Recurrences of disease activity in patients with cardiac sarcoidosis under corticosteroid therapy: prevalence, clinical background and prognosis

Background

Corticosteroid therapy (CTx) has been widely accepted as first-line therapy for cardiac sarcoidosis (CS), but there are very limited data regarding recurrence of disease activity of CS. We retrospectively investigated the prevalence, patient characteristics and prognostic significance in patients with recurrences of CS.

Methods

We identified 102 consecutive patients who were clinically diagnosed CS (admission: 2012 and 2019) and whose disease activity was diminished clinically at least once. Recurrence of CS was defined as detection of increased uptake of 18F-fluoro-2-deoxyglucose or gallium-67 in the follow-up examination. Composite adverse events (events) were defined as all-cause of death or hospitalization for heart failure. Echocardiographic and laboratory data before initiation of CTx were obtained.

Results

During the follow-up term (median: 4.9 years), the recurrences of CS occurred in 28 patients at 30 months (median) after the initiation of CTx. In patients with recurrence, left ventricular (LV) ejection fraction before initiation of CTx was lower than in those without recurrences (median: 31% vs. 39%, p<0.05). After the detection of CS recurrences, 17 patients were treated with only increases of PSL and remaining 11 patients were treated with adding other immunosuppressive therapies to CTx. The univariate analysis demonstrated that there were no parameters in echocardiographic and laboratory examinations to predict the recurrences of CS. The results of univariate analysis for event occurrences (n=12) are shown in the Table. Additionally, the Kaplan-Meier analysis showed that there were no differences in event free survival rate in the patients with and without CS recurrences (Figure).

Conclusion

This study showed that the recurrences of disease activity were observed in a substantial number of patients with CS even under the CTx. All patients received intensification of CTx or additional immunosuppressive therapy, and LV systolic function, rather than the recurrence itself, was associated with clinical outcomes in this study.

Kaplan-Meier analysis for events

Funding Acknowledgement

Type of funding source: None

Diagnostic Value of Model-Based Iterative Reconstruction Combined with a Metal Artifact Reduction Algorithm during CT of the Oral Cavity

BACKGROUND AND PURPOSE

Metal artifacts reduce the quality of CT images and increase the difficulty of interpretation. This study compared the ability of model-based iterative reconstruction and hybrid iterative reconstruction to improve CT image quality in patients with metallic dental artifacts when both techniques were combined with a metal artifact reduction algorithm.

MATERIALS AND METHODS

This retrospective clinical study included 40 patients (men, 31; women, 9; mean age, 62.9 ± 12.3 years) with oral and oropharyngeal cancer who had metallic dental fillings or implants and underwent contrast-enhanced ultra-high-resolution CT of the neck. Axial CT images were reconstructed using hybrid iterative reconstruction and model-based iterative reconstruction, and the metal artifact reduction algorithm was applied to all images. Finally, hybrid iterative reconstruction + metal artifact reduction algorithms and model-based iterative reconstruction + metal artifact reduction algorithm data were obtained. In the quantitative analysis, SDs were measured in ROIs over the apex of the tongue (metal artifacts) and nuchal muscle (no metal artifacts) and were used to calculate the metal artifact indexes. In a qualitative analysis, 3 radiologists blinded to the patients' conditions assessed the image-quality scores of metal artifact reduction and structural depictions.

RESULTS

Hybrid iterative reconstruction + metal artifact reduction algorithms and model-based iterative reconstruction + metal artifact reduction algorithms yielded significantly different metal artifact indexes of 82.2 and 73.6, respectively (95% CI, 2.6-14.7; P < .01). The latter algorithms resulted in significant reduction in metal artifacts and significantly improved structural depictions(P < .01).

CONCLUSIONS

Model-based iterative reconstruction + metal artifact reduction algorithms significantly reduced the artifacts and improved the image quality of structural depictions on neck CT images.

