Chronic remote ischaemic conditioning in patients with symptomatic intracranial atherosclerotic stenosis (the RICA trial): a multicentre, randomised, double-blind sham-controlled trial in China.

BACKGROUND: Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide, and it is associated with a high risk of recurrent stroke with currently recommended treatments. We aimed to evaluate the effect of chronic remote ischaemic conditioning on prevention of ischaemic events in patients with symptomatic ICAS. METHODS: The RICA trial is a multicentre, randomised, double-blind, sham-controlled trial at 84 stroke centres in China. Patients aged 40-80 years with ischaemic stroke or transient ischaemic attack attributable to angiographically verified 50-99% stenosis of a major intracranial artery were randomly assigned (1:1), via an interactive web-based system by computer-generated randomisation code, to either remote ischaemic conditioning or sham remote ischaemic conditioning once daily for 12 months and voluntarily thereafter. All investigators and patients were masked to treatment allocation. The primary efficacy endpoint was the time to first occurrence of non-fatal or fatal ischaemic stroke, with survival analysed by the Kaplan-Meier method. Primary and safety analyses were done in the intention-to-treat population. The RICA trial is registered with ClinicalTrials.gov, number NCT02534545. FINDINGS: Between Oct 28, 2015, and Feb 28, 2019, 3033 patients were enrolled and randomly assigned to either remote ischaemic conditioning (n=1517; intervention group) or sham remote ischaemic conditioning (n=1516; sham group). Median follow-up was 3·5 years (IQR 2·7-4·4). A non-fatal or fatal ischaemic stroke occurred in 257 (16·9%) patients in the intervention group compared with 288 (19·0%) patients in sham group. There was no difference in the survival distribution for time to first occurrence of non-fatal or fatal ischaemic stroke (hazard ratio 0·87, 95% CI 0·74-1·03; p=0·12). In the intervention group, 79 (5·2%) patients died from any cause, and in the sham group, 84 (5·5%) patients died from any cause (hazard ratio 0·93, 95% CI 0·68-1·27; p=0·65). No intervention-related serious adverse events were observed. INTERPRETATION: No evidence was found for a difference between remote ischaemic conditioning and sham remote ischaemic conditioning in lowering the risk of ischaemic stroke in patients with symptomatic ICAS. The benefit of remote ischaemic conditioning might have been diluted by poor compliance. Future studies of remote ischaemic conditioning in this population should address challenges in patients' compliance and assess longer term treatment. FUNDING: Ministry of Science and Technology China, Beijing Municipal Education Commission, Beijing Municipal Finance Bureau. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Multiparametric and multilevel characterization of morphological alterations in patients with transient ischemic attack.

Transient ischemic attack (TIA), an important risk factor for stroke, is associated with widespread disruptions of functional brain architecture. However, TIA-related structural alterations are not well established. By analyzing structural MRI data from 50 TIA patients versus 40 healthy controls (HCs), here we systematically investigated TIA-related morphological alterations in multiple cortical surface-based indices (cortical thickness [CT], fractal dimension [FD], gyrification index [GI], and sulcal depth [SD]) at multiple levels (local topography, interregional connectivity and whole-brain network topology). For the observed alterations, their associations with clinical risk factors and abilities as diagnostic and prognostic biomarkers were further examined. We found that compared with the HCs, the TIA patients showed widespread morphological alterations and the alterations depended on choices of morphological index and analytical level. Specifically, the patients exhibited: (a) regional CT decreases in the transverse temporal gyrus and lateral sulcus; (b) impaired FD- and GI-based connectivity mainly involving visual, somatomotor and ventral attention networks and interhemispheric connections; and (c) altered GI-based whole-brain network efficiency and decreased FD-based nodal centrality in the middle frontal gyrus. Moreover, the impaired morphological connectivity showed high sensitivities and specificities for distinguishing the patients from HCs. Altogether, these findings demonstrate the emergence of morphological index-dependent and analytical level-specific alterations in TIA, which provide novel insights into neurobiological mechanisms underlying TIA and may serve as potential biomarkers to help diagnosis of the disease. Meanwhile, our findings highlight the necessity of using multiparametric and multilevel approaches for a complete mapping of cerebral morphology in health and disease.

