results

Eighty-one (32.5%) patients were randomized to incretin-based therapy (n?=?38 received sitagliptin, n?=?28 subsequently switched to liraglutide; n?=?12 received insulin as rescue therapy) or insulin (n?=?43). Adjusted mean change in HbA_1c between treatment arms was – 0.28% (95% CI – 0.63, 0.08) in favor of incretin-based therapy. The most common AE other than hyperglycemia was diarrhea (incretin-based therapy, 28.9%; insulin, 30.2%). Forty-six (18.5%) patients were managed on metformin (n?=?43)/other OAD (n?=?3), 103 (41.4%) patients did not require any oral antidiabetic drugs and 19 patients (7.6%) were receiving insulin at baseline and were not randomized.

Conclusion

Many patients receiving pasireotide do not develop hyperglycemia requiring oral antidiabetic drugs. Metformin is an effective initial treatment, followed by incretin-based therapy if needed.

ClinicalTrials.gov ID: NCT02060383.

     

3.0 T magnetic resonance imaging scanning on different body regions in patients with pacemakers

Purpose

Magnetic resonance imaging (MRI) at 3.0 T is becoming more common, but there is a lack of sufficient evidence on the safety of a 3.0 T scan in patients with pacemakers. This study aimed to investigate the safety and practical concerns of 3.0 T scans for patients with MR-conditional pacemakers.

Methods

Twenty consecutive patients were enrolled. A standardized protocol was developed by cardiologists, pacemaker engineers, and radiologists. Pacemaker interrogation was performed immediately before and after the scan. Scan-related adverse events were documented, and imaging quality was graded as level 1 to 4 by radiologists.

Results

Twenty-three MRI scans of different body regions (brain?=?13, lumbar spine?=?4, cervical spine?=?2, and heart?=?4) were performed, and the average time of a scan was 25?±?11 min. No significant changes in sensing amplitude (atrial 3.1?±?1.1 mV vs. 2.9?±?1.2 mV, P?=?0.71; ventricular 9.3?±?3.5 mV vs. 10.2?±?3.4 mV, P?=?0.46), lead impedances (atrial 647?±?146 Ω vs. 627?±?151 Ω, P?=?0.7; ventricular: 780?±?247 Ω vs.711?±?226 Ω, P?=?0.36), or pacing threshold (atrial 0.6?±?0.2 V/0.4 ms vs. 0.6?±?0.2 V/0.4 ms, P?=?0.71; ventricular 0.7?±?0.3 V/0.4 ms vs. 0.7?±?0.2 V/0.4 ms, P?=?0.85) were observed pre- and postscan. No adverse events were detected. Image quality review showed grade 1 quality in 16 patients and grade 2 quality in 4 patients with artifacts of pulse generators and leads in cardiac MRI scan and no impact on diagnostic value.

Conclusion

Our initial data indicated that 3.0 T scanning might be feasible under a standardized protocol with good diagnostic imaging quality irrespective of body region in patients with MR-conditional pacemakers.

     

Early combination versus initial metformin monotherapy in the management of newly diagnosed type 2 diabetes: An East Asian perspective

Type 2 diabetes (T2D) in the East Asian population is characterized by phenotypes such as low body mass index, an index of β-cell dysfunction, and higher percentage of body fat, an index of insulin resistance. These phenotypes/pathologies may predispose people to early onset of diabetes with increased risk of stroke and renal disease. Less than 50% of patients with T2D in East Asia achieve glycaemic targets recommended by national or regional guidelines, which may be attributable to knowledge and/or implementation gaps. Herein, we review the latest evidence with special reference to East Asian patients with T2D and present arguments for the need to use early combination therapy to intensify glycaemic control. This strategy is supported by the 5-year worldwide VERIFY study, which reported better glycaemic durability in newly diagnosed patients with T2D with a mean HbA1c of 6.9% treated with early combination therapy of vildagliptin plus metformin versus those treated with initial metformin monotherapy followed by addition of vildagliptin only with worsening glycaemic control. This paradigm shift of early intensified treatment is now recommended by the American Diabetes Association and the European Association for the Study of Diabetes. In order to translate these evidence to practice, increased awareness and strengthening of the healthcare system are needed to diagnose and manage patients with T2D early for combination therapy.     

载药微球经动脉化疗栓塞术治疗肝细胞癌的药物选择新进展

［摘要］　肝细胞癌是发病率和死亡率较高的恶性肿瘤类型,如何有效提高肝细胞癌治疗效果是临床亟需解决的重要问题。经动脉化疗栓塞术（TACE）是中期肝细胞癌和不可外科手术的早期肝细胞癌的首选治疗方式。载药微球经动脉化疗栓塞术是临床常见的经动脉化疗栓塞类型。与传统TACE相比,载药微球经动脉化疗栓塞术可有效减少不良反应的发生,但未显著提高生存期限,如何有效提高载药微球经动脉化疗栓塞术的疗效是值得关注的问题。随着靶向及免疫药物在肝细胞癌治疗中的疗效不断明确,突破只能负载水溶性好的化疗药物的局限,探索新的载药性能是载药微球的新选择,也是提高载药微球经动脉化疗栓塞术整体疗效的新方向。