Prostate tuberculosis mimicking prostate cancer: Case report and literature review.

RATIONALE: Prostate tuberculosis (PTB) has no specific symptoms, or insidious presentation in male reproductive system tuberculosis, and is difficult to detect in the early stage. When PTB develops to the late stage, it leads to disease progression and irreversible organ and tissue damage. At present, the imaging manifestations of prostate tuberculosis vary and are not well known to imaging physicians and urologists. DIAGNOSES AND INTERVENTIONS: This case was a PTB patient, whose main manifestation was elevated serum prostate-specific antigen and the diagnosis was confirmed by ultrasound-guided prostate biopsy. We analyzed the imaging performance of various imaging techniques, and summarized and explored the imaging characteristics reported in the previous literature, with the aim of improving the early detection rate and providing evidence-based practice for early regular antituberculosis treatment in PTB. OUTCOMES: The multiparametric transrectal ultrasound performance of PTB is characteristic, and can be used for the differential diagnosis of prostate cancer causing elevated prostate-specific antigen levels in aged men.

Musculoskeletal Ultrasound in Monitoring the Efficacy of Gout: A Prospective Study Based on Tophus and Double Contour Sign

Background: In patients with gout receiving uric acid-lowering therapy, musculoskeletal ultrasound has the potential to observe changes in gout lesions. Aims: To analyze the effectiveness of uric acid-lowering therapy in patients with gout over one year using musculoskeletal ultrasound as a monitoring technique. Study Design: Prospective cohort study. Methods: A total of 215 patients meeting the 1977 American College of Rheumatology gout classification criteria and treated with uric acid-lowering therapy were separated into two groups, treat-to-target and treat-to-non-target depending on the target serum urate levels. Lower extremity joints were evaluated by ultrasound before therapy (M0), as well as three (M3), six (M6), and twelve (M12) months after therapy. At various moments during uric acid-lowering therapy, the tophus size and the semiquantitative ultrasound scoring system of double contour sign were measured in the treat-to-target and treat-to-non-target groups. Results: Ninety-five tophi (45 in treat-to-target and 50 in treat-to-non-target) and sixty-seven double contour sign (34 in treat-to-target and 33 in treat-to-non-target) were evaluated longitudinally. In both groups, the long diameter, short diameter, and area of tophus in treat-to-target decreased as the duration of uric acid-lowering treatment increased. Differences in the long diameter of tophus between M12 and M0, M3 and M6 were statistically significant (P < 0.05), while differences between the other time points were not significant (P > 0.05). No statistically significant differences were observed in the short diameter and the area of tophus between M0 and M3 (P > 0.05), while there were statistically significant differences between other periods (P < 0.05). In treat-to-non-target, the long diameter, short diameter, and area of tophus showed a slight increase at different uric acid-lowering therapy time points. The differences in the long diameter, short diameter, and area of tophus at different uric acid-lowering therapy time points were not significant (P > 0.05). The semiquantitative ultrasound scoring system of double contour sign of treat-to-target and treat-to-non-target showed a decreasing trend with increasing uric acid-lowering therapy time, with a more pronounced drop in treat-to-target than treat-to-non-target. In treat-to-target, the difference in the semiquantitative ultrasound scoring system of double contour sign at each uric acidlowering therapy time point was significant (P < 0.05). In treat-tonon- target, the difference in semiquantitative ultrasound scoring system of double contour sign scores between M0 and M3 was not statistically significant (P >0.05), but it was statistically significant for the remaining time points (P < 0.05). Conclusion: After one year of uric acid-lowering therapy in patients with gout, an ultrasound indicated that the size of tophus and the semiquantitative ultrasound scoring system of double contour sign score decreased dramatically in the treat-to-target group. Semiquantitative ultrasound scoring system of double contour sign score was dramatically reduced in the treat-to-non-target group, but the size of the tophus remained the same. Therefore, musculoskeletal ultrasound is an effective tool to monitor the efficacy of uric acid-lowering therapy.

Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial.