The Predictive Value of Dynamic Intrinsic Local Metrics in Transient Ischemic Attack.

BACKGROUND: Transient ischemic attack (TIA) is known as "small stroke." However, the diagnosis of TIA is currently difficult due to the transient symptoms. Therefore, objective and reliable biomarkers are urgently needed in clinical practice. OBJECTIVE: The purpose of this study was to investigate whether dynamic alterations in resting-state local metrics could differentiate patients with TIA from healthy controls (HCs) using the support-vector machine (SVM) classification method. METHODS: By analyzing resting-state functional MRI (rs-fMRI) data from 48 patients with and 41 demographically matched HCs, we compared the group differences in three dynamic local metrics: dynamic amplitude of low-frequency fluctuation (d-ALFF), dynamic fractional amplitude of low-frequency fluctuation (d-fALFF), and dynamic regional homogeneity (d-ReHo). Furthermore, we selected the observed alterations in three dynamic local metrics as classification features to distinguish patients with TIA from HCs through SVM classifier. RESULTS: We found that TIA was associated with disruptions in dynamic local intrinsic brain activities. Compared with HCs, the patients with TIA exhibited increased d-fALFF, d-fALFF, and d-ReHo in vermis, right calcarine, right middle temporal gyrus, opercular part of right inferior frontal gyrus, left calcarine, left occipital, and left temporal and cerebellum. These alternations in the dynamic local metrics exhibited an accuracy of 80.90%, sensitivity of 77.08%, specificity of 85.37%, precision of 86.05%, and area under curve of 0.8501 for distinguishing the patients from HCs. CONCLUSION: Our findings may provide important evidence for understanding the neuropathology underlying TIA and strong support for the hypothesis that these local metrics have potential value in clinical diagnosis.

A new risk model of assessing left atrial appendage thrombus in patients with atrial fibrillation - Using multiple clinical and transesophageal echocardiography parameters.

BACKGROUNDS: Predicting left atrial appendage thrombus (LAAT) in non-valvular atrial fibrillation (NVAF) patients need more precisely quantified risk models. In this study, we attempted to review the risk markers for LAAT and develop a simple and reliable model for LAAT prediction. METHODS: The study included 307 patients with NVAF who were scheduled for transesophageal echocardiography (TEE) to exclude LAA thrombus before synchronized electrical cardioversion or radiofrequency ablation for atrial fibrillation (AF). We analyzed the relationship between echo, clinical parameters and the presence or absence of LAAT. RESULTS: A total of 33 patients were found having LAAT (10.7%, 33/307). The age, left atrial appendage emptying velocity (LAAEV), left atrial or left atrial appendage spontaneous echocardiographic contrast (SEC), less than moderate to severe mitral regurgitation (≤mild MR), and left atrial enlargement showed association with LAAT. The multivariate logistic regression analysis revealed that LAAEV, SEC and ≤mild MR were independent risk factors of the LAAT. We used LAAEV ≤ 21.5 cm/s, SEC and ≤mild MR to construct a combined predictive model for LAAT in NVAF patients (the area under receiver operator characteristic curve: 0.88; 95% confidence interval: 0.82-0.95, P < 0.0001). CONCLUSION: Comprehensive evaluation of LAAEV, SEC, and MR with associated LAAT may help risk stratifying the NVAF patients, especially if the LAA imaging quality was suboptimal for identifying thrombus. These parameters may facilitate the decision-making process at the time of TEE.

Altered Functional Connectivity within Default Mode Network in Patients with Transient Ischemic Attack: A Resting-State Functional Magnetic Resonance Imaging Study.