Visualization of ferroaxial domains in an order-disorder type ferroaxial crystal

Ferroaxial materials that exhibit spontaneous ordering of a rotational structural distortion with an axial vector symmetry have gained growing interest, motivated by recent extensive studies on ferroic materials. As in conventional ferroics (e.g., ferroelectrics and ferromagnetics), domain states will be present in the ferroaxial materials. However, the observation of ferroaxial domains is non-trivial due to the nature of the order parameter, which is invariant under both time-reversal and space-inversion operations. Here we propose that NiTiO₃ is an order-disorder type ferroaxial material, and spatially resolve its ferroaxial domains by using linear electrogyration effect: optical rotation in proportion to an applied electric field. To detect small signals of electrogyration (order of 10⁻⁵ deg V⁻¹), we adopt a recently developed difference image-sensing technique. Furthermore, the ferroaxial domains are confirmed on nano-scale spatial resolution with a combined use of scanning transmission electron microscopy and convergent-beam electron diffraction. Our success of the domain visualization will promote the study of ferroaxial materials as a new ferroic state of matter.

The presence of ferroaxial domain states is recently experimentally demonstrated by a nonlinear optical technique, which lacks high spatial resolution to visualize ferroaxial domains. Here, the authors visualize spatial distributions of ferroaxial domains in NiTiO₃ showing an order-disorder type ferroaxial transition.

Interleukin-4 Restores Insulin Sensitivity in Insulin-Resistant Osteoblasts by Increasing the Expression of Insulin Receptor Substrate 1

Obesity and latent inflammation can give rise to insulin resistance and type 2 diabetes. Here we established an insulin resistance model of osteoblasts to explore the restoration effect of anti-inflammatory interleukin-4 (IL-4) on insulin sensitivity and its mechanism. We found that IL-4 inhibited cell proliferation in a concentration- and time-dependent manner. Insulation resistance significantly reduced the phosphorylation levels of the insulin receptor substrate 1 (IRS1; Tyr612), Akt (Ser473), and AS160 (Ser318) proteins. The addition of IL-4 to the insulin resistance model led to a dose-dependent stimulation of the phosphorylation of IRS1, Akt, and AS160. IL-4 fully restored the activation of the insulin cascade in insulin-resistant cells at the concentration of 50 ng/ml. Additionally, IL-4 promoted the expression of IRS1 in a time-dependent manner. We conjecture that IL-4 restores insulin sensitivity in osteoblasts by upregulating the expression of IRS1. It was also found that IL-4 promoted the expression of osteoprotegerin depending on the time of exposure. This effect may play an important role in the regulation of the energy metabolism in the whole body.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

P684Long-term outcomes in patients with cancer undergoing percutaneous coronary intervention: analysis from a Japan multicenter registry

Background

Cancer and cardiovascular disease (CVD) is the most common cause of death in developed countries, and substantial overlap exist in their medical care. However, the detailed and updated information on outcome of cancer patients with cardiovascular disease (CVD), particularly in clinically significant coronary artery disease (CAD) remain unknown.

Purpose

We sought to describe the prevalence and long-term outcomes of cancer patients undergoing percutaneous coronary intervention (PCI), which has become a coronerstone in the management of CVD.

Methods

Patient data extracted from a regional prospectiveprocedure-based multicenter registry for PCI was analyzed. A total of 4,455 patients who underwent PCI at 15 hospitals within metropolitan Tokyo from September 2008 to 2012 were followed for 2 years. “Active” cancer patient was defined as having a history of cancer not cured or in remission. We analyzed in acute and stable presentation.The occurrence of clinical outcomes was assessed via Kaplan-Meier survival curve, and Cox-regression hazard model to adjust for known clinical predictors.

Results

Within the studied patients, 173 (3.9%) had a concomitant “active” cancer at the time of intervention. There was a significant difference between the patients with and without active cancer in each situation. In stable presentation, cancer group were older, lower BMI, frequently had silent ischemia, COPD and cerebrovascular/peripheral disease, and less often had dyslipidemia compared with non-cancer group. In acute presentation, cancer group were older, frequently had COPD, CKD, peripheral disease and history of HF compared with non-cancer group. The prescription rate of RAAS inhibitor was lower in the cancer group than in the non-cancer group in acute presentation. Notably, in both acute and stable presentation, these patients had significantly higher risk of all-cause mortality (HR 8.01: 95%, p<0.001 and HR5.53: 95%, p<0.001, respectively), and they were also at higher risk of major cardo- and cerebrovascular events (MACCE; HR2.38, p<0.001, HR2.33, p=0.001), when referenced to non-cancer patients after 2 year of follow-up.

