Prevalence and Association of Sarcopenia with Mortality in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: The objective of this meta-analysis was to assess the association of sarcopenia defined on computed tomography (CT) head and neck with survival in head and neck cancer patients. METHODS: Following a PROSPERO-registered protocol, two blinded reviewers extracted data and evaluated the quality of the included studies using the Quality In Prognostic Studies (QUIPS) tool, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. A meta-analysis was conducted using maximally adjusted hazard ratios (HRs) with the random-effects model. Heterogeneity was measured using the I2 statistic and was investigated using meta-regression and subgroup analyses where appropriate. RESULTS: From 37 studies (11,181 participants), sarcopenia was associated with poorer overall survival (HR 2.11, 95% confidence interval [CI] 1.81-2.45; p < 0.01), disease-free survival (HR 1.76, 95% CI 1.38-2.24; p < 0.01), disease-specific survival (HR 2.65, 95% CI 1.80-3.90; p < 0.01), progression-free survival (HR 2.24, 95% CI 1.21-4.13; p < 0.01) and increased chemotherapy or radiotherapy toxicity (risk ratio 2.28, 95% CI 1.31-3.95; p < 0.01). The observed association between sarcopenia and overall survival remained significant across different locations of cancer, treatment modality, tumor stages and geographical region, and did not differ between univariate and multivariate HRs. Statistically significant correlations were observed between the C3 and L3 cross-sectional area, skeletal muscle mass, and skeletal muscle index. CONCLUSIONS: Among patients with head and neck cancers, CT-defined sarcopenia was consistently associated with poorer survival and greater toxicity.

Prognostication of Outcomes in Spontaneous Intracerebral Hemorrhage: A Propensity Score-Matched Analysis with Support Vector Machine.

OBJECTIVE: The role of surgery in spontaneous intracerebral hemorrhage (SICH) remains controversial. We aimed to use explainable machine learning (ML) combined with propensity-score matching to investigate the effects of surgery and identify subgroups of patients with SICH who may benefit from surgery in an interpretable fashion. METHODS: We conducted a retrospective study of a cohort of 282 patients aged ≥21 years with SICH. ML models were developed to separately predict for surgery and surgical evacuation. SHapley Additive exPlanations (SHAP) values were calculated to interpret the predictions made by ML models. Propensity-score matching was performed to estimate the effect of surgery and surgical evacuation on 90-day poor functional outcomes (PFO). RESULTS: Ninety-two patients (32.6%) underwent surgery, and 57 patients (20.2%) underwent surgical evacuation. A total of 177 patients (62.8%) had 90-day PFO. The support vector machine achieved a c-statistic of 0.915 when predicting 90-day PFO for patients who underwent surgery and a c-statistic of 0.981 for patients who underwent surgical evacuation. The SHAP scores for the top 5 features were Glasgow Coma Scale score (0.367), age (0.214), volume of hematoma (0.258), location of hematoma (0.195), and ventricular extension (0.164). Surgery, but not surgical evacuation of the hematoma, was significantly associated with improved mortality at 90-day follow-up (odds ratio, 0.26; 95% confidence interval, 0.10-0.67; P = 0.006). CONCLUSIONS: Explainable ML approaches could elucidate how ML models predict outcomes in SICH and identify subgroups of patients who respond to surgery. Future research in SICH should focus on an explainable ML-based approach that can identify subgroups of patients who may benefit functionally from surgical intervention.

Intravenous thrombolysis and endovascular thrombectomy for acute ischaemic stroke in patients with Moyamoya disease - a systematic review and meta-summary of case reports.

BACKGROUND AND AIMS: Patients with Moyamoya disease (MMD) can present with ischaemic or haemorrhagic stroke. There is no good evidence for treatment strategies in MMD-associated acute ischaemic stroke (AIS), particularly for treatments like intravenous thrombolysis (IVT) and endovascular thrombectomy (ET). As the intracranial vessels are friable in MMD, and the risk of bleeding is high, the use of IVT and ET is controversial. To clarify the safety and efficacy of IVT/ET in the treatment of MMD-associated AIS, we performed a systematic review and meta-summary to examine this issue. METHODS: A systematic search was performed from four electronic databases: PubMed (MEDLINE), Cochrane Library, EMBASE and Scopus, profiling data from inception till 21 November 2021, as well as, manually on Google Scholar. RESULTS: Ten case reports detailing 10 MMD patients presenting with AIS and undergoing IVT or ET, or both, were included in the analysis. The median National Institute of Health Stroke Scale score at presentation was 10 (Interquartile Range [IQR] = 6.0-16.5). IVT alone was instituted in 6 patients, primary ET was attempted in 2, and 2 had received bridging IVT with ET. Of the 4 patients who underwent ET, 2 patients achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction scale [mTICI] ≥ 2b). In terms of functional outcomes, One patient achieved complete recovery (modified Rankin Scale 0), 4 patients attained improvement in neurological status, and 4 had no improvement, whilst functional outcome was unreported in 1 patient. No patient experienced symptomatic intracranial haemorrhage. CONCLUSIONS: In this systematic review and meta-summary, the utility of IVT and ET in MMD-associated AIS appears feasible in selected cases. Further larger cohort studies are required to evaluate these treatment approaches. HIGHLIGHTS: · AIS in MMD was typically managed with bypass surgery but not via thrombolysis or thrombectomy. · In this meta-summary, all patients treated with thrombolysis and/or thrombectomy survived and some experienced symptomatic and/or functional improvement. · Further larger cohort studies are necessary for investigating the role of thrombolysis and/or thrombectomy as treatment of AIS in MMD.