Default mode network (DMN) is an important functional brain network that supports aspects of cognition. Stroke has been reported to be associated with functional connectivity (FC) impairments within DMN. However, whether FC within DMN changes in transient ischemic attack (TIA), an important risk factor for stroke, remains unclear. Forty-eight TIA patients and 41 age- and sex-matched healthy controls (HCs) were recruited in this study. Using resting-state functional magnetic resonance imaging seed-based FC methods, we examined FC alterations within DMN in TIA patients, tested its associations with clinical information, and further explored the ability of FC abnormalities to predict follow-up ischemic attacks. We found significantly decreased FC of left middle temporal gyrus/angular gyrus both with medial prefrontal cortex (mPFC) and posterior cingulate cortex/precuneus (PCC/Pcu) and significantly decreased FC among each pair of mPFC, left PCC, and right Pcu in patients with TIA as compared with HCs. Moreover, the connectivity between mPFC and left PCC could predict future ischemic attacks of the patients. Collectively, these findings may provide insights into further understanding of the underlying pathological mechanism in TIA, and aberrant FC between the hubs within DMN may provide a reference for the imaging diagnosis and early intervention of TIA.

Toward neuroimaging-based network biomarkers for transient ischemic attack.

Stroke is associated with topological disruptions of large-scale functional brain networks. However, whether these disruptions occur in transient ischemic attack (TIA), an important risk factor for stroke, remains largely unknown. Combining multimodal MRI techniques, we systematically examined TIA-related topological alterations of functional brain networks, and tested their reproducibility, structural, and metabolic substrates, associations with clinical risk factors and abilities as diagnostic and prognostic biomarkers. We found that functional networks in patients with TIA exhibited decreased whole-brain network efficiency, reduced nodal centralities in the bilateral insula and basal ganglia, and impaired connectivity of inter-hemispheric communication. These alterations remained largely unchanged when using different brain parcellation schemes or correcting for micro head motion or for regional gray matter volume, cerebral blood flow or hemodynamic lag of BOLD signals in the patients. Moreover, some alterations correlated with the levels of high-density lipoprotein cholesterol (an index related to ischemic attacks via modulation of atherosclerosis) in the patients, distinguished the patients from healthy individuals, and predicted future ischemic attacks in the patients. Collectively, these findings highlight the emergence of characteristic network dysfunctions in TIA, which may aid in elucidating pathological mechanisms and establishing diagnostic and prognostic biomarkers for the disease.

The Local Brain Abnormalities in Patients With Transient Ischemic Attack: A Resting-State fMRI Study.

Background: Transient ischemic attack (TIA) is an important risk factor for stroke. Despite the transient episodes of clinical symptoms, brain alterations are still observed in patients with TIA. However, the functional mechanism of transient ischemia is still unclear. Here, we employed resting-state functional magnetic resonance imaging (rs-fMRI) to explore the functional abnormalities in patients with TIA. Methods: 48 TIA patients and 41 age- and sex-matched healthy controls (HCs) were enrolled in the study. For each participant, we collected rs-fMRI data and clinical/physiological/biochemical data. Amplitude of low frequency fluctuation (ALFF), regional homogeneity (ReHo), and degree centrality (DC) were then calculated. Two sample t-tests were performed to compare the ALFF, ReHo, and DC maps between the two groups. Furthermore, a correlation analysis was performed to explore the relationship between local brain abnormalities and clinical/physiological/biochemical characteristics tests in TIA patients. Results: Compared with the HCs, the TIA patients exhibited decreased ALFF in the left middle temporal gyrus, decreased DC in the triangular part of right inferior frontal gyrus, and no significant statistical difference in ReHo. No correlation was found between local abnormalities and clinical/physiological/biochemical scores in the patients with TIA. Conclusion: Collectively, we found decreased ALFF and DC in patients with TIA which provide evidence for local brain dysfunctions and may help to understand the pathological mechanism for the disease.

Non-invasive evaluation of cerebral perfusion in patients with transient ischemic attack: an fMRI study.

