The initial experience of robot-assisted transabdominal transversalis fascial and preperitoneal repair for small ventral hernia

PURPOSE

Despite the widespread of ventral hernia repairs globally, the approach method, dissection planes, defect closure, and the choice and placement layer of mesh are an ongoing debate. We reported the details of surgical techniques, safety and feasibility for robot-assisted transabdominal transversalis fascial and preperitoneal repair (R-TATFPP) for small ventral hernia.

METHODS

This study included 5 cases of R-TATFPP repair among 22 cases performed by robot-assisted ventral hernia repair from 2018 to 2023 with the approval of the Institutional Review Board at St. Luke's International University and clinical ethical committee at St. Luke's International Hospital (19-R147, 22-012).

RESULTS

There were four males and one female, with mean age of 64.4 ± 10.0 years, inclusive of two umbilical and three incisional hernias. Mean height, weight, body mass index (BMI), hernia defect length, width, operation time, console time, and hospital stay were 171.2 ± 11.8 cm, 82.4 ± 13.4 kg, 28.0 ± 2.1 kg/m2, 2.8 ± 1.4 cm, 3.0 ± 1.3 cm, 180 min, 133.8 min, and 2.4 days, respectively. No conversion nor complication was observed except for one acute urinary retention.

CONCLUSION

Robot-assisted transversalis fascial and preperitoneal repair was safe and feasible for small ventral hernia with the minimal disruption to the abdominal wall architecture and structures.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study

INTRODUCTION

We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan.

METHODS

Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve.

RESULTS

In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001).

CONCLUSION

Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.

Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies

BACKGROUND

The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies.

METHODS

Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months).

RESULTS

Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%).

CONCLUSIONS

The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

The endoscopic-assisted or endoscopic mini- or less-open preperitoneal (E/MILOP) approach for primary and incisional ventral hernia repair

INTRODUCTION

The endoscopic-assisted or endoscopic mini- or less-open sublay (E/MILOS) concept describes a contemporary approach of trans-hernial repair of ventral hernia via sublay mesh placement. The term sublay often causes confusion, and preperitoneal placement of mesh should be considered as a distinctive approach. We hereby present our experience of a novel approach, the E/MILOP approach, for the repair of primary and incisional ventral hernias.

METHODS

All patients who underwent E/MILOP between January 2020 and December 2022 were identified and their preoperative and perioperative characteristics, as well as postoperative outcomes, were retrospectively analyzed. The surgical procedure entailed an incision over the hernia defect and careful entrance into, and development of, the preperitoneal space trans-hernially. A synthetic mesh was placed in the preperitoneal space and the defect was closed with sutures.

RESULTS

A total of 26 patients with primary and/or incisional ventral hernias who underwent E/MILOP were identified. Three patients (11.5%) presented with two coexistent types of hernias, and out of a total of 29 hernias, there were 21 (72.4%) umbilical, four epigastric (13.8%) and four incisional (13.8%) hernias. The mean defect width was 2.7 ± 0.9 cm. All cases utilized a mesh with a mean mesh-to-defect ratio of 12.9. The mean postoperative stay was 1.9 days. Surgical site occurrence was observed in eight (30.1%) patients, but none required intervention. No recurrence was observed during a mean follow-up period of 286.7 days.

CONCLUSION

The E/MILOP approach is a novel alternative for primary and incisional ventral hernia repair.

Arteriovenous malformation of the spermatic cord mimicking reducible inguinal hernia

Arteriovenous malformations are a vascular anomaly most often found in the central nervous system; however, they can present ubiquitously in any organs or tissues. We present the case of a 55-year-old man who developed a tender, reducible inguinal bulge and underwent laparoscopic transabdominal preperitoneal inguinal hernia repair under the clinical diagnosis of an inguinal hernia. Intraoperative observation revealed no hernia sac, but a poorly defined spermatic cord mass, appearing to be responsible for the patient's symptoms, was found and removed. The pathology of the mass was consistent with the diagnosis of an arteriovenous malformation of the spermatic cord. Surgeons should keep in mind the small possibility of arteriovenous malformations in patients with clinical presentation of an inguinal hernia, as they may cause massive bleeding during and after the operation unless handled appropriately.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

Long-term results after robot-assisted radical prostatectomy of a simplified inguinal hernia prevention technique without artificial substance use

INTRODUCTION

Durable techniques that prevent postoperative inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) have not been established. This study evaluated the long-term efficacy of a postoperative IH prevention technique that uses no artificial agents to assess the characteristics of IH occurrence after introducing this technique.

