Impact of mental disease on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study

Background

Diabetes mellitus (DM) is known to increase the risk of mental disorders, which increases the health care burden in these patients. Also, DM is one of the risk factors leading to atrial fibrillation (AF), and the presence of concomitant AF and DM adds to the increased risks of stroke and death. It is uncertain whether mental disease is an independent risk factor of incident AF in patients with DM.

Purpose

To investigate whether diabetic patients with mental disease have an increased risk of AF.

Methods

Using the Korea National Health Insurance Service database, we enrolled 2,512,690 patients diagnosed with DM without AF between 2009 and 2021. Newly diagnosed AF was identified during the follow-up period. We compared the risk of AF between patients with mental disease and those without.

Results

Among the total population, 828,929 (32.99%; mean age 61.58±11.28; 56.71% female) patients were diagnosed with mental diseases (Figure 1). Anxiety (564,786 patients, 68.13%) was the most common mental disease, while depression was the second most common (313,773 patients, 37.85%). Diabetic patients with mental diseases had a higher percentage of women, hypertension, dyslipidemia, chronic kidney failure, congestive heart failure, obstructive sleep apnea, and thyroid disease. During a median 7.0 years (IQR 5.93–8.07) follow-up, 34,523 were diagnosed new-onset AF (4.66 per 1,000 person-year). In multivariate analysis, diabetic patients with mental disorders showed a higher risk of new-onset AF (HR 1.19; 95% CI 1.17–1.21; p-value <0.0001) (Figure 2). Among mental diseases, depression, insomnia, and anxiety were associated with increased risks of new-onset AF (HR 1.15; 95% CI 1.12–1.17; HR 1.15; 95% CI 1.13–1.18; and HR 1.19; 95% CI, 1.67–1.21; all p-value <0.0001, respectively), whereas bipolar disorder and schizophrenia showed non-statistically significant trends (due to small numbers). Subgroup analyses showed that younger age had significant interactions with depression, insomnia, and anxiety.

Conclusion

Mental diseases, especially depression, insomnia, and anxiety, showed an increased risk of AF in patients with DM. Awareness and prompt diagnosis and management of AF would be necessary for these high-risk populations at risk of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Increased risk of atrial fibrillation in patients with uterine fibroids: a nationwide population-based study

Background

Uterine fibroid, the most common benign neoplasm of the uterus, is associated with an elevated risk of cardiovascular disease. The link between incident atrial fibrillation (AF) and the uterine fibroid is unclear because earlier studies focused primarily on the development of atherosclerosis and hypertension. We aimed to investigate the risk of AF in patients with uterine fibroid.

Methods

This is a retrospective cohort study using the Korean National Health Insurance Service database (NHIS). From 2009 to 2012, a total of 2,574,349 women (20 to 40 years old) who underwent general health examinations were included. Diagnosis of uterine fibroids and surgical treatment status was defined by the international classification of diseases, 10th revision codes, and procedural codes from the Korean NHIS. The primary outcome was newly diagnosed AF. The risk of AF according to the uterine fibroids and their surgical treatment status was evaluated using Cox proportional-hazard models.

Results

Of the total population, the mean age was 29.76±4.27 years, and 20,682 (0.8%) were identified to have uterine fibroid. Incident AF was identified in 3,868 patients (61 in the fibroid group, 3,807 in the control group) during a mean follow-up of 7.3±1.1 years. Patients of the uterine fibroid group showed a higher incidence of AF compared to the control group (0.41 and 0.20 per 1000 person-years, respectively, Figure 1). Multivariate Cox-regression analysis presented that uterine fibroid was an independent risk factor of AF: hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16–1.93, p=0.002. Compared to the control group, uterine fibroid patients who underwent surgical treatment tend to show a lower risk for AF (HR 1.22, 95% CI 0.79–1.90) than patients without surgical treatment (HR 1.69, 95% CI 1.24–2.30), though statistical significance was indeterminate (Figure 2). After propensity score matching, patients of the uterine fibroid group showed higher risk of AF when compared to the control group (HR 1.77, 95% CI 1.32–2.63, p<0.001), which was in line with our main results. The presence of uterine fibroid was consistently associated with higher risk of AF among all subgroups except for the stroke subgroup.

Conclusion

Patients with uterine fibroids are predisposed to an increased risk of AF compared to the control group. Careful monitoring of arrhythmia development would be warranted in patients of uterine fibroid and surgical treatment as it is associated with a modest risk decrement of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical association between lipid levels and incident atrial fibrillation according to statin usage

Background

In epidemiology studies, a higher level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) is associated with a lower risk of atrial fibrillation (AF). Statin use might exert possible confounding effects in the paradoxical relationship; however, the inverse link between AF and cholesterol level that distinguishes statin users from non-users has not been evaluated.

Objective

We investigated the epidemiological relationships of TC–AF and LDL-C–AF in statin users and non-users, respectively.