Detection of hypoperfused tissue due to the ischemia is considered to be important in understanding the cerebral perfusion status and may be helpful in guiding therapeutic decisions for patients with transient ischemic attack (TIA). We hypothesized that the combination of two non-invasive fMRI techniques: resting-state BOLD-fMRI time-shift analysis (TSA) approach and 3D ASL, could detect the cerebral hemodynamic status in TIA patients noninvasively. From April 2015 to June 2016, 51 TIA patients were recruited in this study. We calculated the time delay between the resting-state BOLD signal at each voxel and the whole-brain signal using TSA approach and compared the results to CBF map derived from ASL. Out of the 51 patients, 24 patients with normal arrival time and CBF were in Stage 0; 14 patients who showed delayed arrival time and normal CBF which indicated elevated CBV were in Stage I; the other 13 patients who had both delayed arrival time and decreased CBF were in Stage II, the group average spatial overlap, i.e., Dice coefficient, of the two measurements was 0.55. Four patients in Stage 0 (17.4%), three patients in Stage I (23.1%) and five patients in Stage II (45.5%) suffered ischemic stroke or TIA symptoms in 1 year after MRI scan. The patients in Stage II was at highest risk of subsequent events when compared to other two stages. The combination of resting-state BOLD-fMRI and ASL hold the potential to noninvasively identify the hemodynamic status in TIA patients and help predict the risk of subsequent events.

Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China: A Randomized Clinical Trial.

Importance: In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. Objective: To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. Design, Setting, and Participants: A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Interventions: Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). Main Outcomes and Measures: The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Results: Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). Conclusions and Relevance: Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02212912.

Serum Soluble Corin Deficiency Predicts Major Disability within 3 Months after Acute Stroke.

OBJECTIVE: Serum soluble corin has been associated with stroke. However, whether it is associated with stroke prognosis has not yet been studied. Therefore, we aimed to study the association of serum soluble corin with risk of poor outcomes within 3 months after stroke. METHODS: We followed 522 stroke patients for 3 months to identify major disability, death and vascular events. Serum soluble corin was measured at baseline for all participants. Logistic regression was used to examine the associations of baseline serum soluble corin with outcomes of stroke, adjusting for age, sex, baseline NIHSS score, hours from onset to hospitalization, smoking, drinking, hypertension, diabetes, coronary heart disease, atrial fibrillation, family history of stroke, and stroke subtype. RESULTS: Patients with high corin had a significantly lower crude risk for the composite outcome of major disability or death (OR = 0.64, 95%CI: 0.43-0.96) than patients with low corin (the lowest tertile). After adjustment for age and baseline NIHSS score, patients with high corin still had a significantly lower risk for the composite outcome of major disability or death (OR = 0.60, 95%CI: 0.36-0.99). This association became bottom line significant after additionally adjusting for other conventional factors (OR = 0.61, P = 0.058). No association was found between serum soluble corin and other composite outcomes. CONCLUSION: Serum soluble corin deficiency predicted risk for major disability within 3 months after stroke, independent of baseline neurological deficient. Our results may indicate a probable role of corin in stroke prognosis.

The effects of DL-3-n-butylphthalide in patients with vascular cognitive impairment without dementia caused by subcortical ischemic small vessel disease: A multicentre, randomized, double-blind, placebo-controlled trial.

