Relationship Between Autonomic Nervous System Activity and Recurrence after Cryoballoon Ablation in Patients with Paroxysmal Atrial Fibrillation.

Objectives: In this study, we aimed to investigate the relationship between autonomic dysfunction (AD) determined according to the blood pressure (BP) and heart rate (HR) response in exercise treadmill test (ETT) prior to cryoballoon ablation (CBA), and the recurrence of atrial fibrillation (AF) after CBA in patients with paroxysmal AF. Patients and Methods: Seventy-six patients (mean age 53±11 years, 61.8% male) with paroxysmal AF who underwent CBA were enrolled. Before CBA the ETT was performed by all patients. BP and HR response in ETT were compared between patients with and without AF recurrence. Results: AD rate was significantly higher in the group with recurrence compared to the non- recurrent group (p<0.001). In addition to AD, age, female gender and lower exercise capacity were also associated with post-CBA AF recurrence ( p>0.05 for all ). Examining AD parameters, systolic blood pressure at peak exercise (SBPpeak) (p<0.001) and diastolic blood pressure at peak exercise (DBPpeak) (p<0.001), slow heart rate recovery (HRR) (p<0.001) were significantly higher in the recurrent group. Conclusion: AD may associated with AF recurrence after CBA in patients with paroxysmal AF. SBPpeak, DBPpeak and slow HRR appear to be predictors of AF recurrence after ablation.

Role of ultrasound in the diagnosis of primary and recurrent dermatofibrosarcoma protuberans

Background Dermatofibrosarcoma protuberans (DFSP) is a rare, low- to intermediate-grade sarcoma, which represents a diagnostic imaging challenge. This study aimed to analyze the clinical and ultrasound features of primary and recurrent DFSP to improve the diagnosis. Methods Clinical, imaging, and pathological data from a total of 58 patients (23 patients with primary DFSP and 35 patients with recurrent DFSP) were retrospectively reviewed. Results There was no statistically significant difference in age, sex, tumor size, or echogenicity between the two groups. Most of the primary DFSP lesions involved the overlying dermis and hypodermis, while most of the recurrent DFSP lesions were fixated to more deeply seated structures at the original surgical incision. Red nodules on the skin were found more frequently in the primary group. There were statistically significant differences in the type of lesion and ultrasound tumor morphology (p < 0.050). The lesions in the primary group showed more tentacle-like projections or a “claw” sign, while the lesions in the recurrent group were more commonly oval, lobulated, and irregularly shaped. Hypervascularity was common in both groups. Conclusions For primary DFSP, a slow-growing, red nodule on the skin involving the overlying dermis and hypodermis, more frequently a hypoechoic mass with tentacle-like projections or a “claw” sign, was observed. For recurrent DFSP, palpable subcutaneous nodules or subcutaneous masses at the original surgical incision and oval, lobulated, and irregularly shaped lesions were more commonly observed. This may be useful for improving diagnostic accuracy.

DESCRIPTIVE EPIDEMIOLOGY STUDY OF THE JUSTIFYING PATELLAR INSTABILITY TREATMENT BY EARLY RESULTS (JUPITER) COHORT

Background: Patellar instability is a common injury in young patients and can lead to significant morbidity and arthritis. Its management is controversial. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population. Purpose: To describe the formation of JUPITER and provide a descriptive, epidemiologic analysis of patient demographics and clinical features of the patients in this prospective cohort. Methods: After training and institutional review board approval, surgeons began enrolling patients between 10-30 years of age who sustained a patellar dislocation. Patient demographics, dislocation history, physical exam characteristics, and PROMs were collected. Results: By January 1, 2019, 28 surgeons from 12 sites had prospectively enrolled 661 patients (677 knees) with patellar instability. 62% were female and mean age was 15.8 years. 447 knees (66%) were in the operative group and 230 (34%) in the non-operative group. 55% of knees reported that they had more than 1 dislocation (operative group 73%; non-operative group 27%, p<0.001). Operative treatment was indicated in 39% of first-time dislocators and 85% of recurrent dislocators (p<0.001). Recurrent and operative group patients had more positive physical exam findings than first-time and non-operative group patients on the affected knee (p<0.05 for J-sign, apprehension, crepitus) and the contralateral knee (p<0.05 J-sign, apprehension). The recurrent group was nearly twice as likely to be ligamentously lax (Beighton score 5 or greater) compared to first-time patients (p<0.001). Baseline PROMs varied with the recurrent group having lower Pedi-FABS (p=0.001) and KOOS-QoL (0.008) scores and higher Kujala (0.009), KOOS ADL (0.008), KOOS Sports (<0.001), and Pedi-IKDC (0.014) scores than the first-time dislocator group. Conclusions: The JUPITER Group has been able to accumulate the largest prospectively collected patellar instability database to date. Over half of patients in this group reported they sustained more than one dislocation. Operative management was indicated in 39% of first-time dislocators, 50% of which had sustained an osteochondral fracture, and 85% of recurrent dislocators. Recurrent dislocators were more likely to have positive physical exam findings on both the affected and contralateral knee.

