DASC-21 score and risk of rehospitalization and all-cause mortality after discharge in older patients with heart failure

AIM

The impact of cognitive dysfunction-associated activities of daily living (ADL) on mortality and rehospitalization for heart failure has not yet been evaluated.

METHODS

We retrospectively evaluated DASC-21, the incidence of all-cause mortality, and rehospitalization for heart failure after discharge in 329 older patients with heart failure.

RESULTS

The mean age was 85.1 ± 7.4 years (62.6% women). There were 110 cases of death from any cause (33.4%) during 25.5 ± 16.1 months of follow-up and 166 cases of rehospitalization from heart failure (50.5%) during 16.1 ± 15.2 months of follow-up. The DASC-21 score was not significantly associated with an increased risk of all-cause mortality or rehospitalization. For each item of the DASC-21 questionnaire, defective route-finding (item 6) (HR = 2.631, P = 0.003), common sense and capacity for judgement (item 9) (HR = 1.717, P = 0.040), instrumental ADL (IADL) for shopping (item 10) (HR = 1.771, P = 0.020), and IADL for meal preparation (item 14) (HR = 1.790, P = 0.019) were significantly associated with an increased risk of all-cause mortality. Disabilities in route finding (HR = 2.257, P = 0.005), IADL for shopping (HR = 1.632, P = 0.016), and IADL for transportation (HR = 1.537, P = 0.033) were significant risk factors for rehospitalization due to heart failure. Even in the multivariate-adjusted model, disability in defective route-finding was significantly associated with an increased risk of all-cause mortality (hazard ratio [HR] = 2.148, 95% confidence interval [CI] 1.090-4.236; P = 0.027) and of rehospitalization for heart failure (HR = 2.138, 95% CI 1.153-3.963, P = 0.016).

CONCLUSIONS

In older patients hospitalized for heart failure, route disability was associated with all-cause mortality and rehospitalization for heart failure after discharge. Geriatr Gerontol Int 2024; ••: ••-••.

Dynamic extraction of residual solvents from pharmaceutical formulations using a needle-type extraction device

This study developed a rapid screening method to determine residual solvents contained in a tablet formulation using a needle-type extraction device. For this, the tablet formulation was pulverized and the powdered sample was rapidly inserted into a pipette tip. After fixing the sample with quartz wool, the pipette tip was capped with a silicon septum. A needle-type extraction device packed with Carbopack X and a carbon molecular sieve was inserted into the pipette tip through the septum, and the gas sample was collected. During this gas sampling, pure N2 gas was introduced into the pipette tip. The extraction time for collecting 100 mL of the sample was approximately 10 min. After gas sampling, the extraction needle was connected to a gas-tight syringe and 0.5 mL of pure N2 gas (desorption gas) was collected. The extraction needle was then inserted into a heated gas chromatographic injection port. The extracted residual solvents were then thermally desorbed and determined using a gas chromatograph-flame ionization detector. The detector response is very low for carbon tetrachloride, although the proposed method showed sufficient sensitivity for five Class 1 compounds. Additionally, this study clearly indicated that the purge efficiency of residual solves with dynamic extraction is different between powdered pharmaceutical formulations.

Association of pulse pressure and mean blood pressure to frailty, sarcopenia, and cognitive dysfunction in elderly outpatients with history of hypertension

This study aimed to evaluate the relationship between pulse pressure (PP) and sarcopenia, frailty, and cognitive function in elderly patients with hypertension. We evaluated 435 elderly patients with a history of hypertension who visited the frail outpatient clinic between July 2015 and October 2021. Data at the 1-, 2-, and 3-year follow-ups were available for 222, 177, and 164 patients, respectively. Sarcopenia, frailty, and cognitive function, including Mini-Mental State Examination (MMSE) scores, were evaluated. The patients' mean age was 79.2 ± 6.3 years (male, 34.9%). PP and mean blood pressure (BP) were 60.1 ± 13.6 mmHg and 94.1 ± 13.0 mmHg, respectively. At baseline, lower PP was associated with probable dementia (MMSE score ≤23 points) (OR = 0.960 per 1 mmHg increase; 95% CI, 0.933-0.989; P = 0.006) in the model adjusted for conventional confounding factors and comorbidities, whereas higher PP was associated with low handgrip strength (OR = 1.018 per 1 mmHg increase; 95% CI, 1.001-1.036; P = 0.041). In multivariate-adjusted logistic regression analysis of patients with preserved handgrip strength at baseline, reductions in PP (OR = 0.844; 95% CI, 0.731-0.974; P = 0.020) and mean BP (OR = 0.861; 95% CI, 0.758-0.979; P = 0.022) were significantly associated with the incidence of low handgrip strength at 3 years. In conclusion, a higher PP induced by increased arterial stiffness was associated with lower handgrip strength, whereas a lower PP was associated with probable dementia. Reduced PP was associated with decreased handgrip strength after three years.

