Challenging and target-based shifting strategies for heart failure treatment: An update from the last decades

Heart failure (HF) is a major global health problem afflicting millions worldwide. Despite the significant advances in therapies and prevention, HF still carries very high morbidity and mortality, requiring enormous healthcare-related expenditure, and the search for new weapons goes on. Following initial treatment strategies targeting inotropism and congestion, attention has focused on offsetting the neurohormonal overactivation and three main therapies, including angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor antagonists, β-adrenoceptor antagonists, and mineralocorticoid receptor antagonists, have been the foundation of standard treatment for patients with HF. Recently, a paradigm shift, including angiotensin receptor-neprilysin inhibitor, sodium glucose co-transporter 2 inhibitor, and ivabradine, has been added. Moreover, soluble guanylate cyclase stimulator, elamipretide, and omecamtiv mecarbil have come out as a next-generation therapeutic agent for patients with HF. Although these pharmacologic therapies have been significantly successful in relieving symptoms, there is still no complete cure for HF. We may be currently entering a new era of treatment for HF with animal experiments and human clinical trials assessing the value of antibody-based immunotherapy and gene therapy as a novel therapeutic strategy. Such tempting therapies still have some challenges to be addressed but may become a weighty option for treatment of HF. This review article will compile the paradigm shifts in HF treatment over the past dozen years or so and illustrate current landscape of antibody-based immunotherapy and gene therapy as a new therapeutic algorithm for patients with HF.

Quantitative relationship between anteriorization of alpha oscillations and level of general anesthesia

A typical electroencephalogram (EEG) change induced by general anesthesia is anteriorization-disappearance of occipital alpha oscillations followed by the development of frontal alpha oscillations. Investigating the quantitative relationship between such a specific EEG change and the level of anesthesia has academic and clinical importance. We quantified the degree of anteriorization and investigated its detailed relationship with the level of anesthesia. We acquired 21-electrode EEG data and bispectral index (BIS) values of 50 patients undergoing surgery from before anesthesia induction until after patient arousal. For each epoch of a 10.24-s window with 1-s offsets, we calculated frontal alpha power [Formula: see text], occipital alpha power [Formula: see text], and their difference [Formula: see text] to quantify anteriorization. We calculated Spearman's rank correlation coefficients between these values and the BIS value. We used locally weighted regression to estimate [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], and [Formula: see text] at each BIS value. Thirty-six patients (26 females and 10 males aged 24-85 years) were analyzed. The 95% confidence intervals for the mean of Fisher transformations of Spearman's rank correlation coefficients between [Formula: see text], [Formula: see text], and [Formula: see text] and BIS value were [- 0.68, - 0.26], [0.02, 0.62], and [- 1.11, - 0.91], respectively. The change in [Formula: see text] and [Formula: see text] with BIS value showed different patterns by the type of anesthetic agent, whereas that in [Formula: see text] was more consistent with smaller individual variance. Anteriorization, quantified by the difference between frontal and occipital alpha powers, continuously developed in conjunction with general anesthesia. Quantifying anteriorization may provide an objective indicator of the level of anesthesia.

Vascular endotheliitis associated with infections: Its pathogenetic role and therapeutic implication

Vascular endothelial cells are major participants in and regulators of immune responses and inflammation. Vascular endotheliitis is regarded as a host immune-inflammatory response of the endothelium forming the inner surface of blood vessels in association with a direct consequence of infectious pathogen invasion. Vascular endotheliitis and consequent endothelial dysfunction can be a principle determinant of microvascular failure, which would favor impaired perfusion, tissue hypoxia, and subsequent organ failure. Emerging evidence suggests the role of vascular endotheliitis in the pathogenesis of coronavirus disease 2019 (COVID-19) and its related complications. Thus, once initiated, vascular endotheliitis and resultant cytokine storm cause systemic hyperinflammation and a thrombotic phenomenon in COVID-19, leading to acute respiratory distress syndrome and widespread organ damage. Vascular endotheliitis also appears to be a contributory factor to vasculopathy and coagulopathy in sepsis that is defined as life-threatening organ dysfunction due to a dysregulated response of the host to infection. Therefore, protecting endothelial cells and reversing vascular endotheliitis may be a leading therapeutic goal for these diseases associated with vascular endotheliitis. In this review, we outline the etiological and pathogenic importance of vascular endotheliitis in infection-related inflammatory diseases, including COVID-19, and possible mechanisms leading to vascular endotheliitis. We also discuss pharmacological agents which may be now considered as potential endotheliitis-based treatment modalities for those diseases.