Predictive Factors for Recurrence of Overactive Bladder after Discontinuation of an Antimuscarinic Agent

Background: Overactive bladder (OAB) is a common disease. However, the patients who stop taking medicines after clinical improvement are at risk for symptom recurrence. Objective: To determine the disease recurrence rates and evaluate the potential predictive factors for recurrent OAB symptoms after discontinuation of an antimuscarinic drug. Materials and Methods: The OAB patients who discontinued antimuscarinic drugs after symptom improvement were studied prospectively. The OAB symptoms were evaluated by the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) questionnaire. The symptom scores were evaluated at the time of recruitment and at 1, 3, 6, and 12 months after drug discontinuation. The curve of time to symptom recurrence was plotted. The factors associated with symptom recurrence were analyzed and compared. Results: Eighty-two patients including 40 (48.78%) males and 42 (51.22%) females, were included in the present study. Forty-one (50.0%) patients experienced recurrent symptoms within 12 months. The median time to symptom recurrence was 3.01 months (interquartile range [IQR] 1.0, 6.0). The mean symptom scores in the recurrent group at 1, 3, and 6 months were significantly higher than those in the non-recurrent group (10.75±7.39 versus 22.76±13.10, p<0.001; 10.89±8.93 versus 16.41±11.70, p=0.040; and 10.51±8.03 versus 22.33±14.59, p=0.001, respectively). The results of the univariate analyses indicated that other factors were not associated with recurrence. Conclusion: Symptom recurrence after antimuscarinic discontinuation is common in OAB patients. The high ICIQ-OAB score might be the predictive factor for recurrence. Most of the cases of symptom recurrence were observed within three months. Keywords: Muscarinic Antagonists, Overactive bladder, Predictive factors, Recurrence

The influence of nasal microbiome diversity and inflammatory patterns on the prognosis of nasal polyps

To understand the inflammatory microenvironment and microbiome factors for prognosis of chronic rhinosinusitis with polyps (CRSwNP), we explored the difference in characteristics of the microbiome of the nasal sinuses and inflammatory cytokines between recurrent and non-recurrent groups. We collected nasal secretions and polyp tissue from 77 CRSwNP patients. Then, we extracted microbial DNA from cotton swabs, performed high-throughput sequencing based on 16S rRNA to detect bacterial community composition, and analyzed cytokines such as IL-5, IL-8, IL-17a, IL-17e, IL-18, IL-27 and INF-gamma from polyp tissue using Luminex. The eosinophil and neutrophil cells in the peripheral blood and polyp tissue were counted. Postoperative follow-up of patients with CRSwNP for 1 year was conducted to record the recurrence of nasal polyps and analyze the correlation between the recurrence of nasal polyps and the characteristics of inflammatory cytokines, inflammatory cell count and nasal microbial diversity. After 1 year of follow-up, there were 12 recurrent patients, including 5 males and 7 females. Postoperative recurrence of nasal polyps was not significantly correlated with age, sex, asthma, allergic rhinitis or other allergic diseases in CRSwNP patients. In terms of the total nasal symptom score, the recurrent group was significantly higher than the non-recurrent group. In nasal polyp tissues, eosinophils (40.83/HP) and neutrophils (30.83/HP) in patients with CRSwNP in the recurrent group were significantly higher than those in the non-recurrent group (13.72/HP), and neutrophils (18.5/HP) were also significantly higher in the recurrent group than the non-recurrent group. The expression levels of IFN-, IL-17A, IL-17E and IL-18 were significantly higher in the recurrent group than in the non-recurrent group, and the positive rates were not different. In Southwest China, Enterobacteria and anaerobic bacteria may be correlated with the inflammatory pattern expression of nasal polyps. The neutrophil-mediated inflammatory response plays an important role in patients with CRSwNP in Southwest China and is correlated with nasal polyp recurrence. Recurrence of nasal polyps after endoscopic sinus surgery may be potentially associated with a reduced abundance of protective microorganisms and an increased number of pathogenic microorganisms.

Clinical Impact of the Prognostic Nutritional Index as a Predictor of Outcomes in Patients with Stage II/III Gastric Cancer: A Retrospective Cohort Study

Background: The Japanese Gastric Cancer Treatment Guidelines recommend S-1 and S-1 plus docetaxel as postoperative chemotherapy for pathological stage II and III gastric cancer (GC). There is currently no strategy for using chemotherapy to treat high-risk recurrent pathological stage II/III. Previous studies reported that the several nutritional, immunological, and inflammatory markers examined the association with clinical outcomes after surgery for GC. Methods: Ninety patients with GC (stage II, n = 48; stage III, n = 42) for whom gastrectomy was performed at our institution between November 2009 and September 2018 were examined. Nutritional, immunological, and inflammatory markers were calculated from blood samples within 1 week before surgery. Results: The prognostic nutritional index (PNI) status correlated with the pathological stage and disease recurrence after surgery (p = 0.015 and p < 0.0001, respectively). Thirty-three patients had disease recurrence after gastrectomy (stage II, n = 11; stage III, n = 22). The PNI was significantly lower in the recurrent group than in the non-recurrent group (p = 0.0003). The PNI correlated with overall survival and recurrence-free survival after gastrectomy (p = 0.0021 and p = 0.0001, respectively). A multivariate analysis identified the PNI as an independent prognostic factor (p = 0.006). Conclusion: The PNI may be useful for predicting the outcomes of patients with pathological stage II/III GC and may contribute to the selection of an appropriate adjuvant chemotherapy regimen.