Association of ambient air pollution with risk of hemorrhagic stroke: A time-stratified case crossover analysis of the Singapore stroke registry.

BACKGROUND: Haemorrhagic stroke (HS) is a major cause of mortality and disability. Previous studies reported inconsistent associations between ambient air pollutants and HS risk. OBJECTIVE: We evaluated the association between air pollutant exposure and the risk of HS in a cosmopolitan city in the tropics. METHODS: We performed a nationwide, population-based, time-stratified case-crossover analysis on all HS cases reported to the Singapore Stroke Registry from 2009 to 2018 (n = 12,636). We estimated the risk of HS across tertiles of air pollutant concentrations in conditional Poisson models, adjusting for meteorological confounders. We stratified our analysis by age, atrial fibrillation and smoking status, and investigated the lagged effects of each pollutant on the risk of HS up to 5 days. RESULTS: All 12,636 episodes of HS were included. The median (1st-to 3rd-quartile) daily pollutant levels from 22 remote stations deployed across the island were as follows: (PM2.5 = 15.9 (12.7-20.5), PM10 = 27.3 (22.7-33.4), O3 = 22.5 (17.3-29.8), NO2 = 23.3 (18.8-28.4), SO2 = 10.2 (5.6-14.4), CO = 0.5 (0.5-0.6). The median (1st-to 3rd-quartile) temperature (°C) was 27.9 (27.1-28.7), that of relative humidity (%) was 79.4 (75.6-83.2), and that of total rainfall (mm) was 0.0 (0.0-4.2). Higher levels of CO were significantly associated with an increased risk of HS (3rd tertile vs 1st tertile: Incidence Rate Ratio (IRR) = 1.06, 95% CI = 1.01-1.12). The increased risk of HS due to CO persisted for at least 5 days after exposure. Individuals under 65 years old and non-smokers had a higher risk of HS when exposed to CO. O3 was associated with increased risk of HS up to 5 days (3rd tertile vs 1st tertile: IRRday 1 = 1.07, 95% CI = 1.02-1.12; IRRday 5 = 1.07, 95% CI = 1.02-1.13). CONCLUSION: Short-term exposure to ambient CO levels was associated with an increased risk of HS. A reduction in CO emissions may reduce the burden of HS in the population.

Implications of Coexisting Aortic Regurgitation in Patients With Aortic Stenosis.

Background: Aortic regurgitation (AR) is a common comorbidity in patients with aortic stenosis (AS), but coexisting AR has often been excluded from major clinical studies on AS. The impact of coexisting AR on the natural history of AS has not been well-described. Objectives: The authors compared clinical outcomes in medically managed patients with moderate-to-severe AS with or without coexisting AR. Methods: Consecutive patients (N = 1,188) with index echocardiographic diagnosis of moderate-to-severe AS (aortic valve area <1.5 cm2) were studied. All patients were medically managed and were divided into those with coexisting AR (at least moderate severity) and those without. Adverse composite clinical outcomes were defined as mortality or admissions for congestive cardiac failure on subsequent follow-up. The authors compared differences in clinical profile and outcomes between the groups. Results: There were 88 patients (7.4%) with coexisting AR and AS. These patients did not differ significantly in age, but had lower body mass index (22.9 ± 3.8 vs 25.3 ± 5.1 kg/m2), lower diastolic blood pressure (68.7 ± 10.7 vs 72.2 ± 12.3 mm Hg), larger end-diastolic volume index (68.8 ± 18.8 vs 60.4 ± 17.8 mL/m2) and larger left ventricular mass index (118.6 ± 36.4 vs 108.9 ± 33.1 g/m2). The prevalence of cardiovascular risk factors did not differ significantly. Coexisting AR was associated with increased incidence of adverse outcomes (log-rank 4.20; P = 0.040). On multivariable Cox regression, coexisting AR remained independently associated with adverse outcomes (HR: 1.36; 95% CI: 1.02-1.82) after adjusting for age, AS severity, left ventricular ejection fraction, and year of study. Conclusions: In patients with AS, coexisting AR was associated with changes in echocardiographic profile and adverse outcomes.

