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Aims Underutilization of guideline-directed heart failure with reduced ejection fraction (HFrEF) medications contributes to poor outcomes. Methods and results A pilot study to evaluate the safety and efficacy of a home-based remote monitoring system for HFrEF management was performed. The system included wearable armband monitors paired with the smartphone application. An HFrEF medication titration algorithm was used to adjust medication daily. The primary endpoint was HFrEF medication utilization at 120 days. Twenty patients (60.5 ± 8.2 years, men: 85%) with HFrEF were recruited. All received angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI) at recruitment; 45% received ≥50% maximal targeted dose (MTD) with % MTD of 44.4 ± 31.7%. At baseline, 90 and 70% received beta-adrenergic blocker and mineralocorticoid receptor antagonist (MRA), 35% received ≥50% MTD beta-adrenergic blocker with % MTD of 34.1 ± 29.6%, and 25% received ≥50% MTD MRA with % MTD of 25.0 ± 19.9%. At 120 days, 70% received ≥50% MTD ACEI/ARB/ARNI (P = 0.110) with % MTD increased to 64.4 ± 33.5% (P = 0.060). The proportion receiving ≥50% MTD ARNI increased from 15 to 55% (P = 0.089) with % MTD ARNI increased from 20.6 ± 30.9 to 53.1 ± 39.5% (P = 0.006*). More patients received ≥50% MTD MRA (65 vs. 25%, P = 0.011*) with % MTD MRA increased from 25.0 ± 19.9 to 46.2 ± 28.8% (P = 0.009*). Ninety-five per cent of patients had reduced NT-proBNP with the percentage reduction of 26.7 ± 19.7%. Conclusion Heart failure with reduced ejection fraction medication escalation with remote monitoring appeared feasible.

IntroductionCurrent international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream management to prevent stroke recurrence remain to be established. The objective of the study was to explore the use of long-term home-based ECG monitoring for AF detection and stroke prevention in patients with a history of stroke.Methods and analysisThis prospective, randomised, open-label trial with blinded endpoint adjudication aimed to evaluate the efficacy of long-term home-based ECG monitoring for AF detection and stroke prevention in a 24-month period. Patients aged >18 years with a history of ischaemic stroke will be stratified according to the time from the index ischaemic stroke: 3 years and then randomised in 1:1 to (1) home-based AF screening and (2) control. The home-based AF screening system comprises (1) a handheld single-lead ECG recorder (Comfit Healthcare Devices, Hong Kong SAR, China) and (2) a patient-facing smartphone application specially designed for the study. Patients randomised to the home-based AF group will record a 30 s single-lead ECG using a specially designed handheld ECG device every morning or when symptomatic. All remotely obtained data will be automatically transmitted in real-time through the study smartphone application to a secured cloud hosting and analysed using an artificial intelligence-based diagnostic system. When a diagnosis of AF is made with the system, the patients will be called back for a formal cardiology consultation within 1 week. The primary endpoint is the time to first detection of AF at 24 months of follow-up. Secondary endpoints include recurrent stroke or transient ischaemic attack, initiation of long-term anticoagulation therapy, hospitalisation for heart failure, cardiovascular death and all-cause death.Ethics and disseminationThe study protocol has been approved by the institutional review board of The University of Hong Kong, and Hong Kong West Cluster, Hospital Authority, Hong Kong SAR, China. Results will be published in peer-reviewed journals.Trial registration numberNCT04523649.

BackgroundInternational guidelines recommend natriuretic peptide biomarker-based screening for patients at high heart failure (HF) risk to allow early detection. There have been few reports about the incorporation of screening procedure to existing clinical practice.ObjectiveTo implement screening of left ventricular dysfunction in patients with type 2 diabetes mellitus (DM).MethodA prospective screening study at the DM complication screening centre was performed.ResultsBetween 2018 and 2019, 1043 patients (age: 63.7±12.4 years; male: 56.3%) with mean glycated haemoglobin of 7.25%±1.34% were recruited. 81.8% patients had concomitant hypertension, 31.1% had coronary artery disease, 8.0% had previous stroke, 5.5% had peripheral artery disease and 30.7% had chronic kidney disease (CKD) stages 3–5. 43 patients (4.1%) had an elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration above the age-specific diagnostic thresholds for HF, and 43 patients (4.1%) had newly detected atrial fibrillation (AF). The prevalence of elevated NT-proBNP increased with age from 0.85% in patients aged =0.007*), CKD (pConclusionNT-proBNP and ECG screening could be implemented with relative ease to facilitate early detection of cardiovascular complication and improve long-term outcomes.

