Grade 2b Research Articles

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline.

Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery. Electronic supplementary materialThe online version of this article (10.1007/s00134-020-05948-0) contains supplementary material, which is available to authorized users.

Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented.

Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.

Snake bites by European vipers in Mainland France in 2017–2018: comparison of two antivenoms Viperfav® and Viperatab®

Context: Today, immunotherapy with Fab or F(ab′)2 fragments is considered as a gold standard treatment for patients bitten by vipers. We compared the efficiency of two antivenoms, Viperfav® and Viperatab®, in mainland France in 2017–2018 with data provided by the French poison control centre (PCC).Methods: Patients with a moderate (2a and 2b) or severe (3) envenomation after a European viper bite and treated with immunotherapy were included and the markers chosen were the risk of post-antivenom treatment worsening, duration of hospital stay and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis.Results: Two hundred and ninety-seven cases were recorded. One hundred and eighty-two (61.3%) patients received Viperfav® and 115 (38.7%) received Viperatab®. Compared to Viperfav®, use of Viperatab® significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). No significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15. Viperfav® and Viperatab® have a similar tolerance (p > .21). Otherwise, duration of hospitalisation was significantly increased by a delay of immunotherapy infusion of more than 12 h (OR 2.70; 95%CI [1.45–5.06]; p = .002) or a preventive administration of LMWH (OR 6.55; 95%CI [1.58–27.13]; p=.02).Discussion: While Viperfav® and Viperatab® have a similar tolerance, our data show that Viperatab® was associated with a higher risk of post-antivenom treatment worsening compared to Viperfav®. Furthermore, this study confirms that the antivenom should be used as soon as possible. Indeed, patients receiving the immunotherapy infusion from the grade 2b presented significantly more frequent exacerbated symptoms (OR 3.99; 95%CI [1.16–13.73]; p=.028) after the antivenom infusion compared to grade 2a group.Conclusions: Whereas no significant difference between these antivenoms was recorded with respect to the duration of hospital stay and persistent functional discomfort on day 15, use of Viperatab®, compared to Viperfav®, significantly increased the risk of post-antivenom treatment worsening (OR* 12.05; 95%CI [3.11; 46.70]; p < .001). Taken together, these data show that Viperfav® is the treatment of choice for the management of snake bites in France.

Neutrophil-to-lymphocyte ratio is associated with survival in patients with unresectable hepatocellular carcinoma treated with lenvatinib.

Lenvatinib, a newly developed molecularly targeted agent, has become available for patients with unresectable hepatocellular carcinoma (HCC). Neutrophil-to-lymphocyte ratio (NLR) has been reported to be associated with poor outcomes in numerous malignancies. In this study, we investigated the impact of NLR on associating outcomes in patients with HCC treated with lenvatinib. A total of 237 patients with HCC treated with lenvatinib were included. We performed univariate and multivariate analyses in this cohort. In addition, we clarified appropriate cut-off NLR levels for associating overall survival using hazard ratio (HR) spline curves. Cumulative overall survival at 100, 200 and 300days was 95.2%, 83.4% and 66.6% respectively. Multivariate analysis showed that NLR≥4 (HR, 1.874; 95% confidence interval [CI], 1.097-3.119), α-foetoprotein≥400ng/mL (HR, 1.969; 95% CI, 1.188-3.265) and modified albumin-bilirubin grade 2b or 3 (HR, 2.123; 95% CI, 1.267-3.555) were independently associated with overall survival. Cumulative progression-free survival at 100, 200 and 300days was 72.4%, 49.8% and 38.7% respectively. Multivariate analysis showed that NLR≥4 (HR, 1.897; 95% CI, 1.268-2.837) and BCLC stage≥C (HR, 1.516; 95% CI, 1.028-2.236) were independently associated with progression-free survival. Disease control rate was significantly different between the patients with low NLR (<4) (85.5%) and high NLR (≥4) (67.3%) (P=.007). Spline curve analysis revealed that NLR of approximately 3.0-4.5 is an appropriate cut-off for associating overall survival. NLR can be associated with outcomes in patients with HCC treated with lenvatinib.