Exposure to aerosol extract from heated tobacco products causes a drastic decrease of glutathione and protein carbonylation in human lung epithelial cells

Heated tobacco products (HTPs) are an emerging class of tobacco goods that claim to have lower health risks than those of smoking combustible tobacco products. In this study, we exposed human lung epithelial cell lines to extracts prepared from HTP aerosols and combustible cigarette smoke to compare cytotoxicity. We focused on the effects of aldehydes present in the aerosols of HTPs at levels close to those in combustible cigarette smoke. Significant toxicity was confirmed for the HTP extract, albeit to a lesser extent than that with the combustible cigarette extract. When redox balance was evaluated by the oxidative loss of low-molecular-weight thiols in the cells, we found that total glutathione (GSH) contents and low-molecular-weight thiol levels were significantly decreased after exposure to the aerosol extract of HTPs. These results indicated that GSH is rapidly consumed during the detoxification of xenobiotics, such as aldehydes from tobacco extracts. Accordingly, exposure to the aerosol extract of HTPs resulted in the enhanced carbonylation of many proteins. In a simple comparison, the results for HTPs were significantly different from those obtained with combustible cigarette smoke, suggesting reduced toxicity of HTPs. However, we found significant and harmful effects after exposing lung epithelial cells to the aerosol extract of HTPs. Thus, a further comprehensive study is needed to clarify the lung damage induced via the long-term inhalation of aerosols from HTPs.

[Vascular hyperpermeable molecules potentially contributing to the development of pulmonary edema in sepsis-associated ARDS]

The acute respiratory distress syndrome (ARDS) is an important cause of respiratory failure in critically ill patients and may become a life-threatening condition where inflammation of the lungs may begin in one lung but eventually affects both, leading to damage to the alveoli and surrounding small blood vessels. ARDS is particularly characterized by noncardiogenic pulmonary edema caused by an increase in pulmonary capillary permeability. Several clinical disorders can precipitate in ARDS, including pneumonia, sepsis, aspiration of gastric contents, and major trauma. The most common cause of ARDS is sepsis, which is a serious and widespread infection of the bloodstream and is now defined as life-threatening organ dysfunction due to a dysregulated reponse of the host to infection. In sepsis, a number of vascular hyperpermeable factors, such as histamine, nitric oxide, thromboxane A₂, and vascular endothelial growth factor, can be overproducted and contribute to the development of pulmonary edema. Given that sepsis can be regarded as a gene-related disorder, the nucleic-acid based gene therapeutic strategy to regulate some transcription factors involved in expression of vascular hyperpermeable genes may be considered to be a promising novel approach for treatment of ARDS in sepsis.

Impact of a long-term high-glucose environment on pro-inflammatory responses in macrophages stimulated with lipopolysaccharide

Cumulative evidence has established that macrophages orchestrate inflammatory responses that crucially contribute to the pathogenesis of insulin-resistant obesity and type 2 diabetes. In the present study, we examined the impact of hyperglycemia on macrophage pro-inflammatory responses under an inflammatory stimulus. To conduct this study, RAW264.7 macrophages were cultured under normal- (5.5 mM) or high-glucose (22 or 40 mM) conditions for 7 days and stimulated with lipopolysaccharide (LPS). Long-term exposure to high glucose significantly enhanced the increase in the production of pro-inflammatory cytokines, including tumor necrosis-α, interleukin (IL)-1β, and IL-6, when macrophages were stimulated with LPS. The LPS-induced increases in inducible nitric oxide (NO) synthase (iNOS) expression and NO production were also significantly enhanced by long-term exposure of macrophages to high glucose. Treatment with N-acetyl-L-cysteine, a widely used thiol-containing antioxidant, blunted the enhancement of the LPS-induced upregulation of pro-inflammatory cytokine production, iNOS expression, and NO production in macrophages. When intracellular reactive oxygen species (ROS) were visualized using the fluorescence dye 5-(and-6)-chloromethyl-2',7'-dichlorofluorescein diacetate, acetyl ester, a significant increase in ROS generation was found after stimulation of macrophages with LPS, and this increased ROS generation was exacerbated under long-term high-glucose conditions. LPS-induced translocation of phosphorylated nuclear factor-κB (NF-κB), a transcription factor regulating many pro-inflammatory genes, into the nucleus was promoted under long-term high-glucose conditions. Altogether, the present results indicate that a long-term high-glucose environment can enhance activation of NF-κB in LPS-stimulated macrophages possibly due to excessive ROS production, thereby leading to increased macrophage pro-inflammatory responses.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