Methods

From the Korean National Health Insurance Service database, we included 9,778,014 adults who underwent a health examination in 2009 and had no prior AF history. The levels of TC and LCL-C at the health exam were categorized in quartile (Q) and decile (D) values of the total study population. The study population was grouped into statin users and non-users, and TC–AF and LDL-C–AF relationships were evaluated.

Results

867,336 (8.9%) were on statin use among the total population. Statin users showed higher TC level (208.4±55.6 vs. 194.1±39.5 mg/dL, p<0.001) and LDL-C level (123.0±102.2 vs. 121.3±226.3, p<0.001) compared to non-users. Inverse associations of TC–AF and LCL-C–AF were observed; higher levels of TC and LDL-C were associated with a lower risk of AF. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.797 (0.786–0.809) for the highest quartile of TC (Q4, TC ≥218) and 0.832 (0.82–0.843) for the highest quartile of LDL-C (Q4, LDL-C ≥135) when adjusted by age, sex, lifestyle behaviors, comorbidities, and low-income status. Statin users exhibited higher AF incidence rate than non-statin users, but the association in statin users generally tracked that seen among non-statin users demonstrating similar HR in Q4 of TC [0.812 (0.790–0.835) for statin users and 0.812 (0.798–0.826) for non-statin users] and LDL-C [0.842 (0.819–0.865) for statin users and 0.849 (0.835–0.863) for non-statin users].

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and incident AF remained consistent both in statin users and non-users. Further research is required to investigate an underlying mechanism for the cholesterol paradox of AF which still seems evident despite the pleiotropic effects of statin.

Funding Acknowledgement

Type of funding sources: None.

Fish oil supplements increase atrial fibrillation risk in healthy individuals: a population-based cohort study and Mendelian randomization analysis

Background

There is a paucity of information on the risk of atrial fibrillation (AF) in healthy individuals taking fish oil supplements.

Purpose

We aimed to investigate the epidemiologic and causal relationships between fish oil supplement intake and the long-term risk of AF.

Methods

From the population-based UK Biobank, we selected healthy individuals without a history of AF, other cardiac arrhythmias, or cardiovascular diseases, who were not taking lipid-lowering medications or dietary supplements other than fish oil. The 10-year risk of AF in Fish-Oil-Users vs. Non-Users was evaluated in the total population and propensity-score matched cohort. The causal relationship between n-3 polyunsaturated fatty acids (PUFA) and AF was evaluated using a two-sample summary-level Mendelian randomization analysis with fixed effects robust inverse-variance weighted method, using genetic instruments from previous studies genome-wide association studies for n-3 PUFA levels and AF, respectively.

Results

A total of 338,199 participants (aged 55.2±8.1, 44.3% men) were analysed. Of these, 35.0% (n=118,300) was taking fish oil supplements. The 10-year risk of AF was significantly higher in the Fish-Oil-Users than in the Non-Users (3.83% vs. 2.91%, adjusted hazard ratio [HR] 1.05, 95% CI [1.01–1.10], P=0.023). The result was consistent in the propensity-score matched cohort (propensity-score matched HR 1.06, 95% CI [1.00–1.12], P=0.043). The increased risk of AF by fish oil supplement was prominent in low-risk participants with healthy lifestyles. Among n-3 PUFA, the docosapentaenoic acid (DPA) showed significant causal estimates for the increased risk of AF (odds ratio [OR] 1.15, 95% CI [1.08–1.22], P<0.001), while higher eicosapentaenoic acid (EPA) levels caused a decrease of AF risk (OR 0.85, 95% CI [0.80–0.90], P<0.001).

Conclusion

Fish oil supplement intake significantly increased the long-term risk of AF in a healthy population. The causal effect of fish oil intake on the risk of AF may depend on the specific types of n-3 PUFA.

Funding Acknowledgement

Type of funding sources: None.

Impact of metabolic syndrome on the risk of ischemic stroke in non-anticoagulated atrial fibrillation patients having low CHA2DS2-VASc scores

Background

Metabolic syndrome (MetS) predisposes to a thromboembolic state. However, conflicting results have been reported on whether MetS confers an increased risk of ischemic stroke in atrial fibrillation (AF), especially in patients with low CHA2DS2-VASc score who are not indicated for oral anticoagulant therapy.

Purpose

We investigated the risk of ischemic stroke according to the presence of MetS, the number of MetS components (metabolic burden), and the individual metabolic components in non-anticoagulated AF patients with low CHA2DS2-VASc score.

Methods

A total of 76,015 oral anticoagulant-naïve AF patients with low CHA2DS2-VASc score (0,1 in male and 1 in female) were included from the Korean National Health Insurance Service database. The status of MetS and individual metabolic components were evaluated based on health examination data within two years of AF diagnosis. We estimated the risk of ischemic stroke according to MetS, metabolic burden, and an individual component of MetS using Cox proportional-hazards models.