PATIENTS AND METHODS

We retrospectively analyzed 201 consecutive patients who underwent RARP at our institution between September 2011 and February 2014. In total, 189 cases were eligible for the study. The non-IH prevention and IH prevention groups comprised 72 and 117 cases, respectively. We compared the incidence of IH between the two groups using Kaplan-Meier curves. Risk factors for IH in the prevention group were determined via multivariable logistic regression analysis.

RESULTS

The rate of IH occurrence was 20.8% (15 cases) in the nonprevention group and 8.5% (10 cases) in the prevention group, with median follow-up periods of 99.5 and 89.9 months, respectively. The Kaplan-Meier curves indicated a significant difference between the two groups (p = 0.011). Only cutting of the vas deferens significantly contributed to reduced occurrence of IH in multivariable analysis (p = 0.047). After reviewing the intraoperative videos, insufficient separation of the vas deferens was considered the main cause of IH in the prevention group.

CONCLUSION

Our simple prevention technique with no artificial agents had a durable effect on IH prevention after RARP over a median follow-up period of more than 7 years. Cutting the vas deferens effectively prevented IH after RARP.

The first case of robotic-assisted transabdominal retrorectus repair for incisional hernia in Japan

Extraperitoneal mesh repair for ventral hernia has garnered attention and its rate has been increasing due to concerns for the potential complications of intraperitoneal mesh repair. Recently, robotic-assisted ventral hernia repair is highlighted as a solution to the technically demanding nature of laparoscopic transabdominal or enhanced-view totally extraperitoneal retrorectus ventral hernia repair. A 78-year-old man, who had undergone robot-assisted radical prostatectomy 10 months earlier, presented with an incisional hernia of European Hernia Society Classification M3W2, length 4 cm, width 5 cm with rectus diastasis. A right single-docking robotic-assisted transabdominal retrorectus repair was performed using a 21 by 14 cm self-gripping mesh and anterior wall reconstruction was done by 0 barbed nonabsorbable running suture. There were no complications and recurrence observed during a 7 months postoperative period. Single-docking robotic-assisted transabdominal retrorectus repair was considered a good option for midline moderate-size incisional hernias from the point of view of the ease of suturing, adequateness of dissection and prevention of bowel injury.

Tongue Muscle for the Analysis of Head Muscle Regeneration Dynamics

Tongue muscle damage impairs speaking and eating, thereby degrading overall health and quality of life. Skeletal muscles of the body are diverse in embryonic origin, anatomic location, and gene expression profiles. Responses to disease, atrophy, aging, or drugs vary among different muscles. Currently, most muscle studies are focused on limb muscles and the tongue is neglected. The regenerative ability of tongue muscle remains unknown, and thus there is need for tongue muscle research models. Here, we present a comprehensive characterization of the spatiotemporal dynamics in a mouse model of tongue muscle regeneration and establish a method for the isolation of primary tongue-derived satellite cells. We compare and contrast our observations with the tibialis anterior (TA) limb muscle. Acute injury was induced by intramuscular injection of cardiotoxin, a cytolytic agent, and examined at multiple timepoints. Initially, necrotic myofibers with fragmented sarcoplasm became infiltrated with inflammatory cells. Concomitantly, satellite cells expanded rapidly. Seven days postinjury, regenerated myofibers with centralized nuclei appeared. Full regeneration, as well as an absence of fibrosis, was evident 21 d postinjury. Primary tongue-derived satellite cells were isolated by enzymatic separation of tongue epithelium from mesenchyme followed by magnetic-activated cell sorting. We observed that tongue displays an efficient regenerative response similar to TA but with slightly faster kinetics. In vitro, tongue-derived satellite cells differentiated robustly into mature myotubes with spontaneous contractile behavior and myogenic marker expression. Comparison of gene expression signatures between tongue and TA-derived satellite cells revealed differences in the expression of positional-identity genes, including the HOX family. In conclusion, we have established a model for tongue regeneration useful for investigations of orofacial muscle biology. Furthermore, we showed that tongue is a viable source of satellite cells with unique properties and inherited positional memory.