AB0131 DIFFERENCES IN CLINICAL PARAMETERS AND LABORATORY DATA OF RHEUMATOID ARTHRITIS PATIENTS IN REMISSION OR WITH LOW DISEASE ACTIVITY TREATED WITH BIOLOGIC AGENTS OR JANUS KINASE INHIBITORS

Background:

There are four kinds of drugs for rheumatoid arthritis (RA) patients who are refractory or intolerant to methotrexate (MTX) or other conventional synthetic disease-modifying anti-rheumatic drugs, namely, tumor necrosis factor inhibitors (TNFi), inteleukin-6 inhibitors (IL-6i), abatacept (ABT) and Janus kinase inhibitors (JAKi). Although these drugs have distinct mechanism of action (MOA) to reduce disease activity of RA, the effects of these drugs of reducing disease activity or inhibiting joint damage are similar according past clinical trials. However, their different MOA may induce different change in body of RA patients. If there are some differences in body of RA patients treated different drugs which have different MOA, some differences may appear in clinical parameters and laboratory data we clinician are able to know in daily clinical practice.

Objectives:

This retrospective cross-sectional study assessed differences in clinical parameters and laboratory data in RA patients who met the treatment goal with biologic agents (BIO) or JAKi.

Methods:

Data from the Toyohashi RA database (TRAD) was used. The TRAD is a collection of single-center retrospective data. Participants were BIO- or JAK-treated RA patients with clinical disease activity remission (REM) or low disease activity (LDA) [clinical disease activity index (CDAI) ≤ 10]categorized by BIO treatment with TNFi (reference), IL-6i, or ABT, and JAKi treatment. Clinical parameters [tender joint counts (TJ), swollen joint counts (SJ), patient’s global assessment (PtGA), patient’s pain assessment (PainVAS), physician’s global assessment (PhGA) and modified health assessment questionnaire (mHAQ)] and laboratory data [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), matrix metalloprotease-3 (MMP-3), white blood cell counts (WBC), hemoglobin (Hb), platelet cell counts (PLT), neutrophils counts (Neut), lymphocyte counts (Lymph) and estimated glomerular filtration rate (eGFR)] were investigated in cross-sectional manner. They are statistically compared using the Dunnett test.

Results:

171 TNFi, 71 IL-6i, 50 ABT, and 18 JAKi cases are categorized in REM or LDA. Patients’ characteristics (means) are as follows (TNFi/IL-6i/ABT/JAKi). Age (63.1/63.7/72.4/60.6; years old), RA duration (17.0/12.7/18.2/11.3; years), %female (83.0/71.8/88.0/83.3), %rheumatoid factor positive (81.9/80.3/90.0/88.9), %anti-cyclic citrullinated peptide antibody (84.6/74.6/97.9/73.3), %prednisolone (PSL) concomitant (3.5/4.2/18.0/11.1) and %MTX concomitant (77.2/15.5/26.0/83.3). Parameters with statistical significance (means) were: TNFi/IL-6i-ESR 34.5/14.0 mm/hr, MMP-3 47.5/71.9 ng/mL, WBC 6124/5404 /µL, Lymph 2112/1646 µL; TNFi/ABT-TJ 0.4/1.0, PtGA 13.3/20.0 mm, PainVAS 15.7/21.6 mm, PhGA 7.4/11.1 mm, CRP 0.1/0.4 mg/dL, ESR 34.5/44.2 mm/hr, MMP-3: 47.5/72.9 ng/mL, Lymph 2112/1816 µL, Neut 3364/4233 µL, eGFR 75.4/65.3 mL/min/1.73m2; and TNFi/JAKi-PLT 21.7/29.3 104/µL, Lymph 2112/1326 µL.

Conclusion:

Although differences of rates of administering concomitant PSL or MTX should be considered, clinical parameter and laboratory data differences result from differences in the targeted cytokine between TNFi and IL-6i, differences in patient characteristics between TNFi and ABT, and differences in the MOA between TNFi and JAKi.