Conclusion

Cancer patient was present in 3.9% of all PCI patients and was strongly associated with both non-cardiac and cardiac adverse events.

P5551Comparison of prognostic predictors of heart failure admission and progression to end-stage in hypertrophic cardiomyopathy

Background

Heart failure (HF) is a common complication within the clinical spectrum of hypertrophic cardiomyopathy (HCM). HCM-related HF is recognized to be multifactorial, including outflow obstruction, diastolic dysfunction, or progression to end-stage; however, prognostic predictors of HF events are not fully understood. We sought to investigate predictors for various HF outcomes in HCM.

Methods

We studied 289 consecutive HCM patients with EF≥50%. Patients with outflow obstruction (peak pressure gradient ≥30mmHg) were defined as obstructive HCM. HF events assessed in this study were 1) HF admission and 2) progression to end-stage (EF<50%).

Results

The mean age was 63±16 years, 53% male, EF 61±5%, NYHA class 1.8±0.7, and 39% obstructive. During a median follow up of 5.2 [3.7–7.0] years, 48 HF admission and 19 progression to end-stage were observed. Only 8/48 (17%) patients with HF admission had progressed to end-stage; while 11/19 (58%) patients with progression to end-stage remained free from HF admission. Univariate Cox regression hazard analysis showed different prognostic predictors between HF admission and progression to end-stage (Table). Multivariate Cox regression hazard analysis showed atrial fibrillation was an independent predictor of HF admission (adjusted HR 2.711 [1.094–7.389], P=0.031); while LV end-systolic dimension was an independent predictor of progression to end-stage (adjusted HR 1.114 [1.018–1.229], P=0.025).

Cox hazard analysis for predicting event HF admission Progression to end-stage HR (95% CI) P value HR (95% CI) P value Age, 1 year 1.042 (1.017–1.071) <0.001 1.002 (0.975–1.035) 0.89 Male sex 1.052 (0.595–1.882) 0.86 2.853 (1.034–10.02) 0.043 Atrial fibrillation 3.247 (1.809–6.608) <0.001 1.434 (0.570–3.559) 0.44 Non-obstructive 0.850 (0.481–1.531) 0.58 5.439 (1.558–34.30) 0.005 LV end-diastolic dimension, 1mm 1.027 (0.981–1.077) 0.25 1.120 (1.035–1.218) 0.005 LV end-systolic dimension, 1mm 1.059 (1.008–1.110) 0.023 1.167 (1.080–1.258) <0.001 EF, 1% 0.974 (0.926–1.032) 0.36 0.894 (0.825–0.980) 0.018 LA volume, 1ml/m2 1.012 (1.001–1.020) 0.044 1.006 (0.978–1.023) 0.64 Transmitral E wave, 1m/s 1.013 (1.002–1.024) 0.025 1.006 (0.987–1.023) 0.50 Transmitral DcT, 1msec 0.999 (0.995–1.003) 0.59 0.985 (0.974–0.994) <0.001 E/e', 1.0 1.062 (1.012–1.109) 0.015 1.089 (1.010–1.164) 0.027

Conclusions

Different prognostic predictors were found for HF admission and progression to end-stage, suggesting the difficulty and multifactorial nature of HCM-related HF.

P915Clinical characteristics, natural history and predictors of disease progression in patients with degenerative mitral stenosis

Background

Mitral annular calcification (MAC) is a common echocardiographic finding and an increasingly recognized cause of degenerative mitral stenosis (DMS). However, little is known about the natural history and predictors of disease progression of DMS, especially compared with rheumatic mitral stenosis (RMS).

Purpose

To compare the clinical characteristics and disease progression among patients with DMS and those with RMS, and to investigate the determinants of disease progression in DMS patients.

Methods

We retrospectively reviewed consecutive MS patients with a trans-mitral mean gradient ≥2 mmHg who underwent echocardiography at our institution between January 2014 and December 2017. We selected patients who had an initial and follow-up echocardiography with a ≥3-month interval and without prior and interim mitral valve intervention. DMS was defined as MS with MAC with normal or minimally reduced leaflet motion without tips restriction. RMS was defined as MS with tip restriction, thickening and restriction of leaflet mainly. We defined MAC severity as mild (focal), moderate (marked density >1/3 but <1/2 of the mitral annulus) and severe (marked density involving >1/2 of the mitral annulus) based on previous reports. We calculated disease progression from the annual increase rate of trans-mitral mean gradient. First, we compared the backgrounds and disease progression between DMS group and RMS group. Second, we investigated the predictors of disease progression in DMS group.

