TIMI myocardial perfusion frame count: A new method to assess myocardial perfusion and its predictive value for short‐term prognosis

Objectives: We sought to develop a new quantitative method to evaluate the degree of myocardial perfusion. Background: Currently available methods for assessing myocardial perfusion, both TIMI myocardial perfusion grading (TMPG) and myocardial blush grading (MBG), are subjective. Methods: TIMI Myocardial Perfusion Frame Count (TMPFC), an objective method that measures the filling and clearance of contrast in the myocardium using cine‐angiographic frame‐counting, was developed to quantify myocardial perfusion. Myocardial perfusion of 45 normal coronary arteries in 15 patients, and 137 culprit arteries in 137 patients immediately after primary angioplasty, was successfully assessed with TMPFC. Results: The mean TMPFC in the normal arteries was 83.47 ± 17.96 frames (95% CI: 78.07 frames ≤ TMPFC ≤ 88.86 frames). Therefore, TMPFC < 90 frames, a value representing the upper bound of the 95% CI for the TMPFC observed in normal arteries, was defined as normal myocardial perfusion. In 137 culprit arteries, the mean TMPFC values after primary angioplasty for the right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCX) were 141 ± 82.6, 112 ± 80.3, and 102 ± 37.5 frames, respectively. Patients with suboptimal myocardial perfusion (ex: TMPG ≤ 2 or MBG ≤ 2 grade) had higher levels of TMPFC. Furthermore, multivariate analysis shows that the TMPFC was an independent predictor for 30‐day (P = 0.0261) and 6‐month incidence of MACE (P = 0.0207). Conclusions: TMPFC is a quantitative index for the assessment of myocardial perfusion; it allows quantification of TMPG and may serve as a discerning tool to predict prognosis in patients undergoing primary angioplasty. © 2009 Wiley‐Liss, Inc.     

Effects of deferred versus immediate stenting on left ventricular function in patients with ST elevation myocardial infarction

Background:Previous studies have shown conflicting results on the benefits of deferred stenting (DS) in infarct size and the incidence of microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, effect of DS on left ventricular (LV) function was not known. We aimed to evaluate whether DS improve LV function and relevant clinical outcomes after STEMI, using follow-up data from the INNOVATION study ({"type":"clinical-trial","attrs":{"text":"NCT02324348","term_id":"NCT02324348"}}NCT02324348).Methods:In total, 114 patients were randomly assigned to DS group or immediate stenting (IS) group at a 1:1 ratio. LV functional remodeling indices and MACE (major adverse cardiac events: a composite of death, non-fatal MI, unplanned target vessel revascularization, or hospitalization due to heart failure) were compared between DS and IS groups.Results:Serial echocardiographic analyses were completed in 89 subjects (78%). There were no significant changes in LV volume in either group. While LV ejection fraction and wall motion score index (WMSI) improved in both groups during follow-up, the increments were not statistically different between the 2 groups (4.3 ± 8.2 vs 3.2 ± 7.1, P = .504 for ΔLV ejection fraction; –0.16 ± 0.25 vs –0.16 ± 0.25, P = .99 for ΔWMSI). However, E/e′’ was decreased and e′ was increased only in the DS group (–3.31 ± 5.60 vs –0.46 ± 3.10, P = .005 for ΔE/e′; 0.77 ± 1.71 vs –0.22 ± 1.64, P = .009 for Δe′). The incidence of major adverse cardiac events was numerically lower in the DS group than in the IS group without a statistical significance at 1-year follow-up.Conclusions:Routine DS improved LV diastolic function but not systolic function compared with IS in patients with STEMI.     

Improving the discomfort and satisfaction of colonoscopy by distraction with smartphones: A prospective randomized controlled study

Background:Colonoscopy is an uncomfortable procedure. Distraction is thought to reduce pain by decreasing the amount of attention a person spends on a painful stimulus. We aimed to assess the usefulness of smartphones on discomfort associated with the colonoscopy.Methods:We designated 360 enrolled patients according to prospective randomized controlled study into two groups, including smartphone (SP) group (Relaxation by smartphones) and Control group (No relaxation). Measured outcomes included the discomfort, satisfaction, polyp detection rate and the willingness to repeat colonoscopy were analyzed between groups.Results:The pain and distension scores of SP group patients were significantly lower than those of the Control group (2.18 ± 2.80 vs 3.55 ± 3.07, P < .001; 4.15 ± 2.35 vs 4.79 ± 2.36, P = .011, respectively). Importantly, patient-reported satisfaction scores of the SP group were significantly higher than those of the Control group (96.45 ± 7.17 vs 91.12 ± 10.49, respectively; P < .001). Moreover, although there were no statistical differences, patients using smartphones were more likely to have shorter reach cecum times (09m:11 s vs 07m:37 s, P = .116) and more polyp detection rate (13.3% vs 9.4%, P = .246). In addition, more patients using smartphones were willing to repeat colonoscopy but no statistical difference (85.0% vs 81.7%, P = .396).Conclusion:Patient using smartphone is a special manner to increase satisfaction during colonoscopy with a less discomfort and is more likely to be polyp detection rate.     

