Kondo-Induced Giant Isotropic Negative Thermal Expansion

Negative thermal expansion is an unusual phenomenon appearing in only a handful of materials, but pursuit and mastery of the phenomenon holds great promise for applications across disciplines and industries. Here we report use of x-ray spectroscopy and diffraction to investigate the 4f-electronic properties in Y-doped SmS and employ the Kondo volume collapse model to interpret the results. Our measurements reveal an unparalleled decrease of the bulk Sm valence by over 20% at low temperatures in the mixed-valent golden phase, which we show is caused by a strong coupling between an emergent Kondo lattice state and a large isotropic volume change. The amplitude and temperature range of the negative thermal expansion appear strongly dependent on the Y concentration and the associated chemical disorder, providing control over the observed effect. This finding opens avenues for the design of Kondo lattice materials with tunable, giant, and isotropic negative thermal expansion.

Cognitive Frailty as a Risk Factor for Incident Disability During Late Life: A 24-Month Follow-Up Longitudinal Study

OBJECTIVES

Association between cognitive frailty as identified by a new operational definition and incident disability in the community setting remains unclear. This will be the catalyst for preventive interventions designed to treat adverse health problems among elderlies.

DESIGN

A 24-month follow-up longitudinal study on a community-based cohort.

SETTING

Community-setting.

PARTICIPANTS

Participants included a total of 9,936 older adults aged 65 years or older.

MEASUREMENTS

Frailty was characterized as slow walking speed or/and muscle weakness represented by grip strength. Cognitive function was assessed according to several tests. Cognitive impairment was defined below the age-education reference threshold. Participants were categorized into the four groups: robust, cognitive impairment alone, frailty alone, and cognitive frailty (both frail and cognitive impairment). Incident disability data was extracted from the Japanese Long-Term Care system.

RESULTS

The prevalence of cognitive frailty was 11.2%. The cumulative incidence rates of incident disability in each group were also estimated (robust, 9.6/1,000 person-years (95% CI 7.9 to 11.7); cognitive impairment, 21.3/1,000 person years (95% CI 16.3 to 27.7); frailty, 45.4/1,000 person years (95% CI 39.5 to 52.3); and cognitive frailty, 79.9/1,000 person years (95% CI 68.6 to 93.1)). Adjusted Cox proportional hazard model revealed that the cognitive frailty group had the highest hazard ratio (HR 3.86, 95%CI 2.95 - 5.05, P < 0.001).

CONCLUSIONS

A proper operational definition was developed to determine cognitive frailty among elderlies. Cognitive frailty is more associated with incident disability in community-setting than cognitive impairment or physical frailty alone.

A PHANTOM STUDY TO DETERMINE THE OPTIMAL PLACEMENT OF EYE DOSEMETERS ON INTERVENTIONAL CARDIOLOGY STAFF

The International Commission on Radiological Protection has substantially reduced the recommended maximum annual eye lens dose for workers. Use of a dedicated eye dosemeter is one method for accurate dose monitoring. The main aim of this study was to yield recommendations for optimal placement of eye dosemeters to estimate the eye dose to interventional cardiology physicians and nurses. A phantom measurement was conducted to simulate typical interventional cardiology procedures. Considering eight X-ray tube angulations, the left side of the head position provide good estimates for physician, and the forehead position provide good estimates for nurse.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

P2619Combined evaluation of nutrition screening indexes on long-term mortality in patients hospitalized for acute heart failure

Background

Along with an aging society, the global burden of heart failure (HF) is evident in Japan. Recent reports showed that malnutrition is one of the frequent comorbidity in patients with HF, and this grievous issue is related to worsening prognosis in such subjects. There are many screening tools of nutrition risks, however, feasible indexes or strategies for evaluating nutrition risk in patients with HF remain to be identified definitively.

Purpose

The purpose of the present study was to examine the effectiveness of various nutrition indexes on 3-year mortality in hospitalized acute HF patients.

Methods

The study population comprised a total of 817 individuals who were hospitalized for acute HF between November 2009 and December 2015, and was followed up for 3 years. All the previously established objective nutritional indexes [The controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and subjective global assessment (SGA)] were evaluated at the time of hospital admission. Malnutrition status of each index was defined as CONUT score ≥5, GNRI <91, or SGA (B and C), respectively. We evaluated combined predictive values of these indexes for 3-year mortality by Cox regression model, and calculated the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI).