Indocyanine green fluorescence-guided laparoscopic removal of infected mesh with chronic sinus formation after inguinal mesh plug repair

Chronic mesh infection with sinus formation is usually amenable to open method with dye. Recently, intraoperative real-time fluorescent imaging has been applied to various organs but not to mesh infection. A 72-year-old man with the history of two times removal of infected mesh was referred for groin bulge with purulent discharge. Laparoscopy assisted infected mesh removal was undertaken using intraoperative real-time fluorescent imaging with indocyanine green injection via the sinus orifice. We experienced the first case of the infected mesh with chronic sinus formation treated by the help of intraoperative indocyanine green fluorescent. This method is simple and easy to apply for laparoscopic assisted removal of chronic mesh infection with sinus.

POS0657 GEOGRAPHIC VARIATION OF SAFETY IN THE FILGOTINIB RHEUMATOID ARTHRITIS PROGRAM

Background:

The Janus kinase-1 preferential inhibitor filgotinib (FIL) improved signs and symptoms of rheumatoid arthritis (RA) in the FIL clinical program.1–3

Objectives:

To assess FIL safety across regions.

Methods:

This was an analysis of patients (pts) meeting 2010 ACR/EULAR RA criteria in pooled phase (P)2 DARWIN 1–2 (D1–2), P3 FINCH 1–3 (F1–3), and long-term extension studies (DARWIN 3, FINCH 4). Data were analyzed by region: North America, South and Central America, Western Europe, Eastern Europe, Asia, South East (SE) Asia, and Other. Week (W)12 placebo (PBO)-controlled analysis included data from pts receiving once-daily FIL 100 mg (FIL100), FIL 200 mg (FIL200), or PBO for ≤12W (D1–2, F1–2); long-term as-treated data included pts from all 7 studies receiving FIL100 or FIL200; data after rerandomization were included and contributed to treatment received. Data presented as exposure-adjusted incidence rates (EAIRs)/100 patient-years of exposure (PYE) of treatment-emergent (TE) adverse events (TEAEs).

Results:

Table 1 shows EAIRs of TEAEs in PBO-controlled analysis. EAIRs/100 PYE of all TEAEs in Western Europe, Asia, and Other were higher than in remaining regions and for PBO vs FIL arms; EAIRs for FIL200/FIL100 in North America and SE Asia were higher vs PBO. EAIRs/100 PYE of TE serious AEs were higher in SE Asia for FIL100 and for FIL200/FIL100 in Other, with high PBO EAIRs in Western Europe. EAIRs/100 PYE of TEAEs leading to study discontinuation were higher in FIL arms vs PBO in Western Europe and Other (FIL200); in Asia and SE Asia, EAIRs were higher for PBO vs FIL200/FIL100.

Table 1.

EAIR of TEAEs (placebo-controlled)

North AmericaN = 481South and Central AmericaN = 350Western EuropeN = 141Eastern EuropeN = 933AsiaN = 236South East AsiaN= 135OtherN = 70TEAEFIL200a216.9 (162.5, 289.5)205.6 (155.1, 272.6)285.0 (188.6, 430.8)150.3 (119.3, 189.4)248.9 (180.6, 343.1)165.1 (104.0, 262.1)298.4 (150.3, 592.5)FIL100b182.2 (136.8, 242.7)159.2 (117.3, 216.1)285.7 (183.7, 444.3)146.4 (115.9, 185.0)246.9 (180.3, 338.1)153.7 (94.2, 251.0)263.5 (113.9, 609.2)PBOC174.5 (130.3, 233.7)162.1 (118.8, 221.2)314.9 (200.7, 493.9)148.4 (117.6, 187.4)259.0 (188.0, 356.8)81.6 (40.8, 163.3)306.0 (142.8, 655.7)TE serious AEFIL200a14.3 (6.0, 34.4)11.4 (3.7, 35.5)8.3 (1.2, 59.0)12.2 (5.2, 28.7)5.5 (0.8, 38.9)0.0 (0.0, ∞)49.6 (10.2, 144.9)FIL100b10.6 (4.0, 28.3)7.2 (1.8, 28.7)19.9 (5.0, 79.7)15.1 (6.8, 33.7)16.2 (5.2, 50.2)28.8 (9.3, 89.4)20.5 (0.5, 114.0)PBOC16.1 (7.2, 35.9)7.5 (1.9, 30.0)29.6 (9.5, 91.7)4.6 (1.3, 15.8)11.4 (2.8, 45.5)10.2 (1.4, 72.4)0.0 (0.0, 69.2)TEAE leading to discontinuationFIL200a8.6 (2.8, 26.6)3.8 (0.1, 21.2)16.6 (4.2, 66.5)12.9 (5.5, 30.5)0.0 (0.0, 20.2)9.2 (1.3, 65.1)16.5 (0.4, 92.1)FIL100b10.6 (4.0, 28.3)7.2 (0.9, 26.0)19.9 (5.0, 79.7)1.9 (0.2, 13.8)5.4 (0.1, 30.1)9.6 (1.4, 68.2)0.0 (0.0, 75.5)PBOC5.4 (1.3, 21.5)0.0 (0.0, 13.8)9.9 (1.4, 70.0)12.9 (5.4, 30.7)17.1 (3.5, 49.9)20.4 (5.1, 81.6)0.0 (0.0, 69.2)

