To the Editor: Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with severe aortic stenosis (AS) at all levels of surgical risk.[1,2] With the exploration of TAVR and technological developments, TAVR is an alternative for patients with intermediate or low surgical risk.[3] There are some studies regarding gender differences in TAVR, but there are few studies on it in Asia.[4] However, the studies of outcomes based on gender differences in TVAR are still lacking, especially in China and other Asian countries. Patients' data were collected in the West China Hospital of Sichuan university Transcatheter Aortic Valve Replacement (WATCH TAVR) registration study (registered number: ChiCTR2000033419). The whole study was approved by the Ethics Committee of Sichuan University West China Hospital (No. 2020-470). This study was retrospective and the patients' informed consent was waived. We consecutively enrolled patients with symptomatic severe AS at Sichuan University West China Hospital from April 2012 to April 2019. All enrolled patients were treated with TAVR. Our multidisciplinary heart team discussed the indication for TAVR in all cases. The primary endpoint was all-cause mortality at 1 year, 3 years, and over 3 years. We also investigated stroke, permanent pacemaker implantation (PPI), and other major adverse cardiac events (MACEs). The endpoints were adjudicated using the standardized VARC-2 criteria.[5] Continuous variables are described as median (interquartile range [IQR]). Categorical variables are expressed as frequency (percentage). Continuous variables were compared through Student's t test or the nonparametric Mann–Whitney U test, as appropriate, and categorical variables were compared through the χ2 test or Fisher's exact test, as appropriate. The analyses of time-to-first events were described using Kaplan–Meier curves and were compared between the groups with the log-rank test. Logistic regression analyses were imputed for the univariate analysis to find predictors for outcomes. All computations relied on commercially available software STATA (v16.0 for Windows; StataCorp LLC., Texas, USA), with statistical significance set at two-tailed P <0.05. A total of 462 patients were included, and 18 were excluded. A total of 444 patients (mean age: 73.9 ± 6.3 years) were finally included in the analysis, with a median follow-up of 1.88 (IQR: 1.03–3.75) years. Fifty-five percent (n = 243) of the patients were male, and 45% (n = 201) were female. Most of the patients underwent TAVR through a transfemoral access via an arterial puncture. The prosthesis used was larger in male patients compared with female patients (26.5 mm [IQR: 26.0–29.0] vs. 26.0 mm [IQR: 23–36], P <0.001). The transcatheter approach and prosthesis type showed no statistically significant difference. The female patients had more vascular complications compared with male patients (29 [14.43%] vs. 13 [5.35%], P = 0.001). Intraprocedural bleeding occurred in 47 (10.63%) patients but happened more in the female patients (19 [7.88%] vs. 28 [13.93%], P = 0.040). Paravalvular leak happened in 60.81% (270/444) patients, which was not statistically significant different between the genders (P = 0.352). A total of 80 (80/444, 18.18%) patients had permanent pacemaker implantation, but no statistically significant difference in gender was detected. Notably, 69 patients died during the follow-up. The one-year mortality and one-to-three-year mortality were not statistically significant different between the genders. However, the long-term (over three years) mortality of males was higher than that of females (10 [4.12%] vs. 1 [0.5%], P = 0.015). Other clinical outcomes, including post-TAVR rehospitalization, cardiac rehospitalization, new-onset left bundle branch block (LBBB), neurological symptoms, thrombotic event, arrhythmia, stroke, and myocardial infarction, showed no statistically significant difference in our study [Table 1]. Table 1 - Procedural Details and Clinical Outcomes of patients underwent TAVR. Characteristics Total (n = 444) Male (n = 243) Female (n = 201) P values Puncture 391 (88.06) 214 (88.07) 177 (88.06) 0.998 Predilation 181 (40.77) 94 (38.68) 87 (43.28) Post-dilation 22 (4.95) 12 (4.94) 10 (4.98) Contrast agent dose, mL 240 (230–330) 240 (220–300) 265 (230–330) Prothesis size, mm 26.0 (26.0–29.0) 26.5 (26.0–29.0) 26.0 (23.0–26.0) <0.001 Transcatheter approach 0.849 TFA 441 (99.32) 242 (99.59) 199 (99) TCA 2 (0.45) 0 2 (1) TSA 1 (0.23) 1 (0.41) 0 Prothesis type 0.066 CoreValve 40 (9.01) 25 (10.29) 15 (7.46) Venus A 245 (55.18) 141 (58.02) 104 (51.74) Venus–A Plus 23 (5.18) 11 (4.53) 12 (5.97) Lotus 29 (6.53) 13 (5.35) 16 (7.96) Vitaflow Ⅰ 28 (6.31) 14 (5.76) 14 (6.97) Vitaflow Ⅱ 2 (0.45) 1 (0.41) 1 (0.50) Edward