Disclosure of Interests:

None declared

POS0450 INCIDENCE RATES OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS IN REAL-WORLD CLINICAL PRACTICE

Background:

A definition of difficult-to-treat rheumatoid arthritis (D2T RA) was recently proposed by the European League Against Rheumatism (EULAR) [1]. However, information on the incidence rates of D2T RA in real-world clinical practice is lacking.

Objectives:

The aim of this retrospective cross-sectional study was to evaluate the incidence rates of D2T RA in clinical practice in Japan.

Methods:

Data from the Toyohashi RA database (TRAD) was used. The TRAD is a collection of single-center retrospective data. Patients with RA who fulfilled the following three requirements were included in this study: (1) had been treated with >1 biological or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD); (2) >1 year had passed since b/tsDMARD treatment was initiated; and (3) regularly visited our institute at the time of investigation. The number of targeted patients was 363. The criteria of D2T RA used in this study were modified from the EULAR definition for simplification of the investigation as follows: (a) ≥2 b/t DMARDs with different mechanisms of action had been administered; (b) at least moderate disease activity (DAS28-ESR > 3.2 or clinical disease activity index [CDAI] > 10) at the time of investigation; and (c) 7.5-mg/day of prednisolone (PSL) or more was administered at the time of investigation. In this study, D2T RA was defined as criteria (a) + (b) or (a) + (c) or (a) + (b) + (c). The 363 patients were categorized into four groups as follows: group A, DT2 RA; group B, patients with RA who had been treated with ≥2 b/tsDMARDs and did not fulfill the D2T RA definition; group C, RA patients who had been treated with one kind of b/tsDMARD with the same mechanism of action (e.g., two kinds of tumor necrosis factor inhibitors) and fulfilled either or both criteria (b) and (c); and group D, patients with RA who had been treated with one kind of b/tsDMARD with the same mechanism of action (e.g., a tumor necrosis factor inhibitors or two interleukin 6 inhibitors) and did not fulfill either or both criteria (b) and (c). The incidence rates of D2T RA were calculated, and the patients’ characteristics at the time of initiation of the b/tsDMARD treatment were compared between the groups.

Results:

The number of patients in groups A, B, C, and D were 34, 53, 94, and 182, respectively. Of all the patients included in this study, 9.4% were categorized into group A, those with D2T RA, and 39.1% were treated with ≥2 b/tsDMARDs and categorized into group A (Fig 1). The patients’ characteristics were as follows (group A/B/C/D): mean age (57.1/54.3/61.4/56.2 years), RA duration (10.0/6.7/13.8/8.2 years), %Steinbrocker stage III+IV (%; 84.0/60.0/77.3/54.3), %Steinbrocker class 3 + 4 (%; 68.0/33.3/43.4/23.0), methotrexate (MTX) concomitant rate (%; 79.4/92.5/74.5/91.8), PSL concomitant rate (%; 91.2/52.8/55.3/43.4), DAS28-ESR score (5.5/5.0/5.5/4.7), and CDAI score (12.3/13.7/22.7/16.9). There were statistically significant differences in RA duration, %stage III+IV, %class 3 + 4 and PSL concomitant rate between group A and B.

Conclusion:

D2T RA occurred in 9.4% of patients treated with b/tsDMARDs. Incidence rate was increased to 39.1% after the treatment with ≥2 b/tsDMARDs. The patients with D2T RA tended to be older, have a long RA duration, be treated without concomitant MTX, be treated with concomitant PSL, and have higher disease activity at the time of starting the b/tsDMARD treatment. The baseline patient characteristics in group C were similar to those in group A. In the future, we suggest that patients with D2T RA be included in group C.

References:

[1]Nagy et al. Ann Rheum Dis 2021; 80: 31-35.

Disclosure of Interests:

None declared

Vascular endothelial growth factor contributes to lung vascular hyperpermeability in sepsis-associated acute lung injury