Data presented as EAIR (95% CI)/100 patient-years

aN = 777, 179.8 PYE bN = 788, 181.6 PYE cN = 781, 178.4 PYE

A subject may contribute to more than one treatment group if they received more than one treatment of interest.

EAIR and corresponding 95% CI were estimated using Poisson regression model by treatment, including study and treatment with an offset of natural log of exposure time, except when 0 events occurred; Poisson model was not adjusted by study.

AE, adverse event; CI, confidence interval; EAIR, exposure-adjusted incidence rate; FIL, filgotinib; PBO, placebo; PYE, patient-years of exposure; TE, treatment-emergent

Figure shows serious infections (SI), venous thromboembolism (VTE) and herpes zoster (HZ) EAIRs.

EAIRs for SI were highest in Other for FIL200 and SE Asia for FIL100. While VTE EAIRs were low, pts in 5/7 regions had VTE. HZ EAIRs were highest in Asia.

Conclusion:

Although EAIR of TEAEs varied between regions, no consistent trend was reflected in any particular region.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

Disclosure of Interests:

Bernard Combe Speakers bureau: BMS; Eli Lilly & Co.; Gilead Sciences, Inc.; MSD; Pfizer; Roche-Chugai; and UCB, Consultant of: AbbVie; Eli Lilly & Co.; Gilead Sciences, Inc.; Janssen; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Tsukasa Matsubara Speakers bureau: Pfizer Japan, Nichi-Iko, Astellas, Meiji Seika, Bristol-Myers Squibb, AbbVie GK, Janssen, Chugai, Eisai, AYUMI, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Jaehyung Hong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, BV, Employee of: Galapagos, BV, Antonio Gomez-Centeno Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly & Co., Gebro, Janssen, Menarini, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sanofi, and UC, Consultant of: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly & Co., Gebro, Gilead Sciences, Inc., Hospira, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sandoz, Sanofi, Grant/research support from: Boehringer Ingelheim, Celltrion, Eli Lilly & Co., Galapagos NV, Gilead Sciences, Inc., Novartis, Pfizer, Roche, Sanofi, UCB, YL Biologics, Maya H Buch Speakers bureau: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Grant/research support from: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB

POS0658 GEOGRAPHIC VARIATION OF EFFICACY IN THE FILGOTINIB RHEUMATOID ARTHRITIS PROGRAM

Background:

The Janus kinase-1 preferential inhibitor filgotinib (FIL) improved signs and symptoms of rheumatoid arthritis (RA) across the FIL clinical program.1–3

Objectives:

To assess FIL efficacy across geographic regions.

Methods:

Pooled data from patients (pts) meeting 2010 ACR/EULAR RA criteria randomised to once-daily FIL 200 mg (FIL200), FIL100 mg (FIL100), or placebo (PBO) with background conventional synthetic disease-modifying antirheumatic drugs in DARWIN 1 (P2; up to week [W]12) and FINCH 1–2 (P3; up to W24) studies were evaluated. Data were analysed by region: North America, South and Central America, Western Europe, Eastern Europe, Asia, South East (SE) Asia, and Other. W12 American College of Rheumatology 20% improvement (ACR20) and W24 Disease Activity Score in 28 joints (C-reactive protein) (DAS28[CRP]) <2.6 and ≤3.2 response rates were analysed by a logistic regression model. Change from baseline (CFB) in Health Assessment Questionnaire-Disability Index (HAQ-DI) at W12 was analysed by a mixed-effects model for repeated measures. Analyses were exploratory and not adjusted for multiplicity.