Abstract TP93: Rapid and Appropriate Evaluation of Collateral Development by Four-Dimensional CT Angiography Covering Only 4-cm Width With a Focus on the Intracranial Internal Carotid Artery and the Middle Cerebral Artery to Identify Candidates of Thrombectomy

Introduction: Four-dimensional computed tomography (CT) angiography (4D-CTA) can visualize time sequential changes of bilateral internal carotid (ICA) and middle cerebral arteries (MCA). Therefore, 4D-CTA could find ICA or MCA occlusion and visualize collateral circulation in case of intracranial artery occlusion. Hypothesis: Four-dimensional CTA covering only 4-cm width with a focus on the intracranial ICA and the MCA can early visualize them because of small volumetric data and evaluate collateral development status to identify candidates of thrombectomy. Methods: We included acute ischemic stroke patients who 1) were admitted from August 2018 to July 2019 due to ICA or MCA occlusion, 2) underwent 4D-CTA covering only 4-cm width on admission and 3) underwent endovascular thrombectomy. We classified collateral status into good, moderate and poor collateral according to opacification of M2 and M3 branches distal to occlusion and evaluated successful recanalization of thrombolysis in cerebral infarction (TICI) grade 2b or 3 and improvement of NIHSS score 7 days after thrombectomy. Results: During the study period, 337 acute ischemic stroke patients were admitted, 92 patients suffered from ICA or MCA occlusion and 23 patients met our inclusive criteria. Median age was 81 years and median ASPECTS was 10. Image reconstruction time of 1,000 images was only 69 seconds and 4D-CTA with only 4-cm width demonstrated MCA occlusion in 14 patients, IC occlusion in 9 patients and collateral status as good in 4 patients, moderate in 13 patients and poor in 6 patients. Median onset-to-recanalization time was 5.2 hours, successful recanalization was achieved in 21 patients (91.3%), median NIHSS score on admission was 20, median 7-day NIHSS score decreased to 6 (p&lt;0.0001) and median decrease of NIHSS score was 13. Two patients without successful recanalization had no early improvement of NIHSS score, whereas 20 of 21 patients with successful recanalization obtained early neurological improvement. Conclusion: Four-dimensional CTA with only 4-cm width rapidly and appropriately evaluated collateral status to identify candidates of thrombectomy for ICA or MCA occlusion and achieved early neurological improvement following successful recanalization.

Abstract TP298: Measuring Quality of Care for Acute Ischemic Stroke Treated With Acute Reperfusion Therapy in Japan: A Nationwide Quality Improvement Initiative of the J-aspect Study

Background and Purpose: There is no consensus about efficiently measuring quality indicators (QIs) of acute ischemic stroke (AIS) in Japan. To evaluate feasibility and reliability of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular therapy (ET), by combining information from health insurance claims database and medical chart. Methods: AIS patients who received rt-PA or ET between 2013 and 2015 were identified from the J-ASPECT Diagnosis Procedure Combination (DPC) database. The 17 and 8 QI measures for primary and comprehensive stroke centers (PSCs and CSCs) were selected for AIS, respectively. More than 60% of data for calculating the QIs were obtained from the DPC database and preset in the tool. Responsible physicians were asked to review accuracy of preset data and add necessary information from medical chart. Adherence rates or performance measures for each QI were calculated for patient- and hospital-levels. Associations between adherence rates and hospital characteristics were analyzed using hierarchical logistic regression analysis. Result: In total, data of 8,506 patients (rt-PA 83.5%, ET 34.9%) from 173 hospitals were obtained. The median age was 76 (interquartile range 65–83) years, and 42.1% were women. Median National Institute of Health Stroke Scale (NIHSS) score at admission was 14 (7-21). All of the target QIs were successfully measured. Among PSC QIs, adherence rates were low (&lt;50%) (e.g. door-to-needle time &lt; 60 minutes 37.9%) and intermediate (50-75%) (e.g. stroke unit care 58.7%) in 4 each. For CSC QIs, median door-to-puncture time was 105 (76-147) minutes and TICI grade 2b and 3 recanalization were achieved in 73%. A higher number of stroke discharge was associated with greater adherence to stroke unit care, early rehabilitation and stroke education. Conclusion: Measuring QIs of AIS by this novel approach was feasible and reliable to provide a national benchmark.

