Vasohibin-1 expression as a biomarker of aggressive nature in ductal adenocarcinoma of the prostate: a retrospective cohort study at two centres in Japan

OBJECTIVES

Vasohibin-1 (VASH1) is an endogenous angiogenesis regulator expressed in activated vascular endothelial cells. We previously reported that high VASH1 expression is a predictor of progression in acinar adenocarcinoma of the prostate. In this study, we evaluated the characteristics of ductal adenocarcinoma of the prostate by comparing the level of VASH1 expression between ductal and acinar adenocarcinoma specimens.

DESIGN AND SETTING

A retrospective cohort study at two centres in Japan.

PARTICIPANTS

Among the 1495 patients who underwent radical prostatectomy or transurethral resection for the past 15 years, a total of 14 patients diagnosed with ductal adenocarcinoma and 20 patients diagnosed with acinar adenocarcinoma with a Gleason score of 4+4 were included.

INTERVENTIONS

We immunohistochemically examined the CD34 expression as the microvessel density (MVD) and activated endothelial cells as the VASH1 density (vessels per mm²).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the association of MVD and VASH1 density between ductal and acinar adenocarcinoma, and the secondary outcome was their oncological outcomes.

RESULTS

Nine patients (64.3%) with ductal adenocarcinoma were diagnosed at an advanced clinical stage, and five patients (35.7%) died from cancer during a median follow-up of 56.0 months. The VASH1 densities (mean±SD) in ductal and acinar adenocarcinoma were 45.1±18.5 vs 16.1±21.0 (p<0.001), respectively, while the MVD (mean±SD) in ductal and acinar adenocarcinoma were 65.3±21.9 vs 80.8±60.7 (p=0.666), respectively. The 5-year cancer-specific survival rates for high and low VASH1 expression were 70.0% and 100.0% (p=0.006), respectively. High VASH1 expression and a diagnosis of ductal adenocarcinoma were significant predictors of cancer-specific survival.

CONCLUSIONS

Ductal adenocarcinoma was more aggressive and had higher VASH1 expression than acinar adenocarcinoma, although MVD was equivalent. These results indicate that VASH1 expression may serve as a novel biomarker for the aggressive nature of ductal adenocarcinoma.

Clinical Characteristics, Achievement of Secondary Prevention Goals, and Outcomes of Patients with Recurrent Acute Coronary Syndrome

BACKGROUND

Because development of acute coronary syndrome (ACS) worsens the prognosis of patients with coronary artery disease, preventing recurrent ACS is crucial. However, the degree to which secondary prevention treatment goals are achieved in patients with recurrent ACS is unknown.

METHODS

214 consecutive ACS patients were classified as having First ACS (n=182) or Recurrent ACS (n=32), and the clinical characteristics of these groups were compared. Fifteen patients died or developed cardiovascular (CV) events during hospitalization, and the remaining 199 patients were followed from the date of hospital discharge to evaluate subsequent CV events.

RESULTS

Patients in the Recurrent ACS group were older than those in the First ACS group (76.8±10.8 years vs 68.8±13.4 years, p=0.002) and had a higher rate of diabetes mellitus (DM) (65.6% vs 36.8%, p=0.003). The rate of achieving a low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL in the Recurrent ACS group was only 28.1%, even though 68.8% of these patients were taking statins. An HbA1c level of <7.0% was achieved in 66.7% of patients with recurrent ACS who had been diagnosed with DM. Overall, 12.5% of patients with recurrent ACS had received optimal treatment for secondary prevention. CV events after hospital discharge were noted in 37.9% of the Recurrent ACS group and 21.2% of the First ACS group (log-rank test: p=0.004). However, recurrent ACS was not an independent risk factor for CV events (adjusted hazard ratio: 2.09, 95% confidence interval: 0.95 to 4.63, p=0.068).

CONCLUSION

Optimal treatment for secondary prevention was not achieved in some patients with recurrent ACS, and achievement of the guideline-recommended LDL-C goal for secondary prevention was especially low in this population.