Results:

Despite high PBO response rates in Eastern Europe and South and Central America, greater proportions of pts receiving FIL200 or FIL100 vs PBO achieved ACR20 at W12 (P <0.05) in all regions, except Other (with lowest sample size, n = 69), where both FIL doses were numerically greater than PBO (Table 1). At W12, least-squares mean CFB in HAQ-DI improved for pts receiving FIL200 or FIL100. vs PBO (P <0.05) in all regions, except SE Asia, where improvement was numeric (Table 1).

Table 1.

Proportion of pts achieving ACR20 and LSM change from baseline HAQ-DI at week 1

ACR20HAQ-DIFIL200FIL100FIL200FIL100FIL200FIL100North America64.8*58.3*33.8−0.63*−0.58*−0.34n = 455(56.7, 72.9)(50.3, 66.4)(26.0, 41.6)(−0.70, −0.56)(−0.65, −0.51)(−0.41, −0.27)South and Central America77.277.357.4−0.77*−0.67*−0.43n = 283(68.1, 86.3)†(65.8, 86.2)†(46.9, 68.0)(−0.85, −0.68)(−0.75, −0.59)(−0.52, −0.35)Western Europe69.4*68.3*24.4−0.69*−0.61*−0.28n = 135(55.5, 83.3)(52.8, 83.8)(10.8. 38.1)(−0.80, −0.58)(−0.73, −0.49)(−0.40, −0.17)Eastern Europe77.1*69.1*54.6−0.62*−0.51*−0.34n = 822(71.9, 82.3)(63.5, 74.7)(48.5, 60.7)(−0.68, −0.56)(−0.57, −0.45)(−0.40, −0.28)Asia81.0*60.0†37.7−0.83*−0.61†−0.42n = 236(71.7, 90.3)(48.6, 71.4)(26.2, 49.1)(−0.92, −0.73)(−0.70, −0.52)(−0.52, −0.33)South East Asia70.2†71.1†39.5−0.61−0.57−0.45n = 135(56.1, 84.4)(56.8, 85.5)(23.8, 55.3)(−0.73, −0.49)(−0.69, −0.45)(−0.58, −0.33)Other60.052.439.1−0.56‡−0.60‡−0.33n = 69(38.8, 81.2)(28.6, 76.1)(17.0, 61.2)(−0.72, −41)(−0.76, −0.43)(−0.49, −0.17)Overall73.4*66.4*45.3−0.71*−0.61*−0.40N = 2135(70.1, 76.8)(62.9, 70.0)(41.5, 49.0)(−0.76, −0.66)(−0.66, −0.56)(−0.45, −0.35)

Includes only patients initially randomised to the treatment groups in each study for the comparison of interest. ACR20 presented as percentage (95% CI); 95% CI was based on normal approximation method with a continuity correction; P values calculated from the logistic regression.HAQ-DI presented as LSM (95% CI); LSM, 95% CI, and P value calculated from a mixed-effects model for repeated measures.*P <0.001, †P <0.01, ‡P <0.05; not adjusted for multiplicity.

ACR20, American College of Rheumatology 20% improvement; CI, confidence interval; FIL, filgotinib; HAQ-DI, Health Assessment Questionnaire-Disability Index; LSM, least square mean; PBO, placebo.

At W24, DAS28(CRP) <2.6 and ≤3.2 response rates were higher for both doses of FIL vs PBO (P <0.05) in all regions, with the exception of Other, where PBO was higher than FIL100 for DAS28(CRP) <2.6 (Figure 1).