"Strokenomics": bending the cost curve in stroke care.

The mortality rates for stroke are decreasing, yet it remains a leading cause of disability and the principal neurological diagnosis in patients discharged to nursing homes. The societal and economic burdens of stroke are substantial, with the total annual health care costs of stroke expected to reach $240.7 billion by 2030. Mechanical thrombectomy has been shown to improve functional outcomes compared to medical therapy alone. Despite an incremental cost of $10,840 compared to medical therapy, the improvement in functional outcomes and decreased disability have contributed to the cost-effectiveness of the procedure. In this study the authors describe a physician-led device bundle purchase program implemented for the delivery of stroke care. The authors retrospectively reviewed the clinical and radiographic data and device-associated charges of 45 consecutive patients in whom a virtual "stroke bundle" model was used to purchase mechanical thrombectomy devices. Use of the stroke bundle to purchase mechanical thrombectomy devices resulted in an average savings per case of $2900.93. Compared to the traditional model of charging for devices à la carte, this represented an average savings of 25.2% per case. The total amount of savings for these initial 45 cases was $130,542.00. Thrombolysis in Cerebral Infarction scale grade 2b or 3 recanalization occurred in 38 patients (84.4%) using these devices. Purchasing devices through a bundled model resulted in substantial cost savings while maintaining the therapeutic efficacy of the procedure, further pushing the already beneficial long-term cost-benefit curve in favor of thrombectomy.

Surgical treatment of gynaecomastia: a standard of care in plastic surgery

BackgroundMany techniques for the surgical treatment of gynaecomastia have been reported to be effective with reasonable limited scar formation. The aim of this study was to develop a grade adopted algorithm for effective and scar sparing techniques in reconstruction of the male breast dependent on aetiology and grading.MethodsOperative techniques, results, rates of revisions and complications were recorded between 2006 and 2018 and results of 164 male patients were analysed, retrospectively. Skin resecting methods have been used in the earlier stage but were later replaced by minimal periareolar incisions and subcutaneous mastectomy. Resections were combined with ultrasound-assisted liposuction up to grade 2b and inferior pedicled breast reduction in 3rd degree gynaecomastias resulting in reduction of scars and effective removal of breast tissue.ResultsRetrospective analysis showed that a periareolar mastopexy was used in 24% of patients with gynaecomastia grade I, IIa and IIb to reshape the breast after subcutaneous mastectomy in the early stage of this study from 2006 to 2010. With the established standardised use of ultrasound-assisted liposuction, only 2% of patients required a mastopexy in the following years. In grade 3 gynaecomastia, the classical approach resulting in an inverted t-scar was later abandoned for an approach with a periareolar and submammary scar and inferior dermoglandular flap. The rate of secondary surgery with the used techniques did not increase.ConclusionsWhen using standardised techniques in reshaping the male breast, an aesthetically pleasing and safe result can be achieved by scar sparing techniques in a safe single-stage procedure.Level of evidence Level IV, therapeutic study.

