Effects of Statin Intensity on Long-term Outcomes After Coronary Artery Bypass Grafting.

BACKGROUND: The current study sought to investigate the association between statin intensity and long-term clinical outcomes according to initial clinical presentation after coronary artery bypass grafting (CABG). METHODS: The 6531 patients who underwent CABG included in this study were classified into 4 groups according to statin intensity: 731 in the no or low statin group (atorvastatin <10 mg), 2310 in the lower-moderate group (atorvastatin 10-mg equivalent), 2404 in the higher-moderate group (atorvastatin 20-mg equivalent), and 1086 in the high-intensity group (atorvastatin ≥ 40-mg equivalent). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) at 5 years. Multivariate Cox and inverse probability weighting methods were performed to adjust for baseline differences. RESULTS: At least moderate-intensity statin use was associated with significantly lower risk of 5-year MACCE compared with no or low-intensity statin use (hazard ratio [HR], 0.694; 95% confidence interval [CI], 0.493-0.977; P = .036). Among patients who were taking at least a moderate-intensity statin, both higher-moderate intensity (HR, 0.622; 95% CI, 0.479-0.807; P < .001) and high-intensity statin (HR, 0.613; 95% CI, 0.421-0.894; P = .011) groups showed significantly lower risks of MACCE than the lower-moderate intensity statin group at 5 years after CABG. There was no significant difference in the risk of MACCE between higher-moderate intensity and high-intensity statin groups (HR, 0.987; 95% CI, 0.661-1.475; P = .950). Multivariable Cox and inverse probability weighting methods yielded similar results. In a subgroup analysis compared with the use of a lower-moderate intensity statin, the use of a higher-moderate or high-intensity statin (equivalent dose with atorvastatin ≥20 mg) was associated with a significantly lower risk of MACCE among CABG patients who presented with acute coronary syndrome but not in those who presented with stable ischemic heart disease (interaction P = .001). CONCLUSIONS: The use of a lower-moderate intensity statin (atorvastatin 10-mg equivalent) was associated with relatively poorer long-term clinical outcomes than the use of higher-moderate or high-intensity statin, especially in acute coronary syndrome patients after CABG.

Differential effects of dual antiplatelet therapy in patients presented with acute coronary syndrome vs. stable ischaemic heart disease after coronary artery bypass grafting.

AIMS: The current study sought to evaluate whether long-term clinical outcomes according to the use of dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) differed between acute coronary syndrome (ACS) and stable ischaemic heart disease (SIHD) patients who underwent coronary artery bypass grafting surgery (CABG). METHODS AND RESULTS: Between January 2001 and December 2017, 3199 patients with ACS (55.3%) and 2583 with SIHD (44.7%) who underwent isolated CABG were enrolled. The study population was stratified using DAPT or SAPT in ACS patients and SIHD patients. The primary outcome was a cardiovascular death or myocardial infarction (MI) at 5 years. After CABG, DAPT was more frequently used in patients with ACS than in those with SIHD [n = 1960 (61.3%) vs. n = 1313 (50.8%), P < 0.001]. Among patients with ACS, the DAPT group showed a significantly lower risk of cardiovascular death or MI at 5 years than the SAPT group [DAPT vs. SAPT, 4.0% vs. 7.8%, hazard ratio (HR) 0.521, 95% confidence interval (CI) 0.339-0.799; P = 0.003]. In contrast, among patients with SIHD, there was no significant difference in the rate of cardiovascular death or MI at 5 years between the use of DAPT and SAPT (4.0% vs. 4.0%, HR 0.991, 95% CI 0.604-1.626; P = 0.971). These findings were robust to multiple sensitivity analyses and competing risk analysis. In the subgroup analysis, the use of DAPT was associated with a significantly lower risk of cardiovascular death or MI among SIHD patients with a previous percutaneous coronary intervention (PCI), with a significant interaction between the use of DAPT and PCI history (interaction P = 0.011). CONCLUSION: Among ACS patients who underwent CABG, the use of DAPT was associated with lower cardiovascular death or MI than the use of SAPT, but this was not the case in SIHD patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03870815.

Application of deep learning to the diagnosis of cervical lymph node metastasis from thyroid cancer with CT: external validation and clinical utility for resident training.