Objectives: To assess the performance of elastography (ES) and ultrasound (US) in predicting the malignancy of breast lesions and to compare their combined diagnostic value with that of magnetic resonance imaging (MRI). Materials and Methods: The study prospectively enrolled 242 female patients with dense breasts treated in 35 heath care facilities in China between November 2018 and October 2019. Based on conventional US and elastography, radiologists classified the degree of suspicion of breast lesions according to the US Breast Imaging Reporting and Data System (BI-RADS) criteria. The diagnostic value was compared between US BI-RADS and MRI BI-RADS, with pathological results used as the reference standard. Results: The results demonstrated that irregular tumor shape, a nonparallel growth orientation, indistinct margins, angular contours, microcalcifications, color Doppler flow and ES score on US imaging were significantly related to breast cancer in dense breasts (P=0.001; P=0.001; P=0.008; P

Background Hepatocellular carcinoma (HCC) is one of the primary causes of cancer-related death and resistance to cytotoxic chemotherapy is the major cause of mortality in HCC patients. miR-122 is a liver specific miRNA and is found to be reduced in HCC, however, the function of miR-122 in HCC chemosensitivity remains elusive. Methods We used qRT-PCR to measure expressions of miR-122, β-catenin and MDR1 in four HCC cell lines. And we assessed the effects of miR-122 or β-catenin on cell viability and apoptosis upon oxaliplatin (OXA) treatment by MTT assay and flow cytometry. In addition, we validated the interactions of miR-122/β-catenin and β-catenin/MDR1 by dual luciferase reporter assay and chromatin immunoprecipitation (ChIP). Western blotting was used to determine the protein levels of β-catenin, Wnt1 and MDR1. In the end, we verified the anti-tumor effect of miR-122 in vivo by using mouse tumor xenograft model. Results We found that miR-122 was down-regulated in HCC cells. Up-regulation of miR-122 or inhibition of Wnt/β-catenin signaling promoted HCC cells apoptosis and increased the sensitivity of HCC cells to OXA. On the molecular level, we showed that miR-122 directly targeted and suppressed Wnt/β-catenin pathway while β-catenin bound with MDR1 promoter and activated its transcription. Overexpression of miR-122 inhibited MDR1 expression via directly suppressing Wnt/β-catenin pathway. Conclusion Our study fully demonstrated that miR-122 inhibits MDR1 expression via suppression of Wnt/β-catenin pathway, thereby enhancing HCC sensitivity to OXA. Therefore, miR-122 could serve as a novel potential therapeutic target for HCC.

Background Ultrafast ultrasound imaging has been demonstrated to be an effective method to evaluate carotid stiffness through carotid pulse wave velocity (PWV) with high reproducibility, but lack of reference values has precluded its widespread use in clinical practice. This study aimed to establish reference values of PWV for ultrafast ultrasound imaging in a prospective, multicenter, population-based cohort study and to investigate the main determinants of carotid PWV. Methods A total of 1,544 healthy Han Chinese volunteers (581 [38%] men; age, 18–95 years) were enrolled from 32 collaborating laboratories in China. The participants were categorized by age, blood pressure (BP), and body mass index (BMI). The basic clinical parameters and the carotid PWV at the beginning of systole (BS) and end of systole (ES) were measured via ultrafast ultrasound imaging techniques. Results The PWV at both BS and ES was significantly higher in the left carotid artery than in the right carotid artery. The PWV at BS was significantly higher in men than in women; however, no significant difference was noted in the PWV at ES between men and women. Multiple linear regression analyses revealed that age, BP, and BMI were independently correlated with the PWV at both BS and ES. The PWV at BS and ES progressively increased with increase in age, BP, and BMI. Further, the age- and sex-specific reference values of carotid PWV for ultrafast ultrasound imaging were established. Conclusions Reference values of carotid PWV for ultrafast ultrasound imaging, stratified by sex and age, were determined for the first time. Age, BP, and BMI were the dominant determinants of carotid PWV for ultrafast ultrasound imaging, which should be considered in clinical practice for assessing arterial stiffness.