INTRODUCTION: Vascular cognitive impairment without dementia is very common among the aged and tends to progress to dementia, but there have been no proper large-scale intervention trials dedicated to it. Vascular cognitive impairment without dementia caused by subcortical ischemic small vessel disease (hereinafter, subcortical Vascular cognitive impairment without dementia) represents a relatively homogeneous disease process and is a suitable target for therapeutic trials investigating Vascular cognitive impairment without dementia. Preclinical trials showed that dl-3-n-butylphthalide (NBP) is effective for cognitive impairment of vascular origin. METHODS: In this randomized, double-blind, placebo-controlled trial, we enrolled patients aged 50-70 years who had a diagnosis of subcortical Vascular cognitive impairment without dementia at 15 academic medical centers in China. Inclusion criteria included a clinical dementia rating ≥0.5 on at least one domain and global score ≤0.5; a mini-mental state examination score ≥20 (primary school) or ≥24 (junior school or above); and brain magnetic resonance imaging consistent with subcortical ischemic small vessel disease. Patients were randomly assigned to NBP 200 mg three times daily or matched placebo (1:1) for 24 weeks according to a computer-generated randomization protocol. All patients and study personnel were masked to treatment assignment. Primary outcome measures were the changes in Alzheimer's disease assessment scale-cognitive subscale (ADAS-cog) and clinician's interview-based impression of change plus caregiver input (CIBIC-plus) after 24 weeks. All patients were monitored for adverse events (AEs). Outcome measures were analyzed for both the intention-to-treat (ITT) population and the per protocol population. RESULTS: This study enrolled 281 patients. NBP showed greater effects than placebo on ADAS-cog (NBP change -2.46 vs. placebo -1.39; P = .03; ITT) and CIBIC-plus (80 [57.1%] vs. 59 [42.1%] patients improved; P = .01; ITT). NBP-related AE were uncommon and primarily consisted of mild gastrointestinal symptoms. DISCUSSION: Over the 6-month treatment period, NBP was effective for improving cognitive and global functioning in patients with subcortical vascular cognitive impairment without dementia and exhibited good safety.

Serum Soluble Corin is Decreased in Stroke.

BACKGROUND AND PURPOSE: Soluble corin was decreased in coronary heart disease. Given the connections between cardiac dysfunction and stroke, circulating corin might be a candidate marker of stroke risk. However, the association between circulating corin and stroke has not yet been studied in humans. Here, we aimed to examine the association in patients wtith stroke and community-based healthy controls. METHODS: Four hundred eighty-one patients with ischemic stroke, 116 patients with hemorrhagic stroke, and 2498 healthy controls were studied. Serum soluble corin and some conventional risk factors of stroke were examined. Because circulating corin was reported to be varied between men and women, the association between serum soluble corin and stroke was evaluated in men and women, respectively. RESULTS: Patients with ischemic and hemorrhagic stroke had a significantly lower level of serum soluble corin than healthy controls in men and women (all P values, <0.05). In multivariate analysis, men in the lowest quartile of serum soluble corin were more likely to have ischemic (odds ratio [OR], 4.90; 95% confidence interval, 2.99-8.03) and hemorrhagic (OR, 17.57; 95% confidence interval, 4.85-63.71) stroke than men in the highest quartile. Women in the lowest quartile of serum soluble corin were also more likely to have ischemic (OR, 3.10; 95% confidence interval, 1.76-5.44) and hemorrhagic (OR, 8.54; 95% confidence interval, 2.35-31.02) stroke than women in the highest quartile. ORs of ischemic and hemorrhagic stroke were significantly increased with the decreasing levels of serum soluble corin in men and women (all P values for trend, <0.001). CONCLUSIONS: Serum soluble corin was decreased in patients with stroke compared with healthy controls. Our findings raise the possibility that serum soluble corin may have a pathogenic role in stroke.

Differential diagnosis of isolated calf muscle vein thrombosis and gastrocnemius hematoma by high-frequency ultrasound.