Utility and safety of low-concentration nitrous oxide anesthesia in ptosis surgery

To evaluate the utility of low-concentration nitrous oxide (N₂O) anesthesia in ptosis surgeryThis study was a retrospective consecutive case series that included 54 successive patients with blepharoptosis who underwent bilateral levator aponeurosis advancement and on whom skin resection performed by the same surgeon between August 2016 and July 2017. Among these patients, 27 were operated with a local anesthesia injection (air group) and 27 with a local anesthesia injection and low-concentration N₂O anesthesia (N₂O group). All N₂O cases used a total of 6 L of gas comprising 70% oxygen and 30% N₂O. Preoperative and postoperative blood pressure (BP) and heart rate (HR) and intraoperative pain, anxiety, nausea, and memory were measured immediately after surgery using visual analog scale score (VASS). Additionally, perioperative side effects were examined.There was no significant difference in age, sex, and preoperative and postoperative margin reflex distance (MRD) between the 2 groups (all P > .05). The intraoperative mean peripheral oxygen saturation was significantly higher (97.5% ± 1.6% vs 99.5% ± .6%, P < .001), intraoperative HR was significantly lower (78.2 ± 12.8 vs 70.7 ± 11.6 bpm, P = .02), and operation time was significantly shorter (33.1 ± 8.1 vs 29.4 ± 10.3 minutes, P = .03) in the N₂O group than in the air group.Difference between intraoperative and preoperative systolic BP (BPs) (+15.8 ± 18.0 vs + 3.1 ± 21.7 mm Hg, P = .02), diastolic BP (BPd) (+7.0 ± 17.4 vs −2.3 ± 13.6 mm Hg, P = .04), and HR (3.2 ± 8.5 vs −3.9 ± 9.4 bpm, P = .01) was significantly lower in the N₂O group than in the air group.VASS of intraoperative pain was significantly lower in the N₂O group than in the air group (49.5 ± 24.7 vs 22.6 ± 14.9, P < .001), whereas intraoperative anxiety and memory did not present significant differences between the groups (P = .09 and P = .45, respectively). Intraoperative nausea score was 0 for all cases in both groups. There was no other side effect.Ptosis surgery with anesthesia using 30% N₂O may effectively suppress intraoperative BP and HR along with pain and shorten the operation time without side effects such as nausea.     

The effect of lung-conduction exercise in chronic obstructive pulmonary disease: Randomized,assessor-blind,multicenter pilot trial

Background:Pulmonary rehabilitation (PR) is a management modality that improves the quality of life of patients with chronic obstructive pulmonary disease (COPD); however, PR is not readily accessible. Therefore, we developed lung-conduction exercises (LCE) that can be performed easily without any limitations. The purpose of this randomized, assessor-blind, multicenter pilot trial was to compare the effects of LCE with PR and standard care (SC) in COPD patients.Methods:Twenty-five participants who met the eligibility criteria were randomly allocated to the SC group (only medication, n = 9), LCE group (medication + LCE, 5 times a week, n = 8), or PR group (medication + PR, 5 times a week, n = 8). The 6-minute walk distance (6WMD), pulmonary function test, modified Medical Research Council dyspnea scale, COPD assessment test (CAT), and St. George Respiratory Questionnaire (SGRQ) survey were carried out before starting the trial and after 4 and 8 weeks to determine motor performance, lung function, and dyspnea.Results:After 8 weeks, the pulmonary function test scores were the same. The 6MWD (PR, 28.3 ± 38.5; LCE, 14.5 ± 53.1; SC, 11.5 ± 20.5; P = .984), modified Medical Research Council dyspnea scale (PR, 0.8 ± 1.0; LCE, 0.8 ± 0.8; SC, 0.3 ± 0.5; P = .772), CAT (PR, 7.3 ± 6.2; LCE, 4.2 ± 5.2; SC, 1.0 ± 2.2; P = .232), and SGRQ scores (PR, 11.5 ± 15.4; LCE, 5.5 ± 13.1; SC, 4.8 ± 5.1; P = .358 [PR vs LCE], P = .795 [PR vs SC]) had improved in order of PR, LCE, and SC group. Although there were no statistically significant differences in the outcome measures between the groups, there were clinically significant improvements in the CAT and SGRQ scores.Conclusions:In this trial, PR showed more improvement in symptoms and quality of life than SC alone. To seek a more precise use of LCE, further full-sized studies with a long duration and additional outcome measures such as psychological assessment tools and cost-effectiveness ratio should be conducted.Trial registration:KCT0004724.     