Precise Spectroscopy of the 3n and 3p Systems via the ^{3}H(t, ^{3}He)3n and ^{3}He(^{3}He, t)3p Reactions at Intermediate Energies

To search for low-energy resonant structures in isospin T=3/2 three-body systems, we have performed the experiments ^{3}H(t,^{3}He)3n and ^{3}He(^{3}He,t)3p at intermediate energies. For the 3n experiment, we have newly developed a thick Ti-^{3}H target that has the largest tritium thickness among targets of this type ever made. The 3n experiment for the first time covered the momentum-transfer region as low as 15  MeV/c, which provides ideal conditions for producing fragile systems. However, in the excitation-energy spectra we obtained, we did not observe any distinct peak structures. This is in sharp contrast to tetraneutron spectra. The distributions of the 3n and 3p spectra are found to be similar, except for the displacement in energy due to Coulomb repulsion. Comparisons with theoretical calculations suggest that three-body correlations exist in the 3n and 3p systems, although not enough to produce a resonant peak.

A Japanese multi-institutional phase II study of moderate hypofractionated intensity-modulated radiotherapy with image-guided technique for prostate cancer

BACKGROUND

The aim of this multi-institutional phase II study was to confirm the safety and the potential efficacy of moderately hypofractionated intensity-modulated radiotherapy (IMRT) with prostate-based image-guidance for Japanese patients.

METHODS

Patients with low- or intermediate-risk localized prostate cancer were eligible. Patients with a part of high risk (having only one of the following factors, cT3a, 20 < PSA ≤ 30, or GS = 8 or 9) were also included. Hypofractionated IMRT using daily image-guided technique with prostate matching was performed with a total dose of 70 Gy in 28 fractions. Neoadjuvant hormonal therapy for 4-8 months was mandatory for patients with intermediate or high-risk prostate cancer.

RESULTS

From 20 institutions, 134 patients enrolled. The median follow-up was 5.16 years (range, 1.43-6.47 years). The number of patients with low, intermediate, and high-risk prostate cancer was 20, 80, and 34, respectively. The 5-year overall, biochemical failure-free, and clinical failure-free survival was 94.5%, 96.0%, and 99.2%, respectively. The 5-year biochemical failure-free survival for patients with low-, intermediate-, and high-risk disease was 94.1%, 97.4%, and 93.9%, respectively. The incidences of grade 2 gastrointestinal (GI) and genitourinary (GU) late toxicities at 5 years were 5.3% and 5.3%, respectively. There are no acute or late toxicities ≥ grade 3. Of 124 patients who were followed for up to 5 years, the grade 2 late GU or GI toxicities were 10.5% (90% confidence intervals, 6.3-16.2%, p = 0.0958).

CONCLUSION

The safety and efficacy of moderately hypofractionated IMRT with prostate-based image-guidance was confirmed among Japanese patients with prostate cancer.

DASC-21 score and the risk of in-hospital death in elderly patients with heart failure

AIM

We investigated whether the Dementia Assessment Sheet for Community-based Integrated Care System-21 Items (DASC-21), a questionnaire that assesses cognitive function, including activities of daily living (ADL), was predictive of in-hospital death and prolonged hospital stay in elderly patients hospitalized for heart failure.

METHODS

We retrospectively assessed the DASC-21 score at the time of admission, in-hospital death, length of hospital stay, and change in the Barthel index in 399 patients hospitalized for heart failure between 2016 and 2019.

