Analyses of non-coding somatic drivers in 2,658 cancer whole genomes.

The discovery of drivers of cancer has traditionally focused on protein-coding genes1-4. Here we present analyses of driver point mutations and structural variants in non-coding regions across 2,658 genomes from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium5 of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). For point mutations, we developed a statistically rigorous strategy for combining significance levels from multiple methods of driver discovery that overcomes the limitations of individual methods. For structural variants, we present two methods of driver discovery, and identify regions that are significantly affected by recurrent breakpoints and recurrent somatic juxtapositions. Our analyses confirm previously reported drivers6,7, raise doubts about others and identify novel candidates, including point mutations in the 5' region of TP53, in the 3' untranslated regions of NFKBIZ and TOB1, focal deletions in BRD4 and rearrangements in the loci of AKR1C genes. We show that although point mutations and structural variants that drive cancer are less frequent in non-coding genes and regulatory sequences than in protein-coding genes, additional examples of these drivers will be found as more cancer genomes become available.

Nonlinear Landau Fan Diagram for Graphene Electrons Exposed to a Moiré Potential.

Due to Landau quantization, the conductance of two-dimensional electrons exposed to a perpendicular magnetic field exhibits oscillations that generate a fan of linear trajectories when plotted in the parameter space spanned by density and field. This fan looks identical, irrespective of the dispersion and field dependence of the Landau level energy. This is no surprise because the position of conductance minima depends solely on the level degeneracy that is linear in flux. The fractal energy spectrum that emerges within each Landau band when electrons are also exposed to a two-dimensional superlattice potential produces numerous additional oscillations, but they also create just linear fans for identical reasons. Here, we report conductance oscillations of graphene electrons exposed to a moiré potential that defy this general rule and form nonlinear trajectories in the density-field plane. We attribute this anomalous behavior to the simultaneous occupation of multiple minibands and magnetic breakdown-induced open orbits.

Investigating the safety profiles of exogenous melatonin and associated adverse events: A pharmacovigilance study using WHO-VigiBase.

Melatonin, a pineal hormone that modulates circadian rhythms, sleep, and neurotransmitters, is widely used to treat sleep disorders. However, there are limited studies on the safety of melatonin. Therefore, we aimed to present the overall patterns of adverse events (AEs) following melatonin administration and identify potential safety signals associated with melatonin. Using VigiBase, a global individual case safety report (ICSRs) database managed by the World Health Organization (WHO), we conducted a retrospective, observational, pharmacovigilance study of melatonin between January 1996 and September 2022. Disproportionality analysis was conducted using two comparator settings: all other drugs and other sleep medications. We used multivariable logistic regression to estimate reporting odds ratios (RORs) with 95% confidence intervals (CIs) to compare the frequencies of AEs reporting between melatonin and each comparator setting. Furthermore, we assessed adverse events of special interests (AESIs) that could potentially be associated with melatonin. Signals were identified when the following criteria were met: cases ≥3, x2 ≥ 4, IC025 ≥ 0, and the lower end of the 95% CI of ROR > 2. These signals were then compared with the AE information on the drug labels provided by regulatory bodies. A total of 35 479 AE reports associated with melatonin were identified, with a higher proportion of reports from females (57.1%) and individuals aged 45-64 years (20.8%). We identified 21 AEs that were commonly detected as safety signals in the disproportionality analyses, including tic, educational problems, disturbance in social behavior, body temperature fluctuation, and growth retardation. In AESI analyses, accidents and injuries (adjusted ROR 2.97; 95% CI, 2.80-3.16), fall (2.24; 2.12-2.37), nightmare (4.90; 4.37-5.49), and abnormal dreams (3.68; 3.19-4.25) were detected as a signal of melatonin when compared to all other drugs, whereas those signals were not detected when compared to other sleep medications. In this pharmacovigilance study, exogenous melatonin showed safety profiles comparable to other sleep medications. However, several unexpected potential safety signals were identified, underscoring the need for further investigation at the population level.