Elevated liver enzymes in hospitalized patients with COVID-19 in Singapore

Liver dysfunction in patients with COVID-19 (coronavirus disease 2019) has been described. However, it is not clear if the presence of abnormal liver function tests at presentation was related to underlying undiagnosed liver disease, or a result of the viral infection.We retrospectively examined the first 554 consecutive polymerase chain reaction positive SARS-CoV-2 patients admitted from February 2020 to April 2020 to our academic medical centre. We reviewed their clinical data, chest radiography and laboratory studies obtained within 24 hour of admission.Despite similar hemodynamic parameters, we found significant aspartate transaminase elevation (64 ± 141 vs 35 ± 23 U/L, P < .001) in those with pneumonia compared to those without. Elevated liver enzymes were seen in 102 patients (18.4%). They presented with higher temperatures (38.5 ± 0.9 vs 37.5 ± 0.8 degC, P = .011), higher total white cell counts (6.95 ± 2.29 vs 6.39 ± 2.19 x10⁹/L, P = .021), serum ferritin (240 ± 274 vs 165 ± 198 ng/ml, P = .002) and lactate dehydrogenase (632 ± 912 vs 389 ± 107 U/L, P < .001). These patients were more likely to require intensive care (6.9% vs 2.7% P = .036) and mechanical ventilation (5.9% vs 2.2%, P = .046). Migrant workers from dormitories had a higher rate of baseline liver function test abnormalities (88/425 vs 14/129, P = .01), which were more likely to persist at the time of discharge.Despite relatively mild COVID-19 disease, there was a significant prevalence of liver dysfunction, particularly amongst migrant workers. Elevated liver enzymes were associated with more severe disease, despite similar haemodynamic characteristics. Future studies should explore whether pre-existing liver disease may predispose to more severe COVID-19 disease.     

Co-infections of SARS-CoV-2 with multiple common respiratory pathogens in infected children: A retrospective study

Since the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, considerable attention has been paid on its epidemiology and clinical characteristics in children patients. However, it is also crucial for clinicians to summarize and investigate the co-infection of SARS-CoV-2 in children.We retrospectively reviewed the clinical manifestations, laboratory findings, and imaging characteristics of COVID-19 patients in co-infection group (CI, n = 27) and single infection group (SI, n = 54). Samples were tested for multiple pathogens.A high incidence (27/81, 33%) of co-infection in children with COVID-19 was revealed. The most frequent co-infected pathogen was mycoplasma pneumoniae (MP, 20/81, 25%), followed by virus (6/81, 7%), and bacteria (4/81, 5%). No significant difference in clinical characteristics, laboratory examinations, or hospital stay was observed between the patients with co-infections and those with monomicrobial, only lower in white blood cell counts (CI: 5.54 ± 0.36 vs SI: 7.38 ± 0.37, P = .002), neutrophil counts (CI: 2.20 ± 0.20 vs SI: 2.92 ± 0.23, P = .024) and lymphocyte counts (CI: 2.72 ± 0.024 vs SI: 3.87 ± 0.28, P = .006). Compared with the patients with monomicrobial, chest imaging of those with co-infections showed consolidation in more cases (CI: 29.6% vs SI: 11.1%, P = .038) and duration of positive in nucleic acid was shorter (CI: 6.69 ± 0.82 vs SI: 9.69 ± 0.74, P = .015).Co-infection was relatively common in children with COVID-19, almost 1/3 had co-infection, most commonly caused by MP. Co-infection did not cause a significant exacerbation in clinical manifestations.     

Left atrial wall dyskinesia assessed during contractile phase as a predictor of atrial fibrillation recurrence after electrical cardioversion performed due to persistent atrial fibrillation