Results

The median age was 79 (interquartile range 70–85) years, and 55.7% of the subjects were male. The frequency of malnutrition was 18.1% in CONUT score, 31.9% in GNRI, and 25.9% in SGA. The rate of 3-year mortality was 32.2%. All indexes were related to the occurrence of 3-year mortality by univariate analyses (P<0.001). We examined combined predictive values by calculating multivariable-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for associations of malnutrition by these 3 indexes and prognostic variables identified by multivariable Cox regression model (age, body mass index, systolic blood pressure, reduced eGFR, albumin, and prior HF hospitalization). Malnutrition of all 3 indexes (5.6% of the subjects) was associated with higher relative risk of 3-year mortality than well-nutrition (aHR 1.90; 95% CI 1.07–3.35, P=0.028), or malnutrition of any 1 index (aHR 1.95; 95% CI 1.18–3.21, P=0.009). Next, we individually included each value into a reference model (age, body mass index, reduced eGFR, albumin, prior HF hospitalization, and ischemic etiology by multivariable logistic regression analysis with P<0.05). SGA was superior according to comprehensive discrimination, calibration, and reclassification analysis (NRI 0.212, P=0.003; IDI 0.005, P=0.029). Similar analysis with other indexes (CONUT score or GNRI) revealed no improvement.

Conclusion

Our present results suggest that simultaneous addition of CONUT, GNRI, and SGA seems useful for predicting long-term mortality in acute HF. In addition, nutritional screening with SGA independently improves mortality risk stratification.

P790Verification of selective arterial blood sampling for the assessment of in-hospital mortality in acute decompensated heart failure

Background

Acidosis or lactate accumulation is frequently observed in patients with acute decompensated heart failure (ADHF). Although each value can be easily obtained and evaluated by arterial blood sampling, sampling to all patients is difficult in daily clinical practice. Therefore, the prognostic impact of acidosis or lactate accumulation on this condition remains to be identified definitively.

Purpose

The purpose of the study was to verify the effectiveness of selective arterial blood sampling at emergency department in patients with ADHF by evaluating an association with in-hospital mortality.

Methods

A total of 917 consecutive patients with ADHF from April 2012 to March 2017 were enrolled. We compared baseline characteristics and in-hospital mortality between patients with or without arterial blood sampling. Patients performed blood sampling were assigned to four groups according to the presence or absence of acidosis (PH <7.35) and lactate accumulation (>2.0 mmol/L), and predictive value of acidosis and/or lactate accumulation for in-hospital mortality was calculated by multivariable logistic regression analysis.

Results

Of all patients, 689 patients (75.1%) underwent blood sampling. Systolic blood pressure and heart rate at hospital arrival, use of emergency medical service, previous heart failure hospitalization, New York Heart Association classification grade IV, presence of jugular vein distention, and the prevalence of hypertension and dementia, were significantly different between the two groups (P<0.05). There was no difference in the occurrence of in-hospital mortality between patients with or without blood sampling (9.3% in patients with blood sampling versus 9.2% in those without blood sampling, respectively; P=0.972). In 689 patients who underwent blood sampling, we examined combined predictive value of acidosis and/or lactate accumulation for in-hospital mortality by multivariable logistic regression analysis with adjustments for covariates with P<0.05 (age, systolic blood pressure at hospital arrival, left ventricular ejection fraction, and cold profile), and showed that acidosis with lactate accumulation [adjusted odds ratio (OR) 3.30, 95% confidence interval (CI) 1.22–8.93, P=0.019], acidosis without lactate accumulation (adjusted OR 4.06, 95% CI 1.12–14.7, P=0.033), lactate accumulation without acidosis (adjusted OR 2.69, 95% CI 1.14–6.33, P=0.024) were significantly (P<0.05) associated with in-hospital mortality. Our results indicated that patients presenting acidosis without lactate accumulation revealed the highest in-hospital mortality among the four groups.

Conclusion

Arterial blood sampling at emergency department could be beneficial for stratifying high risk patients with ADHF. Furthermore, routine blood sampling could be allowed in patients with ADHF if we can secure safety.

