An app to classify a 5-year survival in patients with breast cancer using the convolutional neural networks (CNN) in Microsoft Excel: Development and usability study.

BACKGROUND: Breast cancer (BC) is the most common malignant cancer in women. A predictive model is required to predict the 5-year survival in patients with BC (5YSPBC) and improve the treatment quality by increasing their survival rate. However, no reports in literature about apps developed and designed in medical practice to classify the 5YSPBC. This study aimed to build a model to develop an app for an automatically accurate classification of the 5YSPBC. METHODS: A total of 1810 patients with BC were recruited in a hospital in Taiwan from the secondary data with codes on 53 characteristic variables that were endorsed by professional staff clerks as of December 31, 2019. Five models (i.e., revolution neural network [CNN], artificial neural network, Naïve Bayes, K-nearest Neighbors Algorithm, and Logistic regression) and 3 tasks (i.e., extraction of feature variables, model comparison in accuracy [ACC] and stability, and app development) were performed to achieve the goal of developing an app to predict the 5YSPBC. The sensitivity, specificity, and receiver operating characteristic curve (area under ROC curve) on models across 2 scenarios of training (70%) and testing (30%) sets were compared. An app predicting the 5YSPBC was developed involving the model estimated parameters for a website assessment. RESULTS: We observed that the 15-variable CNN model yields higher ACC rates (0.87 and 0.86) with area under ROC curves of 0.80 and 0.78 (95% confidence interval 0.78-82 and 0.74-81) based on 1357 training and 540 testing cases an available app for patients predicting the 5YSPBC was successfully developed and demonstrated in this study. CONCLUSION: The 15-variable CNN model with 38 parameters estimated using CNN for improving the ACC of the 5YSPBC has been particularly demonstrated in Microsoft Excel. An app developed for helping clinicians assess the 5YSPBC in clinical settings is required for application in the future.

Revealing the Dynamic Nature of Amplitude Modulated Neural Entrainment With Holo-Hilbert Spectral Analysis.

Patterns in external sensory stimuli can rapidly entrain neuronally generated oscillations observed in electrophysiological data. Here, we manipulated the temporal dynamics of visual stimuli with cross-frequency coupling (CFC) characteristics to generate steady-state visual evoked potentials (SSVEPs). Although CFC plays a pivotal role in neural communication, some cases reporting CFC may be false positives due to non-sinusoidal oscillations that can generate artificially inflated coupling values. Additionally, temporal characteristics of dynamic and non-linear neural oscillations cannot be fully derived with conventional Fourier-based analyses mainly due to trade off of temporal resolution for frequency precision. In an attempt to resolve these limitations of linear analytical methods, Holo-Hilbert Spectral Analysis (HHSA) was investigated as a potential approach for examination of non-linear and non-stationary CFC dynamics in this study. Results from both simulation and SSVEPs demonstrated that temporal dynamic and non-linear CFC features can be revealed with HHSA. Specifically, the results of simulation showed that the HHSA is less affected by the non-sinusoidal oscillation and showed possible cross frequency interactions embedded in the simulation without any a priori assumptions. In the SSVEPs, we found that the time-varying cross-frequency interaction and the bidirectional coupling between delta and alpha/beta bands can be observed using HHSA, confirming dynamic physiological signatures of neural entrainment related to cross-frequency coupling. These findings not only validate the efficacy of the HHSA in revealing the natural characteristics of signals, but also shed new light on further applications in analysis of brain electrophysiological data with the aim of understanding the functional roles of neuronal oscillation in various cognitive functions.

Intramedullary Suture Anchor Fixation of a Type Vb Flexor Digitorum Profundus Avulsion: A Case Report.

CASE: Flexor digitorum profundus avulsions are common injuries that manifest as tendinous or bony avulsions from the distal phalanx. Rarely, additional fractures can occur in the distal phalanx. For such injuries, repair of the avulsion and fracture is recommended but difficult because of limited bone stock for fixation. CONCLUSION: We present a case of a 28-year-old man with a combined flexor digitorum profundus bony avulsion and bony mallet finger, and describe a strategic fixation technique using an intramedullary suture anchor and dorsal button that provided stable fixation and resulted in excellent motion and function, with return to sport at 12 weeks.