Direct current cardioversion (DCCV) is one of the basic methods for restoring sinus rhythm (SR) in patients with atrial fibrillation (AF). Left atrial (LA) strain is one of the parameters used to assess the risk of AF recurrence following DCCV. Assessing the strain also allows for the detection of segmental disorders of LA wall contractility, including dispersion or dyskinesia. In the present study, we determined the predictive value of LA wall dyskinesia in assessing the risk of AF recurrence after DCCV. We performed a comprehensive echocardiography in 89 patients with persistent AF following successful DCCV. We assessed the strain and strain rate in the reservoir (r), conduit, and contractile (ct) phases by using speckle tracking echocardiography. Dyskinesia was diagnosed when the strain rate of any segment of the LA wall displayed positive values during contraction. After 12 months, 47.2% of patients maintained SR. Patients who maintained SR had a significantly lower LA strain (LAS)r assessed in the apical 4-chamber view (4c) (11.38 ± 4.63 vs 14.54 ± 5.11; P = .004) and 2-chamber view (2c) (11.05 ± 4.1 vs 14.93 ± 6.82%; P = .006), LASct4c (2.51 ± 2.3 vs 5.09 ± 3.29%; P < .001), LASct2c (3.6 ± 2.98 vs 5.67 ± 4.23%; P = .008), peak strain rate (pLASR) ct4c (0.36 ± 0.24 s vs 0.62 ± 0.4⁻¹; P < .001) and pLASRct2c (0.49 ± 0.30 vs 0.79 ± 0.53 s⁻¹; P = .01). LA dyskinesia was observed less frequently in the 4c view in patients who maintained SR (59.57 vs 17.5%; P < .001). Multivariable logistic regression showed that the LASct4c (odds ratio (OR) 0.78; 95%CI 0.63–0.97; P = .027) and LA dyskinesia observed in the 4c view (OR 3.53; 95%CI 1.16–10.76; P = .027) were significant independent predictors of AF recurrence at 12 months. We conclude that LA dyskinesia observed in the 4c view and LASct4c are independent risk factors for AF recurrence following DCCV.     

Can bipolar transurethral enucleation of the prostate be a better alternative to the bipolar transurethral resection of the prostate?: A prospective comparative study

To analyze the efficacy and safety between bipolar transurethral enucleation of the prostate (BipoLEP) and bipolar transurethral resection of the prostate (B-TURP).One hundred twenty eight patients with benign prostatic hyperplasia were recruited and divided into group 1 (BipoLEP group, n = 72) and group 2 (B-TURP group, n = 56). The study period was from October 2016 to February 2019. All data parameters were prospectively collected and analyzed.In these 2 groups, there were no significant differences of the mean ages (71.88 ± 6.54 years vs 73.05 ± 7.05 years, P = .407), prostate volumes (99.14 ± 9.5 mL vs 95.08 ± 10.93 mL, P = .302) and the mean operation times (93.7 ± 27.5 minutes vs 89.8 ± 22.4 minutes, P = .065). In BipoLEP group, it had more prostate tissue resected (64.2 ± 22.1 g vs 52.7 ± 28.6 g, P = .018), less duration of continuous bladder irrigation (20.7 ± 6.5 hours vs 29.6 ± 8.3 hours, P = .044), shorter catheterization time (4.3 ± 1.5 days vs 5.6 ± 2.1 days, P = .032), shorter hospitalization stay (5.2 ± 1.4 days vs 6.5 ± 1.9 days, P = .031) and less complications (3 cases vs 9 cases, P = .021). There were significant improvements in 3-month postoperative parameters, including: post void residual urine, maximum flow rate, International Prostatic Symptoms Scale, and quality of life in each group (p < 0.01). However, there were no significant differences of preoperative and 3-month postoperative parameters, including: post void residual urine, maximum flow rate, International Prostatic Symptoms Scale, and quality of life between these 2 groups (P > .05).BipoLEP can produce a more radical prostatic resection with better safety profile and faster postoperative recovery. It may become a more favorable surgical alternative to the B-TURP, especially for the prostate larger than 80 g.     

Application effect of initiation of enteral nutrition at different time periods after surgery in neonates with complex congenital heart disease: A retrospective analysis

Early enteral nutrition (EN) promotes the recovery of critically ill patients, but the initiation time for EN in neonates after cardiac surgery remains unclear.This study aimed to investigate the effect of initiation time of EN after cardiac surgery in neonates with complex congenital heart disease (CHD).Neonates with complex CHD admitted to the CICU from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into the 24-hour Group (initiated at 24 hours after surgery in 2015) (n = 32) and 6-hour Group (initiated at 6 hours after surgery in 2016 and 2017) (n = 66). Data on the postoperative feeding intolerance, nutrition-related laboratory tests (albumin, prealbumin, retinol binding protein), and clinical outcomes (including duration of mechanical ventilation, CICU stay, and postoperative hospital stay) were collected.The incidence of feeding intolerance was 56.3% in 24-hour Group and 39.4%, respectively (P = .116). As compared to 24-hour Group, prealbumin and retinol binding protein levels were higher (160.7 ± 64.3 vs 135.2 ± 28.9 mg/L, P = .043 for prealbumin; 30.7 ± 17.7 vs 23.0 ± 14.1 g/L P = .054 for retinol-binding protein). The duration of CICU stay (9.4 ± 4.5 vs 13.3 ± 10.4 day, P = .049) and hospital stay (11.6 ± 3.0 vs 15.8 ± 10.3 day, P = .028) were shorter in 6-hour Group.Early EN improves nutritional status and clinical outcomes in neonates with complex CHD undergoing cardiac surgery, without significant feeding intolerance.     