Vascular endothelial growth factor (VEGF) is a prime regulator of vascular permeability. Acute lung injury (ALI) is characterized by high-permeability pulmonary edema in addition to refractory hypoxemia and diffuse pulmonary infiltrates. In this study, we examined whether VEGF can be implicated as a pulmonary vascular permeability factor in sepsis-associated ALI. We found that a great increase in lung vascular leak occurred in mice instilled intranasally with lipopolysaccharide (LPS), as assessed by IgM levels in bronchoalveolar lavage fluid. Treatment with the VEGF-neutralizing monoclonal antibody bevacizumab significantly reduced this hyperpermeability response, suggesting active participation of VEGF in non-cardiogenic lung edema associated with LPS-induced ALI. However, this was not solely attributable to excessive levels of intrapulmonary VEGF. Expression levels of VEGF were significantly reduced in lung tissues from mice with both intranasal LPS administration and cecal ligation and puncture (CLP)-induced sepsis, which may stem from decreases in non-endothelial cells-dependent VEGF production in the lungs. In support of this assumption, stimulation with LPS and interferon-γ (IFN-γ) significantly increased VEGF in human pulmonary microvascular endothelial cells (HPMECs) at mRNA and protein levels. Furthermore, a significant rise in plasma VEGF levels was observed in CLP-induced septic mice. The increase in VEGF released from HPMECs after LPS/IFN-γ challenge was completely blocked by either specific inhibitor of mitogen-activated protein kinase (MAPK) subgroups. Taken together, our results indicate that VEGF can contribute to the development of non-cardiogenic lung edema in sepsis-associated ALI due to increased VEGF secretion from pulmonary vascular endothelial cells through multiple MAPK-dependent pathways.

Clopidogrel, an ADP-P2Y12 Receptor Antagonist, Can Prevent Severe Postoperative Pain: A Retrospective Chart Review

The purinergic P2Y12 receptor regulates microglial activation, resulting in persistence and aggravation of pain in neuropathic and nociceptive pain models. We conducted a retrospective chart review to explore the analgesic potency of the P2Y12 receptor-specific antagonist, clopidogrel, for clinical management of postoperative pain in patients who underwent abdominal surgery. Twenty-seven patients with cardiovascular comorbidities, who underwent laparoscopic abdominal surgery and had ceased aspirin (ASP, n = 17) or clopidogrel (CLP, n = 10) for 14 days pre-operatively, were enrolled retrospectively. In both groups, the number of opioids and non-steroidal anti-inflammatory drugs (NSAIDs) consumed for managing postoperative pain was compared using the chi-square test and Mann–Whitney test. Our results showed that from postoperative day (POD) 0 to POD 3, the average numerical rating reflecting the postoperative pain was comparable between the two groups (CLP: 4.0 ± 1.4 vs. ASP: 3.7 ± 0.8, P-value = 0.56). However, at POD 7, opioid consumption in the CLP-treated group (fentanyl-equivalent dose: 0.49 ± 0.56 mg) was significantly lower than that in the ASP-treated group (1.48 ± 1.35 mg, P-value = 0.037). After reaching a stable state by repeated systemic administration, clopidogrel sustained the analgesic efficacy for a certain period. In conclusion, microglial P2Y12 receptors may mediate signal transduction of postoperative nociceptive pain and enhance clinical opioid analgesia.

AB0898 IMPACT OF BIOLOGICAL AGENTS, ORAL GLUCOCORTICOIDS, OR BOTH ON THE EFFICACY OF DAILY TERIPARATIDE TREATMENT FOR OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Daily teriparatide (dTP) strongly affects bone metabolism in patients with rheumatoid arthritis (RA), resulting in increased bone mineral density (BMD). We reported the 2-year results of dTP treatment for osteoporosis (OP) in patients with RA in EULAR2014 [1]. Drugs affecting bone metabolism, such as biological agents (BIOs) and glucocorticoids (GCs), are frequently administered to patients with RA in addition to dTP in daily clinical practice. Although dTP increases bone turnover, BIOs reduce osteoclast activity and GCs decrease bone turnover. We reported the effects of GCs or BIOs on the efficacy of dTP in EULAR2015 [2]. The present retrospective study investigated the effects of GCs or BIOs on the efficacy of dTP in patients with RA using a larger patient cohort.

Objectives:

To evaluate the effects of BIOs, GCs, or both on the efficacy of dTP treatment for OP in patients with RA.

Methods:

The study included 56 female patients who had completed 2 years of dTP treatment. We separated these patients into four groups according to their treatment regimen at dTP initiation: B(−)G(−),included patients who did not receive BIOs or GCs (n = 14); B(+)G(−), included patients treated only with BIOs (n = 8); B(−)G(+), included patients treated only with GCs (n = 24); and B(+)G(+),included patients treated with both BIOs and GCs (n = 10). We determined baseline (BL) characteristics, % changes in BMD in the lumbar spine (LS) and total hip (TH) from BL to 24 months, and % changes in serum bone turnover markers (BTMs), such as BAP, P1NP, NTX, and TRACP-5b, from BL to 6 months after dTP initiation. Dunnett’s test was used for comparisons between B(−)G(−) and other groups.