An Aggressive Digital Papillary Adenocarcinoma and a Grossly Similar, Contralateral Callus: A Case Report.

CASE: This is a case of a 44-year-old man with 10 years of history of painful callus-like swellings of bilateral index fingers. Sudden enlargement of the left index finger prompted biopsy, which revealed aggressive digital papillary adenocarcinoma (ADPA) that was treated with partial amputation. Biopsy of the contralateral finger revealed acanthotic skin with no evidence of malignancy. CONCLUSION: Several case reports cite antecedent insult and chronic swelling before diagnosis. We describe a case of bilateral lesions with similar gross appearances, a long history of occupational repetitive trauma, and sudden enlargement of 1 lesion leading to the diagnosis of ADPA.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry.

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.

Cadaveric Study of the Safety and Device Functionality of Magnetically Controlled Growing Rods After Exposure to Magnetic Resonance Imaging.

STUDY DESIGN: Cadaveric study. OBJECTIVE: To establish the safety and efficacy of magnetically controlled growing rods (MCGRs) after magnetic resonance imaging (MRI) exposure. SUMMARY OF BACKGROUND DATA: MCGRs are new and promising devices for the treatment of early-onset scoliosis (EOS). A significant percentage of EOS patients have concurrent spinal abnormalities that need to be monitored with MRI. There are major concerns of the MRI compatibility of MCGRs because of the reliance of the lengthening mechanism on strongly ferromagnetic actuators. METHODS: Six fresh-frozen adult cadaveric torsos were used. After thawing, MRI was performed four times each: baseline, after implantation of T2-T3 thoracic rib hooks and L5-S1 pedicle screws, and twice after MCGR implantation. Dual MCGRs were implanted in varying configurations and connected at each end with cross connectors, creating a closed circuit to maximize MRI-induced heating. Temperature measurements and tissue biopsies were obtained to evaluate thermal injury. MCGRs were tested for changes to structural integrity and functionality. MRI images obtained before and after MCGR implantation were evaluated. RESULTS: Average temperatures increased incrementally by 1.1°C, 1.3°C, and 0.5°C after each subsequent scan, consistent with control site temperature increases of 1.1°C, 0.8°C, and 0.4°C. Greatest cumulative temperature change of +3.6°C was observed adjacent to the right-sided actuator, which is below the 6°C threshold cited in literature for clinically detectable thermal injury. Histologic analysis revealed no signs of heat-induced injury. All MCGR actuators continued to function properly according to the manufacturer's specifications and maintained structural integrity. Significant imaging artifacts were observed, with the greatest amount when dual MCGRs were implanted in standard/offset configuration. CONCLUSIONS: We demonstrate minimal MRI-induced temperature change, no observable thermal tissue injury, preservation of MCGR-lengthening functionality, and no structural damage to MCGRs after multiple MRI scans. Expectedly, the ferromagnetic actuators produced substantial MR imaging artifacts. LEVEL OF EVIDENCE: Level V.

Anti-Platelet Factor 4/Heparin Antibody Plays a Significant Role in Progression of Arterial Stiffness among Hemodialysis Patients.

BACKGROUND: Arterial stiffness is a determinant of cardiovascular disease in end stage renal disease. Hemodialysis patients may develop anti-platelet factor 4/heparin antibody (PF4-H Ab) because of heparin treatment in dialysis. We tested whether PF4-H Ab was associated with progression of arterial stiffness in a 3-year follow-up. METHODS: We enrolled 74 hemodialysis patients and studied their clinical, biochemical and arterial stiffness measurement with brachial-ankle pulse wave velocity (baPWV) over 3 years. Baseline and changes in baPWV after 3 years (ΔbaPWV) were collected and compared with related clinical and biochemical parameters. PF4-H Ab was evaluated by the enzyme-linked immunosorbent assay and titer ≥ 0.4 was defined to have PF4-H Ab. RESULTS: We found a positive PF4-H Ab status in 25 of 74 patients. Mean baPWV was 16.1 ± 3.8 (m/s) at baseline and 17.6 ± 4.0 (m/s) after 3 years. Mean ΔbaPWV was 3.4 ± 2.2 (m/s) in the PF4-H Ab positive group, and 0.6 ± 1.2 (m/s) in the PF4-H Ab negative group. Baseline baPWV was only significantly associated with age (ß = 0.49, p < 0.01). ΔbaPWV was significantly different between the PF4-H Ab positive and negative groups (p < 0.01). In multivariate regression analysis, only PF4-H Ab was positively associated with ΔbaPWV (ß = 0.71, p < 0.01). CONCLUSIONS: Our study concluded that PF4-H Ab was associated with progression of arterial stiffness in hemodialysis patients.