Comparison of the effects of dexmedetomidine and remifentanil on perioperative hemodynamics and recovery profile of patients undergoing laryngeal microsurgery: A prospective randomized double-blinded study

Background:Laryngeal microsurgery (LMS) causes hemodynamic instability and postoperative agitation, cough, pain, nausea, and vomiting. Moreover, because of a short operation time, it is associated with challenging anesthetic management. The aim of this study was to compare the usefulness of continuous administration of dexmedetomidine and remifentanil in inducing general anesthesia in patients undergoing LMS.Methods:This is a prospective randomized control design. Continuous intravenous infusion of dexmedetomidine (group D) or remifentanil (group R) was administered from 10 minutes before the induction of anesthesia to the end of surgery. In both groups, 1.5 mg/kg propofol and 0.5 mg/kg rocuronium were administered for the induction of anesthesia, and desflurane were titrated during the measurement of the bispectral index. We recorded hemodynamic data, recovery time, grade of cough, pain score, and analgesic requirements during the perioperative period.Results:61 patients were finally analyzed (30 for group D, 31 for group R). The incidence of moderate to severe postoperative sore throat was higher in group R than in group D (42% vs 10%, P = .008), and the quantity of rescue fentanyl used in post-anesthesia care unit was significantly higher in group R than in group D (23.2 ± 24.7 mg vs 3.3 ± 8.6 mg; P < .001); however, the time required for eye opening was significantly longer in group D than in group R (599.4 ± 177.9 seconds vs 493.5 ± 103.6 seconds; P = .006). The proportion of patients with no cough or single cough during extubation was comparable between the 2 groups (group D vs group R: 73% vs 70%) as was the incidence of hemodynamic instability.Conclusion:Although there was a transient delay in emergence time, dexmedetomidine reduced postoperative opioid use and the incidence of sore throat. Dexmedetomidine may be used as an alternative agent to opioids in patients undergoing LMS.     

Effects of a preoperative forced-air warming system for patients undergoing video-assisted thoracic surgery: A randomized controlled trial

Background:The incidence of intraoperative hypothermia is still high despite the proposal of different preventive measures during thoracoscopic surgery. This randomized control study evaluated the effects of 30-minute prewarming combined with a forced-air warming system during surgery to prevent intraoperative hypothermia in patients undergoing video-assisted thoracic surgery under general anesthesia combined with erector spinae nerve block.Methods:Ninety-eight patients were randomly and equally allocated to prewarming or warming groups (n = 49 each). The primary outcome was the incidence of intraoperative hypothermia. Secondary outcomes were core temperature, irrigation and infused fluid, estimated blood loss, urine output, type of surgery, intraoperative anesthetic dosage, hemodynamics, recovery time, the incidence of postoperative shivering, thermal comfort, postoperative sufentanil consumption and pain intensity, patient satisfaction, and adverse events.Results:The incidence of intraoperative hypothermia was significantly lower in the prewarming group than the warming group (12.24% vs 32.65%, P = .015). Core temperature showed the highest decrease 30 minutes after surgery start in both groups; however, the rate was lower in the prewarming than in the warming group (0.31 ± 0.04°C vs 0.42 ± 0.06°C, P < .05). Compared with the warming group, higher core temperatures were recorded for patients in the prewarming group from T1 to T6 (P < .05). Significantly fewer patients with mild hypothermia were in the prewarming group (5 vs 13, P = .037) and recovery time was significantly reduced in the prewarming group (P < .05). Although the incidence of postoperative shivering was lower in the prewarming group, it was not statistically significant (6.12% vs 18.37%, P = .064). Likewise, the shivering severity was similar for both groups. Thermal comfort was significantly increased in the prewarming group, although patient satisfaction was comparable between the 2 groups (P > .05). No adverse events occurred associated with the forced-air warming system. Both groups shared similar baseline demographics, type of surgery, total irrigation fluid, total infused fluid, estimated blood loss, urine output, intraoperative anesthetic dosage, hemodynamics, duration of anesthesia and operation time, postoperative sufentanil consumption, and pain intensity.Conclusion:In patients undergoing video-assisted thoracic surgery, prewarming for 30 minutes before the induction of anesthesia combined with a forced-air warming system may improve perioperative core temperature and the thermal comfort, although the incidence of postoperative shivering and severity did not improve.     