P6240The impact of stress myocardial blood flow as a very strong predictor for all-cause mortality, cardiovascular mortality and adverse cardiac and cerebrovascular event in hemodialysis population

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic device for IHD. Although coronary flow reserve is the most important index in IHD diagnosis, there are limited data about stress myocardial blood flow (MBF). We investigated the prognosis predictability of stress MBF in all-cause mortality, cardiovascular (CV) mortality and adverse cardiac and cerebrovascular event (MACCE).

Methods and results

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. 29 cases were excluded due to revascularization therapy in 60 days. In total we collected 409 eligible cases. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. Patients were divided into two group according to the median value of stress MBF levels; low stress MBF group (<2.12) and high stress MBF group (≥2.12). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their all-cause mortality, CV mortality and MACCE. Kaplan-Meyer analysis shows that intergroup difference in all-cause mortality (log rank p=0.001, hazard ratio [HR] 0.411, 95% confident interval [CI] 0.261–0.632), CV mortality (log rank p=0.002, HR 0.324, 95% CI 0.157–0.625) and MACCE (log rank p<0.001, HR 0.465, 95% CI 0.324–0.657). Multiple cox analysis that include established risk factors shows CFR is an independent risk factor for all-cause mortality (HR 0.261, 95% CI 0.154–0.442), CV mortality (HR 0.172, 95% CI 0.079–0.374) and MACCE (HR 0.329, 95% CI 0.213–0.503). As a result of the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors, each indicator shows adding stress MBF on established risk factors improve the predictability in all-cause mortality, CV mortality and MACCE (all-cause mortality; NRI 0.642, p<0.001, IDI 0.091, p<0.001, CV mortality NRI 0.809, p<0.001, IDI 0.116, p<0.001, MACCE; NRI 0.646, p<0.001, IDI 0.072, p<0.001).

Conclusion

Considering prognosis of HD population, stress MBF is an important and independent predictor for all-cause mortality, CV mortality and MACCE. As a result of our investigation, stress MBF is one of most strong predictors in HD population.

P3529Prognostic impact of cohabitation status in hospitalized patients with acute heart failure

Background

The prevalence of heart failure (HF) in the elderly is steadily increasing, therefore, the prudent care and treatment according to individual's characteristics, comorbidities, or prognosis, should be prerequisite. Although cohabitations status in each elderly patient is different, an association of this condition with long-term prognosis remains to be identified definitively in Japan.

Purpose

The purpose of the present study was to examine the prognostic impact of cohabitation status on 3-year mortality among hospitalized acute HF patients.

Methods

The study population comprised a total of 817 individuals who were hospitalized for acute HF between November 2009 and December 2015, and was followed up for 3 years. We classified patients into three groups (cohabitation with spouse, cohabitation with another generation, and living alone). We evaluated relative predictive values between these three groups for 3-year mortality by Cox regression model.

Results

The median age was 79 (interquartile range 70–85) years, and 55.7% of the subjects were male. Median length of hospital stay was 16 (interquartile range 11–23) days. The distribution of three groups was cohabitation with spouse (50.9%), cohabitation with another generation (28.5%), and living alone (20.6%). The overall rate of 3-year mortality was 32.2% (n=263), 31.5% (n=131) in cohabitation with spouse, 38.2% (n=89) in cohabitation with another generation, and 25.6% (n=43) in living alone. Cohabitation with another generation was significantly related to the occurrence of 3-year mortality by univariate analysis (P<0.001). Age (84 years vs. 77 years), the frequency of female (69.1% vs. 33.4%), left ventricular ejection fraction (52.7% vs. 47.5%) were significantly greater, whereas body mass index (21.2 vs. 22.6), smoking status (27.0% vs. 53.4%), ischemic etiology (27.5% vs. 35.6%), and the prevalence of type 2 diabetes mellitus (32.2% vs. 41.4%) and atrial fibrillation (20.6% vs. 29.8%) were significantly (P<0.05) smaller in cohabitation with another generation than others. The ratio of home return and optimal medical therapy were similar between the 2 groups. Cohabitation with another generation was associated with higher relative risk of 3-year mortality than living alone [Hazard Ratio (HR) 1.65; 95% Confidence Interval (CI) 1.15–2.38, P=0.007], or cohabitation with spouse (HR 1.46; 95% CI 1.12–1.92, P=0.006). Multivariable Cox regression model, with adjustment for age, albumin, brain natriuretic peptide, and prior HF hospitalization, revealed that cohabitation with another generation was no longer significant.