BACKGROUND: Differential diagnosis of isolated calf muscle vein thrombosis (ICMVT) and gastrocnemius hematoma is essential for early identification of deep vein thrombosis (DVT). This study aimed to investigate the diagnostic value of high-frequency color Doppler ultrasound for differential diagnosis of ICMVT and gastrocnemius hematoma. METHODS: A retrospective case series of 35 ICMVT (M:F, 21:14; mean age (64.5 ± 10.6) years) and 23 gastrocnemius hematoma (M:F, 16:7; mean age (75.4 ± 11.8) years) patients with bilateral/unilateral lower limb pain was conducted between January 2006 and September 2012. Characteristics and the morphology of high-frequency color Doppler ultrasonography of the lower limb deep vein, great saphenous vein, calf muscles, skin, and soft tissue were examined. RESULTS: ICMVT hypoechoic signals were characterized by long, tube-like masses on longitudinal sections and oval masses on transverse sections, with apparent muscle thrombosis boundaries, distal and proximal venous connections, and, often, lower limb DVT. Gastrocnemius hematoma hypoechoic signals were characterized by large volumes, enhanced posterior hematoma echo, hyperechoic muscle boundaries, no hematoma blood flow, and no DVT, and clear differences in trauma/exercise- and oral anticoagulant-induced hematomas were readily apparent. According to the measurement, the ratio of long diameter/transverse diameter (D/T) in ICMVT patients was about less than 2.0, whereas in gastrocnemius hematoma patients the ratio was more than 2.0. Early stage isoechoic and hypoechoic signals were detected with gradually increasing ovular anechoic areas. Partial muscle fibers in the hematoma due to muscle fractures were apparent. CONCLUSION: High-frequency color Doppler ultrasound was found to be a sensitive and reliable method for differential diagnosis of ICMVT and gastrocnemius hematoma due to trauma and exercise or prolonged oral anticoagulant use.

Effects of apolipoprotein E genotype on the off-line memory consolidation.

Spontaneous brain activity or off-line activity after memory encoding is associated with memory consolidation. A few recent resting-state functional magnetic resonance imaging (RS-fMRI) studies indicate that the RS-fMRI could map off-line memory consolidation effects. However, the gene effects on memory consolidation process remain largely unknown. Here we collected two RS-fMRI sessions, one before and another after an episodic memory encoding task, from two groups of healthy young adults, one with apolipoprotein E (APOE) ε2/ε3 and the other with APOE ε3/ε4. The ratio of regional homogeneity (ReHo), a measure of local synchronization of spontaneous RS-fMRI signal, of the two sessions was used as an index of memory-consolidation. APOE ε3/ε4 group showed greater ReHo ratio within the medial temporal lobe (MTL). The ReHo ratio in MTL was significantly correlated with the recognition memory performance in the APOE ε3/ε4 group but not in ε2/ε3 group. Additionally, APOE ε3/ε4 group showed lower ReHo ratio in the occipital and parietal picture-encoding areas. Our results indicate that APOE ε3/ε4 group may have a different off-line memory consolidation process compared to ε2/ε3 group. These results may help generate future hypotheses that the off-line memory consolidation might be impaired in Alzheimer's disease.

Ultrasonographic assessment of polytetrafluoroethylene upper extremity arteriovenous hemodialysis access: a retrospective analysis of 31 cases.

Polytetrafluoroethylene (PTFE) vascular grafts are used for hemodialysis vascular access. Because their longevity is less than that of autologous fistulae, close surveillance is necessary to reduce the incidence of complications. The purpose of this study was to evaluate the usefulness of Doppler sonography for the surveillance of PTFE graft hemodialysis access. Thirty-one patients with renal failure who had dialysis access created with a PTFE graft were included in this study. The patient records along with ultrasonography were retrospectively reviewed. Two-dimensional ultrasonography clearly revealed the U-shape of the subcutaneous PTFE graft, and autologous artery and superficial vein connecting with the graft. There was no ultrasound echo inside the graft, but the wall was a continuous line-like hyperechoic structure. Blood flow in the graft and hemodynamic parameters could be determined with color Doppler ultrasonography. Ultrasound examination diagnosed graft thromboses in six patients, pseudoaneurysm in two, seroma in one, and subcutaneous edema in three patients. Ultrasonography is useful for the monitoring and diagnosis of complications of PTFE dialysis access grafts.

[The study in detection of microcalcification in early breast cancer by ultrasound and its correlation with pathohistology].