Dexamethasone and post-adenotonsillectomy pain in children: Double-blind,randomized controlled trial

Objective:To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy.Methods:A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage.Results:The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0–7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0–2) and late pain VAS (day 5–7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044).Conclusion:In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.     

Long-term cardiac remodeling associated with heart failure following left-ventricular valve replacement surgery: A retrospective study

To investigate long-term cardiac remodeling and prognosis of patients post-left-ventricular valve replacement, and explored related risk factors of heart failure and management strategies.Retrospective cohort of patients with left-ventricular valve replacement between 2005 and 2007. Major adverse cardiac events were recorded, including death, hospitalization, stroke, and New York Heart Association (NYHA) functional classifications. Cardiac remodeling was assessed by comparing pre-operative, post-operative, and follow-up echocardiographic images.

• (1)Two hundred fifty-seven patients who received left-ventricular mitral, aortic, or double-valve replacement surgery were followed up for 10.4 ± 1.5 years with an all-cause mortality rate 18.7% and an incidence of heart failure that significantly restricted daily life (NYHA III or IV) 21.3%.
• (2)There were no significant differences in classic cardiac-remodeling variables between baseline and long-term follow-up, such as left-ventricular diameter (47.9 ± 8.3 vs 49.9 ± 8.0 mm, P = .14) and left-ventricular ejection fraction (58.6 ± 9.6% vs 57.0 ± 10.3%, P = .34), whereas there were significant differences in terms of left-atrial anteroposterior diameter (LA) (39.7 ± 9.5 vs 49.0 ± 14.3 mm, P < .001) and tricuspid regurgitation (TR) (1.4 ± 1.0 vs 2.2 ± 1.2, P < .001). Multivariable logistic regression analysis showed that LA ≥ 50 mm (P = .011) and more than moderate tricuspid regurgitation (TR > 2) (P = .012) were associated with poor prognoses for long-term consequences of heart failure. Both LA and TR progressed with the length of time after surgery.

LA enlargement and TR after left-ventricular valve replacement surgery were time-dependent events, which represented cardiac remodeling and were closely related to post-operative long-term consequences of heart failure. It is important to be cognizant of and to explore long-term preventive and treatment strategies for adverse cardiac events in patients following left-ventricular valve replacement.     

Investigation of the interaction between proton pump inhibitors and clopidogrel using VerifyNow P2Y12 assay

Background: Randomized trials and observation studies have revealed conflicting results regarding the interaction between clopidogrel and proton pump inhibitors (PPIs). The aim of our study was to provide laboratory evidence regarding whether PPIs blunt the antiplatelet reactivity of clopidogrel.Methods: We included records of Asian patients who received clopidogrel treatment for cardiovascular or cerebrovascular events and the VerifyNow P2Y12 assay for platelet reactivity monitoring. The responsiveness of antiplatelet effect to clopidogrel was analyzed according to 3 criteria:

• (1)percentage of platelet inhibition (PI) > 20%,
• (2)absolute P2Y12 reaction unit (PRU) < 235, and
• (3)PRU < 262.

Results: Patients treated without PPIs did not differ significantly from those concomitantly treated with PPIs in terms of levels of PI (25.7% ± 24.3% vs 23.0 ± 25.3%, P = .4315), PRU (187.3 ± 74.0 vs 197.4 ± 77.3, P = .3373), or responsiveness to antiplatelet (adjusted absolute risk, 3.5%; 95% confidence interval, − 10.7 to 17.7%; P = .6297). Patients treated with lansoprazole, esomeprazole, pantoprazole, and rabeprazole exhibited no significant differences in PRU or PI levels compared with those treated without PPIs. By contrast, patients treated with dexlansoprazole exhibited a significantly decreased level of PI (25.7% ± 24.3% vs 14.0% ± 21.6%, P = .0297) and responsiveness to clopidogrel under the criterion PI > 20% (adjusted absolute risk: 10.5%; 95% confidence interval: 2.6% to 43.6%; P = .0274).Conclusion: No robust interaction between clopidogrel and PPIs was found, but caution should be exercised in the concomitant use of dexlansoprazole and clopidogrel in Asians.     