Providing mammography in workplaces improved screening rates: cluster randomized controlled trial

Background

Despite sufficient evidence on the importance of breast cancer screening, the screening rate has remained less than 50% in Japan. To promote behavioral change of individuals, it is important to reduce barriers to taking screening. The purpose of this study was to examine the effect of an environmental approach providing opportunities for mammography (MMG) in workplaces.

Methods

Female employees aged 40 years or older were eligible. Supermarket stores were randomly assigned into two groups, the intervention arm (leaflet and MMG) and the control arm (leaflet). From May to July 2018, participants in the intervention arm were given a leaflet informing the subsidies for breast cancer screening and were provided the opportunity to have MMG in their workplace. Participants in the control group were given the same leaflet, but they had to take the screening outside the workplace as usual. The primary outcome was the breast cancer screening rate in 2018, evaluated using self-administered questionnaires. The odds ratio (OR) and 95% confidence intervals (CIs) for the screening rate in the intervention arm compared with the control arm was estimated using multilevel logistic regression.

Results

We analyzed 1624 participants (mean age was 53 years) from 25 supermarket stores (intervention: 578 patients in 8 stores, control: 1046 patients in 17 stores). The screening rate in the intervention arm was 312 (54%) and was 125 (12%) in the control arm. The OR (and 95% CIs) was 7.81 (5.03-12.12) in the final model adjusted store level effects (i.e., stores and screening rate in 2017 at each store) and individual age and current smoking.

Conclusions

In a worksite-based cluster-randomized controlled trial conducted in a Japanese population, an environmental approach providing MMG opportunities in workplaces significantly increased the self-reported breast cancer screening rate within one year. (UMIN000030465)

Key messages

Providing the opportunity of mammography in Japanese supermarket stores improved the breast cancer screening rate. An environmental approach reducing barriers to screening may be more effective than conventional approaches in improving breast cancer screening rate.

Starting Neurohormonal Antagonists in Patients with Acute Heart Failure with Mid-Range and Preserved Ejection Fraction

Background

The clinical benefits of neurohormonal antagonist in patients with heart failure (HF) with mid-range and preserved ejection fraction (HFmrEF and HFpEF) were uncertain. This study aimed to evaluate the prognostic effect of starting angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin II receptor blockers (ARB) and β-blocker during HF hospitalization in these patients.

Methods

We analyzed 858 consecutive patients with HFmrEF (EF:40–49%) or HFpEF (EF≥50%), who were hospitalized for acute decompensated HF, were discharged alive, and were not taking ACE-I/ARB or β-blockers at admission. The study population was classified into four groups according to the status of prescription of ACE-I/ARB and β-blocker at discharge: no neurohormonal antagonist (N=342, 39.9%), ACE-I/ARB only (N=128, 14.9%), β-blocker only (N=189, 22.0%), and both ACE-I/ARB and β-blocker (N=199, 23.2%) groups. The primary outcome measure was a composite of all-cause death or HF hospitalization.

Results

The cumulative 1-year incidence of the primary outcome measure was 41.2% in the no neurohormonal antagonist group, 34.0% in the ACE-I/ARB only group, 28.6% in the β-blocker only group, and 16.4% in the both ACE-I/ARB and β-blocker group (P&lt;0.001). Compared with the no neurohormonal antagonist group, the both ACE-I/ARB and β-blocker group were associated with a significantly lower risk for a composite of all-cause death or HF hospitalization (HR: 0.59, 95% CI: 0.38–0.91, P=0.02).

Conclusions

In hospitalized patients with HFmrEF and HFpEF, starting both ACE-I/ARB and β-blocker was associated with a reduced risk of a composite of all-cause death or HF hospitalization compared with not starting ACE-I/ARB or β-blocker.

Funding Acknowledgement

Type of funding sources: None.

Impact of catheter ablation on functional tricuspid regurgitation in patients with atrial fibrillation

Background

Since atrial functional tricuspid regurgitation (AF-TR) is associated with increased heart failure and mortality, the management of AF-TR is clinically important. Atrial fibrillation (AF) plays the main role in AF-TR. However, the effectiveness of catheter ablation (CA) and mechanism of improvement of AF-TR haven't been fully evaluated.