Conclusion

Our present results suggest that cohabitation status affected on long-term prognosis in patients with HF, especially cohabitation with another generation posed as worst predictor. We should pay more attention to social factors including cohabitation status in the clinical practice.

P1959Impact of hemodialysis in patients undergoing bypass surgery for peripheral arterial disease - 10-year follow-up study

Background

Although lower extremities bypass surgery has been commonly performed as the standard option to treat peripheral artery disease (PAD) even in patients on hemodialysis (HD) as well as general population, poorer prognosis still remains major problems in this specific population. In this 10-year follow-up study, we investigated the impact of HD after surgical revascularization in patients with PAD.

Methods

A total of 660 patients undergoing successfully bypass surgery were enrolled. Patients with acute limb ischemia were excluded. We compared 392 HD patients with 428 limbs and 268 non-HD (NHD) patients with 296 limbs during 10 years follow-up period. Primary endpoint was defined as major adverse cardiovascular events (MACE) including all-cause death, non-fatal myocardial infarction and stroke. Second endpoint was major adverse limb events (MALE) including any revascularization and major amputation. To minimize the differences of clinical characteristics between the two groups, propensity score adjusting with all baseline variables was performed.

Results

Prevalence of diabetes (53.3% vs. 35.2%), critical limb ischemia (77.5% vs. 52.1%) and infra-popliteal artery (48.2% vs. 19.6%) were higher in HD group compared to NHD group (p<0.0001 in all), inversely, age was younger in HD group than in NHD group (67±9 years vs. 71±9 years, p<0.0001). The 30-day mortality rate was comparable (3.1% in HD group vs. 1.5% in NHD group, p=0.19). The 10-year event-free survival rate for MACE was significantly lower in HD group compared to NHD group (45.3% vs. 67.4%, p<0.0001) and for MALE (60.0% vs. 80.0%, p=0.0007), respectively. After propensity score adjustment, the freedom rate from MACE was still lower in HD group compared to NHD group [45.6% vs. 67.6%, hazard ratio (HR) 1.89, 95% confidence interval (CI) 1.33–2.72, p=0.0003], however, the rate from MALE was statistically comparable between the two group (65.7% vs. 76.9%, 1.27, 95% CI 0.87–1.90, p=0.21). Furthermore, although the 10-year limb salvage rate was crudely lower in HD group compared to NHD group (80.6% vs. 91.6%, HR 1.57, 95% CI 1.05–2.40, p=0.0027), it was comparable after propensity score adjustment (89.4% vs. 90.1%, HR 1.09, 95% CI 0.59–1.88, p=0.79). Also, the mortality rate was consistently lower in HD patients (adjusted HR 2.37, 95% CI 1.62–3.50, p<0.0001).

Conclusion

The long-term freedom rate from MACE and mortality was markedly lower in HD patients compared to non-HD patients. However, the rate from MALE, especially limb salvage rate was similar between HD and NHD after adjustment for clinical characteristics. These results suggest that detection at the early stage of PAD may potentially improve the poor outcomes in this high risk population.

P4601Reduced exercise capacity and clinical outcomes following acute myocardial infarction

Background

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. The purpose of this study is to assess the associated factors and clinical influence of exercise capacity measured by CPX in AMI patients.

Methods

Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9±11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed five days after the onset of AMI. Reduced exercise capacity was defined as peak oxygen consumption (peak VO2) ≤12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed.

Results

Among 136 patients, reduced exercise capacity (peak VO2 ≤12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atria. Median follow-up term was 12 months (interquartile range: 9–22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2≤12 than those with peak VO2>12 (p<0.001). Multivariate logistic analysis showed that E/e' (Odds ratio, 1.19, 95%, confidence interval 1.09 to 1.31, p<0.001) was an independent predictor of reduced exercise capacity (peak VO2≤12).

Cumulative incidence of clinical events

Conclusion

Diastolic dysfunction is associated with reduced exercise capacity following successful primary PCI in AMI patients and may lead to poorer clinical outcomes.

