Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m2), 2 (normal: BMI of 18.5 to <25 kg/m2), 3 (overweight: BMI of 25 to <30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd

Association between seasonal influenza vaccines and the increased risk of acute disseminated encephalomyelitis, estimated using the Vaccine Adverse Event Reporting System

Acute disseminated encephalomyelitis (ADEM) is a rare and immune-mediated inflammatory disorder of the central nervous system (CNS) that can be triggered by infections and vaccinations. To date, only anecdotal case studies have reported the association between ADEM incidence and seasonal influenza vaccines, and multiple studies have found no association. This study aimed to investigate the association between the incidence of ADEM and seasonal influenza vaccines in a real-world setting using data from the United States Vaccine Adverse Event Reporting System (VAERS). Further, propensity score matching and disproportionality analysis was performed by calculating the adjusted reporting odds ratio (ROR) of reported ADEM cases associated with seasonal influenza vaccines using multiple logistic regression. Additionally, we analysed the time-to-onset using Weibull shape parameters (WSPs). The VAERS database contained 390,352 adverse events reported from January 2011 to December 2020. The ROR of seasonal influenza vaccines for ADEM was 3.02 (95% confidence interval: 1.72-5.33). The median duration (interquartile range) of ADEM was 11.0 (5.0-33.0) days. The median duration of ADEM induced by egg culture-based influenza vaccine (Egg-based vaccine) and cell culture-based influenza vaccine (Cell-based vaccine) was 10.0 (5.0-24.0) and 91.0 (79.0-125.0) days (P < 0.001), respectively. Only Cell-based cases had WSP β > 1, indicating a wear-out failure type. The incidence of ADEM within 30 days after administration of egg- and Cell-based vaccines was 78.6% and 0.0%, respectively. Our findings indicate that ADEM incidence is associated with seasonal influenza vaccines; thus, careful monitoring of ADEM is required within the first month of Egg-based vaccination and after two months of Cell-based vaccination. Neurologists and general practitioners should exercise caution, as the timing for careful monitoring varies depending on the vaccine type.

Dynamic changes in RAS gene status in circulating tumour DNA: a phase II trial of first-line FOLFOXIRI plus bevacizumab for RAS-mutant metastatic colorectal cancer (JACCRO CC-11)

Background

Few prospective studies have used liquid biopsy testing in RAS-mutant metastatic colorectal cancer (mCRC), and its clinical significance remains unknown. Therefore, this study aimed to carry out a biomarker analysis by liquid biopsy using updated data of the phase II trial of FOLFOXIRI plus bevacizumab as first-line chemotherapy for RAS-mutant mCRC.

Materials and methods

A total of 64 patients who received modified FOLFOXIRI regimen (irinotecan 150 mg/m², oxaliplatin 85 mg/m², levofolinate 200 mg/m², and fluorouracil 2400 mg/m²) plus bevacizumab biweekly were enrolled. The primary endpoint was the objective response rate (ORR). Plasma samples were collected at pre-treatment, 8 weeks after treatment, and progression in participants included in the biomarker study. The levels of circulating tumour DNA (ctDNA) and specific KRAS and NRAS variants were evaluated using real-time PCR assays.

Results

There were 62 patients (median age: 62.5 years, 92% performance status 0, 27% right side) who were assessable for efficacy and 51 for biomarker analysis. ORR was 75.8% (95% confidence interval 65.1% to 86.5%). The median progression-free survival was 12.1 months, and the median overall survival (OS) was 30.2 months. In 78% of patients, RAS mutations disappeared in the ctDNA at 8 weeks after treatment; these patients tended to have better outcomes than those with RAS mutations. Interestingly, RAS mutations remained undetectable during progression in 62% of patients. Survival analysis indicated that the median OS from progression was significantly longer in patients with RAS mutation clearance than in those with RAS mutation in the ctDNA at disease progression (15.1 versus 7.3 months, hazard ratio: 0.21, P = 0.0046).