RESULTS

The mean patient age was 85.8 ± 7.7 years (61.3% women). The median DASC-21 score was 38 (64.7% higher than 31). On multivariate logistic regression analysis, a higher DASC-21 score was associated with an increased risk of in-hospital death (odds ratio [OR] = 1.045 per 1 point increase, 95% confidence interval [CI]: 1.010-1.081, P = 0.012), even after adjusting for confounding factors, including atrial fibrillation, ejection fraction, and B-type natriuretic peptide. Difficulties (3 or 4) with the self-management of medication in instrumental ADL inside the home (OR = 3.28, 95% CI: 1.05-10.28, P = 0.042), toileting (OR = 3.66, 95% CI: 1.19-11.29, P = 0.024), grooming (OR = 6.47, 95% CI: 2.00-20.96, P = 0.002), eating (OR = 7.96, 95% CI: 2.49-25.45, P < 0.001), and mobility in physical ADL (OR = 5.99, 95% CI: 1.85-19.35, P = 0.003) were identified as risk factors for in-hospital death. Patients in the highest tertile of the DASC-21 score had a significantly longer hospital stay (P = 0.006) and a greater reduction in the Barthel index (P < 0.001).

CONCLUSIONS

In elderly patients hospitalized for heart failure, higher DASC-21 scores were associated with an increased risk of in-hospital death, prolonged hospital stay, and impaired ADL. Geriatr Gerontol Int 2024; 24: 546-553.

Research and Future Challenges for Disseminating Strengths-Based Nursing and Healthcare in Japan

Strengths-Based Nursing and Healthcare (SBNH) has garnered attention in the field of psychiatric nursing in Japan, yet its adoption in other nursing sectors remains limited. Japan is currently facing the formidable challenge of a rapidly aging population and growing demand for healthcare and welfare services. To address these issues, a shift from hospital-based care to comprehensive community care is underway, underscoring the importance of nurses in community settings, where focusing on client strengths is essential. Therefore, this paper aims to present research and practical examples to advocate for the broader dissemination of SBNH in Japan.

Volatile anticancer drug determination by thermal desorption technique with polydimethylsiloxane-coated macroporous silica adsorbent in gas chromatography-mass spectrometry

An analytical method for quantifying the volatile anticancer drugs ifosfamide (IF) and cyclophosphamide (CP) in air was developed on the basis of thermal desorption (TD)-gas chromatography-mass spectrometry. Polydimethylsiloxane-coated macroporous silica was used as the adsorbent. The extraction tube was prepared by packing 0.2 g of adsorbent particles into a glass tube. The extraction and desorption efficiencies of the proposed method were quantitatively investigated in this study. The limits of detection of the proposed method for IF and CP were 3.3 ng L-1 at an air sampling volume of 3.0 L (30 min). The sensitivity of the proposed method was compared with using a Tenax TA packed tube that is widely used as the extraction medium in TD analysis. Finally, detection of IF and CP that evaporated from aqueous standard solution was investigated.

Long-Term Follow-up of a Randomized Controlled Trial on Accelerated Radiation Therapy Versus Standard Fractionated Radiation Therapy for Early Glottic Cancer (JCOG0701A3)

PURPOSE

We previously reported the primary results of JCOG0701, a randomized, multicenter, phase 3, noninferiority trial comparing accelerated fractionation (Ax) to standard fractionation (SF) for early glottic cancer. In the primary results, although the similar efficacy of 3-year progression-free survival and toxicity of Ax compared with SF was observed, the noninferiority of Ax was not confirmed statistically. To evaluate the long-term follow-up results of JCOG0701, we conducted JCOG0701A3 as an ancillary study of JCOG0701.

METHODS AND MATERIALS

In JCOG0701, 370 patients were randomly assigned to receive SF of 66 to 70 Gy (33-35 fractions; n = 184) or Ax of 60 to 64.8 Gy (25-27 fractions; n = 186). The data cutoff date for this analysis was in June 2020. Overall survival, progression-free survival, and late adverse events including central nervous system ischemia were analyzed.

RESULTS

With a median follow-up period of 7.1 years (range, 0.1-12.4), progression-free survival of the SF and Ax arms were 76.2% and 78.2% at 5 years and 72.7% and 74.8% at 7 years (P = .44). OS of the SF and Ax arms were 92.7% and 89.6% at 5 years and 90.8% and 86.5% at 7 years (P = .92). Among 366 patients with a protocol treatment, the cumulative incidence of late adverse events of the SF and Ax arms were 11.9% and 7.4% at 8 years (hazard ratio, 0.53; 95% CI, 0.28-1.01; P = .06). Central nervous system ischemia of grade 2 or higher was observed in 4.1% for the SF arm and 1.1% for the Ax arm (P = .098).