S3 9 (2.03) 6 (2.47) 3 (1.49) Edward XT 18 (4.05) 7 (2.88) 11 (5.47) Taurasone 47 (10.59) 24 (9.88) 23 (11.44) Clinical outcomes Vascular complications 42 (9.46) 13 (5.35) 29 (14.43) 0.001 Major vascular complications 12 (2.70) 2 (0.82) 10 (4.98) Minor vascular complications 30 (6.76) 11 (4.53) 19 (9.45) Intra-TAVR bleeding 47 (10.63) 19 (7.88) 28 (13.93) 0.040 Minor bleeding 26 (5.88) 11 (4.56) 15 (7.46) Major bleeding 21 (4.75) 8 (3.32) 13 (6.47) Paravalvular leak 270 (60.81) 143 (58.85) 121 (63.18) 0.352 Mild PVL 165 (37.16) 85 (34.98) 80 (39.80) Moderate PVL 105 (23.65) 58 (23.87) 47 (23.38) Thrombotic event 21 (4.73) 10 (4.12) 11 (5.47) 0.502 Arrythmia 8 (1.80) 5 (2.06) 3 (1.49) 0.656 Stroke 8 (1.80) 4 (1.65) 4 (1.99) 0.786 PPI 80 (18.18) 46 (19.17) 34 (16.91) 0.557 New onset LBBB 127 (28.93) 73 (30.17) 54 (27.41) 0.527 Myocardial infarction 1 (0.23) 0 1 (0.50) 0.271 1-year death 35 (7.88) 20 (8.23) 15 (7.46) 0.765 1-to-3-year death 23 (5.18) 14 (5.76) 9 (4.48) 0.544 Over 3-year death 11 (2.48) 10 (4.12) 1 (0.50) 0.015 Data are presented as n (%) or median (interquartile range). LBBB: Left bundle branch block; PVL: Paravalvular leak; PPI: Permanent pacemaker implantation; TAVR: Transcatheter aortic valve replacement; TCA: Transcarotid approach; TFA: Transfemoral approach; TSA: Trans-subclavian approach. The cumulative survival curve showed no statistically significant difference between the gender after TAVR (P = 0.198, Supplementary Figure 1, https://links.lww.com/CM9/B643). We further analyzed the three-year landmark of cumulative survival curves according to TAVR mortality [Supplementary Figure 2, https://links.lww.com/CM9/B643], showing a statistically significant difference between the gender (P = 0.043). Patients who died within three years after TAVR were excluded from the analysis. Among the enrolled factors based on the characteristics we presented above, being male (HR 9.88, 95% CI: 1.1 to 90.6, P = 0.043) was the only predictor of long-term death for patients who survived three years after TAVR [Supplementary Table 1, https://links.lww.com/CM9/B643]. Our study represented a large single-center cohort of TAVR patients in China. The main findings in our study are as follows: (i) women were more likely to have bleeding events during TAVR but had a similar rate of thrombotic events, arrhythmia, stroke, PPI, and myocardial infarction compared with male patients; (ii) the long-term (over 3 years) mortality rate was higher in men than in women, while the 1-year and 1-to-3-year mortality were not statistically significantly different in the two gender groups; and (iii) there was a similar rate of new LBBB and neurological symptoms between the two gender groups. Detailed baseline characteristics and anatomy parameters are available in the Supplementary Tables 2 and 3, https://links.lww.com/CM9/B643. In this study, we found that women were more likely to have procedural bleeding events. However, the results of TAVR will get better with experience. We grouped patients according to whether they were admitted before 2016. Subgroup analysis showed females had more procedural bleeding only before 2016 (20 [40] vs. 14 [18.92], P = 0.01). And the main cause for bleeding was vascular complications (odds ratio [OR] = 8.39, P <0.001). TAVR complications are closely related to prognosis. Appropriate dealing of TAVR complications is quite important.[6,7] In the survival analysis, thirty-day mortality showed no statistical difference between the gender groups (Male vs. Female: 7 [2.88%] vs. 9 [4.48%], P = 0.396). From the survival curve, we can determine the difference in mortality over the 3-year follow-up with a hazard ratio of 9.88 (P = 0.043), Multivariate Cox regression analysis showed that male was the only predictor for higher mortality over 3 years after TAVR. This finding is similar to some studies in European countries.[8,9] However, the difference might be related to the natural life expectancy of human beings. In China, women have six more years of life expectancy on average than men, according to the World Health Organization (WHO) report.[10] The study has several limitations. First, the basic data was collected retrospectively. Second, this single-center study might not best represent the situations in other parts of China and in other Asian countries. Third, in the early exploration of TAVR, we only used the STS score. A comparison between the STS score and EuroSCORE was not performed. Funding This stydy was supported by grants from the West China Hospital "1·3·5" Discipline of Excellence Project-"Mechanisms of aortic stenosis and the clinical applications", National Natural Science Foundation of China (No.82001899) and the National Natural Science Foundation of China (No.81901825).