Conclusions

Our biomarker study demonstrated no RAS mutations in ctDNA at disease progression in 62% of patients with RAS-mutant mCRC. Both OS and post-progression survival were better in patients with clearance of RAS mutations in ctDNA after triplet-based chemotherapy.

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First-line FOLFOXIRI plus bevacizumab is effective for RAS-mutant mCRC with comparable efficacy in elderly patients.

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RAS mutations disappeared in ctDNA after intensive chemotherapy in 62% of patients with mCRC with RAS-mutant tumours.

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Survival time was longer in patients with RAS mutation clearance than in those with RAS mutations in ctDNA.

Expression of Vincristin-induced Peripheral Neuropathy Related to Different Administration Methods

Vincristine (VCR) is an important drug used in R-CHOP regimens for the treatment of non-Hodgkin's lymphoma. The purpose of this study was to examine whether the administration method affects the incidence of VCR-induced peripheral neuropathy. We investigated the ratio of VCR-induced peripheral neuropathy during rapid intravenous infusion and intravenous drip infusion. A total of 71 patients who had received six or more courses of R-CHOP from January, 2015 to December, 2016 at Komaki City Hospital and Ogaki Municipal Hospital were retrospectively investigated. Peripheral neuropathy was observed in 27/39 patients (69 %) and 24/32 (75 %) in rapid intravenous infusion and intravenous drip infusion of VCR, respectively (P = 0.79). Peripheral neuropathy was observed at a high frequency in this study. Additionally, there was no difference in frequency of peripheral neuropathy due to the difference in administration method. In both groups, the degree of peripheral neuropathy was grade 1 and grade 2 in most patients. However, in rapid intravenous infusion, grade 3 peripheral neuropathy was observed. Some cases required dose reduction and discontinuation in rapid intravenous infusion. In contrast, there were no discontinuing patients in the intravenous drip infusion. Therefore, it was suggested that intravenous drip infusion of VCR reduced serious peripheral neuropathy because the ratio requiring dose reduction and discontinuation was less than that in the rapid group. In conclusion, this study is informative as there are few reports focusing on the administration method of vincristine.

Association between lipid profile and residual renal function in incident peritoneal dialysis patients

INTRODUCTION

Residual renal function (RRF) is one of the most crucial factor in the management of peritoneal dialysis (PD). The aim of this study was to evaluate the association between lipid profile and preservation of RRF among incident PD patients.

METHODS

This retrospective cohort study investigated 113 patients (male, 72%; age, 59±14 years) who initiated PD between 2006 and 2017. We investigated the relationships between high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) at PD initiation and change in renal Kt/V during the first year after PD initiation.

RESULTS

Alterations in renal Kt/V during the first year after PD initiation correlated negatively with HDL-C at PD initiation, but not with LDL-C. On multivariate analysis, HDL-C at PD initiation was independently associated with change in renal Kt/V during the first year after PD initiation.

CONCLUSION

These results suggests importance of lipid management among incident PD patients for preservation of RRF.

Pulmonary artery pulsatility index and hemolysis during Impella support

Funding Acknowledgements

Type of funding sources: None.

Background

Impella-related hemolysis is a well-known complication, which we sometimes experience in the clinical practice depending on various hemodynamic status including right ventricular impairment.

Methods

We enrolled consecutive patients with cardiogenic shock who received Impella support between March 2018 and December 2020. The association between pulmonary artery pulsatility index (PAPi) immediately after Impella insertion and the occurrence of hemolysis was investigated. Hemolytic event was defined as detection of hemoglobinuria and elevated lactate dehydrogenase level over 2.5 folds of upper normal range.

Results

Among 38 patients (median 71 y; men 61%; LVEF 29%) included in this study, hemolysis occurred in 18 patients (47%). Incidence of hemolysis was significantly higher in the low PAPi group (&lt; 1.3) compared with the normal PAPi group (≥ 1.3) (67% vs. 33%, p = 0.0176; Figure 1). The low PAPi (&lt;1.3) was significantly associated with the occurrence of hemolysis with a hazard ratio of 5.71 (95% confidence interval 1.09–29.91, p = 0.0313) adjusted for other clinically significant variables.