Results

The mean age was 49.8±11.1 years and 52,388 (68.9%) were male. The average CHA2DS2-VASc score was 0.7±0.5 and MetS was prevalent among 21,570 (28.4%) of the study population. During a mean follow-up of 5.1 years, ischemic stroke was developed in 1,395 (1.84%) patients. MetS was associated with a higher risk of ischemic stroke after adjustment for age, sex, lifestyle behaviors, low income, and cardiovascular comorbidities: adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) 1.06–1.33, p=0.002. A positive linear correlation was observed between metabolic burden and ischemic stroke risk. Patients with five MetS components showed the highest aHR of 1.55 (95% CI 1.14–2.11, Figure 1 and Figure 2), whereas those with a single MetS component had a marginal risk of ischemic stroke (aHR 1.18, 95% CI 0.99–1.41). Among individual metabolic components, elevated blood pressure and increased waist circumference was significantly associated with an increased risk of ischemic stroke: aHR (95% CI), 1.45 (1.30–1.62), p<0.001, and 1.15 (1.03–1.30), p=0.016, respectively.

Conclusions

Among AF patients initially with CHA2DS2-VASc score 0 and 1 with no anticoagulation, the presence of MetS is associated with an increased risk of ischemic stroke. Given the linear incremental correlation between metabolic burden and ischemic stroke, special attention to the care of metabolic derangements is required in AF patients who are not indicated for anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation detection in ambulatory patients using a smart ring powered by deep learning analysis of continuous photoplethysmography monitoring

Background

Atrial fibrillation (AF) detection could be effective with photoplethysmography (PPG) signal monitoring by a wearable device.

Purpose

We aimed to validate the performance of AF detection among ambulatory patients who underwent electrical cardioversion for AF using a smart ring capable of continuous PPG monitoring and deep learning analysis.

Methods

In this prospective single-arm study, participants who underwent successful electrical cardioversion for AF were enrolled. The participants equipped a smart ring (CardioTracker, Sky Labs Inc., Seongnam, Republic of Korea) after the electrical cardioversion. The smart ring then continuously monitored PPG over 14 days to detect AF recurrence. The smart ring alarmed AF episodes based on deep learning analysis of PPG. The participants were asked to measure at least three daily ECGs using the smart ring to validate AF recurrence detected by PPG. All ECG snapshots were recorded along with lead I and saved with simultaneous PPG. ECG data were examined by the three cardiologists independently (SK, SRL, and EKC). The monitoring time, analyzable proportions of monitored signals, detection rates of AF episodes, and the diagnostic performance of PPG-based deep learning were evaluated. At the end of the monitoring, a survey on the use of the smart ring was performed.

Results

A total of 35 participants (mean age 58.9 years, male 74.3%) were enrolled. Figure 1 illustrates an example of PPG monitoring and PPG-ECG snapshots by the smart ring. The study participation period was a median of 14 days and the wearing time of the smart ring was a median of 9.2 days (IQR 7.1–11.5 days). Signal artifacts during daily activity decreased the analyzable proportions of monitored PPG by 68.5%. Irregular pulse episodes were detected by the smart ring in 29 (82.9%) participants after a median of 1 day from the cardioversion (Figure 2). A total of 2532 PPG-ECG snapshots were acquired and 1623 (64.1%) were interpretable by both the cardiologists (using ECG) and the deep learning analysis (using PPG). Comparing PPG by simultaneous ECG, the performance of AF detection by the smart ring was 98.7% for sensitivity, 97.8% for specificity, 2.2% for false positives, and 1.3% for false negatives (Figure 2). After using the smart ring, 76.9% of the participants responded that they had no discomfort in using the smart ring in daily activity and another 76.9% responded that it was helpful to monitor their disease.

Conclusion

Despite the signal artifacts during daily activity, AF detection with PPG monitoring by a smart ring could be effective for AF screening among ambulatory patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by Sky Labs Inc, Seongnam, Republic of Korea, and by the grant No. 0320202040 from the Seoul National University Hospital Research Fund.

Large Memory Window of van der Waals Heterostructure Devices Based on MOCVD-Grown 2D Layered Ge4 Se9

Van der Waals (vdW) heterostructures have drawn much interest over the last decade owing to their absence of dangling bonds and their intriguing low-dimensional properties. The emergence of 2D materials has enabled the achievement of significant progress in both the discovery of physical phenomena and the realization of superior devices. In this work, the group IV metal chalcogenide 2D-layered Ge₄ Se₉ is introduced as a new selection of insulating vdW material. 2D-layered Ge₄ Se₉ is synthesized with a rectangular shape using the metalcorganic chemical vapor deposition system using a liquid germanium precursor at 240 °C. By stacking the Ge₄ Se₉ and MoS₂ , vdW heterostructure devices are fabricated with a giant memory window of 129 V by sweeping back gate range of ±80 V. The gate-independent decay time reveals that the large hysteresis is induced by the interfacial charge transfer, which originates from the low band offset. Moreover, repeatable conductance changes are observed over the 2250 pulses with low non-linearity values of 0.26 and 0.95 for potentiation and depression curves, respectively. The energy consumption of the MoS₂ /Ge₄ Se₉ device is about 15 fJ for operating energy and the learning accuracy of image classification reaches 88.3%, which further proves the great potential of artificial synapses.