INTRODUCTION: Current international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream management to prevent stroke recurrence remain to be established. The objective of the study was to explore the use of long-term home-based ECG monitoring for AF detection and stroke prevention in patients with a history of stroke. METHODS AND ANALYSIS: This prospective, randomised, open-label trial with blinded endpoint adjudication aimed to evaluate the efficacy of long-term home-based ECG monitoring for AF detection and stroke prevention in a 24-month period. Patients aged >18 years with a history of ischaemic stroke will be stratified according to the time from the index ischaemic stroke: <1, 1-3 and >3 years and then randomised in 1:1 to (1) home-based AF screening and (2) control. The home-based AF screening system comprises (1) a handheld single-lead ECG recorder (Comfit Healthcare Devices, Hong Kong SAR, China) and (2) a patient-facing smartphone application specially designed for the study. Patients randomised to the home-based AF group will record a 30 s single-lead ECG using a specially designed handheld ECG device every morning or when symptomatic. All remotely obtained data will be automatically transmitted in real-time through the study smartphone application to a secured cloud hosting and analysed using an artificial intelligence-based diagnostic system. When a diagnosis of AF is made with the system, the patients will be called back for a formal cardiology consultation within 1 week. The primary endpoint is the time to first detection of AF at 24 months of follow-up. Secondary endpoints include recurrent stroke or transient ischaemic attack, initiation of long-term anticoagulation therapy, hospitalisation for heart failure, cardiovascular death and all-cause death. ETHICS AND DISSEMINATION: The study protocol has been approved by the institutional review board of The University of Hong Kong, and Hong Kong West Cluster, Hospital Authority, Hong Kong SAR, China. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04523649.

An initial study of core muscles using ultrasound in postmenopausal women with osteoporosis.

BACKGROUND: Osteoporosis is a systemic bone disease, resulting in bone pain and fragility fractures. This study sought to explore the ultrasonic characteristics of core muscles in postmenopausal women with osteoporosis. METHODS: A total of 91 participants underwent ultrasound examinations of the lumbar and abdominal core muscles. The participants were divided into the following two groups: group 1 (the normal control group, comprising 20 participants, aged 25-35 years); and the osteoporosis group (comprising 71 participants). The participants in the osteoporosis group were further divided into the following three groups: group II (comprising 20 participants, aged 50-59 years); group III (comprising 30 participants, aged 60-69 years); and group IV (comprising 21 participants, aged 70-87 years). The 2-dimensional (2D) sonographic manifestations, thickness and gray values of the core muscles of the lumbar and abdomen were observed, and a further analysis was conducted that included the bone density of the lumbar vertebrae results. RESULTS: Compared to the control group, the total thickness of the core muscles in the osteoporosis group was significantly decreased (P<0.05), and the gray values were significantly increased (P<0.05). The comparison of the osteoporosis groups showed that in relation to the total thickness of the core muscle, group II > group III > group IV (P<0.05). The 2D ultrasonography showed that the muscles of the participants in group I were full and had an equally low echo. Conversely, in the osteoporosis group, the muscles of the participants were less full, the echo was enhanced, the boundary between the muscle and the fascia was unclear, and the long axis of the rectus abdominis and transverse abdominis tracts were wavy and linear, with reduced tension. CONCLUSIONS: In postmenopausal women with osteoporosis, the core muscles of the waist and abdomen are degenerative, which can be evaluated with ultrasonography via the echo, thickness, and gray value of the muscles.

Contrast-enhanced ultrasound and its differential diagnosis in 21 patients with intrahepatic space-occupying lesions under the background of fatty liver.

BACKGROUND: The sonographic appearance in intrahepatic space-occupying lesions under the background of fatty liver is atypical. This study aimed to explore the value of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of intrahepatic space-occupying lesions under the background of fatty liver. METHODS: Twenty-one patients with intrahepatic space-occupying lesions under the background of fatty liver who were treated in our hospital from January 2017 to September 2020 and met the inclusion/ exclusion criteria were enrolled in this study. The clinical and imaging data, size, location, shape, and other characteristics of the lesions were analyzed. The accuracy of conventional ultrasound and contrast-enhanced ultrasound in diagnosing intrahepatic space-occupying lesions under the background of fatty liver were compared. RESULTS: The 21 patients had moderate to severe fatty liver, including 11 cases with malignant lesions (52.38%) and 10 cases with benign lesions (47.62%). The accuracy of CEUS (90.48%) was significantly higher than that of conventional ultrasound (61.90%) in diagnosing intrahepatic space-occupying lesions under the background of fatty liver. A total of 33 lesions were detected in 21 patients, which were hypoechoic. Liver abscesses mainly showed ring-shaped enhancement in the arterial phase and low enhancement in the portal phase, with abscess necrosis in the center and no significant enhancement. Liver cyst lesions showed no significant enhancement in the arterial, portal, and delayed phases. The three stages of focal fat loss were synchronized and simultaneously enhanced with surrounding fatty liver tissues. The area under the diagnostic curve of conventional ultrasound and CEUS was 0.668 and 0.809, respectively, and the area under the curve of CEUS detection was the largest (P<0.05). CONCLUSIONS: CEUS can effectively improve the diagnostic accuracy of intrahepatic space-occupying lesions under the background of fatty liver, and is an effective means to differentially diagnose intrahepatic space-occupying lesions under the background of fatty liver.