Conclusions

In patients with right ventricular impairment with lower PAPi, it might be encouraged to be aware of the risk of hemolysis, maintaining volume status and considering inotropes administration. Abstract Figure.

A novel method of evaluating changes in intrinsic motivation during cognitive rehabilitation

Motivation is one of the most important affecting rehabilitation outcomes. In present study, we propose a novel method to evaluate intrinsic motivation. We conducted experiments of simulated cognitive rehabilitation exercises. The results of these experiments demonstrate that intrinsic motivation is correlated to valence. Furthermore, CIM (Changes in intrinsic motivation) can be detected with up to 80% accuracy, using physiological states. The result showed that this method more precisely detects CIM than occupational therapists.Clinical Relevance-The proposed method enables to evaluate changes in intrinsic motivation during cognitive rehabilitation without disturbing or suspending rehabilitation.

Aspirin vs. P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation: insights from the AFIRE trial

Background

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelets and oral anticoagulants; however, this has the potential to increase bleeding risk.

Purpose

This sub-analysis aimed to evaluate the efficacy and safety of P2Y12 inhibitors and aspirin in patients also receiving oral anticoagulant therapy.

Methods

We evaluated patients from the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received combination therapy (rivaroxaban plus a single antiplatelet agent). The choice of antiplatelets was left to the physician's discretion. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause. The primary safety endpoint was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

Results

A total of 1,075 patients were included (P2Y12 inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs), and there was no significant difference in PPI use in the P2Y12 inhibitor and aspirin groups. Regarding the primary efficacy endpoint, there was no significant difference between the P2Y12 inhibitor and aspirin groups (hazard ratio, 1.31; 95% confidence interval, 0.88–1.94; p=0.178). Likewise, the primary safety endpoint was not different between the groups (hazard ratio, 0.79; 95% confidence interval, 0.43–1.47; p=0.456). In the detailed subgroup analysis, there were no differences in the efficacy and safety endpoints.

Conclusions

There were no significant differences between P2Y12 inhibitors and aspirin in cardiovascular events in patients with AF and stable CAD taking rivaroxaban in the chronic phase.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd. Summary of this study

A study of the association between seasonal influenza vaccines and the increased risk of Guillain-Barré syndrome using Vaccine Adverse Event Reporting System, 2018-2019

The aim of this study was to investigate the association between the incidence of Guillain-Barré syndrome (GBS) and seasonal influenza vaccines using the United States Vaccine Adverse Event Reporting System. Using multiple logistic regression analysis, we calculated the adjusted reporting odds ratio (ROR) of GBS cases associated with seasonal influenza vaccines administered from August 2018 to July 2019. Additionally, we analyzed the time-to-onset profile. The total number of adverse events reported following vaccination during this period was 43,235. Most of the GBS patients received a cell culture-based quadrivalent inactivated influenza vaccine (42.2%), quadrivalent inactivated influenza vaccine (26.6%), or high-dose trivalent inactivated influenza vaccine (15.6%). The adjusted ROR of seasonal influenza vaccines for GBS was 3.44 (2.40-4.95). The adjusted ROR of sex (male) (as reference female) and 0.5-59 years (as reference ≥ 60 years) were 1.90 (0.73-4.95) and 1.57 (0.88-2.78). Male sex and advanced age were not risk factors for GBS. The median duration of GBS was 9.5 (4.0-21.5) days. GBS following seasonal influenza vaccination developed mainly within 14 days and 42 days at most. In sex-stratified analyses, the median durations of GBS in females and males were 12.0 (8.3-28.5) and 5.0 (3.0-15.5) days (P = 0.050). Therefore, our findings indicate that the incidence of GBS is associated with seasonal influenza vaccines, and careful monitoring of GBS is required for up to 42 days, especially in the first 14 days. Moreover, GBS may occur slightly earlier in males than in females.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.