CONCLUSIONS

After long-term follow-up, Ax showed comparable efficacy to SF and a tendency for better safety. Ax may be suitable for early glottic cancer because of its convenience in minimizing treatment time, cost, and labor.

Telephone-Based Cognitive-Behavioral Therapy for Depression in Family Caregivers of Persons Living With Dementia: A Feasibility Study

The current study aimed to examine the usefulness of a telephone-based cognitive-behavioral therapy program for depression in 11 family caregivers of persons living with dementia. Data were collected and analyzed before (Session 1), after (Session 6), and at 3-month follow up using the Zarit Caregiver Burden Interview, General Self-Efficacy Scale, Rosenberg Self-Esteem Scale, and Self-Rating Depression Scale. Depression scores decreased significantly (p < 0.05) from Session 1 to Session 6. Results suggest that the program should address Proactivity of Action, a sub-item of self-efficacy, to reduce depression. In addition, the program enabled caregivers to reduce negative perceptions of their caregiving duty, which may lead to positive thinking and proactive behavior. Despite these findings, the program must be modified and research must continue, as this was a feasibility study with an intervention group only. [Journal of Psychosocial Nursing and Mental Health Services, 61(12), 37-45.].

Sampling bag-based emission chamber for measuring volatile organic compounds from household materials using solid-phase extraction-type collection device

A simple screening analytical method for determining the emission of volatile organic compounds (VOCs) from household materials was developed using a solid-phase extraction (SPE)-type collection device and a gas sampling bag. The VOCs emitted from the sample material placed in the gas sampling bag with a volume of 20 L were extracted on the SPE-type collection device. In this study, complete sampling mode was developed in addition to a conventional flow sampling mode. The extracted VOCs were then eluted with 8 mL of acetone and measured using gas chromatography-mass spectrometry. The proposed method does not require a stainless-steel chamber and a thermal desorption system; therefore, VOC emission from household materials could be easily evaluated with an affordable cost, suggesting that the method is suitable for the screening technique for evaluating VOC emission from solid materials.

Relationship between out-of-facility deliveries and distance and travel time to delivery facilities in Hokkaido, Japan: An ecological study

AIM

This study aimed to investigate the relationship between the distance and travel time from each municipality to the nearest delivery facilities in the other municipalities and the frequency of out-of-facility deliveries in Hokkaido.

METHODS

Vital statistics from 2016 to 2020 were used. For municipalities without delivery facilities, the distance and travel time from the town office of each municipality to the nearest delivery facility was measured using Google maps. Negative binomial regression with an offset term was used to calculate the relative risks (RRs) and 95% confidence intervals (CIs) of out-of-facility delivery for distance (<30, 30-59, ≥60 km), and travel time by car (<30, 30-59, and ≥60 min) from the town office to the nearest delivery facility compared with the presence of delivery facilities.

RESULTS

The overall rate of out-of-facility deliveries in Hokkaido was 2.1‰; in municipalities with delivery facilities, 1.8‰, and in municipalities without delivery facilities, 3.1‰. The adjusted RRs (95% CIs) for out-of-facility deliveries were significantly higher in municipalities with less than 30 km and travel time of less than 30 min to delivery facilities, 2.63 (1.34-5.17) and 2.76 (1.36-5.58), respectively, compared to municipalities with delivery facilities. However, the adjusted RR of out-of-facility delivery for municipalities ≥30 km was higher, although the difference was not significant.

CONCLUSIONS

Even in municipalities with a distance to delivery facilities of less than 30 km or travel time of less than 30 min, we should keep in mind the occurrence of out-of-facility deliveries.