Application of ultrasonic shear wave elastography and contrast-enhanced ultrasound in the differential diagnosis of patients with benign and malignant thyroid lesions.

BACKGROUND: Thyroid nodules are a common thyroid disorder. The aim of the present study was to observe the application value of ultrasonic shear wave elastography (SWE) and contrast-enhanced ultrasound (CEUS) in the differential diagnosis of patients with benign and malignant thyroid lesions. METHODS: Eighty-two patients with thyroid nodules (96 thyroid nodules) at our hospital were enrolled. All patients underwent ultrasonic SWE and CEUS examination. With surgical pathology as the gold standard, the Young's modulus, CEUS imaging features, and quantitative parameters were compared between the benign and malignant groups. The diagnostic efficiency of SWE, CEUS, and their combination was analyzed by receiver-operating characteristic curve (ROC). RESULTS: The average of the Young's modulus in the malignant group was significantly higher than that of the benign group (P<0.05). There were significant differences in the CEUS images of nodules between the benign and malignant groups in terms of boundary conditions, morphology, perfusion intensity, homogeneous enhancement, and perfusion defects (P<0.05), while there were no significant difference in initial increase time, peak intensity, time to peak, and area under the curve (P>0.05). The curve sharpness in the benign group was significantly lower than that of the malignant group (P<0.05). ROC analysis found that the diagnostic sensitivity and specificity of SWE, CEUS, and their combination were 90.1% and 81.6%, 67.8% and 75.4%, and 97.3% and 71.5%, respectively. CONCLUSIONS: Compared with CEUS, the sensitivity and specificity of SWE were relatively higher in the differential diagnosis of benign and malignant thyroid lesions, and a combination of both can improve the diagnostic sensitivity of SWE alone to a certain extent.

Risk of venous thromboembolism in Chinese pregnant women: Hong Kong venous thromboembolism study.

BACKGROUND: Previous Caucasian studies have described venous thromboembolism in pregnancy; however, little is known about its incidence during pregnancy and early postpartum period in the Chinese population. We investigated the risk of venous thromboembolism in a "real-world" cohort of pregnant Chinese women with no prior history of venous thromboembolism. METHODS: In this observational study, 15,325 pregnancies were identified in 14,162 Chinese women at Queen Mary Hospital, Hong Kong between January 2004 and September 2016. Demographic data, obstetric information, and laboratory and imaging data were retrieved and reviewed. RESULTS: The mean age at pregnancy was 32.4±5.3 years, and the median age was 33 years (interquartile range, 29-36 yr). Pre-existing or newly diagnosed diabetes mellitus was present in 627 women (4.1%); 359 (0.7%) women had pre-existing or newly detected hypertension. There was a small number of women with pre-existing heart disease and/or rheumatic conditions. Most deliveries (86.0%) were normal vaginal; the remaining were Cesarean section 2,146 (14.0%). The incidence of venous thromboembolism was 0.4 per 1,000 pregnancies, of which 83.3% were deep vein thrombosis and 16.7% were pulmonary embolism. In contrast to previous studies, 66.7% of venous thrombosis occurred in the first trimester. CONCLUSION: Chinese women had a substantially lower risk of venous thromboembolism during pregnancy and the postpartum period compared to that of Caucasians. The occurrence of pregnancy-related venous thromboembolism was largely confined to the early pregnancy period, probably related to the adoption of thromboprophylaxis, a lower rate of Cesarean section, and early mobilization.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention of Recurrent Cardiovascular Events in a Real-World Cohort of Post-Acute Myocardial Infarction Patients.