Impact of Serum Albumin Levels and Body Mass Index on Outcomes of Open Abdominal Aortic Aneurysm Repair in Korean Population.

BACKGROUND: Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair. METHODS: We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5 kg/m2), normal weight (NW) (18.5-22.9 kg/m2), overweight (OW) (23-24.9 kg/m2), and obese (OB) (≥25 kg/m2). The χ2, Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups. RESULTS: Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P = 0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P = 0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P = 0.05). CONCLUSIONS: Low BMI (<18.5 kg/m2) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25 kg/m2) was associated with better overall survival after elective open AAA repair.

Clinical outcomes and challenges of surgical extirpation for carotid body paraganglioma in South Korea: a single-center retrospective study.

BACKGROUND: Carotid body paraganglioma (CBP) is a rare, highly vascularized, and slow-growing neuroendocrine tumor. Surgical resection is the definitive treatment for CBP, however, it remains challenging due to the tumor's proximity to critical blood vessels and cervical cranial nerves. This study aimed to document the characteristics of CBP and examine the clinical outcomes of patients following surgical extirpation of CBP. METHODS: This is a single-center retrospective review analyzed patients who underwent CBP extirpation. We examined the patient demographics, preoperative clinical features, tumor characteristics, levels of catecholamines and their metabolites in the serum and urine. Surgeries were performed by one vascular surgeon with follow-ups at 1,3,6 months and yearly thereafter. Logistic regression analysis was conducted to identify risk factors associated with the occurrence of either permanent or temporary cervival cranial nerve palsy (CNP). RESULTS: From September 2020 to February 2023, this study examined 21 cases of CBP removal surgeries that were carried out in 19 patients. The mean age of the patients was 38.9 ± 10.9 years and the percentage of males was 57.1% (n = 12). The most common preoperative clinical feature was painless neck mass (n = 12; 57.1%). Complete resection was achieved in 20 cases; excluding one case with pathologically proven sclerosing paraganglioma. Vascular procedures were performed in four cases (ECA resection, n = 2; primary repair of ICA tear without carotid shunting, n = 1; and ICA patch angioplasty with carotid shunting, n = 1). Temporary cranial neurologic complications, specifically aspiration and hoarseness occurred in four (19.0%), and three (14.3%) cases, respectively. Hoarseness associated with permanent CNP persisted for more than 6 months in two cases (9.5%). No recurrence or mortality was observed during the follow-up period. CONCLUSIONS: Surgical resection is the primay treatment approach for CBP; however, it poses risks of vascular or cervical CNP. The intraoperative estimated blood loss was the only identified risk factor for CNP.

Fate assessment of the ectatic common iliac artery using flared limb during endovascular aneurysm repair.

OBJECTIVES: This study aimed to evaluate the outcomes and anatomical predictors of the complications of flared limb (FL) use for ectatic common iliac arteries accompanied by abdominal aortic aneurysm treated with endovascular aneurysm repair (EVAR). METHODS: In this single-center retrospective study, we reviewed data from 391 patients (638 limbs) treated between 2005 and 2020. The cohort was divided into two groups. The standard limbs (SLs, n = 403) included stent graft (SG) of <20 mm in diameter and the FLs (n = 235) included stent graft of ≥20 mm in diameter. Complications within 30 days were investigated as the short-term outcome. Limb events during follow-up including type Ib endoleak (EL), type IIIa EL, and limb occlusion were compared between SLs and FLs using log-rank test. RESULTS: Early results indicated that the FL group had a significantly higher incidence of intraoperative type Ib EL at 5.1% (12), than 1.7% (7) in the SLs (p = .016). For 19 patients in whom intraoperative type Ib EL was discovered, SG extension alone or internal iliac artery embolization was all performed before completing the procedure. Overall, we noted one case of type Ib EL and two cases of limb events in each group at 30 days. Over a median follow-up of 39 months, 31 (4.9%) events (17 type Ib EL, 2 type IIIa EL, and 12 limb events), 13 (5.5%) in FLs and 18 (4.5%) in SLs (p = .984), were observed. The FLs had significantly higher rates of aortic sac enlargement, with 46 (19.6%) cases for FLs and 36 (8.9%) for SLs (p < .001). The Kaplan-Meier analysis revealed significant differences at 5 years in SLs versus FLs for freedom from type Ib EL (96.6% vs 82.4%, respectively; p < .001) and no difference in freedom from limb events (94.7% vs 84.5%, respectively; p = .519). Furthermore, no difference was observed for overall survival and aneurysm-related mortality. CONCLUSIONS: Although an FL for EVAR is used to treat dilated iliac arteries, there is an increased risk of intraoperative and late type Ib EL and aortic sac enlargement. Long-term close follow-up is mandatory, especially in the patients who undergo EVAR using FLs.