BepiColombo mission confirms stagnation region of Venus and reveals its large extent

The second Venus flyby of the BepiColombo mission offer a unique opportunity to make a complete tour of one of the few gas-dynamics dominated interaction regions between the supersonic solar wind and a Solar System object. The spacecraft pass through the full Venusian magnetosheath following the plasma streamlines, and cross the subsolar stagnation region during very stable solar wind conditions as observed upstream by the neighboring Solar Orbiter mission. These rare multipoint synergistic observations and stable conditions experimentally confirm what was previously predicted for the barely-explored stagnation region close to solar minimum. Here, we show that this region has a large extend, up to an altitude of 1900 km, and the estimated low energy transfer near the subsolar point confirm that the atmosphere of Venus, despite being non-magnetized and less conductive due to lower ultraviolet flux at solar minimum, is capable of withstanding the solar wind under low dynamic pressure.

Effects of Arterial Stiffness on Cerebral WM Integrity in Older Adults: A Neurite Orientation Dispersion and Density Imaging and Magnetization Transfer Saturation Imaging Study

BACKGROUND AND PURPOSE

Arterial stiffness is reported to be able to cause axonal demyelination or degeneration. The present study aimed to use advanced MR imaging techniques to examine the effect of arterial stiffness on the WM microstructure among older adults.

MATERIALS AND METHODS

Arterial stiffness was measured using the cardio-ankle vascular elasticity index (CAVI). The high-CAVI (mean CAVI ≥ 9 points) and the low-CAVI groups (mean CAVI < 9 points) were created. The neuronal fiber integrity of the WM was evaluated by neurite orientation dispersion and density imaging and magnetization transfer saturation imaging. Tract-Based Spatial Statistics and the tracts-of-interest analysis were performed. Specific WM regions (corpus callosum, internal capsule, anterior thalamic radiation, corona radiata, superior longitudinal fasciculus, forceps minor, and inferior fronto-occipital fasciculus) were selected in the tracts-of-interest analysis.

RESULTS

In Tract-Based Spatial Statistics, the high-CAVI group showed a significantly lower myelin volume fraction value in the broad WM and significantly higher radial diffusivity and isotropic volume fraction values in the corpus callosum, forceps minor, inferior fronto-occipital fasciculus, internal capsule, corona radiata, and anterior thalamic radiation than the low-CAVI group. In tracts-of-interest analysis using multivariate linear regression, significant associations were found between the mean CAVI and radial diffusivity in the anterior thalamic radiation and the corona radiata; isotropic volume fraction in the anterior thalamic radiation and the corona radiata; and myelin volume fraction in the superior longitudinal fasciculus (P < .05). Additionally, partial correlation coefficients were observed for the significant associations of executive function with radial diffusivity and myelin volume fraction (P < .05).

CONCLUSIONS

Arterial stiffness could be associated with demyelination rather than axonal degeneration.

Neurodevelopmental delay up to the age of 4 years in infants born to women with gestational diabetes mellitus: The Japan Environment and Children's Study

AIMS/INTRODUCTION

This study aimed to investigate the neurodevelopment of infants born to women with gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

Data from the National Birth Cohort in the Japan Environment and Children's Study from 2011 to 2014 (n = 81,705) were used. Japan uses the GDM guidelines of the International Association of Diabetes and Pregnancy Study Groups. The Japanese translation of the Ages and Stages Questionnaires, third Edition, was used to assess neurodevelopment in the following domains: communication skills, gross motor skills, fine motor skills, problem-solving ability, and personal and social skills. The survey was carried out every 6 months from the age of 6 months to 4 years (total of eight times). Generalized estimating equations were used to evaluate the association between maternal GDM and neurodevelopmental delay based on odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Neurodevelopmental delays, particularly in problem-solving ability, fine motor skills, and personal and social skills, were significantly higher in infants born to women with GDM than in those born to women without GDM (adjusted OR 1.24, 95% CI 1.12-1.36; adjusted OR 1.15, 95% CI 1.03-1.27; and adjusted OR 1.18, 95% CI 1.04-1.33). Furthermore, stratification showed no significant increase in the adjusted ORs (95% CIs) of girls.

CONCLUSIONS

Neurodevelopment was significantly delayed up to 4 years-of-age among boys born to women with GDM.