An unusual presentation of Idiopathic hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is a rare but life-threatening multi-organ disease which can be complicated by stroke, with devastating outcomes. Eosinophils can accumulate in multiple organs, most commonly involving the heart, skin, lungs, spleen, and liver. Neurological end-organ complications in hypereosinophilic syndrome are unusual and have been established to be of three types: brain infarction, encephalopathy and sensory polyneuropathy. We present a case where acute ischaemic stroke and encephalopathy are early manifestations of Idiopathic HES. It is important to consider HES as an aetiology for stroke and a high eosinophil count is an initial diagnostic clue. Early initiation of steroid therapy can potentially prevent disease progression.

Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation.

Mitral regurgitation (MR) coexists in a significant proportion of patients with severe aortic stenosis (AS), and portends inferior therapeutic outcomes. In severe AS, MR is thought to contribute to a low-flow state by decreasing forward stroke volume. We investigated concomitant MR on the clinical and echocardiographic features of patients with "paradoxical" low-flow (PLF) and normal-flow (NF) severe AS. Clinical and echocardiographic profiles of 886 consecutive patients with index echocardiographic diagnosis of severe AS (AVA < 1.0 cm2) were analysed retrospectively. All patients had preserved ejection fraction (LVEF ≥ 50%, n = 645), and were divided into PLF (stroke volume index, SVI < 35 mL/m2) and NF AS. They were then further subdivided based on the presence or absence of moderate-or-severe MR (msMR). A higher prevalence of concomitant msMR was observed in patients with PLF AS (14.9%; n = 33/221) compared to those with NF AS (8.0%; n = 34/424). Concomitant msMR was associated with echocardiographic features of increased diastolic dysfunction in both PLF AS and NF AS patients, as evidenced by increased LA diameter (PLF AS 52.9 ± 12.5 to 43.9 ± 8.9 mm; NF AS 29.6 ± 10.8 to 42.4 ± 8.8 mm; p < 0.001) and increased transmitral E/A ratio (PLF AS 1.26 ± 0.56 to 0.92 ± 0.43; NF AS 1.19 ± 0.63 to 0.94 ± 0.45; p = 0.004). Amongst patients with NF AS, msMR was additionally associated with increased E:e' ratio (25.5 ± 15.1 vs 19.3 ± 10.8; p = 0.025). Concomitant MR was more common in PLF AS compared to NF. Although possibly related to the MR, patients severe AS and MR appeared to have more severe diastolic dysfunction. Further studies are warranted to evaluate prognosis and guide management.

Perceptions of a night float system for intern doctors in an internal medicine program: an Asian perspective.

Long duty hours have been associated with significant medical errors, adverse events, and physician "burn-out". An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors' perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p<0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p<0.001) and reduce physician "burn-out" (95% vs. 5%, p<0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician "burn-out".

Comparing characteristics and clinical and echocardiographic outcomes in low-flow vs normal-flow severe aortic stenosis with preserved ejection fraction in an Asian population.

BACKGROUND/OBJECTIVES: In severe aortic stenosis (AS), deterioration of left ventricular ejection fraction (LVEF) to <50% is an AHA/ACC class I indication for valve replacement, regardless of symptoms. Controversy surrounds prognosis of low-flow AS compared to normal-flow, and no study has examined LVEF deterioration. We compared factors associated with LVEF deterioration (to <50%) and clinical outcomes. METHODS: Consecutive subjects with low-flow (stroke volume index <35 mL/m2 , n=56) and normal-flow (n=72) severe AS (aortic valve area <1 cm2 ) with preserved LVEF (>50%) and with paired echocardiography were studied. Univariate and multivariate analyses identified factors associated with LVEF deterioration. Clinical outcomes were determined on follow-up for more than 5 years. RESULTS: Significant LVEF deterioration (to <50%) was seen in 18% of low-flow (initial LVEF 63±8% to 32±9%) and 18% of normal-flow AS (61±7% to 31±12%). Independent factors in low-flow AS were hypertension (OR: 30.7, 95% CI: 2.0-467.6, P=.014) and higher end-systolic wall stress (OR: 1.086, 95% CI: 1.022-1.153, P=.008), compared to normal-flow, which were hypertension (OR: 15.9, 95% CI: 3.1-81.9, P=.001), higher septal E/E' ratio (OR: 1.16, 95% CI: 1.01-1.35, P=.043), lower septal S' velocity (OR: 0.204, 95% CI: 0.061-0.682, P=.010), and higher end-systolic wall stress (OR: 1.051, 95% CI: 1.001-1.104, P=.047). Overall, a third of the cohort experienced MACE, regardless of flow (log-rank 0.048, P=.827). However, aortic valve replacement (AVR) rates were lower in low-flow AS (20% vs 43%, P=.005). CONCLUSIONS: Low-flow AS despite normal LVEF appears similar to normal-flow in terms of LVEF deterioration and clinical outcomes in our Asian population. AVR rate was lower even though low-flow may not reflect less severe disease.