P1583The association of carotid atherosclerosis, protein-energy wasting and inflammation status with mortality in patients on haemodialysis

Background

Carotid atherosclerosis such as increased intima-media thickness (IMT) is associated with poor cardiovascular outcome. On the other hand, protein-energy wasting (PEW) or malnutrition, currently considered to be due to inflammatory process rather than poor nutritional intake, is highly prevalent in in chronic kidney disease (CKD) patients, particularly those on haemodialysis (HD). We investigated the association of carotid atherosclerosis, PEW and inflammation, and their joint role with prediction of mortality in chronic HD patients.

Methods

Carotid ultra-sound was performed in a total of 774 CKD patients stably undergoing HD therapy. Carotid atherosclerosis is defined as IMT>0.8mm as median value with hyperechoic plaque. Geriatric nutritional risk index (GNRI) which calculated from serum albumin levels, body weight and height as a surrogate marker of the PEW, and C-reactive protein (CRP) were measured at the same point. Patients were followed-up for 7 years.

Results

Declined GNRI and elevated CRP levels were independently associated with carotid atherosclerosis [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93–0.98, p=0.0082 and OR 1.30, 95% CI 1.04–1.64, p=0.019, respectively] accompanied with age (OR 1.03, 95% CI 1.01–1.05, p=0.0024) and hypertension (OR 1.78, 95% CI 1.12–2.91, p=0.013). During follow-up period (median of 67 months), 180 patients (23.3%) died. Carotid atherosclerosis [62.7% vs. 79.3% for 7-year survival rate, hazard ratio (HR) 1.57, 95% CI 1.12–2.16, p=0.0078], GNRI<91.2 as an established cut-off value (58.8% vs. 83.7%, HR 1.87, 95% CI 1.35–2.59, p=0.0002) and CRP>1.1 mg/l as a median value (65.8% vs. 88.6%, HR 2.87, 95% CI 2.00–4.22, p<0.0001) were identified as independent predictors of mortality after adjustment for other confounders. When patients were divided into groups according to number of these three risk factors, 7-year Kaplan-Meier survival rate was 92.7%, 91.1%, 56.8% and 37.2% among groups with no risk factor, any 1 risk factor, any 2 risk factors and all risk factors, respectively (p<0.0001 for trend). After adjustment for other confounders, patients with any 1, any 2 and all risk factors had 2.21-fold (95% CI 1.26–4.14), 5.44-fold (95% CI 3.13–10.1) and 7.19-fold (95% CI 3.67–14.6) higher risk for mortality compared to those without any risk factor, respectively (p<0.0001 for trend).

Conclusions

Presence of carotid atherosclerosis was closely associated with both declined GNRI and elevated CRP levels in CKD patients on HD. Combination of these predictors was also additively associated with an increasing risk of mortality. These results clearly manifested the so-called malnutrition, inflammation and atherosclerosis (MIA) syndrome in this high-risk population.

P2527Accumulative impact of poor nutrition and frailty on 1-year mortality among acute decompensated heart failure patients

Background

Several studies have proved that both poor nutrition (PN) and Frail are associated with poor prognosis among heart failure patients. However, it has not been fully revealed whether PN and frail could have impact on prognosis accumulatively.

Purpose

The purpose of the present study was to evaluate the impact of nutritional and Frailty status on 1-year mortality among hospitalized patients with acute decompensated heart failure (ADHF).

Methods

Study subjects comprised of 315 hospitalized patients with ADHF. To evaluate the nutritional and Frailty status, we calculated the controlling nutritional status (CONUT) score and the Study of Osteoporotic Fractures (SOF) index at hospital admission. PN and Frailty were defined as the CONUT score ≥5 and SOF index ≥2, respectively.

Results

z Sixty-nine subjects (21.9%) were died within 1-year. PN and Frailty were observed in 33.3% and 55.6% of study subjects, respectively. Both PN and Frailty were similarly related to the 1-year mortality by univariate cox regression analysis (Hazard Ratio (HR) 2.43, 95% confidence interval (CI) 1.51–3.91, p=0.0003: HR 3.13, 95% CI 1.83–5.66, p<0.0001, respectively).

Study subjects were classified into 4 groups according to the nutritional and frailty status: control (normal nutrition without Frailty, n=110), PN alone (PN without Frailty, n=30), Frailty alone (Frailty without PN, n=100), and PN + Frailty (PN with Frailty, n=75). The Kaplan-Meier event curves for 1-year all-cause mortality illustrated that subjects with PN + Frailty had a significantly higher mortality than in subjects with control, PN alone and Frailty alone (log rank p=0.0001, 0.0180, 0.0070, respectively).