A pilot cadaveric study of temperature and adjacent tissue changes after exposure of magnetic-controlled growing rods to MRI.

PURPOSE: To test for possible thermal injury and tissue damage caused by magnetic-controlled growing rods (MCGRs) during MRI scans. METHODS: Three fresh frozen cadavers were utilized. Four MRI scans were performed: baseline, after spinal hardware implantation, and twice after MCGR implantation. Cross connectors were placed at the proximal end and at the distal end of the construct, making a complete circuit hinged at those two points. Three points were identified as potential sites for significant heating: adjacent to the proximal and distal cross connectors and adjacent to the actuators. Data collected included tissue temperatures at baseline (R1), after screw insertion (R2), and twice after rod insertions (R3 and R4). Tissue samples were taken and stained for signs of heat damage. RESULTS: There was a slight change in tissue temperature in the regions next to the implants between baseline and after each scan. Average temperatures (°C) increased by 0.94 (0.16-1.63) between R1 and R2, 1.6 (1.23-1.97) between R2 and R3, and 0.39 (0.03-0.83) between R3 and R4. Subsequent histological analysis revealed no signs of heat induced damage. CONCLUSION: Recurrent MRI scans of patients with MCGRs may be necessary over the course of treatment. When implanted into human cadaveric tissue, these rods appear to not be a risk to the patient with respect to heating or tissue damage. Further in vivo study is warranted. LEVEL OF EVIDENCE: N/A.

Risk of Developing Coronary Artery Disease in Patients with Type 2 Diabetes Receiving Traditional Chinese Medicine Therapy.

OBJECTIVES: To compare risk of developing coronary artery disease (CAD) between diabetic patients receiving Traditional Chinese Medicine (TCM) therapy and those treated by Western medicine (WM). METHODS: This prospective cohort study included 13,655 diabetic patients receiving solely TCM and 435,165 patients treated exclusively by WM. Study patients were identified from Taiwan's National Health Insurance (NHI) ambulatory claims in 2000-2001. These patients were then linked to the 2000-2008 NHI inpatient claims, searching for possible new onset of hospitalization for CAD. A Cox proportional hazard model and logistic regression model were used to assess the hazard ratio of CAD admission and odds ratio (OR) of higher rates of admission for CAD in relation to TCM. RESULTS: During 9 years of follow-up, 2607 diabetic patients with TCM were hospitalized for CAD, representing a cumulative incidence rate of 19.1% and an incidence density of 50.5 per 1000 person-years. The corresponding figures for patients treated by WM were 24.1% and 72.7 per 1000 person-years. Compared with the patients treated by WM, those treated by TCM were associated with a slightly reduced, but insignificantly, adjusted OR of CAD admission (0.96; 95% confidence interval, 0.92-1.01). Moreover, the adjusted OR for a higher rate (≥0.212 admission per person-year) of CAD admission for the patients with TCM was also insignificantly decreased at 0.97. CONCLUSIONS: After adjustment for prior co-morbidity score, risk or rate of CAD admission did not significantly differ between diabetic patients receiving TCM therapy and those treated by WM, suggesting that TCM is as efficacious as WM in preventing diabetes from being complicated with CAD.

Anti-platelet factor 4/heparin antibody is associated with progression of peripheral arterial disease in hemodialysis patients.

