Background and Aims Colorectal endoscopic submucosal dissection (ESD) is difficult and time consuming. Optimization of ESD with snaring (optimized hybrid ESD) may shorten the procedure time. The ...purpose of this study was to prospectively compare ESD and optimized hybrid ESD in the colorectum. Methods We prospectively enrolled 70 patients with colorectal neoplasia ≥20 mm. The patients were randomized to receive either ESD (36 patients) or optimized hybrid ESD (34 patients). In the optimized hybrid ESD group, snare resection was performed after an adequate amount of submucosal dissection. The primary outcome was procedure time. Secondary outcomes were en bloc and complete resection rates and adverse event rates. Results ESD could not be completed in 5 patients (13.9%) in the ESD group because of technical difficulties. We tried hybrid ESD to finish the resection, and en bloc resection was achieved in 4 patients (80%). The mean procedure time was shorter in the optimized hybrid ESD group compared with the ESD group (27.4 vs 40.6 minutes; P = .005). The en bloc resection rates were similar (94.1% vs 100%; P = .493), as were the complete resection rates (91.2% vs 93.5%; P > .999) and perforation rates (3 patients 8.8% vs 2 patients 6.5%; P > .999). Conclusions Optimized hybrid ESD achieves shorter procedure times than ESD, with similar en bloc resection rates and adverse event rates. Optimized hybrid ESD in the colorectum may offer an easy alternative to colorectal ESD and a rescue method for failed ESD cases. (Clinical trial registration number: NCT01944540 .)
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background and Aims The incidence of rectal neuroendocrine tumors (NETs) is increasing, and most small rectal NETs can be treated endoscopically. Cap-assisted EMR (EMR-C) was suggested as an ...effective treatment for rectal NETs in a few studies. We aimed to compare the outcomes of conventional EMR, EMR-C, and endoscopic submucosal dissection (ESD) for the treatment of rectal NETs. Methods A total of 138 rectal NETs were treated endoscopically by a single endoscopist at Asan Medical Center. We analyzed 122 rectal NETs that had been removed by using EMR (n = 56), EMR-C (n = 34), or ESD (n = 32). Results The histologic complete resection rate was higher in the EMR-C group than in the EMR group (94.1% vs 76.8%, P = .032). Intraprocedural bleeding tended to be more frequent in the EMR-C group than in the EMR group (8.8% vs 0%, P = .051). No differences in the rates of adverse events or histologic complete resections were observed between the EMR-C group and the ESD group for 6-mm to 8-mm NETs; however, the procedure time was significantly shorter in the EMR-C group (3.9 ± 1.1 minutes) than in the ESD group (19.0 ± 12.1 minutes) ( P < .001). There was no recurrence in any of the 3 groups. Conclusions EMR-C is the preferable technique for endoscopic resection of small rectal NETs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The effect of oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) with a history of intracranial hemorrhage (ICH) is poorly defined.
The purpose of this study was to evaluate ...the efficacy and safety of OAT in patients with AF with an ICH history.
We retrospectively compared the composite end point, including thromboembolic and major bleeding events, between patients with AF with a history of ICH who were (OAT group, n = 254) and those who were not (no-OAT group, n = 174) taking OAT.
During a mean follow-up of 39.5 ± 31.9 months, 5.5 and 3.1 major bleeding events/100 patient-years were observed in the OAT and no-OAT groups, respectively (P = .024). Recurrent ICH was observed only in patient with OAT. Thromboembolic events occurred in 2.4 and 8.3 events/100 patient-years in OAT and no-OAT groups, respectively (P < .001). There was no significant differences in composite end points between OAT and no-OAT groups (11.5 events/100 patient-years vs 7.9 events/100 patient-years; P = .154). Patients with OAT who achieved a time-in-therapeutic range of ≥60% of the international normalized ratio of 2.0-3.0 demonstrated a better cumulative survival free of the composite end point (P < .001) than did patients without OAT. Early (<2 weeks) OAT after an index ICH did not improve composite end points because of the increased incidence of major bleeding events. However, OAT at 2 weeks after an index ICH was associated with decreased clinical events including thromboembolic events and composite end point.
In patients with AF who require anticoagulation and have a history of ICH, maintaining optimal OAT with time-in-therapeutic range ≥ 60% and the initiation of OAT at least 2 weeks after an index ICH were associated with improved clinical outcomes.
