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Supplemental Digital Content is available in the text., OBJECTIVES: To determine methylprednisolone’s dose, duration, and administration from onset of symptoms and association with 60 days in hospital survival of coronavirus disease 2019 pneumonia. DESIGN: Cohort study. SETTING: Thirteen hospitals in New Jersey, United States during March to June 2020. PATIENTS: Seven-hundred fifty-nine hospitalized coronavirus disease 2019 patients. INTERVENTIONS: We performed a propensity matched cohort study between patients who received methylprednisolone and no methylprednisolone. Patients in the methylprednisolone group were further differentiated into dose (high dose and low dose), duration, and administration from onset of symptoms. MEASUREMENTS AND MAIN RESULTS: In the propensity matched sample, 99 out of 380 (26%) in no methylprednisolone, 69 out of 215 (31.9%) in low-dose methylprednisolone, and 74 out of 164 (55.2%) high-dose methylprednisolone expired. Overall median survival for no methylprednisolone (25.0 d), low-dose methylprednisolone (39.0 d), high-dose methylprednisolone (20.0 d), less than or equal to 7 days duration (19.0 d), 7–14 days duration (30.0 d), greater than 14 days duration (44.0 d), onset of symptoms less than or equal to 7 days (20.0 d), and onset of symptoms 7–14 days (27.0 d) were statistically significant (log-rank p ≤ 0.001). Multivariate Cox regression showed nursing home residents, coronary artery disease, and invasive mechanical ventilation were independently associated with mortality. Methylprednisolone was associated with reduced mortality compared with no methylprednisolone (hazard ratio, 0.40; 95% CI, 0.27–0.59; p < 0.001) but no added benefit with high dose. Low-dose methylprednisolone for 7–14 days was associated with reduced mortality compared with less than or equal to 7 days (hazard ratio, 0.45; 95% CI, 0.22–0.91; p = 0.0273), and no additional benefit if greater than 14 days (hazard ratio, 1.27; 95% CI, 0.60–2.69; p = 0.5434). Combination therapy with tocilizumab was associated with reduced mortality over monotherapy (p < 0.0116). CONCLUSIONS: Low-dose methylprednisolone was associated with reduced mortality if given greater than 7 days from onset of symptoms, and no additional benefit greater than 14 days. High dose was associated with higher mortality.

Background The diagnosis of cardiac sarcoidosis ( CS ) is challenging because endomyocardial biopsy has only a 20% to 30% sensitivity rate for diagnosis and it presents with similar clinical features of idiopathic dilated cardiomyopathy ( DCM ). Lymphatic vessel proliferation in pulmonary sarcoidosis has been previously demonstrated. In this study, we compared endomyocardial biopsy samples obtained from patients with CS and DCM to determine whether lymph vessel counts using D2‐40 immunostaining can be utilized as a complementary tool to distinguish CS from DCM . Methods and Results Endomyocardial biopsy tissues were obtained from 62 patients with CS (30 patients with a diagnosis made histologically, 32 patients with a diagnosis made clinically), and hematoxylin/eosin, Masson trichrome, and D2‐40 immunostaining were performed. Their results were compared with those from 53 patients with DCM. The histological CS group showed significantly increased lymphatic vessels (12.0 [4.0–40.0] versus 2.6 [1.9–3.4], P P DCM group. The optimal threshold was 7.5 lymphatic vessels, and this resulted in a sensitivity of 0.67 and specificity of 0.96. The clinical CS group diagnosed according to Japanese Circulation Society 2016 criteria showed increased lymphatic vessels (4.0 [3.3–9.0] versus 2.6 [1.9–3.4], P P P P =0.0012) compared with the DCM group. The optimal threshold of lymphatic vessels was 3.5, which resulted in a sensitivity of 0.75 and specificity of 0.68. Conclusions Lymphatic vessel counts using D2‐40 immunostaining may help to distinguish clinical CS without granuloma from DCM .