Evidence for Nonlinear Gluon Effects in QCD and Their Mass Number Dependence at STAR

The STAR Collaboration reports measurements of back-to-back azimuthal correlations of di-π^{0}s produced at forward pseudorapidities (2.6<η<4.0) in p+p, p+Al, and p+Au collisions at a center-of-mass energy of 200 GeV. We observe a clear suppression of the correlated yields of back-to-back π^{0} pairs in p+Al and p+Au collisions compared to the p+p data. The observed suppression of back-to-back pairs as a function of transverse momentum suggests nonlinear gluon dynamics arising at high parton densities. The larger suppression found in p+Au relative to p+Al collisions exhibits a dependence of the saturation scale Q_{s}^{2} on the mass number A. A linear scaling of the suppression with A^{1/3} is observed with a slope of -0.09±0.01.

POS0451 DEFICIENCY OF PPM1A IN MACROPHAGE AGGRAVATES PRISTANE-INDUCED LUPUS-LIKE DISEASE

Background

Protein phosphatase Mg2+/Mn2+-dependent 1A (PPM1A) is a phosphatase which regulates various intracellular cell signaling pathways including inflammation. We previously suggested that the inflammatory signal decreased the PPM1A protein level in macrophage and this reduction had correlation with the chronic inflammatory bone disease, implying the possible role of PPM1A in inflammatory responses of macrophage.

Objectives

In this study, we aim to elucidate the potential role of PPM1A in macrophage to regulate inflammatory response during the disease progression of systemic lupus erythematosus.

Methods

We generated macrophage-specific conditional gene-knockout (PPM1Afl/fl;LysM-Cre) mice and developed a lupus-like disease with immune complex glomerulonephritis in these PPM1Afl/fl;LysM-Cre mice by intraperitoneal pristane injection. Mouse serum was collected every 4 weeks after pristane injection. Serum anti-dsDNA IgG, anti-ssDNA IgG, interleukin-17 (IL-17) and tumor necrosis factor-α (TNF-α) was quantified by ELISA. After 41 weeks from pristane injection, histological changes in the kidney, spleen, and lung tissues were observed. To analyze M1/M2 polarization in vitro, LysM-Cre and PPM1Afl/fl;LysM-Cre mouse bone marrow-derived macrophages were cultured with lipopolysaccharide (LPS)/interferon-γ (IFN-γ) or interleukin-4 (IL-4) to check M1 or M2 related genes.

Results

We found that macrophages of PPM1Afl/fl;LysM-Cre mice displayed different gene expression with LPS stimulation especially in M1/M2 related genes through the RNA-seq analysis and showed a decrease in both M1 and M2 polarization induced by LPS/IFN-γ or IL-4 stimulation. Notably, we found that PPM1Afl/fl;LysM-Cre mice with pristane injection showed a significant increase of anti-ssDNA IgG compared to LysM-Cre mice. PPM1Afl/fl;LysM-Cre mice showed severe lupus-like phenotypes such as global glomerular enlargement indicated by endocapillary proliferation and glomerular cellularity in kidney and lung inflammation accompanied by fibrosis, compared to LysM-Cre mouse by pristane injection. Together, serum IL-17 and TNF-α, which are proinflammatory cytokines, were increased in PPM1Afl/fl;LysM-Cre after pristane injection. These results indicate that PPM1A depletion in macrophage deteriorates inflammation and contributes to the tissue damage in a lupus-like disease.

Conclusion

Our findings suggest that the deficiency of PPM1A in macrophages impairs M1/M2 macrophage polarization leading to an immune imbalance in lupus-like disease model, providing a potential link between the loss of function of PPM1A in macrophages and its molecular target for treatment of systemic lupus erythematosus.

References

[1]Kwon, O. C., Choi, B., Lee, E. J., Park, J. E., Lee, E. J., Kim, E. Y., Kim, S. M., Shin, M. K., Kim, T. H., Hong, S., Lee, C. K., Yoo, B., Robinson, W. H., Kim, Y. G., & Chang, E. J. (2020). Negative Regulation of Osteoclast Commitment by Intracellular Protein Phosphatase Magnesium-Dependent 1A. Arthritis & rheumatology (Hoboken, N.J.), 72(5), 750–760. https://doi.org/10.1002/art.41180

[2]Smith, S. R., Schaaf, K., Rajabalee, N., Wagner, F., Duverger, A., Kutsch, O., & Sun, J. (2018). The phosphatase PPM1A controls monocyte-to-macrophage differentiation. Scientific reports, 8(1), 902. https://doi.org/10.1038/s41598-017-18832-7

Disclosure of Interests

None declared.