As well as, cox regression analysis revealed that PN + Frailty showed significantly higher mortality than control, PN alone and Frailty alone. (HR 5.33, 95% CI 2.75–11.1, p<0.0001: HR 2.99, 95% CI 1.26–8.78, p=0.011: HR 2.07, 95% CI 1.21–3.61, p=0.008, respectively). Moreover, multivariate cox regression analysis also revealed that PN with Frailty was independently associated with 1-year mortality even after adjustment for age, body mass index, systolic blood pressure, and chronic kidney disease. (HR 3.40, 95% CI 1.69–7.32, adjusted p<0.001)

Kaplan-Meier curve for 1year mortality

Conclusions

The combination assessment consisted with nutrition and frailty could identify poor prognosis patients with ADHF.

P1582Prognostic value of C-reactive protein/albumin ratio for cardiovascular morbidity and mortality in end-stage renal disease patients with incident haemodialysis therapy

Background

Hypoalbuminemia, a manifestation of protein-energy wasting or malnutrition, is commonly observed in patients with end-stage renal disease (ESRD), and is associated with chronic inflammation and increasing cardiovascular (CV) risk. Recently, C-reactive protein (CRP)/albumin ratio at discharge is reportedly a well-predictor of mortality in severe sepsis or cancer patients.

We investigated prognostic value of the CRP/albumin ratio at just starting haemodialysis (HD) therapy for CV morbidity and mortality in patients with ESRD.

Methods

A total of 1,548 ESRD patients were enrolled and were divided into quartiles according to CRP/albumin levels at initiation of HD; quartile 1 (Q1): <0.22, Q2: 0.23–0.54, Q3: 0.55–1.83 and Q4: >1.84. They were followed up for 10-year after starting HD therapy. Primary endpoint was CV events defined as hospitalization due to CV events such as cardiac disease, stroke and peripheral artery disease and CV death. We also evaluated the incremental value with C-index when CRP alone, albumin alone and the CRP/albumin ratio were added into a model with established risk factors.

Results

During follow-up period (median: 59 months), 512 cases experienced CV events (33.1%) including 165 cases of CV deaths (10.7%). Kaplan-Meier analysis shows that CV event-free survival rates for 10 years were 63.5%, 53.8%, 47.5% and 31.9% in Q1, Q2, Q3 and Q4, and that CV survival rates were 90.4%, 83.9%, 77.2% and 64.6% in Q1, Q2, Q3 and Q4, respectively (p<0.0001 in both). After adjustment for all baseline variables, elevated CRP/albumin ratio was identified as an independent predictor for CV events [hazard ratio (HR) 1.51, 95% confidence interval (CI) 1.11–2.07, p=0.0093 for Q2 vs. Q1, HR 1.79, 95% CI 1.33–2.42, p<0.0001 for Q3 vs. Q1and HR 2.27, 95% CI 1.70–3.07, p<0.0001 for Q4 vs. Q1, respectively]. As to CV mortality, similar results were obtained (HR 1.80, 95% CI 0.98–3.44, p=0.056 for Q2 vs. Q1, HR 2.56, 95% CI 1.45–4.71, p=0.0009 for Q3 vs. Q1 and HR 2.66, 95% CI 1.53–4.86, p=0.0004 for Q4 vs. Q1, respectively). Furthermore, adding the CRP/albumin ratio to a baseline model with established risk factors improved the C-index greater than that of CRP alone or albumin alone, respectively (0.715 from 0.692, p=0.0095 and from 0.683, p=0.0019)

Conclusion

The CRP/albumin ratio, which easily available from daily practice, could strongly stratify the risk of future CV morbidity and mortality in ESRD patients who need HD therapy.

P2434Digital zoom decreases radiation exposure dose up to 30% in percutaneous coronary intervention

Background

Interventional cardiology is gaining greater popularity worldwide with each passing year. Reduction of exposure dose is a very imminent and an important issue in cardiology procedure. Although a newer radiation reduction technique, device and procedure are very valuable and expected, we should consider about therapy technique, radiation technique, devices, and the way to protection. Digital zoom digitally enlarges images in real time by up to 2.5-fold at lower doses than those used with traditional field of view changes. In our phantom examination the average dose reduction of digital zoom was 27%.