Direct observations of energy transfer from resonant electrons to whistler-mode waves in magnetosheath of Earth

Electromagnetic whistler-mode waves in space plasmas play critical roles in collisionless energy transfer between the electrons and the electromagnetic field. Although resonant interactions have been considered as the likely generation process of the waves, observational identification has been extremely difficult due to the short time scale of resonant electron dynamics. Here we show strong nongyrotropy, which rotate with the wave, of cyclotron resonant electrons as direct evidence for the locally ongoing secular energy transfer from the resonant electrons to the whistler-mode waves using ultra-high temporal resolution data obtained by NASA's Magnetospheric Multiscale (MMS) mission in the magnetosheath. The nongyrotropic electrons carry a resonant current, which is the energy source of the wave as predicted by the nonlinear wave growth theory. This result proves the nonlinear wave growth theory, and furthermore demonstrates that the degree of nongyrotropy, which cannot be predicted even by that nonlinear theory, can be studied by observations.

Gut Microbiota Influence the Development of Abdominal Aortic Aneurysm by Suppressing Macrophage Accumulation in Mice

BACKGROUND:

Abdominal aortic aneurysm (AAA) is a life-threatening cardiovascular disease characterized by dilated abdominal aorta. Immune cells have been shown to contribute to the development of AAA, and that the gut microbiota is associated with numerous diseases, including cardiovascular diseases, by regulating immune systems or metabolic pathways of the host. However, the interaction between the gut microbiota and AAA remains unknown.

METHODS:

Apolipoprotein E–deficient male mice were fed a high-cholesterol diet and divided into three groups: the control group was maintained under normal water (control group), the oral AVNM group was maintained under drinking water supplemented with ampicillin, vancomycin, neomycin, and metronidazole, and the i.p. AVNM group was injected AVNM intraperitoneally. After 1 week of pretreatment with antibiotics, these mice were administrated Ang II via subcutaneous osmotic pumps for 4 weeks and euthanized to evaluate AAA formation.

RESULTS:

Depletion of gut microbiota by oral AVNM ameliorated the incidence of AAAs (control group: 58.9% versus oral AVNM group: 28.6% versus i.p. AVNM group: 75.0%, P = 0.0005) and prevented death due to ruptured aneurysms (control group: 11% versus oral AVNM group: 0% versus i.p. AVNM group: 15%). Oral AVNM suppressed monocyte storage in the spleen, but not in other organs. Despite possessing a higher level of cholesterol, recruitment of monocytes into the suprarenal aorta was suppressed in the oral AVNM group. In AVNM drinking mice, NOD1 ligand, a kind of PRR ligands, increased the development of AAAs and accumulation of macrophages in the aortae.

CONCLUSIONS:

The gut microbiota plays a critical role in AAA formation. Therefore, regulation of the microbiota or the immune system can be a therapeutic approach for AAA.

Increasing the class of foundational medication for heart failure is associated with improved prognosis in hospitalized patients with heart failure with reduced or mildly reduced ejection fraction

Aim

To clarify the association between changes in the number of foundational medications for heart failure (FMHF) during hospitalization for worsening heart failure and post-discharge prognosis.

Methods and results

We retrospectively analyzed a combined dataset of three large-scale registries of hospitalized patients with heart failure in Japan (NARA-HF, WET-HF, and REALITY-AHF) and included patients already diagnosed with heart failure with reduced or mildly reduced left ventricular ejection fraction (HFr/mrEF) before admission. Patients were stratified by changes in the number of prescribed FMHF classes, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and mineralocorticoid receptor blockers, from admission to discharge. The primary endpoint was defined as the combined endpoint of heart failure rehospitalization and all-cause death within 1-year of discharge. The cohort consisted of 1,113 patients, and 482 combined endpoints were observed. In total, 413 (37.1%) patients were on increased FMHF (increased group), 607 (54.5%) remained unchanged (unchanged group), and 93 (8.4%) had a decreased number of FMHF (decreased group) at discharge compared to the time of admission. In multivariable analysis, the increased group was associated with a significantly lower incidence of the primary endpoint compared with the unchanged group (hazard ratio 0.56, 95% confidence interval 0.45–0.60; P&lt;0.001) and decreased group (hazard ratio 0.58, 95% confidence interval 0.40–0.84; P=0.004).

Conclusion

Increasing the number of FMHF cases during heart failure hospitalization is associated with a better prognosis in patients with HFr/mrEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): REALITY registry was funded by the Cardiovascular Research Fund of Japan.WET-HF registry was supported by a Grant-in-Aid for Young Scientists (Y.S. JSPS KAKENHI, 18K15860).