Purpose

We sought to investigate the impact of CA for AF on AF-TR in patients with moderate or more TR.

Methods

We retrospectively investigated consecutive 2685 patients with AF who received CA from February 2004 to December 2019 in Japan. The current study population consisted of 102 patients with moderate or greater TR who underwent CA for AF. The echocardiographic parameters were compared between pre-ablation and post-ablation transthoracic echocardiography (TTE), and the recurrence rate of AF/ atrial tachycardia (AT) was measured.

Results

The mean age was 73.2 years, 53% were women. TR severity and TR jet area significantly improved after CA for AF (TR jet area: 5.8 [3.9–7.6] cm2 to 2.0 [1.1–3.0] cm2, p&lt;0.001). In addition, mitral regurgitation (MR) jet area, left atrial (LA) area, mitral valve diameter, right ventricular (RV) end-diastolic area, right atrial (RA) area, tricuspid valve (TV) diameter decreased after CA (p&lt;0.001, &lt;0.001, &lt;0.001, = 0.02, &lt;0.001, and &lt;0.001, respectively). There was no significant difference between one-year recurrence of AF/AT and TR severity at pre-ablation TTE (moderate 28.6%, moderate to severe 37.2%, and severe 31.6%, p=0.72).

Conclusions

TR severity and jet area improved after CA in patients with AF and moderate or more TR. RV size, RA size, TV diameter also decreased after CA, which may be associated with TR improvement. There was no significant difference between one-year recurrence of AF/AT and TR severity at pre-ablation TTE.

Funding Acknowledgement

Type of funding sources: None.

10-year clinical outcomes after radiofrequency catheter ablation for atrial fibrillation. A single center experience

Background

Radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) is becoming a routine procedure to treat patients with drug-refractory symptomatic AF. However, data regarding very long-term clinical outcomes is limited. The aim of the present study was to evaluate the 10-year clinical outcomes of patients who underwent RFCA for paroxysmal and persistent AF.

Methods

We retrospectively enrolled 503 consecutive patients (mean age 66,9±9,51 years; 71,6% male) who underwent RFCA for drug-refractory symptomatic AF between February 2004 and June 2011. Follow-up information was obtained using medical records and/or telephonic interviews with the patient, relatives and/or referring physicians.

Results

Among 503 patients enrolled in this study, 362 had paroxysmal atrial fibrillation (PAF) and 141 had persistent atrial fibrillation (PeAF) (72% and 28%, respectively). Mean follow-up was 8,84±3,05 years. The 10-year event-free rate for recurrent atrial tachyarrhythmia (AT) after the first procedure was 44,5% (49,4% for PAF vs 31,9% for PeAF; p=0,002 by log-rank test) and 81,9% after the last procedure (87,3% for PAF and 67,9% for PeAF; p≤0,001 by log-rank test). AT recurrence was observed most commonly during the first 12 months of the initial procedure (56%), with only 18% of them occurring after 60 months. Multivariate analysis revealed that persistent AF (hazard ratio=1,366; 95% confidence interval 1,058–1,76; p=0,017) and duration of AF &gt;5 years (hazard ratio=1,357; 95% confidence interval 1,064–1,732; p=0,005) were independent risk factors for AT recurrence. Regarding adverse events, there were 24 (4,8%) hospitalizations for acute decompensated heart failure, 20 (4%) ischemic strokes and 14 (2,8%) bleeding complications requiring hospital admissions. Patients taking oral anticoagulation and antiarrhythmic drugs at the end of the study accounted for 32,8% and 16,7% respectively.

Conclusions

RFCA for AF provided favorable results in terms of arrhythmia event-free survival in long-term follow-up with better results in patients with paroxysmal AF. Persistent AF and long-standing AF (beyond 5 years) were associated with AT recurrence. Despite the large number of patients who discontinued oral anticoagulation, thromboembolic adverse events were rare.

Funding Acknowledgement

Type of funding sources: None.