OBJECTIVE: To discuss the role of ultrasound in examining microcalcification of early breast cancer and its correlation with pathohistological type and grade. METHODS: 178 lesions in 165 cases of early breast cancer confirmed by pathology after surgical resection were examine by high frequency ultrasound, meanwhile microcalcification were detected and reported. 39 lesions in 32 cases are carcinoma in situ and microinvasive carcinoma of breast. 139 lesions in 133 cases are early invasive breast carcinoma that is below 2 cm in diameter and doesn't invasive the lymph node and other parts of the body. To analyse the sensitivity of detection micro-calcification of early breast cancer by ultrasound and its correlation with pathohistological type and grade. RESULTS: The sensitivity is 81.6% in detecting microcalcification of early breast cancer by ultrasound. There is no significant statistical difference in detecting microcalcification between the two group (P = 0.217). There is no significant statistical difference in detecting microcalcification of early invasive breast cancer between the different pathologic types (P > 0.05), and there are no significant differences in detecting microcalcification of early breast cancer between the different pathologic grades (group I: P = 0.202, group II: P = 0.415). There is significant difference in detecting microcalcification of solid tumor by ultrasonic examination in group I between the different pathologic grades (P = 0.029). CONCLUSION: There is higher sensitivity in detecting microcalcification of early breast cancer by ultrasonography. Microcalcification of early breast cancer may be no closely related to pathologic grades. US has a certain value to clinic in detecting microcalcification of early breast cancer.

Study of endorectal ultrasonography in the staging of rectal cancer.

BACKGROUND: There is no consensus regarding the performance for endorectal ultrasonography (ERUS) at every stage of rectal cancer. Thus, the purpose of our study was to further assess the value of ERUS in the preoperative staging of rectal cancer. METHODS: A retrospective study was performed with 44 consecutive patients (mean age: (63.3 ± 10.2) years) who underwent surgical treatment for endorectal carcinoma and were preoperatively evaluated using Biplane ERUS between September 2008 and December 2010. We compared the ERUS staging with the pathological findings based on surgical specimens. RESULTS: ERUS staging agreed with the histologic staging in 39 of the 44 (88.6%) patients: the agreement on the depth of transmural invasion was good (κ = 0.73; 95%CI: 0.60 - 0.86, P = 0.000). The detection sensitivities of rectal cancer with ERUS were as follows: T1 85.7%, T2 87.5%, T3 88.9%, and T4 100.0% with specificity values of T1 97.3%, T2 92.9%, T3 96.2%, and T4 97.6%. ERUS correctly staged patients with T1 95.5%, T2 90.9%, T3 70.5%, and T4 97.7%. The positive predictive value of ERUS was lowest for T4 (75%), but highest for T3 (94.1%) followed by T2 (87.5%) and T1 (85.7%); the negative predictive values of ERUS from high to low were ordered as T4 (100%), T1 (97.3%), T2 (92.9%), and T3 (92.6%). The percentage of total over-staged cases was 4.5% and the under-staged cases was 6.8%. The extent of perirectal lymph node metastases was determined with a sensitivity of 68.4% (13/19), specificity of 80.0% (20/25), and diagnostic accuracy of 75.0% (33/44). CONCLUSION: Biplane ERUS has a high diagnostic accuracy for tumoral invasion of the rectal wall at every T stage, but relatively low diagnostic accuracy for lymph node metastases.

[Retrospective analysis of ultrasonography for autoimmune pancreatitis].

OBJECTIVE: To explore the sonographic characteristics of autoimmune pancreatitis (AIP). METHODS: The ultrasonographic features and clinical data of 8 AIP patients were analyzed retrospectively and compared with the findings of computed tomography and magnetic resonance imaging. RESULTS: Ultrasound images showed diffuse pancreatic swelling (n = 6), focal pancreatic head thickening (n = 1) and tail enlargement (n = 1). In 7 patients, pancreatic echogenicities were of Grade 1 or less while the other 1 patient Grade 2. Among them, 6 showed hyperechoic "pseudocapsule". And enlarged gallbladder, dilated biliary and pancreatic ducts were seen in 2 patients with jaundice. CONCLUSION: Ultrasonic features play an important role in an early diagnosis of AIP.