Measurements of Proton High-Order Cumulants in sqrt[s_{NN}]=3 GeV Au+Au Collisions and Implications for the QCD Critical Point

We report cumulants of the proton multiplicity distribution from dedicated fixed-target Au+Au collisions at sqrt[s_{NN}]=3.0  GeV, measured by the STAR experiment in the kinematic acceptance of rapidity (y) and transverse momentum (p_{T}) within -0.5<y<0 and 0.4<p_{T}<2.0  GeV/c. In the most central 0%-5% collisions, a proton cumulant ratio is measured to be C_{4}/C_{2}=-0.85±0.09 (stat)±0.82 (syst), which is 2σ below the Poisson baseline with respect to both the statistical and systematic uncertainties. The hadronic transport UrQMD model reproduces our C_{4}/C_{2} in the measured acceptance. Compared to higher energy results and the transport model calculations, the suppression in C_{4}/C_{2} is consistent with fluctuations driven by baryon number conservation and indicates an energy regime dominated by hadronic interactions. These data imply that the QCD critical region, if created in heavy-ion collisions, could only exist at energies higher than 3 GeV.

Measurements of _{Λ}^{3}H and _{Λ}^{4}H Lifetimes and Yields in Au+Au Collisions in the High Baryon Density Region

We report precision measurements of hypernuclei _{Λ}^{3}H and _{Λ}^{4}H lifetimes obtained from Au+Au collisions at sqrt[s_{NN}]=3.0  GeV and 7.2 GeV collected by the STAR experiment at the Relativistic Heavy Ion Collider, and the first measurement of _{Λ}^{3}H and _{Λ}^{4}H midrapidity yields in Au+Au collisions at sqrt[s_{NN}]=3.0  GeV. _{Λ}^{3}H and _{Λ}^{4}H, being the two simplest bound states composed of hyperons and nucleons, are cornerstones in the field of hypernuclear physics. Their lifetimes are measured to be 221±15(stat)±19(syst)  ps for _{Λ}^{3}H and 218±6(stat)±13(syst)  ps for _{Λ}^{4}H. The p_{T}-integrated yields of _{Λ}^{3}H and _{Λ}^{4}H are presented in different centrality and rapidity intervals. It is observed that the shape of the rapidity distribution of _{Λ}^{4}H is different for 0%-10% and 10%-50% centrality collisions. Thermal model calculations, using the canonical ensemble for strangeness, describes the _{Λ}^{3}H yield well, while underestimating the _{Λ}^{4}H yield. Transport models, combining baryonic mean-field and coalescence (jam) or utilizing dynamical cluster formation via baryonic interactions (phqmd) for light nuclei and hypernuclei production, approximately describe the measured _{Λ}^{3}H and _{Λ}^{4}H yields. Our measurements provide means to precisely assess our understanding of the fundamental baryonic interactions with strange quarks, which can impact our understanding of more complicated systems involving hyperons, such as the interior of neutron stars or exotic hypernuclei.

Gas-Phase Alkali Metal-Assisted MOCVD Growth of 2D Transition Metal Dichalcogenides for Large-Scale Precise Nucleation Control

Advances in large-area and high-quality 2D transition metal dichalcogenides (TMDCs) growth are essential for semiconductor applications. Here, the gas-phase alkali metal-assisted metal-organic chemical vapor deposition (GAA-MOCVD) of 2D TMDCs is reported. It is determined that sodium propionate (SP) is an ideal gas-phase alkali-metal additive for nucleation control in the MOCVD of 2D TMDCs. The grain size of MoS₂ in the GAA-MOCVD process is larger than that in the conventional MOCVD process. This method can be applied to the growth of various TMDCs (MoS₂ , MoSe₂ , WSe₂ , and WSe₂ ) and the generation of large-scale continuous films. Furthermore, the growth behaviors of MoS₂ under different SP and oxygen injection time conditions are systematically investigated to determine the effects of SP and oxygen on nucleation control in the GAA-MOCVD process. It is found that the combination of SP and oxygen increases the grain size and nucleation suppression of MoS₂ . Thus, the GAA-MOCVD with a precise and controllable supply of a gas-phase alkali metal and oxygen allows achievement of optimum growth conditions that maximizes the grain size of MoS₂ . It is expected that GAA-MOCVD can provide a way for batch fabrication of large-scale atomically thin electronic devices based on 2D semiconductors.

Probing the Gluonic Structure of the Deuteron with J/ψ Photoproduction in d+Au Ultraperipheral Collisions

Understanding gluon density distributions and how they are modified in nuclei are among the most important goals in nuclear physics. In recent years, diffractive vector meson production measured in ultraperipheral collisions (UPCs) at heavy-ion colliders has provided a new tool for probing the gluon density. In this Letter, we report the first measurement of J/ψ photoproduction off the deuteron in UPCs at the center-of-mass energy sqrt[s_{NN}]=200  GeV in d+Au collisions. The differential cross section as a function of momentum transfer -t is measured. In addition, data with a neutron tagged in the deuteron-going zero-degree calorimeter is investigated for the first time, which is found to be consistent with the expectation of incoherent diffractive scattering at low momentum transfer. Theoretical predictions based on the color glass condensate saturation model and the leading twist approximation nuclear shadowing model are compared with the data quantitatively. A better agreement with the saturation model has been observed. With the current measurement, the results are found to be directly sensitive to the gluon density distribution of the deuteron and the deuteron breakup process, which provides insights into the nuclear gluonic structure.