Prenatal ultrasonographic diagnosis and prognosis of fetal meconium peritonitis

Objective To investigate the maternal and neonatal outcomes of fetal meconium peritonitis (FMP) cases with different ultrasonic manifestations. Methods The clinical data of 31 pregnant women with FMP diagnosed by prenatal ultrasound and confirmed by postnatal imaging examination in Guangzhou Women and Children's Medical Center from January 2011 to December 2018 were analyzed retrospectively. According to the last prenatal ultrasonographic findings, the 31 cases were classified into the following grades: grade 0 (three cases), grade 1 (20 cases, grade 1A: nine cases, grade 1B: three cases, grade 1C: eight cases), grade 2 (seven cases) and grade 3 (one case). All neonates were also divided into two groups: the operation group (19 cases) and conservative treatment group (12 cases) based on whether or not underwent surgery. Statistical methods were independent sample t-test and Chi-square test. Results (1) The gestational ages at the first diagnosis of FMP and birth of the operation group were both lower than those of the conservative treatment group [(29.9±4.5) vs (38.2±1.0) weeks, t=-6.202; (36.2±2.7) vs (38.2± 1.0) weeks, t=-2.426; both P<0.05]. (2) The operation rates in cases of grade 0, 1, 2 and 3 groups were 0/3, 55%(11/20), 7/7 and 1/1, respectively (χ2=10.136, P=0.017). However, the operation rates in grade 1A, 1B and 1C groups were 7/9, 1/3 and 3/8, respectively (χ2=3.446, P=0.179). Conclusions The rate of operation of FMP newborn was related to the gestational age of the first prenatal ultrasound diagnosis of FMP and the ultrasonic grade. The different grades of prenatal ultrasound in FMP cases can provide important information for guiding perinatal treatment. Key words: Peritonitis; Meconium; Ultrasonography, prenatal; Fetal diseases

Thrombolysis in Cerebral Infarction Grade 2C or 3 Represents a Better Outcome than 2B for Endovascular Thrombectomy in Acute Ischemic Stroke: A Network Meta-Analysis

Although Thrombolysis in Cerebral Infarction (TICI) grade 2B or 3 is considered successful after endovascular thrombectomy (EVT) for acute ischemic stroke, TICI 2B was found to be associated with poorer outcomes than was 3. Furthermore, the newly proposed TICI 2C grade seems to be clinically equivalent to TICI 3 rather than to 2B. This network meta-analysis aimed to assess the differences in clinical outcomes between TICI grades and redefine successful reperfusion. PubMed, Embase, and Cochrane Central Register were queried. A random-effect model with frequentist framework was applied to evaluate outcomes using odds ratios (ORs) and 95% confidence intervals (CIs). Using surface under the cumulative ranking curve (SUCRA), the hierarchy of TICI grades was indicated. Analysis of 12 studies, with 2084 patients, indicated that TICI 2C (OR, 2.28; 95% CI, 1.65-3.13) and 3 (OR, 2.40; 95% CI, 1.74-3.30) were significantly more associated with favorable 90-day clinical outcomes than were 2B; there was no significant difference between TICI 2C and 3 (OR, 1.05; 95% CI, 0.76-1.46). Based on the SUCRA, TICI 2C and 3 were considered as more effective reperfusion end points than was 2B (TICI 3, 80.8%; 2C, 69.2%; 2B, 0.0%) and showed significant association with lower rates of mortality and symptomatic intracranial hemorrhage. Patients with TICI 2C grade would be distinguished from those with 2B, because 2C is clinically equivalent to 3 and has a better outcome than 2B. Therefore, achieving 2C or 3 is likely to be closer to the successful aim of endovascular thrombectomy in acute ischemic stroke than achieving 2B.

Nutrition to Prevent or Treat Cognitive Impairment in Older Adults: A GRADE Recommendation.

Aging is associated with cognitive declines leading to mild cognitive impairments or Alzheimer disease. Nutrition appear to protect from aging. Some dietary factors could either increase or protect against cognitive declines. This article aimed to provide GRADE recommendations related to nutrition aspects able to prevent or to treat cognitive impairments. A comprehensive literature review was performed using Medline database. The GRADE approach was used to classify quality of the existing evidence (systematic review or meta-analysis).The GRADE process led us to formulate seven key nutritional recommendations to manage cognitive declines, but did not allow us to do it for protein, vitamin B or antioxidants. Thus, 1) adherence to a Mediterranean diet (GRADE 1B); 2) high-level of consumption of mono- or poly- unsaturated fatty acids combined to a low consumption of saturated fatty acids (GRADE 1B); 3) high consumption of fruits and vegetables (GRADE 1B); 4) higher vitamin D intake (GRADE 1C) than the recommended daily allowance. In addition, a ketogenic diet, a low consumption of whole-fat dairy products or a caloric restriction are promising nutritional habits although the evidence does not yet support widespread uptake (GRADE 2C). In conclusion, nutrition is an important modifiable factor to prevent or protect against cognitive decline. Nevertheless, more studies are required to determine specific guidelines such as duration and amounts of nutrients to help older adult to maintain a healthy cognitive life.