Results:

The mean ages of the B(−)G(−), B(+)G(−), B(−)G(+), and B(+)G(+) groups at BL were 70.0, 65.5, 69.6, and 71.5 years, whereas the mean duration of RA in these groups were 15.4, 20.8, 69.9, and 71.5 years, respectively. Furthermore, the mean baseline DAS28-CRP levels in these groups were 2.8, 2.2, 2.8, and 2.3. The mean LS-BMD (g/cm2) at BL were 0.795, 0.819, 0.826, and 0.853, whereas the mean TH-BMD at BL were 0.619, 0.570, 0.601, and 0.629, respectively. The mean % changes in LS-BMD at 24 months were 15.5%, 12.7%, 11.9%, and 8.1%, respectively (Fig 1A). There were no significant differences between B(−)G(−) and other groups. The mean % changes in TH-BMD at 24 months in the B(−)G(−), B(+)G(−), B(−)G(+), and B(+)G(+) groups were 6.4%, 5.3%, 4.4%, and 1.5%, respectively (Fig 1B) A significant difference was observed between the B(−)G(−) and B(+)G(+) groups (p = 0.03). The % changes in BTMs in the B(−)G(−), B(+)G(−), B(−)G(+), and B(+)G(+) groups were as follows: BAP, 90.5%, 44.0%, 29.5%, and 87.7%; P1NP, 374.1%, 338.2%, 225.9%, and 640.0%; NTX, 75.2%, 106.6%, 42.5%, and 80.5%; and TRACP-5b, 75.8%, 43.85, 20.4%, and 122.3%, respectively. No significant differences were observed in the changes in BTMs among the groups.

Conclusion:

This study suggested that concomitant use of BIOs and GCs inhibited the increase in BMD induced by dTP treatment in patients with RA, particularly TH-BMD. Although BTM analysis revealed no statistical significance, GCs tended to decrease the % change in BTMs.

References:

[1]Hirano et al. Ann Rheum Dis 2014: 73 (Suppl 2): 166

[2]Hirano et al. Ann Rheum Dis 2015: 74 (Suppl 2): 528

Disclosure of Interests:

Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Hironobu Kosugiyama: None declared, Kyosuke Hattori: None declared, Daisuke Kihira: None declared

Moderating effect of schizotypy on the relationship between smoking and neurocognition

Purpose

Smoking rates in schizotypic individuals are shown to be elevated, as in patients with schizophrenia, although findings on the association of smoking with different symptomatology of schizotypy have been mixed. Moreover, possible moderating effects of schizotypy on the relationship between smoking and cognition have not been well documented.

Subjects and methods

The Schizotypal Personality Questionnaire (SPQ) and the full version of the Wechsler Memory Scale-Revised (WMS-R) were administered to 501 healthy adults. Subjects were divided into smokers (n = 85) and non-smokers (n = 416) based on the presence/absence of current smoking.

Results

The analysis of covariance (ANCOVA) on the three factor scores as well as the total score of the SPQ, controlling for age and gender, revealed that cognitive-perceptual factor was significantly associated with an increased rate of smoking (P = 0.048). The ANCOVA on the WMS-R indices, with smoking group as a fixed factor and age, gender and total SPQ score as covariates, revealed that the schizotypy-by-smoking interaction was significant for attention/working memory (P = 0.029).

Discussion and conclusion

Positive schizotypy may be associated with more smoking. Schizotypy and smoking could interact with each other to negatively affect attention/working memory.

Quantitative evaluation of stress in Japanese anesthesiology residents based on heart rate variability and psychological testing