BACKGROUND: Patients who survive myocardial infarction (MI) are at risk of recurrent cardiovascular (CV) events. This study stratified post-MI patients for risk of recurrent CV events using the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P). Methods and Results: This was an observational study that applied TRS 2°P to a consecutive cohort of post-MI patients. The primary outcome was a composite endpoint of CV death, non-fatal MI, and non-fatal ischemic stroke. A total of 1,688 post-MI patients (70.3±13.6 years; male, 63.1%) were enrolled. After a mean follow-up of 41.5±34.4 months, 405 patients (24.0%) had developed a primary outcome (9.3%/year) consisting of 278 CV deaths, 134 non-fatal MI, and 33 non-fatal strokes. TRS 2°P was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P 0 was 1.0%, and increased progressively to 39.9% for those with TRS 2°P ≥6 (HR, 27.6; 95% CI: 9.87-77.39, P<0.001). The diagnostic sensitivity of TRS 2°P for the primary composite endpoint was 76.3% (95% CI: 72.1-80.5%). Similar associations were also observed between TRS 2°P and CV death and non-fatal MI, but not non-fatal ischemic stroke. CONCLUSIONS: TRS 2°P reliably stratified post-MI patients for risk of future CV events.

Systemic immune-inflammation index and ultrasonographic classification of breast imaging-reporting and data system predict outcomes of triple-negative breast cancer.

INTRODUCTION: This research was conducted to explore the relationship between the systemic immune-inflammation index (SII) and breast imaging-reporting and data system (BI-RADS) classification using ultrasonography and the survival of patients with triple-negative breast cancer (TNBC) in a cohort of Chinese. METHODS: A total of 215 TNBC patients treated at our hospital between November 2008 and March 2016 were enrolled in this study. We used the log-rank test and Kaplan-Meier curves to assess the overall survival (OS) and disease-free survival (DFS) differences between groups. The prognostic role of SII and other clinicopathological characteristics in TNBC patients were identified using the Cox regression model. RESULTS: Patients with low and high SII had median OS of 60.9 and 40.3 months, respectively, (HR=3.78, 95% CI: 2.16-4.15, P<0.001); while the median DFS was 22.4 months and 14.4 months for TNBC patients with low and high SII, respectively (HR =3.16, 95% CI: 1.82-4.02, P<0.001). For patients with grade 5 ultrasonographic BI-RADS classification, the median DFS and OS were 41.2 and 16.5 months, respectively, whereas, it was 57.7 and 21.3 months, respectively, for those with BI-RADS grades 3-4 (P<0.01). According to multivariable analyses, increased SII was a risk factor that independently predicted poor OS (HR =2.96, 95% CI: 2.18-3.98, P<0.001) and DFS (HR = 2.85, 95% CI: 1.62-3.81, P=0.005). In addition, tumor stage, BI-RADS, and histological grade also independently predicted poor OS (P=0.002, <0.001, 0.004). CONCLUSION: Pretreatment SII and BI-RADS 5 were independent indicators for prognosis in TNBC patients. It is imperative to conduct prospective studies to evaluate the potential role of SII in patient selection, treatment guidance, and design of clinical trials.

Rationale and design of the screening of pulmonary hypertension in systemic lupus erythematosus (SOPHIE) study.

Current guideline-recommended screening for pulmonary hypertension in patients with systemic sclerosis has not been evaluated in systemic lupus erythematosus (SLE), which is disproportionately prevalent in Asians. This multicentre, cross-sectional screening study aims to study the prevalence of pulmonary hypertension among SLE patients using these guidelines, and identify independent predictors and develop a prediction model for pulmonary hypertension in SLE patients. SLE patients from participating centres will undergo an echocardiography- and biomarker-based pulmonary hypertension screening procedure as in the DETECT study. Standard right heart catheterisation will be provided to patients with intermediate or high echocardiographic probability of pulmonary hypertension. Those with low echocardiographic probability will rescreen within 1 year. The primary measure will be the diagnosis and types of pulmonary hypertension and prevalence of pulmonary hypertension in SLE patients. The secondary measures will be the predictors and prediction models for pulmonary hypertension in SLE patients. The estimated sample size is approximately 895 participants. The results of the SOPHIE study will be an important contribution to the literature of SLE-related pulmonary hypertension and may be immediately translatable to real clinical practice. Ultimately, this study will provide the necessary evidence for establishing universal guidelines for screening of pulmonary hypertension in SLE patients.

Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin.