Comparison of the surgical outcomes of free flap reconstruction for primary and recurrent head and neck cancers: a case-controlled propensity score-matched study of 1,791 free flap reconstructions

This study was designed to compare the outcome and analyze the operation-related risk factors in free flap reconstruction for patients with primary and recurrent head and neck cancers. A 1:1 propensity score-matched analysis of the microsurgery registry database of the hospital. The primary outcome of the free flap reconstruction had a higher failure rate in the recurrent group than the primary group (5.1% vs. 3.1%, p = 0.037). Among the 345 pairs in the matched study population, there were no significant differences between the primary and recurrent groups regarding the rate of total flap loss (3.5% vs. 5.5%, p = 0.27) and secondary outcomes. This study revealed that free flap reconstruction had a higher failure rate in the recurrent group than the primary group, but such a difference may be attributed by the different patient characteristics.

Carotid intraplaque neovascularisation as a predictive factor for future vascular events in patients with mild and moderate carotid stenosis: an observational prospective study

Background: Intraplaque neovascularisation (IPN) increases the vulnerability of plaques, which makes them more likely to rupture and increases the risk of vascular events. However, it is unclear whether IPN can predict future vascular events (stroke recurrence and cardiovascular events). Previous studies on IPN have focused on patients with severe stenosis but overlooked patients with mild and moderate stenosis. This study aimed to investigate whether IPN assessed by contrast-enhanced ultrasonography (CEUS) in patients with mild and moderate degrees of stenosis is associated with future vascular events. Methods: One hundred and twenty-one patients participated in this study. 76 patients who met the inclusion and exclusion criteria were included in the final dataset of the study. IPN was graded from 0 to 2 according to the extent of the microbubbles assessed using CEUS. The degree of carotid stenosis was graded as mild, moderate, or severe. We recorded future vascular events during the follow-up. Univariate and multivariate logistic regression analyses were used to evaluate risk factors for future vascular events. Results: After a follow-up period of 30 ± 6 months, 30 patients (39.5%) experienced subsequent vascular events. Compared with the ‘non-recurrent’ group, the ‘recurrent’ group showed a higher proportion of grade 2 neovascularisation ( p < 0.05), and it was an independent predictor of subsequent vascular events (odds ratio 6.066, 95% confidence interval 1.565–23.512, p < 0.05). Furthermore, in patients with mild and moderate stenosis, future vascular events occurred in an unexpectedly high proportion (up to 42.9%). In the ‘recurrent’ group, 55% of patients with mild and moderate stenosis had grade 2 neovascularisation. Conclusion: IPN by CEUS was an independent predictor of future vascular events in patients with recent ischemic stroke, and the high proportion of neovascularisation in patients with mild and moderate stenosis requires more attention.

Retinal Microcirculation and Cytokines as Predictors for Recurrence of Macular Edema after Intravitreal Ranibizumab Injection in Branch Retinal Vein Occlusion

Purpose: To investigate the relationship between retinal blood flow, presence or absence of recurrence of macular edema, and levels of cytokines, after intravitreal ranibizumab injection (IRI) in patients with branch retinal vein occlusion (BRVO). Methods: In 47 patients with BRVO and macular edema, we used laser speckle flowgraphy (LSFG) to measure the relative flow volume (RFV) of the retinal arteries and veins passing through the optic disc in the occluded and non-occluded regions of the retina before and after IRI. Aqueous humor samples were obtained at the time of IRI. Levels of vascular endothelial growth factor (VEGF), soluble VEGF receptor (sVEGFR)-1, sVEGFR-2, placental growth factor (PlGF), platelet-derived growth factor (PDGF)-AA, soluble intercellular adhesion molecule (sICAM)-1, monocyte chemoattractant protein 1 (MCP-1), interleukin (IL)-6, IL-8, IL-12 (p70), IL-13 and interferon-inducible 10-kDa protein (IP-10) were measured by the suspension array method. Patients were categorized into two groups on the basis of whether or not macular edema recurred at 2 months after IRI: the nonrecurrent group, n = 24; and the recurrent group, n = 23. Results: In the veins of the occluded region, RFV showed a significant difference between baseline and 1 month after IRI (p < 0.001) in the recurrent group and the percent change of RFV showed a significant difference between the recurrent and nonrecurrent groups (p = 0.005). Furthermore, we found a significant negative correlation between RFV in the veins of the occluded region and aqueous levels of MCP-1, IL-8 and IP-10 at baseline (p = 0.029, p = 0.035, and p = 0.039, respectively). In the recurrent group, the arteries and veins of the non-occluded and occluded regions showed no significant association between RFV and the aqueous levels of any factors. Conclusions: These findings suggested that a decrease in RFV in the veins of the occluded region might be associated with the recurrence of macular edema and that the recurrence might depend on the change in RFV in the veins of the occluded region rather than the levels of cytokines.