[Assessment of synovitis in the knee of patients with newly-diagnosed rheumatoid arthritis using high frequency and color Doppler ultrasonography].

OBJECTIVE: To investigate the value of high frequency and color Doppler ultrasonography in detection of synovitis and the intra-articular vascularization in the knee joint of patients with newly-diagnosed rheumatoid arthritis (RA). METHODS: Forty-one patients (30 women, 11 men) with newly-diagnosed RA were recruited to a cross sectional study (RA group). Forty-one age and gender-matched healthy volunteers were used as control group. The thickness of hydatid fluid, synovium hyperplasia, color flow imaging, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI), venous blood flow and intra-articular perfusion were evaluated by high frequency and color Doppler ultrasonography. RESULTS: Totally 91.46% knee joints with synovial hyperplasia (> 2 mm) were found in 41 patients with RA (75/82 knee joints), and the thickness of the synovial membrane was 2.2 - 19.7 mm (average 6.3 ± 3.4 mm). In aspect of blood flow, the percentage of 0 to 3 grade were 18.67% (14/75), 29.33% (22/75), 45.33% (34/75) and 6.67% (5/75), respectively; the results of arterial blood were indicated with PSV (10.82 ± 3.71 cm/s), EDV (3.86 ± 1.12 cm/s) and RI (0.61 ± 0.07), while the average of venous blood velocity was 2.72 ± 1.02 cm/s. Joint effusion was found in 69 joints (84.15%) with the anteroposterior diameter 2.4 - 16.1 mm (average 6.9 ± 3.2 mm). The thickness of synovial membrane was 1.2 - 1.8 mm (average 1.4 ± 0.4 mm) and no significant difference were observed in joint effusion, signal of blood flow and thickness of synovial membrane in the control group. CONCLUSIONS: High frequency and power Doppler ultrasonography may be a valuable and optimal clinical tool to accurately and objectively detect synovial hyperplasia, vascular pannus formation and joint effusion in the knee joint of patients with RA.

Long-term results of a phase II clinical trial of superantigen therapy with staphylococcal enterotoxin C after microwave ablation in hepatocellular carcinoma.

PURPOSE: To prospectively evaluate safety and effectiveness of intratumoural injection of superantigen staphylococcal enterotoxin C (SEC) for hepatocellular carcinoma (HCC) after percutaneous microwave ablation (PMWA). METHODS: HCC patients (260) with tumours of 60 mm or less (average 29.2 ± 11.1 mm) that achieved technique effectiveness evidenced on imagings within one week of PMWA were enrolled. The SEC group consisted of 45 patients with 2000 U SEC injected into the marginal area of ablated tumour under ultrasound guidance on day 24, 28 and month 2, 5, and 7 after PMWA. The control group consisted of 215 patients receiving PMWA alone. RESULTS: The overall survival rates for 1, 3, and 5 years were 93.3%, 72.9%, 60.8% in the SEC group and 94%, 66%, 44.4% in the control group. The overall survival time had significant difference (p = 0.032). Treatment method was prognostic significance for overall survival on univariate (p = 0.045) and multivariate (p = 0.049) analyses. The disease-free survival time of the SEC group was longer than the control group (p = 0.195). The disease free survival rates at 1 and 3 years were 62% versus 56.6%, 37% versus 9.4% in the SEC and control subgroup of larger (D > 30 mm) tumours, and disease free survival time had significant difference (p = 0.032). Treatment method was a prognostic significance factor for disease free survival of larger tumours on univariate (p = 0.03) and multivariate (p = 0.023) analyses but was not for small tumours. No serious adverse event related to SEC injection happened. CONCLUSIONS: Local superantigen injection at ablated HCC early after PMWA is safe, and achieves longer overall survival as well as disease free survival of larger tumours.