INTRODUCTION: The importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised. AIM: To evaluate the impact of provision of TTR results during clinic visits on anticoagulation management. DESIGN: Single-centred, randomised controlled study. SETTING: Fifteen arrhythmia clinics in Hong Kong. PATIENTS: AF patients prescribed warfarin. INTERVENTIONS: Provision of TTR or no provision of TTR. MAIN OUTCOME MEASURES: A documented discussion between doctors and patients about switching warfarin to a non-vitamin K oral anticoagulant (NOAC). RESULTS: Four hundred and eighty one patients with AF prescribed warfarin were randomly assigned to (1) a TTR provision group or (2) control. Their mean age was 73.6±12.0 years and 60.7% were men. The mean CHA2DS2-VASc score was 3.2±1.6 and the mean HASBLED score was 1.7±1.2. The mean TTR was 63.9%±29.9%. At the index clinic visit, 71 of 481 patients (14.8%) had a documented discussion about switching warfarin to a NOAC. Patients with provision of TTR results were more likely to discuss switching warfarin to a NOAC than controls (19.1% vs 10.6%, P=0.03), especially those with a TTR <65% (35.2% vs 10.6%, P<0.001). A higher proportion of patients with provision of TTR results switched to a NOAC (5.9% vs 4.1%, P=0.49). CONCLUSIONS: The provision of TTR among patients on warfarin was associated with a discussion about switching from warfarin to a NOAC in those with TTR <65%, but did not result in actual switching to a NOAC, suggesting additional barriers.

iPSC-MSCs with High Intrinsic MIRO1 and Sensitivity to TNF-α Yield Efficacious Mitochondrial Transfer to Rescue Anthracycline-Induced Cardiomyopathy.

Mesenchymal stem cells (MSCs) can donate mitochondria and rescue anthracycline-induced cardiomyocyte (CM) damage, although the underlying mechanisms remain elusive. We determined that the superior efficiency of mitochondrial transfer by human induced-pluripotent-stem-cell-derived MSCs (iPSC-MSCs) compared with bone marrow-derived MSCs (BM-MSCs) is due to high expression of intrinsic Rho GTPase 1 (MIRO1). Further, due to a higher level of TNFαIP2 expression, iPSC-MSCs are more responsive to tumor necrosis factor alpha (TNF-α)-induced tunneling nanotube (TNT) formation for mitochondrial transfer to CMs, which is regulated via the TNF-α/NF-κB/TNFαIP2 signaling pathway. Inhibition of TNFαIP2 or MIRO1 in iPSC-MSCs reduced the efficiency of mitochondrial transfer and decreased CMs protection. Compared with BM-MSCs, transplantation of iPSC-MSCs into a mouse model of anthracycline-induced cardiomyopathy resulted in more human mitochondrial retention and bioenergetic preservation in heart tissue. Efficacious transfer of mitochondria from iPSC-MSCs to CMs, due to higher MIRO1 expression and responsiveness to TNF-α-induced nanotube formation, effectively attenuates anthracycline-induced CM damage.

[Assessments of carotid adventitial remodeling in metabolic syndrome patients using high-frequency ultrasound].

OBJECTIVE: To evaluate the changes of carotid adventitial thickness (AT) and intima media thickness (IMT) and their relationship in metabolic syndrome (MS) patients using high-frequency ultrasound. METHODS: The values of mean AT and mean IMT were measured and calculated for 161 MS patients and compared them with 94 age and gender-matched controls as determined by high-frequency ultrasound between 2009-2011. And 161 patients were divided further into 2 groups of MS with plaque (MS-P, n = 70) and MS without plaque (MS-NP, n = 91). RESULTS: MS-P and MS-NP patients had significantly higher values of mean IMT and carotid artery wall thickness than controls and MS-P patients had significantly higher values of mean AT than controls ((0.77 ± 0.13) mm vs (0.66 ± 0.11) mm, P < 0.01). Moreover, MS-P patients had significantly higher values of mean IMT ((0.98 ± 0.20) mm vs (0.76 ± 0.10) mm, P < 0.01), mean AT ((0.77 ± 0.13) vs (0.69 ± 0.13) mm, P < 0.01) and carotid artery wall thickness ((1.61 ± 0.16)mm vs (1.42 ± 0.09) mm, P = 0.002) than MS-NP patients. And mean AT was positively correlated with mean IMT in controls,MS-P and MS-NP patients (r = 0.603, P < 0.01, r = 0.325, P = 0.005 and r = 0.344, P = 0.004 separately). CONCLUSION: For IMT and AT in MS patients with and without plaques, adventitia participates in vascular remodeling and may be distinguished by high-frequency ultrasound.

Remodelling of cardiac sympathetic re-innervation with thoracic spinal cord stimulation improves left ventricular function in a porcine model of heart failure.