Feasibility of photobiomodulation therapy for the prevention of radiodermatitis: a single-institution pilot study.

Acute radiodermatitis is one of the major complications when radiation therapy (RT) is delivered to the head and neck region in cases of head and neck cancers or lung cancers with supraclavicular lymph node metastasis. In these cases, high dose of RT is generally used so that acute radiodermatitis is observed in more than 90% of patients, and it negatively affects patients' quality of life. In this pilot study, we evaluated the clinical feasibility of photobiomodulation (PBM) therapy before conducting a randomized trial based on the hypothesis that PBM therapy may reduce the severity of radiodermatitis in participants receiving 60Gy or higher dose. Patients who were to receive 60Gy or higher dose in the neck were included in the study. Thirty-three patients received PBM therapy three times a week during RT. The severity of radiodermatitis was evaluated by two dermatologists and a radiation oncologist using the modified Common Terminology Criteria for Adverse Events (CTCAE). Patients were followed up until a week after RT. In all patients, 90.6% of planned PBM schedule was completed. There was no significant side effect of PBM therapy. Thirteen (39%) patients showed wet desquamation (CTCAE grade 2b or higher). Only three (9%) of them showed grade 3 toxicity, which is a favorable result compared with previous studies. This pilot study showed that PBM therapy is safe and feasible in the clinic, and it might reduce the severity of radiodermatitis. A randomized trial should be warranted to prove the efficacy of PBM therapy.

Exploring Students’ Ability in Using Preposition “By” and “With”

In this study, the writer wants to know how well the students’ ability of second grade at SMP Muhammadiyah Aimas in understanding preposition “by” and “with”. Why the writer took this problem because the prepositions are important classes of function word in English. The population of this study are the second grade (A are 24 students and B are 25 students) of SMP Muhammadiyah Aimas. The total number of the students are 49 students. the writer chose probability sampling to get samples. Because, SMP Muhammadiyah only has two class of second grade (2A and 2B). Based on information from the English teacher there, the class both have same ability in learning English.The writer gives tests to the students without a treatment. Because, the writer want to know the real students’ ability in understanding its.The writer gave fifty (50) items for the test. The kind of instrument is fill the blanks. And the writer used percentage form x 100% to analysed the data. From twenty-four (24) students the writer got result of students’ ability in using preposition “by” = 16.2%, students’ ability in using preposition “with” = 11.6%, and calculated in overall their ability was 56% on preposition “by” and “with” included in bad category.

Ultra-short duration direct acting antiviral prophylaxis to prevent virus transmission from hepatitis C viremic donors to hepatitis C negative kidney transplant recipients.

We conducted an adaptive design single-center pilot trial between October 2017 and November 2018 to determine the safety and efficacy of ultra-short-term perioperative pangenotypic direct acting antiviral (DAA) prophylaxis for deceased hepatitis C virus (HCV)-nucleic acid test (NAT) positive donors to HCV negative kidney recipients (D+/R-). In Group 1, 10 patients received one dose of SOF/VEL (sofusbuvir/velpatasvir) pretransplant and one dose on posttransplant Day 1. In Group 2A (N=15) and the posttrial validation (Group 2B; N=25) phase, patients received two additional SOF/VEL doses (total 4) on Days 2 and 3 posttransplant. Development of posttransplant HCV transmission triggered 12-week DAA therapy. For available donor samples (N=27), median donor viral load was 1.37E+06IU/mL (genotype [GT]1a: 70%; GT2: 7%; GT3: 23%). Overall viral transmission rate was 12% (6/50; Group 1:30% [3/10]; Group 2A:13% [2/15]; Group 2B:4% [1/25]). For the 6 viremic patients, 5 (83%) achieved sustained virologic response (3 with first-line DAA therapy; and two after retreatment with second-line DAA). At a median follow-up of 8months posttransplant, overall patient and allograft survivals were 98%, respectively. The 4-day strategy reduced viral transmission to 7.5% (3/40; 95% confidence interval [CI]: 1.8%-20.5%) and could result in avoidance of prolonged posttransplant DAA therapy for most D+/R-transplants.