Impact of decreased lymphocyte, total cholesterol, and albumin levels at discharge on all-cause death in patients with acute heart failure

Background

Lymphocyte, total cholesterol, and albumin levels consist of Controlling Nutritional Status (CONUT) score, which has been reported to prognosticate patients with acute heart failure (AHF). However, the influence of each component of CONUT score on outcomes in patients with AHF was not fully elucidated.

Purpose

We aimed to evaluate the prognostic implication of the decrease in lymphocyte, total cholesterol, and albumin levels in patients with AHF.

Methods

We analyzed 1812 AHF patients in whom data at discharge were available from a multicenter registry. The decrease of lymphocyte (Ly) count was assigned with Ly≥1600/mL (31.0%), 1200≤ Ly &lt;1600 (26.9%), 800≤ Ly &lt;1200 (28.6%), Ly &lt;800 (13.5% of patients). The decrease of total cholesterol (TC) was assigned with TC≥180mg/dL (28.9%), 140≤ TC &lt;180 (42.2%), 100≤ TC &lt;140 (26.7%), TC &lt;100 (2.1% of patients). The decrease of albumin (Alb) was assigned and doubled with Alb≥3.5g/dL (45.7%), 3≤ Alb &lt;3.5 (35.1%), 2.5≤ Alb &lt;3 (15.2%), Alb &lt;2.5 (3.9% of patients). The primary outcome measure was all-cause death after discharge from the index hospitalization. Cumulative incidences were estimated by the Kaplan-Meier method and differences were assessed with the log-rank test. We constructed multivariable Cox proportional hazard models to estimate the risk of the decrease in each value per grade, with the results expressed as the hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

Cumulative one-year incidence of the all-cause death was higher with decreasing Ly, TC, and Alb levels (P&lt;0.0001, P&lt;0.0001, and P=0.02, respectively) (Figure 1). The adjusted hazard ratio for all-case death per grade decrease is most prominent in albumin (HR: 1.36, 95% CI: 1.20–1.54), followed by lymphocyte count (HR: 1,23, 95% CI: 1.10–1.38), whereas it became insignificant in total cholesterol (HR: 1.05, 95% CI: 0.91–1.21).

Conclusions

The prognostic implications after discharge were different in albumin, lymphocyte count, and total cholesterol in patients with AHF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Autoimmune disorders and venous thromboembolism: a report from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a major health problem in the world. Several studies reported that autoimmune disorder is one of important risk factors for development of VTE. Furthermore, autoimmune disorder is thought to be a relatively strong risk factor for VTE recurrence, and extended anticoagulation therapy are recommended for prevention of VTE recurrence in patients with autoimmune disorders. However, it remains controversial whether patients with autoimmune disorders have higher risk for clinical events after VTE than those without.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with autoimmune disorders after excluding patients with active cancer in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE. After excluding patients with active cancer, the current study population consisted of 2332 patients, who were divided into 2 groups: patients with autoimmune disorders and those without. We estimated the cumulative incidences of the clinical outcomes. To adjust for the clinically relevant confounders, we used the multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and their 95% confidence interval (CI) for the risk of patients with autoimmune disorders relative to those without for the clinical outcome measures. Furthermore, we added corticosteroids use at discharge to explore the effect of corticosteroids use.

Results

There were 188 patients (8.1%) with autoimmune disorders and 2144 patients (92%) without autoimmune disorders. Patients with autoimmune disorders were more often women (74%), and more often received corticosteroids at discharge (69%). The discontinuation rate of anticoagulation therapy was not significantly different between patients with autoimmune disorders and those without (38.0% vs. 39.7% at 3-year, P=0.35). The cumulative 5-year incidences of recurrent VTE and major bleeding were significantly higher in patients with autoimmune disorders than in those without (recurrent VTE: 14.3% vs. 8.3%, P=0.01; major bleeding: 14.9% vs. 8.8%, P=0.02). Even after adjusting confounders of patient characteristic, the excess risk of patients with autoimmune disorders relative to those without remained significant for recurrent VTE (HR 1.81, 95% CI 1.08–2.88, P=0.03) and major bleeding (HR 1.70, 95% CI 1.05–2.63, P=0.03). However, after adjusting for corticosteroids use at discharge, the excess risk was no longer significant for recurrent VTE (HR 1.42, 95% CI 0.75–2.61, P=0.27) nor major bleeding (HR 1.53, 95% CI 0.84–2.69, P=0.16).

