Neck Location on the Outer Convexity is a Predictor of Incomplete Occlusion in Treatment with the Pipeline Embolization Device: Clinical and Angiographic Outcomes

BACKGROUND AND PURPOSE:With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up.MATERIALS AND METHODS:In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle,  <160°), inner convexity type (included angle,  >200°), and lateral wall type (160° ≤ included angle  ≤200°). This classification reflects the metal coverage rate and flow dynamics.RESULTS:Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity–type saccular aneurysms (versus inner convexity type: OR, 30.3; P < .001; versus lateral wall type: OR, 9.71; P = .001) were independently associated with a higher rate of incomplete occlusion at the last follow-up. No permanent neurologic deficits or rupture were observed in the follow-up period.CONCLUSIONS:The aneurysm neck located on the outer convexity is a new, incomplete occlusion predictor, joining older age, fusiform aneurysms, and aneurysms with the branching artery from the dome. No permanent neurologic deficits or rupture was observed in the follow-up, even with incomplete occlusion.

Flow-diversion stents with the Pipeline Embolization Device (PED; Medtronic) were first reported in 2008.¹ Since then, multiple trials^2-6 and retrospective studies^3,7,8 have reported the safety and efficacy of the PED in the treatment of intracranial aneurysms. Long-term follow-up data showed a 95.2% occlusion rate at 5 years after treatment^3,8 and no evidence of recanalization of previously occluded aneurysms.³ Angiographic and clinical long-term follow-up data are important because incomplete occlusion leads to retreatment or rerupture in coil embolization.⁹Several factors such as age, sex, smoking, fusiform-type aneurysms, small aspect ratios, and dome-neck ratios have been reported to be predictors of incomplete or complete occlusion.^10-17 However, there is debate about outcomes when using these factors because of limited analysis of the confounding factors. Moreover, the follow-up imaging rate of incomplete occlusion is sometimes insufficient (around 50% at 6 months).¹ Additionally, the same morphologic indices used in coil embolization were used in previous PED studies, even though the 2 methods are different in their treatment mechanism for aneurysms. The metal coverage ratio (MCR)^18-20 is an important metric of PED treatment.Although the MCR correlates with the occlusion rate,¹⁹ it is calculated after treatment and additional work-up is needed to acquire it. Therefore, in this study, we introduced a new classification based on the included angle of the parent artery against the neck location for the aneurysm, which can be measured before the PED treatment and complements the MCR: outer convexity type, inner convexity type, and lateral wall type. In addition, we clarified factors, including our new classification, affecting incomplete occlusion and clinical outcome in PED treatment, on the basis of data with a high follow-up rate.     

The impact of musculoskeletal diseases on the presence of locomotive syndrome

Objectives: We assessed the impact of musculoskeletal diseases, depressive mental state, and hypertension on locomotive syndrome, a condition of reduced mobility requiring nursing care. Since locomotive syndrome is a major public health issue that needs attention, its relationship with functional inconvenience in performing daily activities was also investigated.

Methods: We conducted a cross-sectional study using an Internet panel survey, comprising 747 persons aged 30–90 years. Demographics, personal medical history, and daily activity data were assessed. The 25-question Geriatric Locomotive Function Scale was used to diagnose locomotive syndrome. Stepwise linear regression analysis and logistic regression analysis were conducted to evaluate the association between locomotive syndrome, musculoskeletal diseases, and functional inconvenience.

Results: Aging, osteoporosis, and low back pain significantly increased the risk of locomotive syndrome, followed by knee osteoarthritis and lumbar spinal stenosis. Locomotive syndrome was significantly related to depressive mental state and hypertension, and led to functional inconvenience in Seiza sitting, cleaning, shopping, and strolling.

Conclusion: Locomotive syndrome was associated with functional inconvenience in performing common daily activities involving the lower extremities and spine. Osteoporosis and aging were significantly associated with locomotive syndrome. The risk of locomotive syndrome may be decreased by treating comorbid osteoporosis and instituting exercise and diet-related modifications.     

Wound,pressure ulcer and burn guidelines – 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers

The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.     

Elucidation of demographic,clinical and trichoscopic features for early diagnosis of self-healing acute diffuse and total alopecia

The term “acute diffuse and total alopecia” (ADTA) has been often used as a synonym for self-regressing severe alopecia areata (AA). However, ADTA is originally defined as a rapidly-progressive subtype of AA (RP-AA) with short recovery time and favorable prognosis irrespective of interventions. Indeed, a subpopulation of ADTA recovers spontaneously. We focused on this unique subset of AA, which we coined as “self-healing ADTA” (sADTA). Prompt and accurate differentiation of sADTA from other RP-AA is important to avoid unnecessary treatments, which is still challenging due to the lack of predictive diagnostic hallmarks. In this study, 18 sADTA patients were retrospectively analyzed to delineate their demographics and clinical features, including gentle hair pull test and trichoscopic findings, followed by statistical comparison with those of RP-AA. All sADTA cases were female and the average age was 38.1 ± 15.9 years. The progression of hair loss areas peaked at 3.6 ± 1.5 months, and complete hair regrowth was achieved in 7.9 ± 1.7 months. The identified factors supporting the diagnosis of sADTA included being female; the absence of scalp pain and itch; the absence of extra-scalp hair loss; club hair predominance in hair pull test; predominant short vellus hairs; and increase in vacant follicular ostia on trichoscopy. Subsequently, a scoring system for early diagnosis of sADTA was developed by counting the number of six identified factors present in a tested case. When analyzed by the developed system, all sADTA cases, including an additional four cases, had scores of 4 or above, while all RP-AA cases had scores below 3 except one case. Therefore, the system successfully differentiated sADTA from RP-AA (P < 0.01). Despite some technical limitations, the current study suggested that sADTA is a distinctive entity with unique pathophysiology and that early diagnosis before intervention is feasible based on the characteristics.     

Identification and evaluation of antioxidants in Japanese parsley

Two cultivars of Japanese parsley were harvested in different seasons; their antioxidant capacities were evaluated by oxygen radical absorbance capacity (ORAC) methods, and the contents of hydrophilic and lipophilic antioxidants were compared. Japanese parsley possessed potent antioxidant capacities both in hydrophilic and lipophilic extracts when evaluated by ORAC methods. LC/MS/MS analyses revealed that chlorogenic acid and four kinds of quercetin glycosides were major antioxidants in the hydrophilic extract. Lutein was the main contributor to the antioxidant capacity of the lipophilic extract. Antioxidant capacities of the hydrophilic extracts of both cultivars tended to be higher in winter because of the increase in the contents of chlorogenic acid and quercetin glycosides. An obvious trend in the lipophilic antioxidant capacities or lutein contents was not observed irrespective of the cultivar.