BACKGROUND: Heparin therapy may induce anti-platelet factor 4/heparin antibody (PF4-H Ab). Hemodialysis patients receive scheduled heparin and are at a risk of developing PF4-H Ab. Hemodialysis patients are also at a high risk of peripheral arterial disease (PAD). This study examines whether chronic PF4-H Ab exposure contributes to the progression of PAD measured by ankle brachial index (ABI) in hemodialysis patients. MATERIALS AND METHODS: A total of 71 hemodialysis patients were enrolled, and the association between clinical, biochemical parameters and ABI after 3 years was studied. PF4-H Ab was evaluated by ELISA, and patients with titer ≥ 0.4 were taken as having PF4-H Ab. RESULTS: Mean ABI was 1.04 ± 0.18 at baseline and 1.01 ± 0.17 after 3 years. Mean ΔABI (change in ABI after 3 years) was -0.04 ± 0.13. PF4-H Ab was positive in 26 patients. PF4-H Ab was not related to hemodialysis duration, DM history, smoking and age. Platelet count showed no correlation with PF4-H Ab. However, there was significance in ΔABI between PF4-H Ab-positive and PF4-H Ab-negative patients (p = 0.002). ΔABI was negatively correlated with PF4-H Ab and 3-year averaged serum Ca × P only (ß = -0.378, p = 0.001; ß = -0.263, p = 0.018, respectively). However, in PF4-H Ab-positive patients, the extent of ΔABI did not correlate with PF4-H Ab titers (r = -0.021, p = 0.921). CONCLUSIONS: PF4-H Ab positivity, along with high levels of serum Ca × P, played a potential role in the progression of PAD over time.

Involvement of p38 MAPK in the Anticancer Activity of Cultivated Cordyceps militaris.

Cordyceps militaris is a traditional Chinese medicine frequently used for tonic and therapeutic purposes. Reports from our laboratory and others have demonstrated that extracts of the cultivated fruiting bodies of C. militaris (CM) exhibit a potent cytotoxic effect against many cancer cell lines, especially human leukemia cells. Here, we further investigated the underlying mechanism through which CM is cytotoxic to cancer cells. The CM-mediated induction of PARP cleavage and its related DNA damage signal (γH2AX) was diminished by caspase inhibitor I. In contrast, a ROS scavenger failed to prevent CM-mediated leukemia cell death. Moreover, two signaling molecules, AKT and p38 MAPK, were activated during the course of apoptosis induction. Employing MTT analysis, we found that a p38 MAPK inhibitor but not an AKT inhibitor could rescue cells from CM-mediated cell death, as well as inhibit the cleavage of PARP, formation of apoptotic bodies and up-regulation of the γH2AX signal. These results suggest that CM-mediated leukemia cell death occurs through the activation of the p38 MAPK pathway, indicating its potential therapeutic effects against human leukemia.

Simvastatin prodrug micelles target fracture and improve healing.

Simvastatin (SIM), a widely used anti-lipidemic drug, has been identified as a bone anabolic agent. Its poor water solubility and the lack of distribution to the skeleton, however, have limited its application in the treatment of bone metabolic diseases. In this study, an amphiphilic macromolecular prodrug of SIM was designed and synthesized to overcome these limitations. The polyethylene glycol (PEG)-based prodrug can spontaneously self-assemble to form micelles. The use of SIM trimer as the prodrug's hydrophobic segment allows easy encapsulation of additional free SIM. The in vitro studies showed that SIM/SIM-mPEG micelles were internalized by MC3T3 cells via lysosomal trafficking and consistently induced expression of both BMP2 and DKK1 mRNA, suggesting that the prodrug micelle retains the biological functions of SIM. After systemic administration, optical imaging suggests that the micelles would passively target to bone fracture sites associated with hematoma and inflammation. Furthermore, flow cytometry study revealed that SIM/SIM-mPEG micelles had preferred cellular uptake by inflammatory and resident cells within the fracture callus tissue. The treatment study using a mouse osteotomy model validated the micelles' therapeutic efficacy in promoting bone fracture healing as demonstrated by micro-CT and histological analyses. Collectively, these data suggest that the macromolecular prodrug-based micelle formulation of SIM may have great potential for clinical management of impaired fracture healing.

Synergistic property of cordycepin in cultivated Cordyceps militaris-mediated apoptosis in human leukemia cells.