Robust Interlayer-Coherent Quantum Hall States in Twisted Bilayer Graphene.

We introduce a novel two-dimensional electronic system with ultrastrong interlayer interactions, namely, twisted bilayer graphene with a large twist angle, as an ideal ground for realizing interlayer-coherent excitonic condensates. In these systems, sub-nanometer atomic separation between the layers allows significant interlayer interactions, while interlayer electron tunneling is geometrically suppressed due to the large twist angle. By fully exploiting these two features we demonstrate that a sequence of odd-integer quantum Hall states with interlayer coherence appears at the second Landau level (N = 1). Notably the energy gaps for these states are of order 1 K, which is several orders of magnitude greater than those in GaAs. Furthermore, a variety of quantum Hall phase transitions are observed experimentally. All the experimental observations are largely consistent with our phenomenological model calculations. Hence, we establish that a large twist angle system is an excellent platform for high-temperature excitonic condensation.

The Impact of age and outcomes of high-risk patients on carotid revascularization.

OBJECTIVES: To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups. METHODS: We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs). RESULTS: A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group (n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922-10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391-11.155; p < 0.001) was also higher for CAS than CEA. In the age <75 subgroup of the Hr group (n = 428), CAS was associated with higher 30-day stroke/death (OR, 14.089; 95% CI, 1.314-151.036; p = 0.029). In the age ≥75 subgroup of the Hr (n = 139), there was no difference in 30-day stroke/death between CEA and CAS. In the age <75 subgroup of the Nr group (n = 1318), 30-day stroke/death (OR, 6.300; 95% CI, 2.797-14.193; p < 0.001) was higher in CAS. In the age ≥75 subgroup of the Nr group (n = 460), 30-day stroke/death (OR, 6.468; 95% CI, 1.862-22.471; p = 0.003) was higher in CAS. CONCLUSIONS: In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.

Remote Estimation of Blood Pressure Using Millimeter-Wave Frequency-Modulated Continuous-Wave Radar.

This paper proposes to remotely estimate a human subject's blood pressure using a millimeter-wave radar system. High blood pressure is a critical health threat that can lead to diseases including heart attacks, strokes, kidney disease, and vision loss. The commonest method of measuring blood pressure is based on a cuff that is contact-based, non-continuous, and cumbersome to wear. Continuous remote monitoring of blood pressure can facilitate early detection and treatment of heart disease. This paper investigates the possibility of using millimeter-wave frequency-modulated continuous-wave radar to measure the heart blood pressure by means of pulse wave velocity (PWV). PWV is known to be highly correlated with blood pressure, which can be measured by pulse transit time. We measured PWV using a two-millimeter wave radar focused on the subject's chest and wrist. The measured time delay provided the PWV given the length from the chest to the wrist. In addition, we analyzed the measured radar signal from the wrist because the shape of the pulse wave purveyed information on blood pressure. We investigated the area under the curve (AUC) as a feature and found that AUC is strongly correlated with blood pressure. In the experiment, five human subjects were measured 50 times each after performing different activities intended to influence blood pressure. We used artificial neural networks to estimate systolic blood pressure (SBP) and diastolic blood pressure (SBP) with both PWV and AUC as inputs. The resulting root mean square errors of estimated blood pressure were 3.33 mmHg for SBP and 3.14 mmHg for DBP.