Clinical anesthesiologists, particularly residents, work in stressful environments. However, evidence-based physiological and psychological tests to evaluate stress are still lacking. In this single-center study of 33 residents, we investigated the relationship between heart rate variability (HRV), which had the potential to screen residents' stress levels using Holter electrocardiography (ECG) and psychological mood as assessed by the Profile of Mood States (POMS) questionnaire. HRV analysis revealed 2 findings. Firstly, standard deviation of the average of 5-min normal-to-normal R-R intervals (SDANN) was significant lower than that of same-aged healthy volunteers (69.3 ± 27.9 vs. 137.0 ± 43.0 ms, P < 0.05), which indicated suppression of autonomic nervous system activity throughout their work. Secondly, at induction of anesthesia, significant higher low frequency/high frequency ratio (LF/HF ratio: 1.326 vs. 0.846; P < 0.05) and lower HF (3326 vs. 5967 ms²; P < 0.05) and lower standard deviation of normal-to-normal R-R intervals (SDNN: 50.5 vs. 79.4 ms; nervous system was suppressed at the induction of anesthesia: expected to be the most stressful period of their work. On the other hand, deviation scores of POMS questionnaire elucidated that all the residents were within normal range of psychological mood, and without any significant diurnal changes with respect to total mood disturbance deviation (TMD) scores (48 vs. 47; P = 0.368). HRV elucidated physiological stress among anesthesiology residents quantitatively by evaluating autonomic nervous activities, especially at induction of anesthesia. These changes in HRV could be observed regardless of psychological mood.

P4384Noninvasive and novel method to evaluate left ventricular contractility using pressure-volume loop area obtained by 3-dimensional speckle tracking echocardiography

Introduction

Left ventricular (LV) pressure-volume (P-V) loop area reflects stroke work (SW), but clinical use of this index is limited by the need of invasive pressure measurement. A noninvasive method to obtain LV pressure-strain loop was recently introduced to assess myocardial work (MW). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau and we reported that Tau was noninvasively evaluated by speckle tracking echocardiography (STE).

Purpose

We sought to evaluate the impact of preload change by leg lifts on LV SW noninvasively obtained by the novel method and to examine the utility to assess LV contractility by SW and end-diastolic (ED) volume relation (SW-VED).

Methods

Thirty six controls (age 71±10) and 30 patients with heart failure with reduced ejection fraction (EF) <50% (HF) (age 73±6) were enrolled. LV pressure in a cardiac cycle was estimated using systolic blood pressure (SBP), minimum diastolic pressure (mDP) and ED pressure (EDP) by utilizing the profile of an empiric, normalized reference curve. The mDP and EDP were estimated as (Tau − 33.7)/2.06 and as 12.3 − 10.1 x Log (left atrial active emptying function/minimum volume) as we reported. LVSW was obtained by P-V loop by the combination of these pressures and LV volume using 3-D STE.

Results

LVEF and longitudinal strain in HF before leg up by 3D-STE were lower compared to normal (LVEF; normal: 58±5 vs HF: 39±10*% and strain; −12±3 vs −8±3%*, *p<0.05 vs normal). LVEF was increased after leg up by 7±6% in normal and by 8±8% in HF associated with increased LVED volume (normal: 84±24 to 90±24 and HF: 124±36* to 136±42*ml). LV MW and SW in HF before leg up were lower compared to normal (MW: 1790±412 vs 1002±432*mmHg% and SW: 3946±1682 vs 3352±1026mmHgml). LV SW increased after leg up by 26±19% in normal and by 25±20% in HF. LV SW-VED in normal was greater than HF (241±151 vs 90±54*).

Conclusion

LV SW noninvasively obtained by P-V loop area was increased after leg up in both normal and HF but SW-VED in HF was smaller than normal, indicating reduced contractility in HF. This noninvasive method may be a new echocardiographic approach for quantification of LV SW and contractility.

P2474Noninvasive estimation of pulmonary capillary wedge pressure by novel 3D speckle tracking echocardiography and validation study by cardiac catheterization

Background

We previously reported that pulmonary capillary wedge pressure (PCWP) was noninvasively evaluated by 2D speckle tracking echocardiography (STE). Recently, novel software was introduced to examine volume and function of left ventricular and left atrium (LA) by 3D-STE automatically.

Purpose

We sought to compare the PCWP estimated by conventional 2D-STE (2D-ePCWP) and by novel 3D-STE (3D-ePCWP), and validate those values by cardiac catheterization.

Methods

Echocardiography and catheterization were performed in 29 patients (age 72±2) (7 ischemic heart disease, 2 hypertensive heart disease, 5 dilated cardiomyopathy, 12 valvular heart disease and 3 primary pulmonary hypertension).The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 x Log (left atrial active emptying function/minimum volume) as we previously reported. Echocardiography was performed just before the catheterization and we analyzed the 2D and 3D data by novel off-line software. 3D data was automatically analyzed and the border settings were fixed at default (ES60, ED30) (Figure).