Perforation of small intestinal metastasis of lung adenocarcinoma treated with pembrolizumab: a case report

BackgroundPembrolizumab is an immune checkpoint inhibitor and is an anti-human programmed cell death-1 (PD-1) monoclonal antibody. Pembrolizumab is used for non-small cell lung carcinoma with high programmed cell death ligand-1 (PD-L1) expression. It has been found that better overall survival can be obtained using pembrolizumab compared to the existing chemotherapy. We report a case of perforation of small intestinal metastasis after pembrolizumab treatment.Case presentationA 62-year-old man was treated by pembrolizumab for PD-L1 highly expressed lung adenocarcinoma, with multiple metastasis (small intestinal, lymph nodes, and bone). The treatment was stopped owing to drug-induced pneumonitis. One month after drug withdrawal, the patient visited the emergency department of our hospital with the complaint of severe stomachache. He had a rigid abdomen and generalized tenderness, and computed tomography scans showed free air within the abdomen. We diagnosed bowel perforation and performed emergency surgery. Surgical findings revealed multiple small intestine metastasis and mesenteric lymph node metastasis. Perforation was found in the metastatic site in the jejunum located around 40 cm anal to Treitz’s ligament. This perforated part was resected, and functional end-to-end anastomosis was performed using linear staplers. The post-operative course was uneventful. Pathological examination revealed lung adenocarcinoma metastasis at the perforation site, and the effectiveness of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition).ConclusionsThis is the first report of perforation of small intestinal metastasis of lung adenocarcinoma after pembrolizumab treatment. Because pembrolizumab causes some side effects, particularly autoimmune side effects, careful attention during treatment is warranted.

Comparison between radiography and MRI features in evaluation of osteoarthritis of knee joint

Background: Osteoarthritis (OA) is a widely prevalent disease worldwide and is a major public health problem that primarily affects the elderly. The present study was undertaken to define the radiographic findings of osteoarthritis (OA) of knee joint using Kellgren-Lawrence (K-L) scores and to define cartilage abnormalities on magnetic resonance imaging (MRI).Materials & Methods: Present study was conducted on 50 patients presenting with knee pain and clinical suspicion of osteoarthritis. Antero-posterior radiographs of the knee were obtained in a weight-bearing extended position by using a standard radiographic technique. All radiographs were assigned scores by using the Kellgren-Lawrence scoring system. Cartilages alterations on MRI were assigned grades as follows: grade 0, normal; grade I, internal signal intensity alteration only; grade IIA, defect of cartilage of less than 50%; grade IIB, defect of cartilage of 50%–99%; grade IIIA, 100% defect of cartilage with no bony changes; or grade IIIB, 100% defect of cartilage with subjacent bony changes. Radiographic and MR imaging findings were compiled and analysed using appropriate statistical tests.Results: Among 26 patients of grade 0 K-L score, 6, 4, 6, 4, 4 and 2 patients had grade 0, grade 1, grade 2A, grade 2B, grade 3A and grade 3B Cartilage abnormality (On MRI) respectively. Among 8 patients of grade 1 K-L score, 2, 2, 2 and 2 patients had grade 0, grade 2A, grade 2B and grade 3A Cartilage abnormality (On MRI) respectively. Among 14 patients of grade 2 K-L score, 1, 4, 4 and 5 patients had grade 2A, 2B, 3A and grade 3B Cartilage abnormality (On MRI) respectively. Among 2 patients of grade 3 K-L score, both of these had grade 3B Cartilage abnormality (On MRI).Conclusion: Conventional radiography being easily available is a common investigation tool to diagnose osteoarthritis knee. But MRI reveals structural changes of articular cartilage, joint effusion and meniscal extrusion or tear etc. thereby helping in early diagnosis. This can lead to timely management and hence better functional outcome in OA knee cases.