Derivation and validation of a machine learning-based risk prediction model for in-hospital mortality in patients with acute heart failure

Background

Although risk stratification is important in patients with acute heart failure (AHF) to predict patient prognosis, pre-existing risk models have not often been used due to its complexity. Recently, machine learning methods have been presented as an alternative approach to analyzing the predictive probability of large clinical datasets.

Purpose

The aim of this study is to develop a user-friendly risk score developed by one of machine learning methods and compare the performance of the new risk score to the existing conventional risk models.

Methods

A machine-learning-based risk model was developed using least absolute shrinkage and selection operator (LASSO) regression by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF) and externally validating and comparing its performance with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry (ADHERE) risk model.

Results

In-hospital deaths in the derivation and validation (NARA-HF) cohorts were 76 (5.1%) and 61 (4.9%), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4V-RS). Even though 4V-RS comprised fewer variables, In the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; P=0.059) and a significant improvement in net reclassification (0.359; 95% CI, 0.10–0.67; p=0.006). 4V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p=0.426) and net reclassification (0.176; 95% CI, −0.08–0.43; p=0.178).

Conclusions

The 4V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiovascular Research Fund

Predicting new-onset heart failure hospitalization of patients with atrial fibrillation: development and external validations of a risk score

Background

Atrial fibrillation (AF) is a well-known risk factor for heart failure (HF), and HF development as a complication of AF is associated with a decline in the quality of life and poor prognosis. However, unlike thrombotic events, incidence of HF in patients with AF has not changed for decades, and a preventive strategy has yet to be developed.

Purpose

We sought to develop a risk model for new-onset HF admission in patients with AF and without a history of HF. Additionally, we attempted to externally validate the developed risk model.

Methods

We utilized two multicenter, prospective, observational registries of AF and analyzed the patients without a history of AF. One of which is defined as a derivation cohort, which included 2,857 patients, and the other is defined as a validation cohort, which included 2,516 patients. We developed a risk model by selecting variables with regularized regression and weighing coefficients by Cox regression analysis with the derivation cohort. The external validity was tested in the validation cohort.

Results

During the follow-up period, 148 patients (5.2%) in the derivation cohort and 104 patients (4.1%) in the validation cohort developed HF during the median follow-up period of 1,396 (interquartile range [IQR]: 1,078–1,820) days and 1,168 (IQR: 844–1,309) days, respectively. In the derivation cohort, four predictors (age, hemoglobin, serum creatinine, and log-transformed brain natriuretic peptide) were identified as potential risk factors for HF development. The developed risk model showed good discrimination and calibration in both the derivation (area under the curve [AUC], 0.77 [95% confidence interval (CI) 0.73–0.81]; Hosmer-Lemeshow test, P=0.257) and validation cohorts (AUC: 0.76 [95% CI 0.72–0.81]; Hosmer-Lemeshow test, P=0.475). Considering death not due to HF as a competing risk, the cumulative incidence curves for HF admission stratified by the risk score were generated, which showed higher HF hospitalization rate for the higher risk score categories.

Conclusion

The newly developed risk model with four readily available clinical characteristics and biomarkers performed well in the prediction of new-onset HF admission of patients with AF in both derivation and validation cohort.

Funding Acknowledgement

Type of funding sources: None.

Quantitative estimation of pulmonary artery wedge pressure from chest radiographs by a regression convolutional neural network

Introduction

Recent studies reported that a convolutional neural network (CNN; a deep learning model) can detect elevated pulmonary artery wedge pressure (PAWP) from chest radiographs, the diagnostic images most commonly used for assessing pulmonary congestion in heart failure. However, no method has been published for quantitatively estimating PAWP from such radiographs. We hypothesized that a regression CNN, an alternative type of deep learning, could be a useful tool for quantitatively estimating PAWP from chest radiographs in cardiovascular diseases.

Methods

We retrospectively enrolled 936 patients with cardiovascular diseases who had undergone right heart catheterization (RHC) and chest radiography and estimated PAWP by constructing a regression CNN based on the VGG16 model. We randomly categorized 80% of the data as training data (training group, n=748) and 20% as test data (test group, n=188). Moreover, we tuned the learning rate–one of the model parameters–by 5-hold cross-validation of the training group. Correlations between PAWP measured by RHC (ground truth [GT] PAWP) and PAWP derived from the regression CNN (estimated PAWP) were tested. To visualize how the regression CNN assessed the images, we created a regression activation map (RAM), a visualization technique for regression CNN.