Thyroid associated ophthalmopathy (TAO) is an autoimmune inflammatory disorder which disfigures appearance, threatens vision, and results in a pronounced loss of quality of life. The diversity and ethnic difference of the disease manifestations have made it difficult to tailor therapies for each patient. Few studies have analyzed its characteristics in Chinese populations. We therefore enrolled 354 patients with moderate-to-severe TAO from February 2015 to July 2016. A single ophthalmologist consistently performed detailed ophthalmic examinations. Orbital computed tomography or magnetic resonance imaging scans were performed to verify enlarged extraocular muscles. Multiple linear regression was used to analyze the association between sex, age, smoking, family history of thyroid diseases, degree of proptosis and disease severity. The mean age of males (46.56±11.08 years) was significantly higher than that of females (41.39±years), with a female-to-male ratio of 1.09. The females and males between 31~40 and 41~50 years, respectively, had the highest incidence of TAO. 81.48% of the patients suffered hyperthyroidism. TAO was diagnosed either after (47.17%) or simultaneously with thyroid dysfunction (27.68%). Proptosis (91.24%), eyelid retraction (83.33%), together with eyelid swelling (79.38%) and extraocular muscle enlargement (75.42%), were the most common clinical sign. 19.77% of patients manifested lower eyelid retraction. The mean values of exophthalmos and asymmetry on proptosis were 19.94±3.45mm and 2.18±2.06mm, respectively in males, 18.58±3.31mm and 1.61±1.53mm, respectively in females. The severity of disease was significantly associated with male, older age, smoking, family history of thyroid diseases and degree of proptosis. We found several differences in Chinese compared with White. The female-to-male ratio and mean value of exophthalmos were significantly lower than the data of White. Inferior and superior rectus became the most common extraocular muscles. Lower eyelid retraction should be included in diagnostic criteria in Asian patients. Understanding these differences, may allow better identification and treatment for TAO in China.
An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.
Salt stress is one of the abiotic stresses affecting crop quality and yield, and the application of exogenous brassinosteroids (BRs) can be used in response to salt stress. However, the function of BR in tea plants under salt stress remains to be elucidated. This study investigated the effects of exogenous spraying of BR on the malondialdehyde, soluble sugar, soluble protein, and antioxidant enzyme activities in tea plants under salt stress and explored the expression changes in genes related to the synthesis pathways of proline and secondary metabolites (flavonoids and theanine). The results show that 200 mM NaCl solution inhibits the physiology of tea plants, but 0.2 mg/L BR could partially reduce the damage by increasing photosynthetic pigments, osmoregulatory substances (such as soluble sugar, soluble protein, and proline), and the activity of antioxidant enzymes (including peroxidase, catalase, and superoxide dismutase), while decreasing the malondialdehyde content in salt-stressed leaves. The qRT-PCR experiment also shows that the genes related to the synthesis pathways of proline and secondary metabolites (flavonoids and theanine) were upregulated under salt stress, and the proline degradation genes were downregulated, thus promoting the accumulation of proline under salt stress in both varieties. When tea plants were subjected to salt stress, the expression of genes related to the synthesis of secondary metabolites was regulated accordingly to resist salt stress. Moreover, spraying BR had an obvious effect on improving the salt tolerance of tea plants. Therefore, exploring a way to improve the salt tolerance of tea trees provides a reference for the subsequent study of its salt tolerance mechanism, which is of great significance for expanding the introduction area of tea trees, increasing the planting area of tea trees, and improving the yield and quality of tea.
Objectives To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery. Data Sources PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database. Methods Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no‐deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions. Secondary outcome: the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications [including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV)]. Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded. Results Four articles with 242 patients were identified for analysis. The results indicated that compared with no‐deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio [RR] = 1.29, 95% CI: 1.07–1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR = 0.32; 95% CI: 0.21–0.49) (lower incidence of vocal fold movement [1.85% vs. 34%; RR = 0.08, 95% CI: 0.02–0.41] and coughing [15.53% vs. 38.78%; RR = 0.42, 95% CI: 0.27–0.66]). There were no differences in the overall incidence of postoperative complications (RR = 2.10, 95% CI: 0.12–36.40). Conclusions Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications. Level of Evidence 1 Laryngoscope , 133:2055–2065, 2023
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