788P - A phase I study of docetaxel/oxaliplatin/S-1 (DOS) combination neoadjuvant chemotherapy for patients with locally advanced adenocarcinoma of the esophagogastric junction

BackgroundA triple chemotherapeutic regimen including docetaxel, oxaliplatin, and S-1 (DOS) for a neoadjuvant setting has a promising efficacy for locally advanced adenocarcinoma of the esophagogastric junction (AEG). However, the optimal dose of each drug in Japanese population remained to be clarified. The aim of this phase I study is to determine a recommended dose for a triweekly combination neoadjuvant DOS chemotherapy for patients with locally advanced AEG. MethodsPatients with cT3 or more advanced AEG without distant metastasis were eligible for this study. The planned dosages of docetaxel (mg/m2, day 1), oxaliplatin (mg/m2, day 1), and S-1 (mg/day, days 1–14) were 50/100/80–120 at level 1, and 60/100/80–120 at level 2. The treatment cycle was repeated every 3 weeks, and patients were assessed for response to the treatment after 2 and 3 cycles. This study was registered with UMIN Clinical Trial Registry (UMIN 000022210). ResultsTwelve patients with locally advanced AEG were enrolled in this study. At dose level 1, one of six patients experienced dose-limiting toxicity (DLT) of grade 3 febrile neutropenia. At dose level 2, two of the next six patients experienced the same DLT of need for withdrawal of chemotherapy due to serious adverse events. Based on these results, level 2 was considered the recommended dose for this regimen. Total or proximal gastrectomy plus lower esophagectomy, or subtotal esophagectomy was performed in all the 12 patients with the R0 resection rate of 92% (11/12). Histological response evaluation based on the classification defined by Japanese Gastric Cancer Association revealed four patients with grade 1a, two with grade 1b, three with grade 2, and three with Grade 3. ConclusionsRecommended doses for a neoadjuvant DOS chemotherapy regimen for locally advanced AEG were determined as Docetaxel: 60mg/m2, Oxaliplatin: 100mg/m2 on day 1, S-1: <1.25m2, 80mg; 1.25–1.5m2, 100mg; >1.5m2, 120mg twice a day on days 1–14. DOS chemotherapy showed good preliminary efficacy with acceptable toxicity in this study warranting a further phase II trial to investigate the efficacy of the DOS regimen. Clinical trial identificationUMIN 000022210. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Factors Associated with Unsuccessful Recanalization in Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: Mechanical thrombectomy (MT) for acute ischemic stroke has become a standard therapy, and the recanalization rate has significantly improved. However, some cases of unsuccessful recanalization still occur. We aimed to clarify patient factors associated with unsuccessful recanalization after MT for acute ischemic stroke. Methods: This was a single-center, retrospective study of 119 consecutive patients with anterior circulation acute ischemic stroke who underwent MT at our hospital between April 2015 and March 2019. Successful recanalization after MT was defined as modified Treatment in Cerebral Ischemia (mTICI) grade 2b or 3, and unsuccessful recanalization was defined as mTICI grades 0–2a. Several factors were analyzed to assess their effect on recanalization rates. Results: Successful recanalization was achieved in 88 patients (73.9%). The univariate analysis showed that female sex (38.6 vs. 67.7%, p = 0.007), a history of hypertension (53.4 vs. 83.9%, p = 0.003), and a longer time from groin puncture to recanalization (median 75 vs. 124 min, p < 0.001) were significantly associated with unsuccessful recanalization. The multivariate analysis confirmed that female sex (OR 3.18; 95% CI 1.12–9.02, p = 0.030), a history of hypertension (OR 4.84; 95% CI 1.32–17.8, p = 0.018), M2–3 occlusion (OR 4.26; 95% CI 1.36–13.3, p = 0.013), and the time from groin puncture to recanalization (per 10-min increase, OR 1.22; 95% CI 1.09–1.37, p < 0.001) were independently associated with unsuccessful recanalization. Conclusion: Female sex and a history of hypertension might be predictors of unsuccessful recanalization after MT for anterior circulation acute ischemic stroke. Further studies are needed to fully evaluate predictors of recanalization.