Methods and results

This study is designated as single-center, retrospective, not-randomized, observation study. 2101 eligible cases were collected. We assigned the cases of PCI without the use of Digital zoom to the Conventional group and those involving the use of Digital zoom to the Digital zoom group. There were 806 patients in the Conventional group and 1195 in the Digital zoom group. Because we had begun using Digital zoom from January 2015 onwards, all patients in the Conventional group had undergone PCI from January 2013 to December 2014 and all patients in the Digital zoom group had undergone PCI from January 2015 to December 2016. In addition, we calculated the RAK/minute and DAP/minute for an accurate assessment. To minimize the difference of characteristics between two groups, propensity score including all baseline variables was performed. Furthermore, Predictors of radiation exposure were investigated using multivariable least square methods. Inter group differences were observed in DAP, RAK, DAP/min, and RAK/min (Digital zoom group vs conventional group: DAP, 16000 cGy cm2 [from 1st quartile to 3rd quartile; 10300–24400] vs 20700 [13400–29500], p<0.001; DAP/min, 557 cGy cm2/min [392–737] vs 782 [571–1010], p<0.01; RAK, 1590 Gy [990–2410] vs 1850 [1220–2720], p<0.01; RAK/min, 54.7 Gy/min [38.5–73.2] vs 71.2 [51.5–93.0], p<0.01). Even after propensity score matching, intergroup differences in DAP (810 cases), DAP/min (811 cases), RAK (746 cases), and RAK/min (744 cases) persisted. Furthermore, the least squares method showed that Digital zoom is an important predictor of DAP (β=0.17, p<0.01) and RAK (β=0.12, p<0.01).

Conclusion

Digital zoom is an old and cost-free technique, but one of most powerful reduction of exposure method. Propensity score adjustment and least square methods show that digital zoom is one of independent effective method.

P6243Impact of coronary flow reserve as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13N-ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic test for IHD. We have reported about the predictability of coronary flow reserve (CFR) in poor prognosis in HD population. Some prior studies show that low CFR predicts poor prognosis for not only cardiovascular event but also all-cause mortality. Although it is well-known that CFR is an important predictor, there are limited data about CFR of patients without myocardial perfusion (MP) abnormality. We investigated the prognostic predictability of adverse cardiac and cerebrovascular event (MACCE) in HD patients without MP abnormality.

Methods

A total 438 of HD patients who underwent 13NH3PET for suspected IHD were enrolled. All patients were underwent 13NH3PET at our facility. After we excluded patients whose summed stress score (SSS) >3, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR; low CFR group (≤2.405) and high CFR group (>2.405). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Results

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.04, hazard ratio (HR) 0.54, 95% confidential interval (CI) 0.30–0.97]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.04, HR 0.54, 95% CI 0.30–0.97). As regarding model discrimination, all of C-index (0.82 vs 0.80, p=0.23), NRI (0.51, p<0.01) and IDI (0.03, p=0.03) were greatest in a predicting model with established risk factors plus CFR.

Conclusions

The low CFR group had poor prognosis in MACCE comparing to the high CFR group. CFR would be an independent risk factor for MACCE. Adding CFR on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Combined ultrasound and Sestamibi scintigraphy provides accurate preoperative localisation for patients with primary hyperparathyroidism

INTRODUCTION

Minimally invasive parathyroidectomy has advantages over the traditional bilateral neck exploration for the surgical treatment of primary hyperparathyroidism. It requires accurate localisation of the parathyroid pathology prior to surgery. The best method of preoperative localisation in a district general hospital setting is not well understood.

METHODS

All patients who underwent parathyroidectomy for primary hyperparathyroidism from 2008 to 2016 were identified from a prospectively maintained database. Operative findings were correlated with radiological and histological results. Sensitivity and specificity of ultrasound, sestamibi scintigraphy and the two together were calculated for diagnostic precision and compared.