Background Little is known about the impact of the provision of handheld point-of-care ultrasound (POCUS) devices on physical examination skills of medical students. Methods We describe an educational initiative that comprised a POCUS workshop followed by allocation of a POCUS device to medical students for use over the subsequent 8 weeks. They were encouraged to scan patients and correlate their physical examination findings. A mobile instant messaging group discussion platform was set to provide feedback from instructors. Physical examination skills were assessed by means of clinical examination. Results 210 final-year medical students from the University of Hong Kong participated in the programme. 46.3% completed the end of programme electronic survey: 74.6% enjoyed using the POCUS device, 50.0% found POCUS useful to validate physical examination findings and 47.7% agreed that POCUS increased their confidence with physical examination. 93.9% agreed that the programme should be incorporated into the medical curriculum and 81.9% would prefer keeping the device for longer time from 16 weeks (45.6%) to over 49 weeks (35.3%). Medical students who participated in the POCUS programme had a higher mean score for abdominal examination compared with those from the previous academic year with no POCUS programme (3.65±0.52 vs 3.21±0.80, p=0.014), but there was no statistically significant difference in their mean score for cardiovascular examination (3.62±0.64 vs 3.36±0.93, p=0.203). Conclusion The POCUS programme that included provision of a personal handheld POCUS device improved students’ attitude, confidence and ability to perform a physical examination.

Objective To determine the impact of smoking status in the prediction of stroke using CHADS2 and CHA2DS2-VASc schemes. Methods Five hundred twenty-eight consecutive patients with arrhythmic symptoms and without any documented arrhythmia from Queen Mary Hospital, Hong Kong, were followed up to determine the incidence of ischemic stroke, new-onset atrial fibrillation (AF), or all-cause mortality. Smoking status was classified into nonsmokers and smokers. The pairwise comparisons of C-statistics for outcomes were performed. Results During a median follow-up period of 6.2 years, 65 (12.3%) individuals developed ischemic stroke. Smokers experienced higher annual incidence of stroke, a new-onset AF, and all-cause death compare to nonsmokers, with corresponding hazard ratio (HR) of stroke, AF, and all-cause death being 2.51 (95% confidence intervals, CI 1.36als, CIse death bein 1.15a3.24), and 1.95 (95% CI 1.161.95 (95% CIath being 2.51 (95% confidence corr2 and CHA2DS2-VASc for stroke were 0.60 (95% CI 0.51 for stp = 0.09) and 0.59 (95% CI 0.50 (95%, p = 0.15) respectively, whereas the C-statistics of CHADS2 and CHA2DS2-VASc were 0.66 (95% CI 0.61 were 0p = 0.005), 0.75 (95% CI 0.7 CI 0.7p < 0.0001), respectively among nonsmokers. After incorporating smoking, both the CHADS2-smoking and CHA2DS2-VASc-smoking achieved better C-statistics for new-onset ischemic stroke prediction superior to baseline score systems in male groups. Conclusion Cigarette smoking status has impact on stroke stratification using CHADS2 and CHA2DS2-VASc scheme. The discrimination of the CHADS2 and CHA2DS2-VASc scheme for stroke can be significantly improved if smoking status is additionally considered.

Aims Currently, available Doppler echocardiographic reference values are derived mainly from North American and European population studies, which may not applicable to the Chinese population. We aimed to establish normal reference values of Doppler echocardiographic parameters in a nationwide, population-based cohort of healthy Han Chinese adults. Methods and results A total of 1394 qualified healthy subjects (mean age 47.3 ± 16.0 years, 678 men) were enrolled at 43 collaborating laboratories, 37 transvalvular flow and tissue Doppler parameters were obtained, and the impacts of gender and age on each parameter were analysed. Significant differences were found between men and women in 48.6% (18/37) of the parameters analysed, and among different age groups in 83.8% (31/37) of the parameters in men and in 86.5% (32/37) of the parameters in women. Conclusions Normal reference values of Doppler echocardiographic parameters were established for the first time in a nationwide, population-based cohort of healthy Han Chinese adults. Since most of these parameters differed by gender and/or age, reference values specified for gender and age should be recommended in clinical practice. [10.1093/ehjci/jev353][1] [1]: /lookup/doi/10.1093/ehjci/jev353

Background To facilitate differentiation between normal and abnormal values, it is necessary to correct echocardiographic measurements for physiologic variance induced by age, gender, and body size variables. Methods A total of 34 two-dimensional echocardiographic parameters were measured in 1,224 healthy Chinese adults with body mass index 0.20, P 0.80) between the corrected and uncorrected values. Results Before correction, all 34 parameters correlated significantly with one or more of the physiologic variables of age and body size and differed significantly between men and women on 29 parameters (85.3%) in both groups. The success rate of correction with the single-variable isometric model was only 11.0% (15 of 136 corrections due to four variable corrections used for each parameter), while use of the optimized multivariate allometric model successfully corrected all 34 parameters (100%) for physiologic variance induced by age and body size variables and eliminated the gender differences in 32 parameters (94.1%). A new set of reference values for corrected echocardiographic measurements independent of age, gender, and body size variables were established. Conclusions The novel optimized multivariate allometric model developed in this study is superior to traditional the single-variable isometric model in the correction of echocardiographic parameters for physiologic effects of age, gender, and body size variables and thus should be encouraged in both scientific research and clinical practice.