Blood pressure characteristics in patients with acute basilar artery occlusion undergoing endovascular thrombectomy

Acute basilar artery occlusion (BAO) is a rare but potentially life-threatening neurological condition. While endovascular therapy (EVT) has been shown to improve outcome, there is limited knowledge about prognostic factors beyond early recanalization. We studied whether blood pressure (BP) exceeds or falls below suggested thresholds during intervention and whether these changes are associated with complications and outcome. BP measurements mostly with one-minute intervals were available in 39 patients. An individual systolic blood pressure (SBP) reference value was defined as the median of the first five intra-procedural measurements. Half of the patients (51.3%) received drugs for BP augmentation and two a BP lowering drug (5.1%). Thrombolysis in cerebral infarction grade 2b and 3 (TICI) was achieved in 29 (74.4%) and 23 patients (58.9%) had good outcome at three months. We observed a continuous intra-procedural increase of median SBP (+11%) and mean arterial pressure (MAP, +10%, both p < 0.001), and a unique temporal pattern of intermittent peaks and troughs. Successful recanalization was more common in patients whose intra-procedural duration with SBP under 140 mmHg was shorter (p = 0.009). Patients with isolated tip of basilar artery (TBA) occlusion had significantly more BP excursion of 20% below the reference SBP and required more frequent use of sympathomimetic drugs compared to vertebrobasilar occlusion (p = 0.008 and p = 0.041, respectively). Brain hemorrhage was more prevalent in patients who experienced SBP excursions at least 20% above the individual reference value (p = 0.038) and a longer duration of time spent with SBP above 180 mmHg (p = 0.029). Patients with higher pre-procedural mean SBP had a greater chance of a good outcome (p = 0.03). This study using high resolution BP monitoring suggests a relationship between intra-procedural BP characteristics and recanalization, hemorrhagic complications and outcome in patients receiving EVT for acute posterior circulation cerebrovascular syndromes. Differences with regard to BP regulation during recanalization therapy for vertebrobasilar and TBA occlusion deserves further attention.

Acute Stroke Interventions Performed by Cardiologists: Initial Experience in a Single Center

ObjectivesThe aim of this study was to evaluate the technical and clinical success of acute stroke interventions performed in our interventional cardiology center. BackgroundDedicated interventional stroke centers remain limited. Interventional cardiologists have established networks of catheterization laboratories and the necessary infrastructure to provide around the clock interventional therapy. These networks may also provide the currently lacking universal rapid access to prompt stroke intervention. MethodsBetween July 2012 and July 2018, 70 consecutive patients underwent acute stroke intervention for large-vessel occlusions. Seventeen patients (24%) had tandem or multiple vessel occlusions. The majority (n = 63, 90%) were admitted via our local stroke unit, and 7 (10%) patients were transferred from other regional referral centers. ResultsIn 43 (61%) patients, systemic fibrinolytic therapy was started after baseline imaging. Mean time between symptom onset and arrival to the cath lab was 138 min; mean door-to-vascular access time was 64 min; mean time between cath lab activation and its operational readiness was 13 min. In all cases, access to supra-aortic vessels was achieved. Mean time between femoral arterial puncture and lesion crossing was 26 min. Stent implantation for extracranial stenosis or dissection was performed in 14 (20%) cases. Thrombectomy of intracranial occlusions was done with a stent retriever (n = 64, 91%) or an aspiration system (n = 14, 20%). In 20 (28%) cases, a combination of techniques was used. Recanalization was technically successful (Thrombolysis In Cerebral Infarction flow grade 2b or 3) in 65 (93%) patients. The 30-day mortality was 18% (n = 13). Favorable clinical outcome, defined as a modified Rankin Scale score of 0 to 2, was achieved in 61% at 3-month follow-up. ConclusionsAcute stroke interventions can be performed safely and with high technical and clinical success by experienced interventional cardiologists.