In a prior study of patients with diabetes, diastolic function was similarly impaired in masked hypertension (MHT) and sustained hypertension (SHT). We evaluated whether MHT is associated with impaired diastolic function compared with SHT and sustained normotension (NT) in the general population.From February 2005 to December 2010, 798 participants without a history of cardiovascular disease or treated hypertension, were enrolled in the Masked Hypertension Study. Participants underwent clinic blood pressure (CBP) and 24-hour ambulatory blood pressure (ABP) measurements. A 2-dimensional Doppler echocardiogram was performed to evaluate diastolic function,s cardiac structure, volume, and systolic function. The 9 CBPs obtained across 3 clinic visits and awake ABP measurements were averaged. Clinic hypertension was defined as systolic/diastolic blood pressure (SBP/DBP) ≥ 140/90 mmHg. Ambulatory hypertension was defined as awake SBP/DBP ≥ 135/85mm Hg. MHT was defined as having ambulatory but not clinic hypertension. White-coat hypertensives (n = 8) were excluded from the analysis.Of the 790 participants, 116 (14.7%) participants had MHT, 37 (4.7%) participants had SHT, and 637 (80.6%) participants had NT. After age, sex, race/ethnicity, and body mass index adjustment, compared with NT, E'-velocities were significantly lower in MHT (P0.01) and SHT (P0.05), and E/E' ratios were significantly higher MHT (P0.05) and SHT (P0.05). These associations were independent of left ventricular mass. Diastolic function parameters did not significantly differ between MHT and SHT.Diastolic function was impaired in MHT compared with NT independent of changes in left ventricular mass.

Aims The planimetry method using three-dimensional (3D) echocardiography is useful for providing an accurate mitral annulus area (MAA) value. However, this method is relatively unavailable. Therefore, we evaluated the accuracy of conventional methods for MAA measurement compared with that of 3D planimetry. Methods and results Two-dimensional (2D) and 3D transoesophageal echocardiography (TEE) were performed in 70 patients. The mitral annulus diameter (MAD) was measured using four standard TEE imaging planes: four-chamber (4Ch), two-chamber (2Ch), anterior–posterior (LAX), and commissure–commissure (CC). MAA was calculated using a single diameter based on that of a circle and using two diameters based on that of an ellipse. MAA measurements using the single 4Ch MAD method ( r = 0.84, P < 0.001), and two anatomically orthogonal MAD method in 4Ch/2Ch ( r = 0.93, P < 0.001) and LAX/CC ( r = 0.97, P < 0.001) planes correlated with 3D planimetric MAA measurements. Further analysis with Bland–Altman plots revealed that the LAX/CC MAD measurement exhibited the closest limits of agreement with the 3D planimetric MAA measurement. Notably, in patients showing an elliptical annulus shape, only LAX/CC MAD, but not 4Ch or 4Ch/2Ch MAD, provided results comparable with those of 3D planimetric MAA measurements. However, in patients with a circular annulus shape, reliable MAA measurements can be achieved using either single 4Ch MAD or any biplane MAD. Conclusion Conventional LAX/CC MAD can be recommended for MAA measurements in a diverse patient population. This method is applicable as an alternative to the 3D planimetric method, regardless of the mitral annulus shape.

BACKGROUND: Noninvasive and accurate assessment of mitral valve anatomy has become integral in the presurgical evaluation of patients with mitral valve prolapse (MVP). Recently developed real time three-dimensional (RT3D) ultrasound allows online acquisition, rendering, and can provide accurate information on cardiac structures. We sought to evaluate the feasibility of RT3D for the assessment of MVP segments when compared with transesophageal echocardiography (TEE) and intraoperative findings. METHODS: We examined 42 patients with MVP using RT3D, two-dimensional (2D) transthoracic echocardiography (TTE) and TEE. For RT3D analysis, cropping planes were used to slice the 3D volume on line to visualize the prolapsed segments of the mitral valve leaflets. The mitral valve was divided into six segments based on the American Society of Echocardiography's recommendations. Two experienced cardiologists evaluated echocardiographic images. RESULTS: Adequate RT3D images of the mitral valve were acquired in 40 out of 42 patients. The sensitivity and specificity of RT3D for defining prolapsed segments when compared with TEE were 95% and 99%, respectively (anterior leaflet: 96% and 99%, posterior leaflets: 93% and 100%, respectively). The sensitivity and specificity of TTE were 93% and 97%, respectively (anterior leaflet: 96% and 98%, posterior leaflets: 90% and 97%, respectively). Interobserver agreement for RT3D (Kappa 0.95, 95% confidence interval [CI] 0.91-1.00) was significantly greater than for TTE (Kappa 0.85, 95% CI 0.78-0.93) (P < 0.05). The elapsed time for completion of RT3D (14.4 +/- 2.8 min) was shorter than for TEE (26.4 +/- 4.7 min, P < 0.0001) and TTE (19.0 +/- 3.1 min, P< 0.0001). CONCLUSIONS: RT3D is fast, accurate, and highly reproducible for assessing MVP.