Results

Estimated PAWP correlated significantly with GT PAWP in both the training (r=0.76, P&lt;0.001) and test group (r=0.62, P&lt;0.001). Bland-Altman plots found a mean (SEM) difference between GT and estimated PAWP of −0.23 (0.16) mm Hg in the training and −0.05 (0.41) mm Hg in the test group. The RAM showed that our regression CNN model estimated high PAWP by focusing on the cardiomegaly and pulmonary congestion. In the test group, the area under the curve (AUC) for detecting elevated PAWP (≥18 mm Hg) produced by the regression CNN model was similar to the AUC of an experienced cardiologist (0.86 vs 0.83, respectively; P=0.24).

Conclusion

This proof-of-concept study shows that regression CNN can quantitatively estimate PAWP from standard chest radiographs in cardiovascular diseases.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The Bayer Academic Support

Hospital-associated disability and hospitalization costs for acute heart failure stratified by body mass index- insight from the JROAD/JROAD-DPC database

BACKGROUND

The impact of body mass index (BMI) on hospital mortality in patients with acute heart failure has been well documented in Asian populations. However, the relationship between BMI, hospital-associated disability (HAD), and hospitalization costs in patients with heart failure is poorly understood. This study aimed to explore the impact of BMI on HAD and hospitalization costs for acute heart failure in Japan.

METHODS

From April 2012 to March 2020, the Japanese Registry of All Cardiac and Vascular Disease Diagnosis Procedure Combination (JROAD-DPC) database was used to identify patients with acute heart failure. All patients were categorized into five groups according to the World Health Organization Asian BMI criteria. The hospitalization costs and HAD were evaluated.

RESULTS

Among the 238,160 eligible patients, 15.7% were underweight, 42.2% were normal, 16.7% were overweight, 19.3% were obese I, and 6.0% were obese II, according to BMI. The prevalence of HAD was 7.43% in the total cohort, and the risk of HAD increased with a lower BMI. Restricted cubic spline analysis showed a U-shaped relationship between BMI and hospitalization costs for all ages. Furthermore, developing HAD was associated with greater costs compared with non-HAD, regardless of BMI category.

CONCLUSIONS

We found that the lower the BMI, the higher the incidence of HAD. A U-shaped association was confirmed between BMI and hospitalization costs, indicating that hospitalization costs increased for both lower and higher BMI regardless of age. BMI could be an important and informative risk stratification tool for functional outcomes and economic burdens.

A Pacing-Controlled Protocol for Frequency-Diastolic Relations Distinguishes Diastolic Dysfunction Specific to A Mouse HFpEF Model

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is characterized as an insufficient exercise capacity and is a growing health problem worldwide. One major difficulty with experimental research of HFpEF is the lack of methods to consistently detect diastolic dysfunction in mouse models. We focus on the exercise intolerance and developed a pacing-controlled PV loop protocol for the assessment of diastolic function at different heart rates in mouse cardiac disease models, including a HFpEF model and a pressure-overload hypertrophy model (PO).

METHODS

A HFpEF model was generated by high-fat diet (HFD)-feeding with concomitant L-NAME administration, and a PO model was produced by surgical constriction of transverse aorta (TAC). HR was slowed (lower than 400 bpm) by i.p. injection of ivabradine. PV loop data were acquired at HR incrementing by 100 bpm from 400 to 700 bpm via atrial pacing.

RESULTS

At baseline without pacing, no significant difference was detected between groups. Frequency-diastolic pacing, however, distinguished HFpEF from other two groups in diastolic parameters like tau or stiffness-coefficient of end-diastolic pressure volume relationship. No remarkable difference was observed with systolic parameters.

CONCLUSIONS

Frequency-dependent pressure-volume analysis could detect and characterize diastolic dysfunction specific to the HFpEF, though no significant difference between HFpEF and pressure overload models could be detected at baseline analysis. One of characteristic of HFpEF is exercise intolerance, but no physiological analysis or modality associated with exercise capacity was available in analyzing cardiac functions of murine models. This protocol would significantly contribute to the basic research for HFpEF.