PURPOSE: This study aimed to validate a deep learning model's diagnostic performance in using computed tomography (CT) to diagnose cervical lymph node metastasis (LNM) from thyroid cancer in a large clinical cohort and to evaluate the model's clinical utility for resident training. METHODS: The performance of eight deep learning models was validated using 3838 axial CT images from 698 consecutive patients with thyroid cancer who underwent preoperative CT imaging between January and August 2018 (3606 and 232 images from benign and malignant lymph nodes, respectively). Six trainees viewed the same patient images (n = 242), and their diagnostic performance and confidence level (5-point scale) were assessed before and after computer-aided diagnosis (CAD) was included. RESULTS: The overall area under the receiver operating characteristics (AUROC) of the eight deep learning algorithms was 0.846 (range 0.784-0.884). The best performing model was Xception, with an AUROC of 0.884. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of Xception were 82.8%, 80.2%, 83.0%, 83.0%, and 80.2%, respectively. After introducing the CAD system, underperforming trainees received more help from artificial intelligence than the higher performing trainees (p = 0.046), and overall confidence levels significantly increased from 3.90 to 4.30 (p < 0.001). CONCLUSION: The deep learning-based CAD system used in this study for CT diagnosis of cervical LNM from thyroid cancer was clinically validated with an AUROC of 0.884. This approach may serve as a training tool to help resident physicians to gain confidence in diagnosis. KEY POINTS: • A deep learning-based CAD system for CT diagnosis of cervical LNM from thyroid cancer was validated using data from a clinical cohort. The AUROC for the eight tested algorithms ranged from 0.784 to 0.884. • Of the eight models, the Xception algorithm was the best performing model for the external validation dataset with 0.884 AUROC. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 82.8%, 80.2%, 83.0%, 83.0%, and 80.2%, respectively. • The CAD system exhibited potential to improve diagnostic specificity and accuracy in underperforming trainees (3 of 6 trainees, 50.0%). This approach may have clinical utility as a training tool to help trainees to gain confidence in diagnoses.

Alternatively activated brain-infiltrating macrophages facilitate recovery from collagenase-induced intracerebral hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is one of the major causes of stroke. After onset of ICH, massive infiltration of macrophages is detected in the peri-hematoma regions. Still, the function of these macrophages in ICH has not been completely elucidated. RESULTS: In a collagenase-induced ICH model, CX3CR1(+) macrophages accumulated in the peri-hematoma region. Characterization of these macrophages revealed expression of alternatively activated (M2) macrophage markers. In the macrophage-depleted mice, ICH-induced brain lesion volume was larger and neurological deficits were more severe compared to those of control mice, indicating a protective role of these macrophages in ICH. In the ICH-injured brain, mannose receptor-expressing macrophages increased at a delayed time point after ICH, indicating M2 polarization of the brain-infiltrating macrophages in the brain microenvironment. To explore this possibility, bone marrow-derived macrophages (BMDM) were co-cultured with mouse brain glial cells and then tested for activation phenotype. Upon co-culture with glia, the number of mannose receptor-positive M2 macrophages was significantly increased. Furthermore, treatment with glia-conditioned media increased the number of BMDM of M2 phenotype. CONCLUSIONS: In this study, our data suggest that brain-infiltrating macrophages after ICH are polarized to the M2 phenotype by brain glial cells and thereby contribute to recovery from ICH injury.

[Early gastric cancer with cellulitis-like skin metastasis].

Skin metastasis from internal carcinoma rarely occurs and it has an incidence of 0.7% to 9%. Although the prognosis of the skin metastases varies considerably depending on the type of the primary malignancy, presence of metastatic skin cancer usually implies a widespread systemic disease and a high mortality. A 50-year-old Korean male patient visited Dankook University Hospital for evaluation of skin rash on his whole abdomen of about 1 month's duration. He had undergone laparoscopy-assisted distal gastrectomy due to early gastric cancer about 3 months ago. He did not complain of any noticeable symptoms like febrile sense or pruritus. Skin biopsy was performed on the periumbilical area at previous port site and around the scar. Microscopic examination revealed multiple malignant cells in lymphatic spaces, consistent with metastatic carcinoma. He was therefore diagnosed with isolated skin metastasis from early gastric cancer. Because of patient's poor liver function, systemic chemotherapy could not be performed and only best supportive care was provided. Herein, we report a rare case of cellulitis-like skin metastasis from early gastric cancer with a brief review of the literature.

[A case of basaloid squamous cell carcinoma of rectosigmoid colon].

Basaloid squamous cell carcinoma is a rare and aggressive variant of squamous cell carcinoma, which mostly occurs in the upper aerodigestive tracts. Basaloid squamous cell carcinoma also typically arises in the anal canal, but is extremely rare in the lower gastrointestinal tract. A 70-year-old man presented with loose stool and intermittent hematochezia 2 months ago. Colonoscopy showed an ulceroinfiltrative mass on the rectosigmoid colon from 16 cm to 18 cm above the anal verge. Conventional colonoscope could not pass through the lesion but it was possible with pediatric colonoscope. Abdominal CT scan showed 1.6 cm sized wall thickening with circumferential luminal narrowing in the rectosigmoid colon and multiple ill-defined low density masses in both lobes of the liver. Therefore, colon cancer with liver metastasis was suspected. However, basaloid cells were noted on histologic examination, and they were weakly positive for synaptophysin on immunohistochemical study. After palliative lower anterior resection, histologic examination of the resected specimen revealed basaloid differentiation with keratin pearls, and tumor cells were positively stained with high molecular weighted cytokeratin (34BE12) and CK 5/6. Thus, the patient was finally diagnosed with basaloid squamous cell carcinoma of rectosigmoid colon with distant metastases.