Inflammation has been suggested to play an important role in age-related chronic diseases and disability, and it is associated with nutritional status including obesity and malnutrition. While numerous studies have examined the validity of inflammatory markers in the population studies in Caucasian elderly people, very little information is available for the factors affecting inflammatory markers in Asian elderly people. Among inflammatory markers frequently used for the studies of aging, tumor necrosis factor α (TNF-α) is produced mainly by macrophages, and contributes to production of interleukin-6 (IL-6) and C-reactive protein (CRP), thus directing a chronic inflammatory process in the body. In the present study, we examined the associations between plasma TNF-α level and several factors related to nutrition status, including BMI, albumin, and energy intake in community-dwelling Japanese elderly. We conducted a cross-sectional study of 390 men and women aged 70-86 y (average 73.5 y), who participated in health check-ups. Associations between plasma TNF-α levels, other clinical parameters, and lifestyle factors were analyzed using Spearman's rank correlation coefficient analysis and multiple linear regression analysis. In elderly men, plasma TNF-α level was positively associated with age, white blood cell count, monocyte count, plasma CRP level, serum creatinine, ureic acid, and triacylglycerol levels, and negatively associated with albumin/globulin ratio, eGFR, and serum HDL-cholesterol level. In elderly women, plasma TNF-α level was positively associated with age, plasma CRP level, and serum triacylglycerol level, and negatively associated with serum albumin and HDL-cholesterol levels. The results of this study suggest that plasma TNF-α is associated with inflammation and insulin resistance in both Japanese elderly men and women, and a prominent association of TNF-α with malnutrition status was observed in elderly women.

The purpose of this study was to evaluate the possibility of using high-intensity focused ultrasound (US), or HIFU, to create lesions in cardiac valves in vitro. Calf mitral valves and aortic valves were examined. Focused US energy was applied with an operating frequency of 4.67 MHz at a nominal acoustic power of 58 W for 0.2, 0.3 and 0.4 s at 4-s intervals. Mitral valve perforation was achieved with 20.8 3.7 exposures of 0.2 s, 15.4 2.1 exposures of 0.3 s or 11.2 2.3 exposures of 0.4 s. Aortic valve perforation was achieved with 13.3 2.4 exposures of 0.2 s, 10.3 2.2 exposures of 0.3 s or 8.4 1.8 exposures of 0.4 s. The mean diameter of the perforated area was 1.09 0.11 mm. The lesions were slightly discolored and coagulation of tissue around the perforation was observed. HIFU was successful in perforating cardiac valves. With further refinement, HIFU may prove useful for valvulotomy or valvuloplasty. (E-mail: otsukaryo@aol.com) © 2005 World Federation for Ultrasound in Medicine & Biology.

An important goal in clinical cardiology is the non-invasive quantification of regional cardiac deformation. While many methods have been proposed for the estimation of 3D left ventricular deformation and strains derived from 4D ultrasound, currently there is a lack of in vivo clinical validation of these algorithms on humans. In this paper, we describe the experiments used in validating cardiac deformation and strain estimates of 4D ultrasound using correlation-based optical flow tracking on two different COPD patients with normal left ventricular function. Validation of the algorithm was done by 1) validation of cardiac volume across multiple scans of the same patient and 2) validation of the repeatability of cardiac displacement and strain results from multiple scan acquisitions of the same patient. The preliminary results are encouraging with our algorithm producing consistent cardiac volume and strain results across multiple acquisitions. Furthermore, our derived 4D cardiac strains showed qualitatively correct results. We also observed particularly interesting results in the radial displacements of the posterior and lateral walls of our COPD patients.

Methods: From 2000 to 2006, we retrospectively investigated the 30-day mortality and long-term MACE in 4 groups of total 1,026 consecutive AMI patients: 152 CKD patients with MetS, 165 CKD patients without MetS, 301 non-CKD patients with MetS, 408 non-CKD patients without MetS. MetS was deined as at least three of the following 5 component conditions (modiied NCEP-ATP III criteria); glucose intolerance, obesity (body mass index≥25kg/m2), hypertriglyceridemia, low HDL cholesterol and hypertension. CKD was deined estimated glomerular iltration rate < 60ml/min.

A 19-year-old man was admitted for severe traumatic tricuspid regurgitation (TR) 4 months after a traffic accident. Transthoracic echocardiography revealed severe TR, with an abnormal chordal structure. Three-dimensional echocardiography showed widely lacerated right ventricular endocardium involving many subvalvular components. In this case of traumatic TR, three-dimensional echocardiography was useful not only for its diagnosis but also in providing important information for surgical decision making.