The frequency and distribution of thin-cap fibroatheromas (TCFA) have important clinical implications. We evaluated the frequency and distribution of TCFA identified by virtual histology ...intravascular ultrasound (VH-IVUS) in acute coronary syndrome (ACS) and stable angina pectoris (SAP). Preintervention 3-vessel VH-IVUS was performed in 105 patients with ACS and 107 with SAP. The length of left anterior descending artery imaged was 72 ± 16 mm—54 ± 12 mm in the left circumflex and 92 ± 19 mm in the right coronary. VH-IVUS-derived TCFA (VH-TCFA) had a necrotic core ≥10% of plaque area without overlying fibrous tissue in a plaque burden ≥40%. There were 76 ruptured plaques (55 in ACS and 21 in SAP) and 439 VH-TCFA (262 in ACS and 177 in SAP, 2.5 ± 1.5 vs 1.7 ± 1.1 TCFA per patient with ACS and with SAP, respectively; p <0.001). Twelve patients with ACS and 1 with SAP had multiple ruptured plaques (p <0.001); 76 patients with ACS and 58 with SAP had multiple VH-TCFA (p = 0.009). Presentation of ACS was the only independent predictor for multiple ruptured plaques (p = 0.013) or multiple VH-TCFA (p = 0.011). Eighty-three percent of VH-TCFA were located within 40 mm of the coronary: 111 ≤10 (25%), 110 from 11 to 20 (25%), 83 from 21 to 30 (19%), and 61 from 31 to 40 mm (14%). The axial distribution of VH-TCFA was similar in patients with ACS and those with SAP and was similar to the axial distribution of ruptured plaques. In conclusion, 3-vessel VH-IVUS imaging showed a higher frequency of VH-TCFA in primary and secondary lesions in patients with ACS compared with those with SAP, but showed a similar clustering of VH-TCFA in the proximal 40 mm of each coronary artery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Although the degree of electroanatomical remodeling of the left atrium (LA) is influenced by left ventricular (LV) diastolic function, clinical implications of estimated LV ...filling pressure (E/Em) are limited in patients with atrial fibrillation (AF). We hypothesized that increased E/Em is related to an advanced LA remodeling, a high CHA2 DS2 -VASc score, and the presence of stroke or transient ischemic attack (TIA) in patients with paroxysmal AF. Methods We included 1098 patients with paroxysmal AF (male 74.5%, 57.6 ± 11.3 years old) who underwent AF catheter ablation. We compared E/Em to clinical parameters, echocardiography, and three-dimensional-computed tomography findings. Results The E/Em > 15 group ( n = 98) was older ( p < 0.001) and had more females ( p < 0.001), greater LA volume index ( p < 0.001), higher CHA2 DS2 -VASc score ( p < 0.001), and stroke/TIA prevalence ( p = 0.001) than groups with an E/Em of 8–15 ( n = 676) or <8 ( n = 324). An E/Em was independently associated with the presence of stroke/TIA (OR 1.638, 95% CI 1.050–2.554, p = 0.030) after adjusting for age, sex, body surface area, LA volume index, and LA appendage volume index. Conclusions In patients with paroxysmal AF, the elevated LV filling pressure estimated by E/Em is independently associated with the presence of stroke or TIA.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background Radiofrequency catheter ablation (RFCA) for long-standing persistent atrial fibrillation (L-PeAF) is challenging and has a relatively high recurrence rate. We explored clinical ...and genetic characteristics associated with being good responders (no early or clinical recurrence within 12 months in the absence of anti-arrhythmic drugs) to RFCA among patients with L-PeAF. Methods Of 1319 patients in the Yonsei AF Ablation Cohort, this study included 141 consecutive patients with L-PeAF (80.9% male, age 57.8 ± 9.7 years) who were followed >12 months after RFCA. Results During 25 (19–35) months follow-up, the recurrence rate was 39%, and 38 patients (27%) were categorized as good responders, those had a shorter AF duration ( p = 0.010), and smaller left atrial (LA) size ( p = 0.033) than others. The rs2106216 (16q22/ ZFHX3 ) genetic polymorphism was independently associated with being a good responder in multivariate analysis (adjusted OR = 2.70, 95% CI 1.41–5.14, p = 0.003), after adjusting for LA size and AF duration. The rs2106261 had predictive value for clinical recurrence of AF after RFCA among patients with an AF duration 12–65 months (log rank, p = 0.025). Conclusions Despite a relatively high recurrence rate after RFCA for L-PeAF, patients with a shorter AF duration and smaller LA size showed a more favorable outcome. The rs2106216 polymorphism ( ZFHX3 ) was independently associated with being good responders to RFCA for L-PeAF, especially with AF duration 12–65 months.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Notably, there was a recent case report on abatacept treatment in an adult with idiopathic autoimmune enteropathy.7 To investigate the molecular effect of the drug, we sampled the patient's blood at ...the trough level (ie, 0 day) and at 1, 4, 6, and 8 days (among these, samples from the trough level and days 4 and 8 were subjected to the fluorescence-activated cell sorting analysis) after the administration of the drug (Fig 2, A-D; for drug treatment details, see the Methods section in this article's Online Repository at www.jacionline.org). Here we report a direct effect of CTLA-4 dysfunction in human; enhancing the CTLA-4-mediated signal with CTLA-4-Ig toned down immune responses in a patient with severe autoimmune features, eventually achieving substantial clinical improvements. ...it would be worthwhile to investigate patients with idiopathic autoimmune features for additional CTLA-4 mutations that may affect proper protein function and use CTLA-4-Ig as a potential therapeutic solution.