Cordyceps militaris is a well-known Chinese traditional medicinal mushroom frequently used for tonics and recently of a potential interest for cancer intervention. Here, we explored the cancer cell killing activity of the hot water extracts of C. militaris cultured mycelia (CM(MY)) and cultivated fruiting bodies (CM(FB)). We found that CM(FB) exhibited a greater cytotoxic effect against various cancer cells over CM(MY). Apoptotic phenotypes including apoptotic body formation, DNA laddering, caspase 3 activation and cleavage of PARP proteins were induced by CM(FB) treatment but only slightly induced by same concentration of CM(MY) treatment in human HL-60 leukemia cells. Cordycepin in CM(FB) (10.47 mg/g) is significantly higher (∼ 15.2 times) than that of CM(MY) (0.69 mg/g). Using isobolographic analysis, the synergy of cytotoxicity was observed across different combined concentrations of CM(MY) and cordycepin. By complementing cordycepin into CM(MY) to the level comparable with CM(FB), we observed that CM(MY) (500 µg/ml) with cordycepin (4.8 µg/ml) induced apoptosis to a level similar to that induced by CM(FB) (500 µg/ml). Together, our results suggest that cordycepin possesses a synergistic cytotoxic effect with Cordyceps militaris-mediated apoptosis in human leukemia cells and therefore explaining a better anti-proliferating activity of CM(FB) over CM(MY).

Therapy-related acute lymphoblastic leukemia with t(4;11)(q21;q23) masqueraded as marrow lymphocytosis in a patient with breast cancer.

Therapy-related acute leukemia develops in patients after chemotherapy and/or radiotherapy for a prior cancer, and most cases are acute myeloid leukemia with a much lower frequency of acute lymphoblastic leukemia (ALL). One unique feature of these therapy-related ALL (t-ALL) is an increased incidence of chromosome band 11q23 aberrations as compared with de novo ALL. In adult female patients, breast cancer is the most common primary cancer. Herein, we report the case of a 49-year-old Taiwanese lady who developed t-ALL with t(4;11)(q21;q23) 16 months after cyclophosphamide, epirubicin, and 5-fluorouracil chemotherapy for her breast cancer. The unusual feature is that the t-ALL was heralded 4 months ago by marrow lymphocytosis comprising atypical small lymphocytes with condensed chromatin mimicking a B-cell chronic lymphoproliferative disorder. Retrospective studies using additional antibodies for immunophenotyping and PCR-based clonality study for immunoglobulin gene rearrangement showed that these atypical small lymphocytes shared similar features with the leukemic blasts at the frank leukemic stage. Our results suggest that these atypical small lymphocytes are lymphoblasts in disguise and that the clinicopathological correlations with ancillary pathological studies are important to reach a definitive diagnosis of such an unusual case.

Brachial-ankle pulse wave velocity as an early indicator of left ventricular diastolic function among hypertensive subjects.

While increased arterial stiffness is a known risk of cardiovascular disease, pulse wave velocity (PWV) is a conventionally adopted index of arterial stiffness. However, the relationship between PWV and left ventricular functions are not thoroughly evaluated. This cross-sectional study investigated whether PWV measurement is an early indicator of left ventricular (LV) dysfunction. A noninvasive, volume-plethysmographic apparatus was used to determine blood pressure, electrocardiogram, heart sounds, and PWV in 42 consecutively diagnosed subjects with hypertension, and 42 sex- and age-matched nonhypertension subjects were studied. Arterial stiffness and aortic stiffness were evaluated by brachial-ankle (b-a) PWV, heart-carotid (h-c) PWV, heart-femoral (h-f) PWV, carotid-femoral (c-f) PWV, and femoral-ankle (f-a) PWV. Function of LV was estimated by tissue Doppler imaging (TDI) echocardiography. Hypertension subjects exhibited higher b-a PWV and late diastolic mitral flow velocity values than those of nonhypertensive subjects. Pearson correlation analysis revealed that LV diastolic function (Em(av)) negatively correlated with c-f PWV and b-a PWV. Multiple linear regression analysis indicated that b-a PWV was independently and negatively associated with LV diastolic function (Em(av)). Further analysis by stratified hypertensive status, the b-a PWV were independently and negatively associated with Em(av) in hypertensive subjects (p = 0.004) only. In conclusion, the b-a PWV, but not c-f PWV, h-c PWV, h-f PWV, or f-a PWV, is significantly correlated with LV diastolic function in hypertensive subjects, indicating that b-a PWV involving both central and peripheral components of arterial stiffness may be an early indicator of LV dysfunction.