Patent foramen ovale is associated with stroke. However, the rate of recurrent events in medically treated patients with patent foramen ovale remains undefined. Estimates differ by the studies. In order to provide a more accurate estimate of the recurrent adverse event rates in medically treated patients with patent foramen ovale, we reviewed the literature and analyzed the results from a total of 1,108 patients combining 12 studies. We found the annual rate of stroke or death to be 3.12% (95% CI, 2.32-4.11%). This estimate will provide a valuable guideline for any future study to compare the efficacy of other modalities such as percutaneous device closure of patent foramen ovale with medical treatment., Otvoreni foramen ovale (OFO) udružen je s moždanim udarom. Međutim, učestalost rekurentnih neželjenih događaja u bolesnika liječenih lijekovima s otvorenim foramen ovale nije poznata, a procjene iz različitih studija se razlikuju. Stoga smo obavili pregled literature i analizirali rezultate za ukupno 1.108 bolesnika iz 12 studija, kako bismo dobili točniju procjenu učestalosti neželjenih događaja u bolesnika s otvorenim foramen ovale liječenih lijekovima. Utvrdili smo godišnju stopu moždanog udara ili smrti od 3,12% (95% CI, 2,32-4,11%). Ova će procjena poslužiti kao vrijedna smjernica za buduća ispitivanja u kojima će se uspoređivati učinkovitost drugih načina liječenja, primjerice, zatvaranje otvorenog foramen ovale pomoću perkutanog uređaja uz medikamentno liječenje.

Background: Rituximab is currently used as a standard agent in many B cell malignancies. High doses of rituximab may be more efficacious in the treatment of chronic lymphocytic leukemia and mantle cell lymphoma, because CD20 antigenic sites occur in low density per cell, and soluble CD20 in the plasma binds with infused rituximab. We describe our results with escalated high doses of single agent rituximab given as weekly induction doses followed by monthly maintenance doses. Methods: 18 patients (10 males, 8 females) with median age 58 years (range 42 – 80); 4 patients with MCL and 14 patients with CLL were enrolled. Rai stages were: Stage 0–1, Stage I–2, Stage II–5, Stage III–8, Stage IV–2. 9 patients had at least one prior treatment (range, 1–8 treatments): fludarabine-7 patients, chlorambucil-6 patients, chlorambucil and fludarabine-4 patients. Median duration of disease prior to rituximab administration was 23 months (1–143 months). 9 patients had bulky disease (mass largest diameter > 5 cm). All patients received the standard single agent rituximab dose 375 mg/m2 with weekly escalation up to 2,250 mg/m2, followed by the highest escalated dose of rituximab as a monthly maintenance dose. The median monthly dose 1000 mg/m2 (range 500 – 2,250 mg/m2), and the median number of monthly doses was 18 (4–76 doses). Results: The overall response rate (CR + PR) was 88% (CR 50%, PR 38%). CR median duration is 17 + months (6 – 46 + months). CD20 intensity of staining (range of mean fluorescense intensity ratio 162–4766) and CD38 expression (range 5–99%) did not correlate with responses. The median time to progression was not reached. 8 patients progressed and their median time to progression is 25 months (14–48). None of the patients with bulky disease reached CR. 2 CR and 4 PR were observed in previous fludarabine failures. 3 of 4 patients with MCL reached CR and one continues in CR 46+ months off treatment. Rituximab was very well tolerated and only 2 episodes of grade 3 infusion related toxicity were observed. Both patients completed infusion with appropriate supportive care. Conclusion: Single agent rituximab in high doses can induce durable clinical response in non-bulky early stage CLL/MCL. Higher than standard doses improve responses possibly by saturating CD20 binding sites and overcoming the obstacle of circulating CD 20 antigen.

Background: Vascular malformations with arteriovenous shunt components can cause significant disability, chronic pain, and functional impairment. Effective treatment may require serial procedures, yet an imaging modality optimized to control cost and reduce radiation exposure in this predominantly pediatric population has not yet been identified. Methods and Results: We describe the use of contrast-enhanced sonography as a novel tool to define vascular anatomy and localize arteriovenous shunting in a young patient with a symptomatic vascular malformation. Conclusions: This method may effectively reduce radiation exposure and cost, and additionally provide unique information about arteriovenous shunting, offering a novel imaging application for patients with these conditions. Background Vascular malformations (VM) are congenital lesions with diverse clinical manifestations. In contrast to hemangiomas, a separate category of vascular tumors which tend to involute spontaneously, VM often grow in proportion with the child but may expand at an accelerated pace [1]. VM can occur throughout the body, involve multiple vessel types, and may be localized or extensive [2]. Although criteria have been developed for classifying vascular malformations according to flow velocity and vessel type [3], diagnosis of these heterogeneous lesions remains challenging. While these abnormalities may be asymptomatic, VM become clinically important when associated with disfigurement, functional impairment, pain, infection, and serious bleeding [4,5]. These patients require treatment, which varies according to the specific lesion, its location, functional impairment, and goals of therapy. Assembly of a multi-disciplinary team is advantageous when planning therapy. Further, precise characterization of problematic lesions is critically important both in designing the approach and understanding, likely outcomes (such