Single-spin resonance in a van der Waals embedded paramagnetic defect.

A plethora of single-photon emitters have been identified in the atomic layers of two-dimensional van der Waals materials1-8. Here, we report on a set of isolated optical emitters embedded in hexagonal boron nitride that exhibit optically detected magnetic resonance. The defect spins show an isotropic ge-factor of ~2 and zero-field splitting below 10 MHz. The photokinetics of one type of defect is compatible with ground-state electron-spin paramagnetism. The narrow and inhomogeneously broadened magnetic resonance spectrum differs significantly from the known spectra of in-plane defects. We determined a hyperfine coupling of ~10 MHz. Its angular dependence indicates an unpaired, out-of-plane delocalized π-orbital electron, probably originating from substitutional impurity atoms. We extracted spin-lattice relaxation times T1 of 13-17 µs with estimated spin coherence times T2 of less than 1 µs. Our results provide further insight into the structure, composition and dynamics of single optically active spin defects in hexagonal boron nitride.

Estimation of Urine Flow Velocity Using Millimeter-Wave FMCW Radar.

This study investigated the feasibility of remotely estimating the urinary flow velocity of a human subject with high accuracy using millimeter-wave radar. Uroflowmetry is a measurement that involves the speed and volume of voided urine to diagnose benign prostatic hyperplasia or bladder abnormalities. Traditionally, the urine velocity during urination has been determined indirectly by analyzing the urine weight during urination. The maximum velocity and urination pattern were then used as a reference to determine the health condition of the prostate and bladder. The traditional uroflowmetry comprises an indirect measurement related to the flow path to the reservoir that causes time delay and water waves that impact the weight. We proposed radar-based uroflowmetry to directly measure the velocity of urine flow, which is more accurate. We exploited Frequency-Modulated Continuous-Wave (FMCW) radar that provides a range-Doppler diagram, allowing extraction of the velocity of a target at a certain range. To verify the proposed method, first, we measured water speed from a water hose using radar and compared it to a calculated value. Next, to emulate the urination scenario, we used a squeezable dummy bladder to create a streamlined water flow in front of the millimeter-wave FMCW radar. We validated the result by concurrently employing the traditional uroflowmetry that is based on a weight sensor to compare the results with the proposed radar-based method. The comparison of the two results confirmed that radar velocity estimation can yield results, confirmed by the traditional method, while demonstrating more detailed features of urination.

Odd Integer Quantum Hall States with Interlayer Coherence in Twisted Bilayer Graphene.

We report on the quantum Hall effect in two stacked graphene layers rotated by 2°. The tunneling strength among the layers can be varied from very weak to strong via the mechanism of magnetic breakdown when tuning the density. Odd-integer quantum Hall physics is not anticipated in the regime of suppressed tunneling for balanced layer densities, yet it is observed. We interpret this as a signature of Coulomb interaction induced interlayer coherence and Bose-Einstein condensation of excitons that form at half filling of each layer. A density imbalance gives rise to reentrant behavior due to a phase transition from the interlayer coherent state to incompressible behavior caused by simultaneous condensation of both layers in different quantum Hall states. With increasing overall density, magnetic breakdown gains the upper hand. As a consequence of the enhanced interlayer tunneling, the interlayer coherent state and the phase transition vanish.

Comparable surgical outcomes of abdominal aortic aneurysm repair in patients with and without Marfan syndrome.