Search for the Chiral Magnetic Effect via Charge-Dependent Azimuthal Correlations Relative to Spectator and Participant Planes in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

The chiral magnetic effect (CME) refers to charge separation along a strong magnetic field due to imbalanced chirality of quarks in local parity and charge-parity violating domains in quantum chromodynamics. The experimental measurement of the charge separation is made difficult by the presence of a major background from elliptic azimuthal anisotropy. This background and the CME signal have different sensitivities to the spectator and participant planes, and could thus be determined by measurements with respect to these planes. We report such measurements in Au+Au collisions at a nucleon-nucleon center-of-mass energy of 200 GeV at the Relativistic Heavy-Ion Collider. It is found that the charge separation, with the flow background removed, is consistent with zero in peripheral (large impact parameter) collisions. Some indication of finite CME signals is seen in midcentral (intermediate impact parameter) collisions. Significant residual background effects may, however, still be present.

Measurement of the Sixth-Order Cumulant of Net-Proton Multiplicity Distributions in Au+Au Collisions at sqrt[s_{NN}]=27, 54.4, and 200 GeV at RHIC

According to first-principle lattice QCD calculations, the transition from quark-gluon plasma to hadronic matter is a smooth crossover in the region μ_{B}≤T_{c}. In this range the ratio, C_{6}/C_{2}, of net-baryon distributions are predicted to be negative. In this Letter, we report the first measurement of the midrapidity net-proton C_{6}/C_{2} from 27, 54.4, and 200 GeV Au+Au collisions at the Relativistic Heavy Ion Collider (RHIC). The dependence on collision centrality and kinematic acceptance in (p_{T}, y) are analyzed. While for 27 and 54.4 GeV collisions the C_{6}/C_{2} values are close to zero within uncertainties, it is observed that for 200 GeV collisions, the C_{6}/C_{2} ratio becomes progressively negative from peripheral to central collisions. Transport model calculations without critical dynamics predict mostly positive values except for the most central collisions within uncertainties. These observations seem to favor a smooth crossover in the high-energy nuclear collisions at top RHIC energy.

Development and validation of a prediction model for bothersome stress urinary incontinence after prolapse surgery: a retrospective cohort study

OBJECTIVE

To develop and validate a prediction model for bothersome stress urinary incontinence after prolapse surgery and to compare it with an existing clinical prediction model (CUPIDO model).

DESIGN

Retrospective cohort study.

SETTING

Two tertiary hospitals in South Korea.

POPULATION

A total of 1142 patients who underwent prolapse surgery with or without a concomitant midurethral sling.

METHODS

To construct a prediction model, we performed logistic regression using both exhaustive and stepwise variable selection, validating the model both internally and externally.

MAIN OUTCOME MEASURES

Bothersome stress urinary incontinence defined as the presence of bothersome symptoms of stress urinary incontinence and/or subsequent continence procedure one year after surgery.

RESULTS

Postoperative bothersome stress urinary incontinence occurred in 10% of patients. A model containing six predictors (age, diabetes mellitus, subjective urinary incontinence, prolapse reduction stress test result, type of prolapse surgery, and a concomitant midurethral sling) showed excellent performance for predicting bothersome stress urinary incontinence (area under the curve 0.74, 95% confidence interval 0.62-0.86) and outperformed the CUPIDO model (area under the curve 0.63, 95% confidence interval 0.49-0.76; DeLong's test P = 0.014).

CONCLUSIONS

This prediction model might be a useful tool to guide patient decision making regarding a concomitant continence procedure at the time of prolapse surgery. The predictive value of this model needs to be validated further in cohorts with different characteristics.

TWEETABLE ABSTRACT

The proposed prediction model for bothersome stress urinary incontinence after prolapse surgery outperforms an existing model.

Net clinical benefit of direct oral anticoagulants in very elderly and high bleeding risk patients with atrial fibrillation who are often excluded from oral anticoagulation therapy: a nationwide popul

Background

In the Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial, low-dose edoxaban (15mg once daily) showed better efficacy for stroke prevention and positive net clinical benefit compared to placebo in very elderly and high bleeding risk patients with atrial fibrillation (AF) who often excluded from oral anticoagulation (OAC) therapy. However, there are limited data to generalize the ELDERCARE-AF results into daily practice.

Purpose

To investigate the optimal OAC strategy for the best net clinical benefit in ELDERCARE-AF-like patients.

Methods

Using the Korean nationwide claims database, we included patients with incident non-valvular AF aged 80 years or older between 2014 and 2017. Among these, patients with one or more of the following criteria were finally included in the analysis: a low creatinine clearance (15 to 30 mL/min), a history of bleeding from a critical area or organ or gastrointestinal bleeding, low body weight (≤45kg), continuous use of nonsteroidal anti-inflammatory drugs, or current use of an antiplatelet drug. The risks of ischemic stroke, major bleeding, all-cause death, and composite clinical outcome (ischemic stroke+major bleeding+all-cause death) as a measure of net clinical outcome were evaluated during follow-up. The inverse probability of treatment weighting (IPTW) method was used to balance covariates between the groups.