Background Currently available echocardiographic reference values are derived mainly from North American and European population studies, and no echocardiographic reference values are available for the Chinese population. The aim of this study was to establish normal values of echocardiographic measurements of the cardiac chambers and great arteries in a nationwide, population-based cohort of healthy Han Chinese adults. Methods A total of 1,586 healthy Han Chinese volunteers aged 18 to 79 years were screened at 43 collaborating laboratories throughout China. Standard M-mode and two-dimensional echocardiography was performed to obtain measurements of the cardiac chambers and great arteries. The impacts of gender and age on all echocardiographic measurements were analyzed. Results A total of 1,394 qualified healthy subjects (mean age, 47.3 ± 16.0 years; 678 men) were ultimately enrolled. Except for left ventricular ejection fraction, values of cardiac chamber and great arterial dimensions were significantly higher in men than in women. Most measurements of the atrial and great arterial dimensions, left ventricular wall thickness, and left ventricular mass increased with age in both men and women. Conclusions Normal reference values of cardiac dimensional parameters were established for the first time in a nationwide, population-based cohort of healthy Han Chinese adults. Because most of these parameters were found to vary with gender and age, reference values stratified for gender and age should be used in clinical practice.

OBJECTIVES The purpose of this study is to validate the use of tissue Doppler acceleration imaging (TDAI) for evaluation of the onset of ventricular contraction in humans. BACKGROUND Tissue Doppler acceleration imaging can display the distribution, direction and value of ventricular acceleration responses to myocardial contraction and electrical excitation. METHODS Twenty normal volunteers underwent TDAI testing to determine the normal onset of ventricular acceleration. Two patients with paroxysmal supraventricular tachycardia and 30 patients with permanent pacemakers underwent introduction of esophageal and right ventricular pacing electrodes, respectively, and were studied to visualize the onset of pacer-induced ventricular acceleration. Eight patients with dual atrioventricular (AV) node and 20 patients with Wolff-Parkinson-White (WPW) syndrome underwent TDAI testing to localize the abnormal onset of ventricular acceleration, and the results were compared with those of intracardiac electrophysiology (ICEP) tests. RESULTS The normal onset and the onset of dual AV node were localized at the upper interventricular septum (IVS) under the right coronary cusp within 25 ms before the beginning of the R wave in the electrocardiogram (ECG). In all patients in the pacing group, the location and timing of the onset conformed to the positions and timing of electrodes (100%). In patients with WPW syndrome, abnormal onset was localized to portions of the ventricular wall other than the upper IVS at the delta wave or within 25 ms after the delta wave in the ECG. The agreement was 90% (18 of 20) between the abnormal onset and the position of the accessory pathways determined by ICEP testing. CONCLUSIONS These results suggest that TDAI is a useful noninvasive method that frequently is successful in visualizing the intramural site of origin of ventricular mechanical contraction.

To quantitatively analyze the characteristics of regional myocardial velocities of paced heart over His bundle, and explore the myocardial velocity pattern.5 dogs were paced at 120 times/min over His bundle. We defined the His bundle adjacent region and the top region of interventricular septum (IVS) as our regions of interest (ROI). Images of Doppler tissue velocity in ROI and corresponding electrocardiograms were observed and recorded by a 2-D Color Doppler tissue imaging (DTI) system. Quantitative velocities of myocardial DTI images were mapped by a neural network from the image sequences. Finally the velocity characteristics of the myocardium around His bundle and IVS were analyzed.We obtained myocardial time-velocity curves in the ROI, and some results based on those curves: In the His bundle adjacent region intervals of myocardial systole and diastole were (209.75 +/- 19.41) ms and (294.50 +/- 17.87) ms, respectively. Myocardial systole velocity (S), early diastole velocity (E) and late diastole velocity (A) were (5.43 +/- 1.53) cm/s, (3.95 +/- 1.18) cm/s and (1.72 +/- 0.77) cm/s, respectively, E/A was 2.06 +/- 0.95; In IVS region intervals of myocardial systole and diastole were (191.33 +/- 17.23) ms and (294.70 +/- 17.91) ms, respectively. S, E and A were (3.17 +/- 1.34) cm/s, (2.17 +/- 0.64) cm/s and (1.48 +/- 0.52) cm/s, respectively. E/A was 1.305 +/- 0.287.The primary characteristics of myocardial velocities paced over His bundle were: 1) Myocardial velocities in His bundle adjacent region were higher than those in IVS. 2) E/A was greater than one.