Increased epicardial adipose tissue (EAT) volume in type 2 diabetes mellitus and association with metabolic syndrome and severity of coronary atherosclerosis.

OBJECTIVE: Epicardial adipose tissue (EAT) is a part of visceral fat deposited around the heart between the pericardium and myocardium along the distribution of coronary arteries. EAT thickness is reported to be associated with coronary atherosclerosis; however, no study has measured EAT volume in patients with type 2 diabetes or investigate its association with coronary artery disease. DESIGN: A hospital-based case control study. PATIENTS: A total of 49 patients with type 2 diabetes mellitus (T2DM) and 78 nondiabetic controls were studied. MEASUREMENTS: Cardiac multislice computed tomography was used to measure EAT volume, Gensini score, coronary artery calcium score and, coronary lesions. The relationships between EAT volume, markers of coronary atherosclerosis and anthropometric and biochemical parameters of metabolic syndrome (MetS) were investigated. RESULTS: EAT volume was significantly higher in patients with T2DM than in nondiabetic subjects (166.1 +/- 60.6 cm(3) vs. 123.4 +/- 41.8 cm(3), P < 0.0001). Logistic regression analysis revealed independent and significant associations between EAT and diabetic status. EAT volume was significantly associated with components of MetS (BMI, waist circumference, fasting serum glucose, total cholesterol, HDL-cholesterol, and triglycerides levels), Gensini score, coronary lesions, coronary disease and coronary calcium scores. Univariate, multivariate and trend analyses confirmed that EAT volume was associated with MetS component clustering and the coronary atherosclerosis index. CONCLUSIONS: The analytical results indicate that EAT volume is increased in T2DM patients and is associated with unfavourable components of MetS and coronary atherosclerosis. The close anatomical relationship between EAT and the coronary arteries, combined with other evidence indicating that EAT is a biologically active adipokine-secreting tissue, suggest that EAT participates in the pathogenesis of diabetic coronary atherosclerosis.

Percutaneous coronary intervention for iatrogenic left main coronary artery dissection.

BACKGROUND: Although catheter-induced left main coronary artery (LMCA) dissection is a rare complication of coronary catheterization, it is a common cause of periprocedural mortality. Emergent coronary artery bypass surgery (CABG) is the mainstay for managing this acute complication. However, hemodynamic deterioration may progress while patients await emergent CABG; consequently, a high postoperative mortality rate has been reported. Although the number of cases was small, prompt bail-out stenting for iatrogenic LMCA dissection had reportedly reversed this complication with favorable clinical outcomes. METHODS: This study included 13 cases of attempted stenting for iatrogenic LMCA dissection classified as grades C-F based on the National Heart, Lung and Blood Institute (NHLBI) classification system. Angiographic success, in-hospital mortality and long-term outcomes were analyzed. RESULTS: The incidence of iatrogenic LM dissection was 0.071%. Most of the patients were initially asymptomatic. Angiographic success was achieved in 11 of 13 patients (84.6%). Including one patient who underwent emergent CABG after a failed wiring attempt, two mortalities occurred in this series. Mean follow-up duration of the ten patients discharged was 30.1+/-11.8 months, and no cardiac deaths occurred. Follow-up angiogram of eight patients with a mean interval of 5.2+/-2.3 months after initial event demonstrated restenosis in three patients occurring either at the ostiums of the left anterior descending artery or left circumflex artery. Revascularization was performed on two patients. CONCLUSIONS: Successful bail-out stenting resulted in good long-term survival and should be considered for initial management of iatrogenic LMCA dissection.

Intensity of C-reactive protein immunohistochemical staining of atherosclerotic plaque macrophages and extracellular tissue of patients with angina pectoris undergoing directional coronary atherectomy.