Conclusion:

In exploratory analyses, ACR20, DAS28(CRP) <2.6 and ≤3.2 response rates and HAQ-DI scores varied between regions; however, no stable trend was shown in any particular region. Small pt numbers in some subgroups may confound statistical analysis.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

Disclosure of Interests:

Maya H Buch Speakers bureau: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB., Grant/research support from: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB., Tsukasa Matsubara Speakers bureau: Pfizer Japan, Nichi-Iko, Astellas, Meiji Seika, Bristol-Myers Squibb, AbbVie GK, Janssen, Chugai, Eisai, AYUMI, Bernard Combe Speakers bureau: BMS; Eli Lilly & Co.; Gilead Sciences, Inc.; MSD; Pfizer; Roche-Chugai; and UCB, Consultant of: AbbVie; Eli Lilly & Co.; Gilead Sciences, Inc.; Janssen; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Jaehyung Hong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, BV, Employee of: Galapagos, BV, Antonio Gomez-Centeno Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly & Co., Gebro, Janssen, Menarini, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sanofi, and UCB, Consultant of: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly & Co., Gebro, Gilead Sciences, Inc., Hospira, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sandoz, Sanofi, Grant/research support from: Boehringer Ingelheim, Celltrion, Eli Lilly & Co., Galapagos NV, Gilead Sciences, Inc., Novartis, Pfizer, Roche, Sanofi, UCB, YL Biologics

Advance Care Planning for Intensive Care Patients During the Perioperative Period: A Qualitative Study

INTRODUCTION

Patients in intensive care units (ICUs) may transition into an end-of-life phase during treatment. Advance care planning (ACP) for this population has not been studied comprehensively, and support for its implementation is insufficient.

OBJECTIVE

This study aims to clarify the ACP support needs among critical perioperative patients.

METHODS

In this qualitative descriptive study, semistructured interviews were conducted with patients previously admitted to the ICU. The survey was conducted from September to November 2019. Participants comprised 13 individuals, who were admitted to the ICU for a period of 3 months to 2 years after surgery.

RESULTS

The average age of the participants was 63.8 years. The average mechanical ventilation duration following surgery was 24.5 h. The interviews focused on the ACP needs from the preoperative period to discharge. About 90% of the patients thought about the possibility of death before surgery and considered giving advance orders (e.g., "I don't want life-sustaining treatment"). The participants discussed inheritance, work-related matters, and household issues with their families but rarely spoke about treatment and care. Although they examined the content of the advance directives, the medical staff was not informed about them. Patients revealed that they wanted to understand the distinction between life-prolonging and life-saving treatments and discuss it with the medical staff, apart from being educated on ACP. Many patients previously admitted to the ICU are unclear about the difference between life-prolonging and life-saving treatments; this is also true for medical staff.

CONCLUSION

Patients who had been admitted to the ICU after high-risk surgery thought they needed help with ACP before surgery. Therefore, patients have the right to know about treatment risks; however, medical staff believes that this is difficult to communicate. Thus, medical staff should consider ways to communicate clearly with patients, including discussing the risks associated with surgery.

Impact of body mass index on the clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Increased body mass index (BMI) has recently shown to have a favorable effect on the prognosis in heart failure (HF) patients. However, the impact of BMI on clinical events and mortality in HF patients who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

This study aimed to investigate whether the obesity paradox is present in HF patients who have undergone CR.

Methods

This study enrolled 238 consecutive HF patients who had undergone CR at our university hospital between November 2015 and October 2017. The clinical characteristics and anthropometric data of these patients, including BMI, were collected at the beginning of the CR. The major adverse cardiovascular event (MACE) was defined as a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data regarding the primary endpoints were collected until November 2018.

Results

Patients (mean age 68.7 years, male 61%) were divided into four groups as per BMI quartiles. More patients in the highest BMI group were women, were significantly younger, and had a higher prevalence of hypertension, dyslipidemia, and diabetes mellitus; however, no significant differences were observed in the prevalence of chronic kidney disease, left ventricular ejection fraction, and brain natriuretic peptide levels of the four groups. During a median follow-up duration of 583 days, 28 patients experienced all-cause mortality, and 42 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the highest BMI quartiles had lower rates of MACE (Log-rank P&lt;0.05) (Figure 1). After adjusting for confounding factors, Cox regression multivariate analysis revealed that BMI was negatively and independently associated with the incidence of MACE (hazard ratio: 0.89, 95% confidence interval: 0.83–0.96, P&lt;0.05).

Conclusion

Increased BMI was associated with better clinical prognosis even in HF patients who have undergone CR Therefore, BMI assessment may be useful for risk stratification in HF patients who have undergone CR.