OBJECTIVE: Marfan syndrome (MFS) affects the cardiovascular system. Aortic root aneurysm is a pathognomonic feature of MFS; however, the abdominal aorta is rarely affected. A consensus on surveillance for the abdominal aorta in patients with MFS has not been established. In the present study, we compared the outcomes after open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in patients with and without MFS. METHODS: We conducted a retrospective, single-center cohort study from 2003 to 2020. We reviewed and compared 28 patients with MFS and 426 patients without MFS who had undergone OSR for AAAs. The baseline characteristics, medical comorbidities, previous cardiovascular surgery, anatomic features of the AAAs, and surgical treatment outcomes were compared between the two groups. RESULTS: The patients with MFS were younger than those without MFS at the AAA diagnosis (47.2 ± 12.3 vs 70.6 ± 7.9 years; P < .001). The proportion of women was also greater for those with MFS (46.4% vs 15.7%; P < .001). The AAAs were most often located at the infrarenal aorta in both groups. However, thoracoabdominal AAAs were more often found among patients with MFS (10.7% vs 0.9%; P < .012). The proportion of symptomatic patients was lower in the MFS group (3.6% vs 21.6%; P = .022). The maximum median diameter of the AAA at surgery was smaller in the patients with MFS (52 mm vs 58 mm; P = .001). However, concomitant aortic dissection (32.1% vs 3.3%; P < .001) was more prevalent among the patients with MFS. Consequent aneurysmal changes in the iliac artery after AAA repair were more frequent in the patients with MFS (7.1% vs 0%; P = .004). No significant differences were found in 30-day or overall mortality between the patients with and without MFS during a median follow-up period of 71 months (interquartile range, 24.7-121.1 months) and 26.7 months (interquartile range, 7.4-69.5 months), respectively. CONCLUSIONS: The surgical outcomes of OSR for AAAs for patients with MFS were not significantly different from those for patients without MFS in a well-established surveillance program of MFS.

White matter hyperintensity determines ischemic stroke severity in symptomatic carotid artery stenosis.

INTRODUCTION: The aim of this study is to investigate the influence of white matter hyperintensity (WMH) on stroke severity and prognosis in patients with symptomatic carotid artery stenosis. METHODS: Patients with symptomatic carotid artery stenosis were retrieved from the Samsung Medical Center stroke registry from January 2011 to December 2016. Stroke severity was categorized into three levels according to National Institutes of Health Stroke Scale (NIHSS): transient ischemic attack (TIA) or transient symptoms with infarction (TSI), mild stroke, and moderate to severe stroke. WMH volume was measured with medical image processing and visualization. The clinical outcome was assessed using the modified Rankin scale on the 90th day from which the latest onset of the neurological symptom. Logistic regression was used to predict stroke severity, and ordinal regression was used to compare the clinical outcome. RESULTS: Among 158 patients, the numbers of patients with TIA or TSI, mild stroke, and moderate to severe stroke were 48 (30.4%), 59 (37.3%), and 51 (32.3%), respectively. The larger WMH volume was associated with moderate to severe strokes (TIA/TSI vs. moderate to severe strokes, odds ratio (OR) 2.318, 95% confidence interval (CI) 1.194-4.502, p = 0.007; mild vs. moderate to severe strokes, OR 1.972, 95% CI 1.118-3.479, p = 0.013). Patients with larger volume of WMH showed poorer clinical outcome (cutoff value: 9.71 cm3, OR 2.099, 95% CI 1.030-4.311, p = 0.042). CONCLUSION: Our study showed that larger WMH volume is associated with more severe stroke and poorer prognosis in patients with symptomatic carotid artery stenosis.

Culture-Negative Mycotic Aortic Aneurysms Probably Have a Less Severe Clinical Nature Than Culture-Positive Counterparts.