Results

A total of 23,858 patients were finally included (no OAC, n=16,575; warfarin, n=2390; and direct oral anticoagulants (DOACs), n=4893, respectively). Among DOAC group, 69% used low-dose including rivaroxaban 15 mg once daily, dabigatran 110 mg twice daily, apixaban 2.5 mg twice daily, and edoxaban 30 mg once daily and 9% used very low dose including rivaroxaban 10 mg once daily and edoxaban 15 mg once daily (Figure). Median follow-up duration was 2 years (interquartile ranges, 1 to 3 years). Baseline characteristics were well-balanced after IPTW. Compared to the no OAC group, the DOAC group was associated with a lower risk of ischemic stroke (hazard ratio [HR], 95% confidence interval [CI]: 0.81, 0.68–0.95) and all-cause death (0.90, 0.85–0.95), and a higher risk of major bleeding (1.43, 1.20–1.69) (Figure). Patients treated with DOAC showed a lower risk of composite clinical outcome compared to those without OAC treatment (0.93, 0.88–0.98). Warfarin treatment did not reduce the risk of ischemic stroke (1.03, 0.85–1.23) and all-cause death (1.05, 0.99–1.12), but increased the risk of major bleeding (1.60, 1.32–1.92) and the composite clinical outcome (1.08, 1.02–1.15) compared to no OAC group.

Conclusion

In very elderly patients with non-valvular AF who had one or more frail components, DOACs which were currently prescribed in usual clinical practice showed better effectiveness and positive net clinical benefit compared to no OAC treatment. Compared to the latter, warfarin did not show benefit and possible harm.

Funding Acknowledgement

Type of funding sources: None.

Less dementia in patients with newly diagnosed atrial fibrillation adhering with a clustering of healthy lifestyle behaviours: a nationwide population-based cohort study

Background

Atrial fibrillation (AF) increases the risk of dementia. A new paradigm for AF management should include a new pillar targeting lifestyle modification. There are limited data on the clinical impact of healthy lifestyle behaviours on the risk of dementia in patients with newly diagnosed AF.

Purpose

To evaluate the association between the combination(s) of healthy lifestyle behaviours and the risk of incident dementia in patients with AF

Methods

Using the Korean National Health Insurance database between 2009 and 2016, we identified adult patients who were newly diagnosed as AF without dementia and underwent national health screening examination within 2-year after their AF diagnosis. Patients were categorized into 4 groups according to a healthy lifestyle-behavior score (HLS) 0, 1, 2, and 3 by assigning 1 point each for no current smoking, abstaining alcohol, and performing regular exercise. For the comparison, each group was balanced using the inverse probability of treatment weighting (IPTW). The primary outcome was incident dementia during follow-up.

Results

Among a total of 199,952 patients (mean age 63.2; 60.2% male) were included, the number of patients within the HLS 0, 1, 2, and 3 groups were 8709 (4.4%), 34839 (17.4%), 106796 (53.4%) and 49608 (24.8%), respectively. After IPTW, weighted incidence rates of dementia were 21.8, 16.8, 16.8, and 13.6 per 1000 person-years for HLS 0, 1, 2, and 3 groups, respectively. After multivariable adjustment of subjects edited by IPTW, HLS 1,2, and 3 groups were associated with a lower risk of dementia compared to HLS 0 group: Hazard Ratio [HR] 0.769, 95% confidence interval [CI] 0.704–0.842 for score 1; HR 0.770, 95% CI 0.709–0.836 for score 2; HR 0.622, 95% CI 0.569–0.679 for score 3. The effect of healthy lifestyle was similar for Alzheimer's dementia (HR 0.823, 95% CI 0.739–0.917 for score 1; HR 0.839, 95% CI 0.760–0.927 for score 2; HR 0.660, 95% CI 0.594–0.734 for score 3) and vascular dementia (HR 0.532, 95% CI 0.437–0.648 for score 1; HR 0.503 95% CI 0.422–0.600 for score 2; HR 0.458, 95% CI 0.378–0.554 for score 3). There was consistency in subgroup analyses stratified by age, sex, CHA2DS2-VASc score, oral anticoagulation use and prior stroke history.

Conclusion

A combination of a healthy lifestyle, including quitting smoking, abstaining from alcohol consumption, and performing regular physical activity, was associated with a significantly lower risk of dementia in both Alzheimer's dementia and vascular dementia in patients with new-onset AF. These findings support the promotion of a healthy lifestyle within an integrated care approach to AF patient management, which could reduce the risk of dementia.

Funding Acknowledgement

Type of funding sources: None.

A population-based study for difference in contribution of type 2 diabetes mellitus to cardiovascular outcomes in adult cancer survivors and general population without history of cancer

Background/Introduction

Type 2 diabetes mellitus (T2DM) is a well-established risk factor for cardiovascular disease (CVD). However, evidence is scarce on the difference in burden of T2DM as a cardiovascular risk factor in adult cancer survivors compared to the general population without history of cancer. This evidence gap needs to be addressed as increased risk for CVD in adult cancer survivors compared to the general population has been consistently reported from observational studies.