The clinical efficacy of external application of mirabilite and rhubarb combined with intrathoracic chemotherapy in treating malignant pleural effusion: A prospective,randomized, controlled clinical trial

Background:Malignant pleural effusion (MPE) is one of the commonest causes of an exudative pleural effusion. Breathlessness, dyspnea and other symptoms often seriously distress and affect the quality of life. The external application of mirabilite and rhubarb (EAMR) combined with intrathoracic infusion of cisplatin, as an alternative treatment for MPE, is popular in China. The study aims to assess its effectiveness and safety combined with intrathoracic chemotherapy.Methods:This study is a prospective, randomized controlled clinical trial. Patient visits were performed at baseline and days 14 and 28 after treatment. Clinical outcomes were measured after chest drain placement using the criterion of efficacy refer to WHO standard, and QLQ-C30 questionnaire.Results:Database records of patients treated in our institution for MPE between October, 2016 and March, 2019. The study included 84 eligible patients. They were categorized with a randomization schedule into treatment group (N = 42) and control group (N = 42). There is statistical significance in the comparison of the total effective rate between these 2 groups (66.67% vs 54.76%, P < .05). Furthermore, there is statistical significance in the comparison of items of Physical (1.95 ± 0.50 vs 2.19 ± 0.58%, P < .05), Pain (1.98 ± 0.42 vs 2.07 ± 0.32, P < .05), and Global Health (1.23 ± 0.64 vs 1.13 ± 0.23%, P < .05) between these 2 groups. None of the patients had adverse reactions such as skin allergy and chest tightness.Conclusions:The total effective rate of treatment group using extra external application of mirabilite rhubarb powder is significantly higher than that of control group. The improvement of patients’ clinical symptoms is greater in treatment group and no adverse reactions is found. Therefore, external application of mirabilite and rhubarb combined with intrathoracic infusion of cisplatin is an effective method for the treatment of MPE, which is worth popularizing.     

Septal and Anterior Reverse Mismatch of Myocardial Perfusion and Metabolism in Patients With Coronary Artery Disease and Left Bundle Branch Block

The effects of left bundle branch block (LBBB) on left ventricular myocardial metabolism have not been well investigated. This study evaluated these effects in patients with coronary artery disease (CAD).Sixty-five CAD patients with complete LBBB (mean age, 61.8 ± 9.7 years) and 65 without LBBB (mean age, 59.9 ± 8.4 years) underwent single photon emission computed tomography, positron emission tomography, and contrast coronary angiography. The relationship between myocardial perfusion and metabolism and reverse mismatch score, and that between QRS length and reverse mismatch score and wall motion score were evaluated.The incidence of left ventricular septum and anterior wall reverse mismatching between the two groups was significantly different (P < 0.001 and P = 0.002, respectively). The incidences of normal myocardial perfusion and metabolism in the left ventricular lateral and inferior walls were also significantly different between the two groups (P < 0.001 and P < 0.001, respectively). The incidence of septal reverse mismatching in patients with mild to moderate perfusion was significantly higher among those with LBBB than among those without LBBB (P < 0.001). In CAD patients with LBBB, septal reverse mismatching was significantly more common among those with mild to moderate perfusion than among those with severe perfusion defects (P = 0.002). The correlation between the septal reverse mismatch score and QRS length was significant (P = 0.026).In patients with CAD and LBBB, septal and anterior reverse mismatching of myocardial perfusion and metabolism was frequently present; the septal reverse mismatch score negatively correlated with the QRS interval.     

Postoperative hypoalbuminemia is an independent predictor of 1-year mortality after surgery for geriatric intertrochanteric femoral fracture: A retrospective cohort study

Preoperative hypoalbuminemia from malnutrition is associated with increased morbidity and mortality after geriatric hip fracture surgery. However, little is known regarding the correlation between postoperative hypoalbuminemia and mortality. This study aimed to evaluate whether postoperative hypoalbuminemia could predict 1-year mortality after intertrochanteric femoral fracture surgery in elderly patients.The medical records of 263 geriatric patients (age ≥65 years) who underwent intertrochanteric femoral fracture surgery between January 2013 and January 2016 in a single hospital were reviewed retrospectively. The patients were allocated to 2 groups based on lowest serum albumin levels within 2 postoperative days (≥3.0 g/dL [group 1, n = 46] and <3.0 g/dL [group 2, n = 217]. Data between the non-survival and survival groups were compared. Multivariable logistic regression analysis was conducted to identify the independent predictor for 1-year mortality.The 1-year mortality rate was 16.3% after intertrochanteric femoral fracture surgery. Multivariable logistic regression analysis revealed that postoperative hypoalbuminemia was significantly associated with 1-year mortality (adjusted odds ratio, 8.03; 95% confidence interval, 1.37-47.09; P = .021). The non-survival group showed a significantly increased incidence of postoperative hypoalbuminemia (95.4% vs 80.0%, P = .015) and intensive care unit admission (11.6% vs 2.7%, P = .020), older age (82.5 ± 5.8 years vs 80.0 ± 7.2 years, P = .032), lower body mass index (20.1 ± 3.2 kg/m² vs 22.4 ± 3.8 kg/m², P < .001), and increased amount of transfusion of perioperative red blood cells (1.79 ± 1.47 units vs 1.43 ± 2.08 units, P = .032), compared to the survival group.This study demonstrated that postoperative hypoalbuminemia is a potent predictor of 1-year mortality in geriatric patients undergoing intertrochanteric femoral fracture surgery. Therefore, exogenous albumin administration can be considered to improve postoperative outcomes and reduce the risk of mortality after surgery for geriatric hip fracture.     