BACKGROUND: An elevated C-reactive protein (CRP) level plays a crucial role in cell biology of atherosclerosis and unstable plaque formation. However, direct evidence of CRP involvement in atherosclerotic plaque development and vulnerability is still limited. We hypothesized that CRP is present in the vulnerable plaques and that CRP staining intensity is stronger in vulnerable plaques compared to stable plaques. METHODS: Directional coronary atherectomy (DCA) was performed on 58 patients with stable angina (group 1) and 40 patients with unstable angina (group 2). White blood cell (WBC) counts were measured prior to DCA. Immunohistochemical staining (IHCS) was performed to localize CRP in the atheroma. Staining intensity in macrophages and extracellular tissue was graded as: 0, no staining; 1+, < 30%; 2+, 30%-60%; 3+, > 60%. RESULTS: The IHCS demonstrated that CRP staining - 1+ intensity in macrophages and extracellular tissue were significantly higher in group 1 than in group 2 patients (all p values < 0.0001). However, IHCS demonstrated that CRP staining a 2+ intensity in macrophages and extracellular tissue were significantly higher in group 2 than in group 1 patients (all p values < 0.0001). By multiple analysis, only stable angina was independently associated with CRP staining : 1+ intensity in both macrophages and extracellular tissue (p < 0.0001), whereas unstable angina and WBC counts were independent predictors of CRP staining > or = 2+ intensity in both macrophages and extracellular tissue (p < 0.0001). CONCLUSION: CRP was frequently found in atherosclerotic plaques of patients with unstable angina. This analytical finding suggests that CRP directly mediates an inflammatory process in the atherosclerotic plaque.

Impact of PercuSurge GuardWire device on prevention and reduction of recovery time from complete heart block in patients with acute inferior myocardial infarction undergoing primary percutaneous coronary intervention.

Second-degree heart block or complete heart block (CHB) is a relatively frequent complication of acute inferior wall myocardial infarction (AIWMI). This study investigated whether the PercuSurge device can prevent procedure-related CHB or can shorten CHB recovery time in patients with AIWMI undergoing primary percutaneous coronary intervention (PCI). Between May 2002 and April 2005, a PercuSurge device was utilized in 113 patients (study population, group 1) with AIWMI due to obstruction of the right coronary artery (RCA) with a reference lumen diameter (RLD) > or = 3.5 mm. The control subjects (group 2) consisted of 119 patients who experienced AIWMI due to RCA obstruction with a RLD > or = 3.5 mm from May 2000 to April 2002. The combined incidence of new onset of CHB following the interventional procedure was significantly higher in group 2 than in group 1. Additionally, recovery time from CHB to first-degree heart block or normal sinus rhythm was remarkably longer in group 2 than in group 1. Furthermore, the duration of hospitalization in group 2 was significantly longer than in group 1. Multiple stepwise analyses demonstrated that the PercuSurge device was the only independent predictor of preventing new onset of CHB during the procedure. Additionally, this mechanical device along with final TIMI-3 flow and final myocardial blush grade > or = 2 was independently associated with reducing recovery time from CHB. In conclusion, the PercuSurge device can prevent procedure-related CHB and shorten the recovery time for CHB in patients with AIWMI undergoing primary PCI.

Impact of PercuSurge device conjugative with intracoronary administration of nitroprusside on no-reflow phenomenon following primary percutaneous coronary intervention.

BACKGROUND: The present study tested the hypothesis that when administered in conjunction with a PercuSurge device for treatment of acute myocardial infarction (AMI), intracoronary (IC) administration of nitroprusside (NTP) is safe and superior to IC administration of NTP alone or nitroglycerin (NTG) for reversing slow-flow or no-reflow, both of which occur frequently during primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Sixty-two patients with ST-segment elevation AMI of <12 h duration undergoing primary PCI were enrolled. When the final Thrombolysis In Myocardial Infarction (TIMI) flow was normal (TIMI-3), NTG 200 microg was administered first, followed by (5 min later) NTP 100 microg via an intra-guiding catheter. When final TIMI flow was