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Purpose To investigate changes in corneal higher-order aberrations (HOAs) associated with the incision location in cataract surgery. Setting Asan Medical Center, University of Ulsan College of ...Medicine, Seoul, Korea. Design Observational case series. Methods Eyes were divided into 3 groups according to the different axes of incision location: superior, temporal, and nasal. Preoperative and 1-month postoperative corneal coma, trefoil, and spherical aberrations were compared. Results The study evaluated 119 eyes that had uneventful cataract surgery with a 2.2 mm limbal incision. The superior incision group showed significant changes in the vertical coma (amount of change: −0.119 μm ± 0.153 SD; P < .001) and vertical trefoil (amount of change: 0.185 ± 0.260 μm, P = .001). The nasal incision group showed a significant change in oblique trefoil (amount of change: 0.176 ± 0.207 μm; P < .001). The temporal incision group did not show significant changes in HOAs. Conclusion The superior incision in 2.2 mm phacoemulsification cataract surgery caused a change in the corneal vertical coma in a negative direction. Corneal trefoil changes were dependent on the incision location. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
Background Self-expandable metal stent (SEMS) placement and palliative gastrojejunostomy (GJJ) are palliative treatment options for malignant gastric outlet obstruction. Objective To compare clinical ...outcomes of palliative treatments for gastric outlet obstruction caused by unresectable gastric cancer. Design Retrospective study. Setting University-affiliated tertiary-care hospital in the Republic of Korea. Patients Two hundred fifty-six patients with gastric outlet obstruction caused by unresectable gastric cancer. Intervention SEMS placement and palliative GJJ. Main Outcome Measurements Patency duration and overall survival duration. Results In total, 217 and 39 patients underwent SEMS placement and palliative GJJ, respectively, as an initial palliative treatment. Treatment modality affected reobstruction after clinical success (hazard ratio HR 95% confidence interval {CI}, 0.5 0.3–0.8 of palliative GJJ). In addition, carcinomatosis with ascites was an independent associated factor of clinical success and reobstruction (HR 95% CI, 0.3 0.1–0.7 and 1.4 1.0–2.0, respectively). In a subgroup of patients with good performance who had neither carcinomatosis nor ascites, patency duration and overall survival duration did not differ between the 2 groups ( P = .079 and P = .290, respectively). In patients with good performance who had carcinomatosis without ascites, patency duration was longer in the palliative GJJ group than in the SEMS placement group ( P = .016). Overall survival, however, did not differ between the 2 groups ( P = .062). In a subgroup of patients with good performance who had carcinomatosis with ascites, both patency duration and overall survival were longer in the palliative GJJ group than in the SEMS placement group ( P = .007 and P = .012, respectively). Limitations Nonrandomized, retrospective study. Conclusion Long-term clinical outcomes of the palliative treatment modality for gastric outlet obstruction caused by unresectable gastric cancer were affected by carcinomatosis and ascites status.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Hemodynamic burden is thought to play a role in valvular atrial fibrillation (AF), but the detailed pathophysiology is unclear. We hypothesized that atrial natriuretic peptide ...(ANP) tissue levels and amyloid deposits in the left atrial appendage (LAA) were associated with the pre-operative hemodynamic status and post-operative rhythm outcome in patients undergoing a concomitant mitral valve and maze surgery. Methods We quantified the fibrosis, atrial amyloid deposits, ANP tissue levels, and multiple biomarker proteins (Western blot) in LAA tissues taken from 26 patients (53.8% male, 58.4 ± 9.7 years) who underwent concomitant maze and mitral valve surgery. The histologic and biochemical results were compared with the pre-operative pulmonary artery pressure (PAP) and post-operative rhythm outcome. Results The ANP tissue level was positively correlated with the atrial amyloid deposit areas ( R = 0.880, p < 0.001), but not with the degree of fibrosis. The pre-operative systolic PAP negatively correlated with both the ANP tissue expression level ( R = −0.467, p = 0.019) and atrial amyloid deposit area ( R = −0.589, p = 0.008). The angiotensin II tissue expression level was significantly higher in tissues without ANP expression than in those with expression ( p = 0.003). AF recurrence after the maze operation was significantly lower in patients without than in those with ANP expression (log rank p = 0.031, HR 3.779, 95% CI 1.163–12.277, p = 0.027). Conclusions A lower ANP atrial tissue expression and amyloid deposits were correlated with a high pre-operative hemodynamic loading, and those patients had a paradoxically lower AF recurrence after relief of the hemodynamic burden by concomitant maze and mitral valve surgery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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