AIMS: Thoracic spinal cord stimulation (SCS) has been shown to improve left ventricular ejection fraction (LVEF) in heart failure (HF). Nevertheless, the optimal duration (intermittent vs. continuous) of stimulation and the mechanisms of action remain unclear. METHODS AND RESULTS: We performed chronic thoracic SCS at the level of T1-T3 (50 Hz, pulse width 0.2 ms) in 30 adult pigs with HF induced by myocardial infarction and rapid ventricular pacing for 4 weeks. All the animals were treated with daily oral metoprolol succinate (25 mg) plus ramipril (2.5 mg), and randomized to a control group (n = 10), intermittent SCS (4 h ×3, n = 10) or continuous SCS (24 h, n = 10) for 10 weeks. Serial measurements of LVEF and +dP/dt and serum levels of norepinephrine and B-type natriuretic peptide (BNP) were measured. After sacrifice, immunohistological studies of myocardial sympathetic and parasympathetic nerve sprouting and innervation were performed. Echocardiogram revealed a significant increase in LVEF and +dP/dt at 10 weeks in both the intermittent and continuous SCS group compared with controls (P < 0.05). In both SCS groups, there was diffuse sympathetic nerve sprouting over the infarct, peri-infarct, and normal regions compared with only the peri-infarct and infarct regions in the control group. In addition, sympathetic innervation at the peri-infarct and infarct regions was increased following SCS, but decreased in the control group. Myocardium norepinephrine spillover and serum BNP at 10 weeks was significantly decreased only in the continuous SCS group (P < 0.05). CONCLUSIONS: In a porcine model of HF, SCS induces significant remodelling of cardiac sympathetic innervation over the peri-infarct and infarct regions and is associated with improved LV function and reduced myocardial norepinephrine spillover.

Refinement of ischemic stroke risk in patients with atrial fibrillation and CHA2 DS2 -VASc score of 1.

BACKGROUND: Patients with atrial fibrillation (AF) with CHA2 DS2 -VASc score of 1 (where CHA2 DS2 -VASc is CHA2 DS2 -Vascular disease, Age 65-74 years, Sex category) are recommended to receive antithrombotic therapy. Nonetheless, it remains unclear whether individual components that constitute CHA2 DS2 -VASc score contribute equally to the ischemic stroke risk, particularly in patients with CHA2 DS2 -VASc score of 1. The objective was to describe and compare the risk of ischemic stroke of the six individual components constituting CHA2 DS2 -VASc among AF patients with CHA2 DS2 -VASc score of 1. METHODS AND RESULTS: We studied all patients with CHA2 DS2 -VASc score of 1 and no antithrombotic therapy from our cohort of 9,727 Chinese AF patients. A total of 548 patients were studied: 190 patients with CHA2 DS2 -VASc score of 0 and 358 patients with CHA2 DS2 -VASc score of 1. Of those with a baseline CHA2 DS2 -VASc score of 1, 51.1% patients aged 65-75; 29.3% patients were female; 12.0% had hypertension; 4.5% had heart failure; 2.5% had diabetes; and 0.6% had vascular disease. After 1,758 patient-years of follow-up, the annual incidence of stroke was 2.4% and 6.6% for patients with CHA2 DS2 -VASc score of 0 and 1, respectively. Compared with patients with CHA2 DS2 -VASc score of 0, patients with hypertension leading to CHA2 DS2 -VASc score of 1 were at the highest risk of stroke (Hazard ratio [HR]: 9.8, 95% confidence interval [CI]: 2.7-35.6), followed by patients aged 65-74 (HR: 3.9, 95% CI: 2.3-6.6) and female gender (HR: 2.3, 95% CI: 1.1-4.8). Heart failure, diabetes mellitus, and vascular disease were not associated with stroke. CONCLUSION: In AF patients with CHA2 DS2 -VASc score of 1, hypertension confers the highest risk for stroke among other risk factors comprising the score. A more aggressive thromboprophylaxis strategy may be justified among AF patients with CHA2 DS2 -VASc score of 1 due to hypertension.

Prevalence of and associations with reduced exercise capacity in peritoneal dialysis patients.