BACKGROUND: Mycotic aortic aneurysm constitutes a potentially devastating disease that necessitates prompt suspicion and diagnosis. There is no exact consensus for treatment, but removal of infected tissues and prolonged use of antimicrobials based on the identified causative microorganisms seem widely acceptable and have been similarly practiced worldwide. However, some patients still show no identified microorganisms. In this study, we sought to determine whether there are any clinical significance or differences of note in culture-negative mycotic aortic aneurysms. METHODS: Between October 2003 and August 2018, 71 patients were identified as treated for mycotic aortic aneurysms at a single tertiary institution. Review of medical records and imaging studies were completed to collect the following information: demographics, previous medical/surgical history regarding potential infection sources, laboratory and radiologic findings, clinical presentations, treatment method, and morbidity and mortality rates. For analysis, patients were categorized into two groups: the blood and/or tissue culture-positive (CP) group and the blood and/or tissue culture-negative (CN) group. The latter was further divided as CN with identified microorganism by molecular biologic methods [CN(+)] and CN with no identified microorganism [CN(-)]. RESULTS: More patients in the CP group were symptomatic than were in the CN(+) group (100% vs. 80%; P = 0.034). However, identification of causative microorganisms did not result in a difference in symptom status upon comparing the [CP + CN(+)] and [CN(-)] groups. Inflammatory markers were the most elevated in the CP group and least elevated in the CN(-) group. The aneurysm growth rate seemed slower in the CN(-) group than in the CN(+) and CP groups (1.3 vs. 3.4 vs. 9 mm/month respectively). Aneurysm rupture at initial presentation was more prevalent in the CP group (33.3%). 18F-Fluorodeoxyglucose-positron emission tomography showed increased uptake regardless of whether or not the microorganisms were identified. Early mortality and disease-specific mortality rates during the follow-up period were higher in the CP group but without statistical significance. CONCLUSIONS: Compared with the CP group, the CN groups appeared clinically less severe, and also exhibited a relatively less devastating course as exhibited by the slower aneurysm expansion rate and smaller number of ruptured aneurysms at the initial presentation.

Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea.

BACKGROUND: Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. METHODS: All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. RESULTS: Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients. CONCLUSION: Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.

Comparative Analysis Using Propensity Score Matching Analysis: Primary Closure versus Patch Angioplasty During Carotid Endarterectomy.

BACKGROUND: Primary closure (PC) and patch angioplasty (PA) during carotid endarterectomy (CEA) have been disputed in many studies. Some studies announced that PC is associated with a higher restenosis rate. The aim of this study was to evaluate the outcomes of PC and PA using propensity score matching (PSM). METHODS: Between November 1994 and October 2016, 1,044 patients underwent primary CEA procedures at our institution and were retrospectively analyzed. The study endpoints included rates of ipsilateral stroke, any clinical stroke, cranial nerve palsy, hematoma, bleeding warranting repeat surgery within 30 postoperative days. We also investigated the restenosis rates, overall survival, stenosis-free survival, and stroke-free survival during follow-up (median follow-up 37.1 months). RESULTS: This study includes 435 cases of PC and 476 cases of PA. After PSM analysis, baseline characteristics (age, gender, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status within 6 months) were balanced. Finally, 377 pairs of matched cases were analyzed. Statistical analysis showed no significant differences between the 2 groups in ipsilateral stroke (P = 0.45), clinical stroke (P = 0.75), cranial nerve palsy (P = 1), hematoma (P = 0.18), bleeding which required reoperation (P = 0.12) within 30 postoperative days, and restenosis rates during follow-up (P = 0.16). In addition, there were no differences between the 2 groups during follow-up in overall, stroke-free, and restenosis-free survival with P values of 0.136, 0.07, and 0.06, respectively. CONCLUSIONS: According to the analysis using PSM, there were no significant differences between PC and PA closure during CEA in perioperative and long-term outcomes.

The Effect of Left Renal Vein Division on Renal Function Following Open Abdominal Aortic Surgery Using Propensity Score Matching Analysis.