Comparative analysis of vascular bulldog clamps used in laparoscopic liver resection

To compare the clinical effect of Bulldog clamps with traditional Pringle for vascular occlusion during laparoscopic hepatectomy.One hundred ten patients were retrospectively investigated in this research from December 2014 to January 2019 in the second hospital of Anhui Medical University, who underwent laparoscopic liver resection using Bulldog (modified group, n = 54) and cotton tourniquet (traditional group, n = 56) for blocking the liver inflow-blood. Intraoperative blood loss, duration of the operation time, clamping time, postoperative outcomes were analyzed.All the operations were accomplished successfully without conversion to laparotomy, perioperative period clinical date was calculated. Intraoperative operative time, blood loss and resection sections had no statistical significance, but the clamping time (36.2 ± 5.6 vs 277.3 ± 88.4 s, P < .001) was significantly shorter in the bulldog group. Albumin, alanine aminotransferase, aspartate aminotransferase and serum total bilirubin had no statistical differences in postoperative day (POD) 1and 3, but POD 5 alanine aminotransferase (71.0 ± 46.8vs 105.8 ± 61.7IU/L P = .018) and aspartate aminotransferase (72.8 ± 39.7 vs 100.2 ± 16.7 IU/L P = .028). The postoperative hospital stays (7.02 ± 1.56 vs 8.50 ± 2.35 days P = .026) in bulldog group were lower than cotton group and differences had statistical significance. The C-reactive protein levels were significantly higher in the traditional group than in the modified group on POD 3 (46.3 ± 19.2 vs 57.7 ± 23.9 mg/L P = .019), and POD5 (13.3 ± 4.2 vs 17.5 ± 7.3 mg/L P = .001). There were 8 postoperative complications occurred in cotton group, while there was 5 in Bulldog group, all patients with complications were discharged after adequate drainage and symptomatic treatment.Bulldog is an effectively performed approach for vascular occlusion during laparoscopic hepatectomy than traditional Pringle maneuver.     

Cyclophosphamide induction dose and outcomes in ANCA-associated vasculitis with renal involvement: A comparative cohort study

Treatment of ANCA-associated vasculitis (AAV) improved over the last decades but disease-unspecific agents such as cyclophosphamide are still associated with serious adverse events, including high rates of infectious complications and malignancy with increased mortality.In this comparative cohort study, we included 121 AAV patients with renal involvement from 2 German vasculitis centers. Patients were separated into subsequent groups: 2.5 to 3 g vs >3 g cumulative cyclophosphamide induction dose. We investigated if a cyclophosphamide induction dose of 2.5 to 3 g could maintain efficacy while minimizing adverse events in AAV patients with renal involvement.Patients with 2.5 to 3 g vs >3 g cumulative cyclophosphamide (median 3.0 g vs 5.5 g, P < .001) had a comparable time to remission (median 4.0 vs 3.8 months, log-rank P = .87) with 90.6% and 91.5% achieving remission after 12 months. Refractory disease was low in both groups (median 3.6% vs 6.2%, P = .68) and relapse rate did not differ (median 36% vs 42%, log-rank P = .51). Kidney function was comparable at disease onset in both groups (eGFR, mean ± SD 29 ± 20 mL/min/1.73 m² vs 35 ± 26 mL/min/1.73 m², P = .34) and improved after 2 years irrespective of the cyclophosphamide dose (ΔeGFR, mean ± SD +8.9 ± 1.4 mL/min/1.73 m² vs +6.0 ± 1.1 mL/min/1.73 m², P = .33). The 2.5–3 g group had a lower rate of leukopenia (HR = 2.73 [95% CI, 1.2−6.3], P = .014) and less infectious episodes per patient (median 1.2 vs 0.7, P = .012), especially urinary tract infections (HR = 2.15 [95% CI, 1.1–4.5], P = .032).A cyclophosphamide induction dose of 2.5 to 3 g was able to induce remission and prevent from relapses with fewer cases of leukopenia and less infectious episodes during follow-up. Especially elderly AAV patients who are particularly susceptible to infectious complications could benefit from minimizing dosing regimens with maintained efficacy to control disease activity.