Figure 1. Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: None

Uninterrupted twice-daily direct oral anticoagulants are safer than once-daily ones for atrial fibrillation catheter ablation

Background

In patients undergoing AF catheter ablation (CA), uninterpreted DOACs reduced bleeding events without increasing ischemic events compared with vitamin K antagonist, and the continuation of anticoagulants is recommended for AF ablation. However, in the past studies, patients received once-daily DOACs in the evening, not in the morning of the procedure day. Moreover, there has been no study comparing uninterrupted 4 DOACs; therefore, the safety and effect of uninterpreted DOACs taken just in the morning of AF ablation is unknown.

Objective

The purpose of this study was to compare bleeding complications and thromboembolism events between 4 DOACs in patients undergoing AF ablation.

Method

This study was the retrospective single-center cohort study of consecutive patients who underwent AF ablation between April 2014 to July 2019. All patients continued DOAC uninterruptedly including just in the morning of the procedure. The primary endpoint included major bleeding events within the first 30 days after CA. The secondary endpoints included the composite events of ischemic stroke, systemic embolism, myocardial infarction, and vascular death.

Result

A total of 713 patients (mean age 64±12 years, 72% male) were included in this analysis; enrolled patients were 88, 238, 218, and 169 respectively in dabigatran, rivaroxaban, apixaban and edoxaban group. At the baseline, the ratio of age ≥75 years and CHADS2 score was higher in apixaban group, though all other baseline variables were similar between them.

The primary endpoint was observed 0%, 2.1%, 0.45%, and 4.7% respectively in dabigatran, rivaroxaban, apixaban, and edoxaban group (P=0.013) without significant difference about secondary endpoint between them (P=0.3).

Comparing twice-daily vs once-daily DOACs, the primary endpoint was observed significantly lower in the twice-daily group than in once-daily group (0.32% and 3.2% respectively, P=0.0054), without any significant difference about secondary endpoint (0% and 0.73% respectively, P=0.26).

Conclusion

Taking DOACs also in the morning of AF ablation, uninterrupted twice-daily DOACs are safer than once-daily DOACs without increasing ischemic event, although twice-daily DOACs, especially apixaban, were used in higher aged patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effect of Oxygen Free Radicals on Cardiac Contractile Activity and Sarcolemmal Na+–Ca2+Exchange

Background

Although oxygen free radicals have been shown to induce myocardial cell damage and cardiac dysfunction, the exact mechanism by which these radicals affect the heart function is not clear. Since the occurrence of intracellular Ca2+overload is critical in the genesis of cellular damage and cardiac dysfunction, and since the sarcolemmal Na+–Ca2+exchange is intimately involved in Ca2+movements in myocardium, this study was undertaken to examine the effects of oxygen free radicals on the relationship between changes in cardiac contractile force development and sarcolemmal Na+–Ca2+exchange activity.

Methods and Results

Isolated rat hearts were perfused with a medium containing xanthine plus xanthine oxidase for different times, and changes in contractile force as well as sarcolemmal Na+–Ca2+exchange activity were monitored. Perfusion of the heart with xanthine plus xanthine oxidase resulted in a transient increase followed by a marked decrease in contractile activity; the resting tension was markedly increased. The xanthine plus xanthine oxidase-induced depression in developed tension, rate of contraction, and rate of relaxation, except the transient increase in contractile activity, was prevented by the addition of catalase, but not by superoxide dismutase, in the perfusion medium. A time-dependent depression in sarcolemmal Na+–Ca2+was also evident upon perfusing the heart with xanthine plus xanthine oxidase. This depression in Na+-dependent Ca2+uptake was associated with a decrease in the maximal velocity of reaction without any changes in the affinity of Na+–Ca2+exchanger for Ca2+. The presence of catalase, unlike superoxide dismutase, prevented the decrease in sarcolemmal Na+–Ca2+exchange activity in hearts perfused with xanthine plus xanthine oxidase.

Conclusion

The results support the view that a depression in the sarcolemmal Na+–Ca2+exchange activity may contribute to the occurrence of intracellular Ca2+overload and subsequent decrease in contractile activity. Furthermore, these actions of xanthine plus xanthine oxidase in the whole heart appear to be a consequence of H2O2production rather than the ‘ generation of superoxide radicals.