Results

2D-ePCWP and 3D-ePCWP had a good correlation with PCWP invasively obtained by catheterization (r=0.87 and 0.83, respectively, both p<0.001). There was an excellent correlation between 2D-ePCWP and 3D-ePCWP (r=0.94, p<0.001) and there was a good correlation between 2D-LA volume index and 3D- LA volume index (r=0.80, p<0.001). Bland-Altman analysis revealed a good agreement between 2D-ePCWP and 3D-ePCWP, and between 2D-ePCWP and 3D-ePCWP without fixed and proportional bias.

Conclusion

This study demonstrated that PCWP might be noninvasively assessed by not only 2D-STE but also 3D-STE with reasonable accuracy and 3D-STE might have utility and value in the routine clinical practice.

P4351Validation by cardiac catheterization of noninvasive evaluation of left ventricular chamber and myocardial stiffness as a diastolic function using speckle tracking echocardiography

Background

Left ventricular (LV) diastolic function is mainly composed of LV relaxation and LV stiffness. We reported that pulmonary capillary wedge pressure (ePCWP) and LV relaxation assessed by Tau (eTau) are noninvasively evaluated by speckle tracking echocardiography (STE). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau. Therefore, LV chamber stiffness (c-stiffness) may be assessed with the use of two LV diastolic pressure-volume coordinates: the mLVP and volume and the end-diastolic pressure (EDP) and volume.

Purpose

We sought to noninvasively assess LV stiffness using STE and validate the value by cardiac catheterization.

Methods

Echocardiography and catheterization were performed in 124 patients (age 72±8) (70 angina pectoris, 20 prior myocardial infarction, 19 hypertensive heart disease, 11 congestive heart failure and 4 paroxysmal atrial fibrillation). The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 × Log (left atrial active emptying function/minimum volume) and the eTau (ms) is obtained as isovolumic relaxation time/(ln 0.9 × systolic blood pressure − ln ePCWP) as previously reported. The mLVP (e-mLVP) was estimate using Tau. The estimated EDP (e-EDP) was calculated as 12.3 − 10.1 × Log (left atrial active emptying function / minimum volume). LV c-stiffness (mmHg/ml) was calculated as LV pressure change (from mLVP to EDP) obtained by catheterization divided by LV volume change during diastole which equals to stroke volume by echocardiography. Estimated c-stiffness (e-c-stiffness) was noninvasively obtained using e-mLVP and e-EDP. Furthermore, LV myocardial stiffness (m-stiffness) was calculated by LVED stress / LV longitudinal strain by STE, where LV stress (kdynes/cm2) was calculated as 0.334 × pressure × dimension / [thickness (1 + thickness/dimension)]. The estimated m-stiffness (e-m-stiffness) was calculated using e-EDP.

Results

The eTau and e-EDP estimated by STE had a good correlation with Tau and EDP invasively obtained by catheterization (r=0.75 and 0.63, respectively, both p<0.001). There was a good correlation between Tau and mLVP (Tau = 2.06 mLVP + 33.7, r=0.70). The estimated LVED stress had good correlation with ED stress obtained by catheterization (r=0.77, p<0.001). The e-c-stiffness and e-m-stiffness had a good correlation with those obtained by catheterization (e-c-stiffness; 0.116±0.07 and c-stiffness; 0.115±0.06, r=0.603, e-m-stiffness; 0.81±0.41 and m-stiffness; 0.85±0.45, r=0.89, respectively). Bland-Altman analysis revealed a good agreement between e-c-stiffness and c-stiffness, and between e-m-stiffness and m-stiffness without fixed and proportional bias.

Conclusion

This study demonstrated that LV stiffness may be noninvasively assessed by STE with reasonable accuracy and may have utility and value in the routine clinical practice for the diagnosis and treatment in patients with diastolic dysfunction.

High rate filtration for local treatment of combined sewer overflow

Combined sewer overflows (CSOs) pollute receiving waters and have a negative impact on ecosystem services. In urban areas rehabilitation of the sewer system to avoid CSOs is associated with high investment costs. Furthermore, not all CSOs can be closed due to the need for hydraulic reliability of the system. Local treatment of CSO with high rate filtration offers an alternative to rehabilitation of the sewer system that is flexible with respect to design and has lower investment cost than separating sewage and storm water runoff. Results from DESSIN, a 4-year EU demonstration project, are presented. The results showed on average 50% removal of particulate matter during CSO events, with higher removal (80%) in the initial first flush period. Other constituents, for example heavy metals, were removed through their association with particles. Potential impacts on ecosystem services in the catchment and the sustainability of the solution were assessed.