BACKGROUND: Open surgery of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD) sometimes requires left renal vein division (LRVD) to gain adequate exposure of the abdominal aorta. The aim of this study is to evaluate the effect of LRVD on the postoperative renal function using propensity score matching (PSM). METHODS: From July 1996 to January 2018, we retrospectively reviewed 698 patients who underwent open aortic surgery, including 543 AAAs and 155 AIODs, at a single institution. 66 patients (9.6%, 47 AAAs, 19 AIODs) needed LRVD during the operation. A 1:3 ratio PSM was used to control the selective bias between the LRVD and non-LRVD groups. We investigated preoperative and postoperative renal function including serum creatinine (sCr) level and estimated glomerular filtration rate (eGFR, mL/min/1.73 m2). Major complications, long-term renal function, and 30-day mortality were also compared. RESULTS: The LRVD group had a significantly higher rate of renal artery reconstruction (15.2% vs. 3.3%, P < 0.001) and suprarenal clamping (54.6% vs. 9.5%, P < 0.001) and higher incidence of juxtarenal AIOD (24.2% vs. 5.4%, P < 0.001). With PSM, 63 patients in the LRVD group and 144 patients in the non-LRVD group were enrolled in this study. The baseline characteristics were well balanced in the groups after PSM. There were no significant differences in preoperative eGFR (72.4 ± 21.3 vs. 76.1 ± 25.0, P = 0.306) and postoperative eGFR on day 3 (69.5 ± 26.6 vs. 77.5 ± 28.5, P = 0.065), day 7 (73.3 ± 24.8 vs. 78.5 ± 27.4, P = 0.264), and in the long-term follow-up period (69.0 ± 22.2 vs. 68.9 ± 27.1, P = 0.986, 50.2 month ± 45.50) in the 2 groups. Only the sCr level (1.40 ± 0.59 vs. 1.21 ± 0.62, P = 0.045) and eGFR (59.5 ± 23.9 vs. 71.4 ± 26.0, P = 0.002) were significantly worse on postoperative day 1 in the LRVD than in the non-LRVD group. There were no significant differences in 30-day mortality (1.6% vs. 1.6%, P = 1.00). CONCLUSIONS: The patients in the LVRD group underwent initial drop in renal function; however, eGFR improved during the follow-up period. There was no difference in renal function and postoperative mortality between LRVD and non-LRVD groups. Therefore, LRVD is a safe and durable procedure during complex abdominal aortic surgery.

A systematic review and meta-analysis comparing the effect of aquatic and land exercise on dynamic balance in older adults.

BACKGROUND: Balance impairments are the leading causes of falls in older adults. Aquatic-based exercises have been broadly practiced as an alternative to land-based exercises; however, the effects on dynamic balance have not been comprehensively reviewed and compared to land exercises. Thus, the purpose of this systematic review and meta-analysis was to compare the effectiveness of aquatic exercises (AE) to land exercises (LE) on dynamic balance in older adults. METHODS: Electronic databases (PubMed, MEDLINE, CINAHL, SPORTDiscus, psycINFO), from inception to November 2019, were searched. Studies met the following eligibility criteria: Randomized controlled trials, English language, older adults aged 65 years or older, a minimum of one AE and LE group, at least one assessment for dynamic balance. For the meta-analysis, the effect sizes of dynamic balance outcomes were calculated using a standardized mean difference (SMD) and a 95% confidence interval (CI). RESULTS: A total of 11 trials met the inclusion criteria, and 10 studies were eligible for the meta-analysis. The meta-analysis presented that older adults in AE groups demonstrated comparable enhancements in dynamic steady-state balance (SMD = - 0.24; 95% CI, -.81 to .34), proactive balance (SMD = - 0.21; 95% CI, -.59 to .17), and balance test batteries (SMD = - 0.24; 95% CI, -.50 to .03) compared with those in LE groups. CONCLUSIONS: AE and LE have comparable impacts on dynamic balance in older adults aged 65 years or older. Thus, this review provides evidence that AE can be utilized as a reasonable alternative to LE to improve dynamic balance and possibly reduce the risk of falls.