Results

We enrolled 111 patients (64 in DMS group and 47 in RMS group) with a mean follow-up period of 2.1 years. Patients in DMS group were significantly older (79±9 vs. 70±10 years; P<0.01), had higher prevalence of hypertension (P<0.01) and coronary artery disease (P=0.02), and had higher plasma BNP level (P<0.01) than those in RMS group. Baseline trans-mitral mean gradient was slightly lower in DMS group than in RMS group (3.9±1.9 vs. 4.7±1.8 mmHg; P=0.02). There were wide variations among individuals in progression rate (range: 0 to 3.5 mmHg/year in DMS group and 0 to 5.8 mmHg/year in RMS group, respectively), and the progression rate was comparable between DMS group and RMS group (0.49±0.79 vs. 0.61±1.37 mmHg/year; P=0.59). In DMS group, higher prevalence of dyslipidemia (P=0.01) and lower baseline trans-mitral mean gradient (P<0.01) were significantly associated with disease progression even after adjustment for age and sex. Unexpectedly, there was no significant difference in the disease progression regardless of the MAC severity among DMS group (Picture).

MAC severity and disease progression

Conclusions

Progression in DMS group is highly variable, but generally slow as that in RMS group. Initial mean gradient was inversely associated with disease progression in DMS group. Furthermore, baseline MAC severity did not correlate with the progression, suggesting the importance of follow-up echocardiography in spite of the MAC severity and initial mean gradient.

P1809Impact of mitral regurgitation on clinical outcome in patients with cardiac sarcoidosis

Background

Mitral regurgitation (MR) is sometimes observed in cardiac sarcoidosis (CS), and might be related to worsening heart failure. However, mechanism and clinical significance of MR associated with CS remains undetermined.

Methods

We retrospectively analyzed consecutive 51 CS patients, and identified 16 patients with moderate to severe MR evaluated by quantitative echocardiography. According to the assessment of coaptation point and tenting height, main mechanisms of the 16 patients with MR were classified into prolapse (P) in 5, and tethering in 11 (T). Prednisolone was started from 30 mg/day, gradually tapered over a period of 6 months to a maintenance dose of 5 to 10 mg/day and continued a lifetime.

Results

At the first visit, patients with MR showed higher incidence of NYHA class IV heart failure as compared to those without MR (56 vs. 9%, p<0.001). Abnormal uptake of fluorine-18 fluorodeoxyglucose in the papillary muscle was more frequent in patients with MR than those without MR (63% vs. 23%, p<0.05). Patients with tethering MR showed higher incidence of complete atrioventricular block (T: 74% vs. P: 40% vs. without MR: 31%, p<0.05), significantly reduced left ventricular (LV) ejection fraction (T: 33±7% vs. P: 52±9% vs. without MR: 52±16%, p<0.001) and increased LV end-diastolic volume index (T: 100±52ml/m2 vs. P: 66±23ml vs. without MR: 62±21ml, p<0.001). During the mean follow-up of 108 months, cardiac-event free survival was significantly worse in patients with tethering MR as compared to the other patients (log-rank; 11.7, p<0.001). Six of the 11 patients with tethering MR received cardiac resynchronization therapy, and then did not experience further hospitalization due to decompensated heart failure for at least 2 years. Multivariate analysis identified tethering MR as an independent predictor of cardiac event (HR: 6.7, p<0.05).

Conclusions

MR associated with CS has variety of mechanisms including prolapse, tethering and inflammation of the LV papillary muscle, and may be related to ventricular remodeling and poor clinical outcome.

Longitudinal changes in 18 F-THK5351 positron emission tomography in corticobasal syndrome

BACKGROUND AND PURPOSE

Corticobasal syndrome (CBS) is pathologically characterized by tau deposits in neuronal and glial cells and by reactive astrogliosis. In several neurodegenerative disorders, ¹⁸ F-THK5351 has been observed to bind to reactive astrocytes expressing monoamine oxidase B. In this study, the aim was to investigate the progression of disease-related pathology in the brains of patients with CBS using positron emission tomography with ¹⁸ F-THK5351.