BACKGROUND: Exercise capacity is reduced in patients with end-stage renal disease on maintenance home peritoneal dialysis therapy, although the potential mechanisms and clinical implications remain unclear. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 95 ambulatory prevalent and incident peritoneal dialysis patients in a well-established renal dialysis center (mean age, 58.26 ± 12.6 [SD] years; 63% men; mean duration of peritoneal dialysis therapy, 3.2 ± 4.1 years). PREDICTOR: Estimated volume status using spectral bioelectrical impedance, echocardiography-derived hemodynamic parameters. OUTCOME: Exercise capacity measured as peak oxygen consumption using symptom-limiting treadmill exercise testing. RESULTS: Exercise capacity was reduced in 96% of patients and severely reduced in 65%. Extracellular to intracellular fluid volume ratio showed the strongest correlation with reduced exercise capacity (R = -0.63; P < 0.001) and was superior to age, pulmonary capillary wedge pressure (E:E' ratio), lean tissue mass index, and hemoglobin and albumin levels in predicting exercise intolerance. LIMITATIONS: Relatively small sample size and echocardiogram that was performed only at rest. CONCLUSIONS: There was a strong relationship between body extracellular to intracellular fluid volume ratio and exercise capacity in peritoneal dialysis patients. These findings provide new evidence for a connection between fluid distribution, muscle mass, and exercise capacity. Therapeutic strategies targeting fluid status and muscle mass may improve the exercise capacity of patients on peritoneal dialysis therapy.

Left ventricular mechanical dyssynchrony impairs exercise capacity in patients with coronary artery disease with preserved left ventricular systolic function and a QRS duration ≤ 120 ms.

BACKGROUND: Left ventricular (LV) mechanical dyssynchrony can lead to impairment of LV function and is associated with adverse clinical outcomes in coronary artery disease (CAD) patients. The impact of LV dyssynchrony on exercise capacity (EC) in patients with CAD was investigated. METHODS AND RESULTS: An echocardiographic examination with tissue Doppler imaging and exercise treadmill testing in 151 CAD patients with normal LV ejection fraction was performed. LV intra- and inter-ventricular dyssynchrony were defined by the standard deviation of time interval between LV 6 basal segments (Ts-SD), and the time interval from the right ventricular (RV) free wall to LV lateral wall (Ts-RV) respectively, and EC was measured as metabolic equivalents (METs) on the treadmill. Patients with impaired EC (defined by a METs ≤ 8, which is the mean MET of the study population) were older (71 ± 7 vs. 62 ± 2 years, P<0.01), however, there were no differences in gender and clinical status such as prevalence of prior myocardial infarction (MI), regional wall motion abnormality (RWMA), and coronary revascularization between patients with (n=90) or without (n=61) impaired EC. Univariate analysis showed that age, body mass index, LV systolic and diastolic volume, mitral inflow A velocity, and Ts-SD were all significantly associated with METs (all P<0.05). However, multivariate regression analysis revealed that old age (odd ratio [OR]: 1.136, 95% confidence interval [CI]: 1.080-1.196, P<0.001), and Ts-SD (OR: 1.026, 95%CI: 1.003-1.049, P=0.027) only were independent predictors for impaired EC. CONCLUSIONS: In patients with CAD, LV systolic dyssynchrony predicts impaired EC independently of history of previous MI or RWMA.

Thoracic spinal cord stimulation improves cardiac contractile function and myocardial oxygen consumption in a porcine model of ischemic heart failure.

BACKGROUND: Prior experimental studies show that thoracic spinal cord stimulation (SCS) improves left ventricular (LV) ejection fraction (LVEF). The mechanism of this improvement in the LV contractile function after SCS and its effects on the myocardial oxygen consumption remains unknown. METHODS AND RESULTS: We performed thoracic SCS (T1-T2 level) followed by 4 weeks of rapid ventricular pacing in 9 adult pigs with ischemic heart failure (HF) induced by myocardial infarction (MI). At 24 hours off-pacing, detailed echocardiogram and invasive hemodynamic assessment were performed to determine LV contractile function and myocardial oxygen consumption. Serum norepinephrine level was measured before and after SCS. SCS was performed on 2 occasions for 15 minutes, 30 minutes apart (recovery) with 50 Hz frequency (pulse width 0.2 millisecond, 90% of motor threshold at 2 Hz output). Echocardiogram revealed significant decrease in LVEF (33.8 ± 1.8% vs 66.5 ± 1.7%, P < 0.01) after induction of MI and HF. Compared with MI and HF, acute SCS significantly increased LVEF and +dP/dt (all P < 0.05). Withdrawal of SCS during recovery decreased +dP/dt, but not LVEF that increased again with repeated SCS. Myocardial oxygen consumption also significantly decreased during SCS compared with MI and HF (P = 0.006) without any change in serum norepinephrine level (P = 0.9). Speckle tracking imaging showed significant improvement in global and regional circumferential strains over the infarcted mid and apical regions, decreased in time to peak circumferential strain over the lateral and posterior wall after SCS, and the degree of intraventricular dyssynchrony during SCS compared with MI and HF (P < 0.05). CONCLUSIONS: In a porcine model of ischemic HF, acute SCS improved global and regional LV contractile function and intraventricular dyssynchrony, and decreased myocardial oxygen consumption without elevation of norepinephrine level.