Purpose

To investigate the association of T2DM with CVD in adult cancer survivors and general population without history of cancer and compare the magnitude of associations for each population using propensity score-matched analyses

Methods

For this population-based cohort study, we used the National Health Insurance Service-National Sample Cohort (NHIS-NSC) established in the Republic of Korea (2002–2015) to identity adult cancer survivors who were aged 18 years or older and survived more than 12 months after the first-ever cancer diagnosis and general population without history of cancer matched for age and sex in a 1:1 ratio. In both cohorts, those with history of CVD prior to the index date were excluded. We used Cox proportional hazards model to compute hazard ratios (HR) and 95% confidence intervals (95% CI) for incident CVD in those with T2DM compared to those without T2DM in both adult cancer survivors and the general population after adjusting for shared confounding factors (income status, cigarette smoking, alcohol consumption, physical inactivity, body mass index, blood pressure, lipid abnormalities, family history of CVD, and aspirin use). Furthermore, we used Q statistic to compare the magnitude of association between T2DM and CVD in this matched cohort.

Results

The overall age and sex matched cohort in the NHIS-NSC comprised of 5,163 adult cancer survivors and the equivalent number of participants categorized as general population without history of cancer. The adjusted HR for CVD among adult cancer survivors with T2DM, as compared to without T2DM was 2.27 (95% CI: 1.25–4.11). Similarly, T2DM was associated with an increased risk of CVD in the general population without cancer (HR=1.88; 95% CI: 1.03–3.42). However, no strong statistical evidence was found for difference in contribution of T2DM to CVD risk between adult cancer survivors and general population without history of cancer (Pheterogeneity = 0.662).

Conclusions

In this population-based cohort study, T2DM was associated with an increased risk for CVD in both adult cancer survivors and those without history of cancer. Difference in magnitude of T2DM-CVD associations between adult cancer survivors and the general population without history of cancer was not substantial from a statistical standpoint. However, adult cancer survivor with T2DM may still need additional clinical attention for CVD prevention compared to those without history of cancer.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Cancer Center (Republic of Korea)

Dual antithrombotic therapy on early clinical outcomes in patients with atrial fibrillation after percutaneous coronary intervention: a nationwide study in the era of NOAC

Background/Introduction

Recent evidence has confirmed low bleeding risk with double antithrombotic therapy, combining oral anticoagulant (OAC) and single platelet inhibitor, in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Among the Asian AF population, most of the patients received dual antiplatelet therapy (DAPT) without OACs, even after the introduction of non-vitamin K oral anticoagulants (NOACs).

Purpose

The current nationwide study assessed 3-month ischemic and bleeding risks of DAPT in comparison to triple antithrombotic therapy among the Korean AF population undergoing PCI.

Methods

We analyzed the claims records of 11,039 patients (mean age 70 years, 66.3% male, and mean CHA2DS2-VASc score 3.2) between 2013 to 2018. Patients were categorized into triple therapy group with vitamin K antagonists (VKAs-TT), or NOACs (NOACs-TT), and DAPT group according to the antithrombotic therapy after PCI. 3-month risks of ischemic stroke, non-fatal myocardial infarction, any in-hospital death, and major bleeding were compared between groups after baseline adjustment using inverse probability weighting.

Results

A total of 1,786, 1,997, and 7,256 patients were allocated to the VKAs-TT, NOACs-TT, and DAPT groups. The DAPT group had a higher prevalence of prior MI and coronary revascularization, but had lower thromboembolic and bleeding risks than the triple antithrombotic therapy groups (mean CHA2DS2-VASc score 3.8, 4.1, and 3.5; and mean HAS-BLED score 3.3, 3.4, and 3.1 for VKAs-TT, NOACs-TT, and DAPT groups, respectively). The NOACs-TT group was associated with a lower risk of ischemic stroke (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.20–0.70) and any in-hospital death (HR 0.70, 95% CI 0.49–0.98) compared with the VKAs-TT group. The DAPT group showed a lower risk of ischemic stroke (HR 0.41, 95% CI 0.27–0.63) and major bleeding (HR 0.55, 95% CI 0.37–0.84) than the VKAs-TT group, especially in patients without prior OAC treatment. The DAPT group showed a comparable ischemic risk against the NOACs-TT group, although the risk of major bleeding was lower in the DAPT group, especially among old age (HR 0.47, 95% CI 0.29–0.78) or OACs-naive patients (HR 0.50, 95% CI 0.29–0.86).

Conclusion

Among the Asian AF population, using short-term DAPT for 3-month after PCI was associated with a lower risk of bleeding without increasing ischemic risk compared to triple antithrombotic therapy with OAC. This may be a therapeutic option in very high bleeding risk patients who have had complex PCI necessitating focus on DAPT in the initial 3 month period.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by grant no 3020200200 from the Seoul National University Hospital Research Fund, by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety) (Project Number: 202013B14), and by the Korea National Research Foundation funded by the Ministry of Education, Science and Technology (grant 2020R1F1A106740). Figure 1Figure 2