RESULTS

One hundred and eighty-four patients met the inclusion criteria, of whom 81.5% had a histological diagnosis of a parathyroid adenoma. Ultrasound had higher sensitivity than sestamibi scintigraphy. Used together, ultrasound and sestamibi scintigraphy performed better than either ultrasound or sestamibi scintigraphy alone (P< 0.001). Twenty-two of 184 cases had no lesion located by either ultrasound or sestamibi scintigraphy preoperatively. Where neither ultrasound nor sestamibi scintigraphy located the lesion, additional computed tomography led to the excision of parathyroid pathology in one in ten patients.

CONCLUSION

The combination of ultrasound and sestamibi scintigraphy provides the highest sensitivity of preoperative localisation. This approach led to a high success rate of minimally invasive parathyroidectomy. Where preoperative localisation is not achieved with ultrasound or sestamibi scintigraphy, computed tomography adds little additional benefit. In this setting other modalities of localisation such a selective venous sampling, intraoperative methylene blue or intraoperative parathyroid hormone levels could be considered.

Associations of Skeletal Muscle Mass, Lower-Extremity Functioning, and Cognitive Impairment in Community-Dwelling Older People in Japan

OBJECTIVE

We examined whether skeletal muscle mass and lower extremity functioning are closely associated with multiple cognitive domains, including global cognition, memory, attention, executive functioning, and processing speed, in community-dwelling older Japanese adults.

DESIGN

A cross-sectional, population-based community study.

SETTING

This study was conducted among community-living older people enrolled in the Obu Study of Health Promotion for the Elderly.

PARTICIPANTS

Participants comprised 5,104 adults (≥ 65 years, mean age: 71 years).

MEASUREMENTS

Data from 4273 participants were analyzed. Appendicular skeletal muscle mass was estimated from bioelectrical impedance analysis and expressed as appendicular skeletal muscle mass index (ASMI). Lower-extremity functioning was assessed by the Five-Times-Sit-to-Stand test (FTSS) and Timed Up and Go test (TUG). Cognitive functions were assessed by the Mini Mental State Examination, word list memory, Trail Making Test parts A and B, and Symbol Digit Substitution Task. Logistic regression analysis were performed to calculate odds ratios (ORs) of cognitive impairment in various domains among skeletal muscle mass, lower-extremity functioning levels adjusted for important demographic variables, and comorbidities.

RESULTS

Participants with lower ASMI and slower FTSS and TUG groups had lower cognitive functioning scores than did participants with higher ASMI and faster FTSS and TUG. The slowest quartiles (Q4) of FTSS and TUG were significantly associated with impaired global functioning (MMSE score < 24) compared to the fastest quartile (Q1) after multivariate adjustment (FTSS, OR = 1.46, 95% confidence interval (CI) = 1.12-1.90; TUG, OR = 1.65, 95% CI = 1.25-2.17). In other dimensions of cognitive functioning, FTSS and TUG were significantly associated with all cognitive impairment in the full adjustment model.

CONCLUSION

Lower-extremity functioning, rather than skeletal muscle mass, is closely related to multiple cognitive domains. This study suggests that maintaining lower-extremity functioning, rather than skeletal muscle mass, may be required for detecting and preventing cognitive impairment.

Decision tree analysis for factors associated with dental caries in school-aged children in Japan

OBJECTIVE

Our study aimed to elucidate the interactive relationship between factors associated with dental caries in school children using decision tree analysis.

RESEARCH DESIGN

Cross-sectional study Methods: Participants were recruited from public primary schools (9-12 years, 4th to 6th grade) and junior high schools (12-13 years, 1st grade) in Japan. A total of 1775 students (928 boys and 847 girls) were analyzed. Questionnaire survey, oral examination, and saliva test were performed. Multiple logistic regression and decision tree analysis were performed.

RESULTS

Multiple logistic regression showed an association between dental caries and toothpaste use, dental attendance and the presence of Streptococcus mutans. Decision tree analysis showed that students with non-regular dental attendance were at a significantly higher risk of dental caries at the late stage of primary school. At the early stage of primary school, high levels of Streptococcus mutans and male sex were factors associated with dental caries. In students with low levels of Streptococcus mutans, using toothpaste occasionally was associated with a high risk of dental caries.

CONCLUSIONS

In early primary school years, S. mutans may be a useful screening and diagnostic tool for dental caries. In students with high levels of S. mutans, sex may be associated with dental caries. Furthermore, in students with low levels of S. mutans, regular use of toothpaste should be encouraged, and in late primary school years, regular dental attendance should be encouraged to prevent dental caries.