Impact of glycemic control on circulating endothelial progenitor cells and arterial stiffness in patients with type 2 diabetes mellitus.

BACKGROUND: Patients with type 2 diabetes mellitus (DM) have increased risk of endothelial dysfunction and arterial stiffness. Levels of circulating endothelial progenitor cells (EPCs) are also reduced in hyperglycemic states. However, the relationships between glycemic control, levels of EPCs and arterial stiffness are unknown. METHODS: We measured circulating EPCs and brachial-ankle pulse wave velocity (baPWV) in 234 patients with type 2 DM and compared them with 121 age- and sex-matched controls. RESULTS: Patients with DM had significantly lower circulating Log CD34/KDR+ and Log CD133/KDR+ EPC counts, and higher Log baPWV compared with controls (all P < 0.05). Among those 120/234 (51%) of DM patients with satisfactory glycemic control (defined by Hemoglobin A1c, HbA1c < 6.5%), they had significantly higher circulating Log CD34/KDR+ and Log CD133/KDR+ EPC counts, and lower Log baPWV compared with patients with poor glycemic control (all P < 0.05). The circulating levels of Log CD34/KDR+ EPC (r = -0.46, P < 0.001) and Log CD133/KDR+ EPC counts (r = -0.45, P < 0.001) were negatively correlated with Log baPWV. Whilst the level of HbA1c positively correlated with Log baPWV (r = 0.20, P < 0.05) and negatively correlated with circulating levels of Log CD34/KDR+ EPC (r = -0.40, P < 0.001) and Log CD133/KDR+ EPC (r = -0.41, P < 0.001). Multivariate analysis revealed that HbA1c, Log CD34/KDR+ and Log CD133/KDR+ EPC counts were independent predictors of Log baPWV (P < 0.05). CONCLUSIONS: In patients with type 2 DM, the level of circulating EPCs and arterial stiffness were closely related to their glycemic control. Furthermore, DM patients with satisfactory glycemic control had higher levels of circulating EPCs and were associated with lower arterial stiffness.

Relationship between ventricular dyssynchrony and T-wave alternans in patients with coronary artery disease.

INTRODUCTION: Coronary artery disease (CAD) is associated with increased dispersion of repolarization and sudden cardiac death. We sought to investigate whether ventricular dyssynchrony is associated with proarrhythmic repolarization dispersion as measured by T-wave alternans (TWA) in patients with CAD. METHODS AND RESULTS: We evaluated 154 patients (67 ± 9 years, 123 men) with documented CAD, who underwent exercise treadmill testing and echocardiographic examination. TWA was analyzed continuously during treadmill testing in all standard precordial leads by time-domain method. Tissue Doppler imaging was performed to measure inter- and intraventricular dyssynchrony. Increased TWA ≥ 60µV was observed in 42 (27%) patients. There was higher prevalence of females (31 vs 16%, P = 0.04) and greater body mass index (25.7 ± 2.6 vs 24.6 ± 3.0 kg/m², P = 0.04) in the TWA ≥ 60µV group of patients than theTWA< 60µV group. The index of interventricular dyssynchrony, Ts-RL, was significantly increased (75.6 ± 37.8 vs 59.9 ± 35.9 ms, P = 0.03) but not intraventricular dyssynchrony (all P > 0.05) in patients with TWA ≥ 60 µV compared with those with TWA < 60 µV. In addition, a weak but significant positive correlation was observed between TWA and Ts-RL (r = 0.25, P = 0.003). Multivariate analysis revealed that only Ts-RL (odds ratio 1.02, 95% confidence interval 1.00­1.03, P = 0.013) was independent predictor for increased TWA. CONCLUSIONS: Our results demonstrated that interventricular dyssynchrony in patients with CAD is associated with increased TWA. This suggests that interventricular dyssynchrony may contribute to proarrhythmic repolarization dispersion.