Objective. To study the method for constructing an ultrasonic tele-diagnosis and quality control system. Method. The standard of Intemet/Intranet technology was used for the system. The compression and up-loading component based on wavelet and the software platform of ultrasound image processing were developed to suit the ultrasound image characteristics. The information exchange and storage (DICOM) was studied for the compatibility between the system and the Hospital Information System (HIS). Both of them were combined to form an integrated system. Result. WWW server, relevant case history managing and image processing software were constructed in the system. Conclusion. It is feasible to establish a low cost and maintainable system for ultrasound tele-diagnosis and quality control system based on Internet/Intranet technology.

To implement dynamic 3D reconstruction of ultrasonic flow images by the technique of 3D reconstruction of ultrasonic medical images combined with Doppler flow imaging method.Through analyzing the color-coded mode of Doppler flow images and utilizing the Color Bar in DFI provided by ultrasound system, the information of anatomical structure and blood flow velocity were separated from original DFI images. Then 3D reconstruction of blood velocity and its fusion display with 3D anatomical structure was implemented.Clinical experiments showed that in vivo blood flow in heart cavity could be shown in 3D space simultaneously with anatomical structure of the heart, and the relationship between them was consistent with cardiology. The images rendered in such a way could show more medical information than that in traditional methods.The combination of 3D reconstruction of ultrasonic medical images and Doppler imaging technique could realize functional 3D reconstruction of ultrasonic medical images so as to give more medical information. It would have great potential application and present a new future for ultrasonic medical imaging.

The present paper studies the method of 3D reconstruction of multiplane transesophageal rotational scanning echocardiography. According to the characteristic of rotational scanning echocardiography, a direct matching interpolation method is exploited to reconstruct regular volume data from distributed ultrasound scanning points. The whole system is developed and clinical ultrasound data is tested for this method. The volume rendering results show that the proposed method is valid and effective. At last, the possibility of functional reconstruction based on tissue Doppler imaging is explored. Keywords: 3D reconstruction; Multiplane transesophageal echocardiography; Volume rendering; Rotational scanning 1. INTRODUCTION Transesophageal 3D echocardiography is an evolving ultrasound imaging technique. It can show the inherent tri-dimensional modality of cardiac structure and help clinician understand the anatomical structure of pathological change and its spatial relationship with other proximate structures. Hence, 3D echocardiography will play an increasing role in the future of medical imaging [1, 2, 3, 4]. After long time experimentation, 3D ultrasound has been put into practical use and clinical evaluation. Now there are two approaches in the implement of 3D ultrasound system: one is to manufacture dedicated, specialized 3D ultrasound devices; the other is to upgrade from already existing 2D systems [1, 2, 3, 4]. The first one involves the core technique of ultrasound transducer, so it’s very complicated and expensive. On the contrary, the later one is cheap and easy to popularize because it can protect investment of existing 2D ultrasound systems. But up to now, there are several reported drawbacks that heavily hindered the application of 3D ultrasound imaging system. The quality of original ultrasound images is quite poor compared with CT or MRI. What’s more, the spatial interpolation of 2D ultrasound images is significantly more difficult than that of CT or MRI and requires the physician to possess interpretational experience. But the appearance of multiplane transesophageal transducer gives a great opportunity to overcome those drawbacks. It can be leaded into body from esophagus and locates in some organs nearby the heart where it can scan the heart in low span, so the quality of original images is quite good. The transducer can rotate in 360 degrees so as to acquire a series of rotary scanning images, and the spatial relationship of those images is fixed. In this paper, we will study the basic 3D reconstruction algorithm of transesophageal rotational scanning echocardiography, and exploit the appropriate method of filtering, extraction, interpolation and visualization. Then the corresponsive 3D reconstruction software system is developed and tested for the clinical experiments. At last, we will explore the possibility of functional reconstruction based on tissue Doppler imaging.