METHODS

Baseline and 1-year follow-up imaging were acquired using magnetic resonance imaging and positron emission tomography with ¹⁸ F-THK5351 in 10 subjects: five patients with CBS and five age-matched normal controls (NCs).

RESULTS

The 1-year follow-up scan images revealed that ¹⁸ F-THK5351 retention had significantly increased in the superior parietal gyrus of the patients with CBS compared with the NCs. The median increases in ¹⁸ F-THK5351 accumulation in the patients with CBS were 6.53% in the superior parietal gyrus, 4.34% in the precentral gyrus and 4.33% in the postcentral gyrus. In contrast, there was no significant increase in the regional ¹⁸ F-THK5351 retention in the NCs.

CONCLUSIONS

Longitudinal increases in ¹⁸ F-THK5351 binding can be detected over a short interval in the cortical sites of patients with CBS. A monoamine oxidase B binding radiotracer could be useful in monitoring the progression of astrogliosis in CBS.

A Case of Feline T-cell Lymphoma with Tropism for Striated Muscle and Peripheral Nerve

An 11-year-old female American shorthair cat was presented with a 3-month history of hindlimb ataxia and knuckling of the left forelimb. Clinical abnormalities included weight loss, hyperaesthesia of the neck and back, cardiac murmur and systemic muscle atrophy. The cat died 10 days after the initial presentation and a necropsy examination was performed. Grossly, extensive pale lesions were seen in the wall of the left ventricle and the septum of the heart. There were no detectable masses in the heart, skeletal muscles or peripheral nerves. Histopathological examination revealed diffuse, extensive infiltration of atypical lymphoid cells in the heart; the cardiac muscles were markedly degenerate and atrophic and were replaced by the neoplastic cells. Neoplastic cells with similar morphology were seen in all specimens of the skeletal muscles and peripheral nerves. Clonality analysis of the paraffin wax-embedded heart tissue revealed a monoclonal rearrangement of the gene encoding the T-cell receptor γ chain. Based on these findings, the case was diagnosed as T-cell lymphoma with tropism for striated muscle and peripheral nerve.

Medication-related osteonecrosis of the jaw after tooth extraction in cancer patients: a multicenter retrospective study

Root amputation, immunosuppressive therapy, mandibular tooth extraction, pre-existing inflammation, and longer duration of treatment with bone-modifying agents were significantly associated with an increased risk of medication-related osteonecrosis of the jaw. Hopeless teeth should be extracted without drug holiday before the development of inflammation in cancer patients receiving high-dose bone-modifying agents.

INTRODUCTION

No studies have comprehensively analyzed the influence of pre-existing inflammation, surgical procedure-related factors such as primary wound closure, demographic factors, and drug holiday on the incidence of medication-related osteonecrosis of the jaw (MRONJ). The purpose of this study was to retrospectively investigate the relationships between these various factors and the development of MRONJ after tooth extraction in cancer patients receiving high-dose bone-modifying agents (BMAs) such as bisphosphonates or denosumab.

METHODS

Risk factors for MRONJ after tooth extraction were evaluated with univariate and multivariate analyses. The following parameters were investigated in all patients: demographics, type and duration of BMA use, whether BMA use was discontinued before tooth extraction (drug holiday), the duration of such discontinuation, the presence of pre-existing inflammation, and whether additional surgical procedures (e.g., incision, removal of bone edges, root amputation) were performed.

RESULTS

We found that root amputation (OR = 22.62), immunosuppressive therapy (OR = 16.61), extraction of mandibular teeth (OR = 12.14), extraction of teeth with pre-existing inflammation, and longer duration (≥ 8 months) of high-dose BMA (OR = 7.85) were all significantly associated with MRONJ.

CONCLUSIONS

Tooth extraction should not necessarily be postponed in cancer patients receiving high-dose BMA. The effectiveness of a short-term drug holiday was not confirmed, as drug holidays had no significant impact on MRONJ incidence. Tooth extraction may be acceptable during high-dose BMA therapy until 8 months after initiation.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.