Conclusions

Patients with autoimmune disorders had a higher risk for recurrent VTE and major bleeding than those without, and the excess risk could at least partly be attributable to corticosteroids use.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Long-term prediction of mortality and comparative treatment benefit following percutaneous or surgical revascularization

Background

The SYNTAX score II 2020 (SSII-2020), which was derived and externally validated from randomized trials, was designed to predict death following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel disease and/or left main disease. We aimed to investigate its value in identifying the safest modality of revascularization in a non-randomized setting.

Methods

Five-year mortality was assessed in 7362 patients with three-vessel disease and/or left main disease enrolled in a Japanese PCI/CABG registry. New-generation drug eluting stents and imaging guidance became the default PCI strategy during enrolment of the last cohort. The discriminative ability of the SSII-2020 for 5-year mortality was assessed using Harrell's C statistic (C-index). Agreement between observed and predicted rates of all-cause mortality following either PCI or CABG and treatment benefit (absolute risk difference) for this outcome were assessed by calibration plots.

Results

The SSII-2020 had helpful discrimination (C-index = 0.72) and good calibration (intercept = −0.11, slope = 0.92) for 5-year mortality. The absolute risk difference in mortality between CABG and PCI (treatment benefit) was well calibrated when the whole population was grouped into quarters according to the predicted absolute risk difference of 5-year mortality. The observed differences in survival in favor of CABG were 4.2% (0.1 to 8.2%, log-rank p=0.05) and 8.5% (3.8 to 13.2%, log-rank p&lt;0.01) in the respective third and fourth quarters. In contrast, the observed differences in survival were not significantly different in either the first (3.0% [−0.8 to 6.8%, log-rank p=0.12]) or the second quarter (1.3% [−2.4 to 5.1%, log-rank p=0.39]).

Conclusions

The SSII-2020 is well able to predict death at 5 years – and the mortality difference between PCI and CABG, and therefore has the potential to support decision making on revascularization in patients with three-vessel disease and/or left main coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Risk factors of recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Patients with venous thromboembolism (VTE), including pulmonary embolism (PE), have a long-term risk of recurrence, and anticoagulation therapy is recommended for the prevention of recurrence. The latest 2019 European Society of Cardiology (ESC) guideline classified the risks of recurrence into low- (&lt;3%/year), intermediate- (3–8%/year), and high- (&gt;8%/year) risk, and recommended the extended anticoagulation therapy of indefinite duration for high-risk patients as well as intermediate-risk patients. However, extended anticoagulation therapy of indefinite duration for all of intermediate-risk patients have been a matter of active debate. Thus, additional risk assessment of recurrence in intermediate-risk patients might be clinically relevant in defining the optimal duration of anticoagulation therapy. Furthermore, bleeding risk during anticoagulation therapy should also be taken into consideration for optimal duration of anticoagulation therapy. However, there are limited data assessing the risk of recurrence as well as bleeding in patients with intermediate-risk for recurrence based on the classification in the latest 2019 ESC guideline.

Purpose

The current study aimed to identify the risk factors of recurrence as well as major bleeding in patients with intermediate-risk for recurrence, using a large observational database of VTE patients in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy.

Results

In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97–14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56–7.50), while the independent risk factors for major bleeding were age ≥75 years (HR 2.04, 95% CI 1.36–3.07), men (HR 1.52, 95% CI 1.02–2.27), history of major bleeding (HR 3.48, 95% CI 1.82–6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04–6.37).

Conclusions

Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors of recurrence in patients with cancer-associated venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Cancer is a strong risk factor for the development of venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT). Patients with VTE have a long-term risk of recurrence, which can be prevented by anticoagulation therapy. Prolonged anticoagulation therapy is recommended for patients with cancer-associated VTE, although the risk of recurrence might depend on the individual patient.

Purpose

We aimed to identify the risk factors of recurrence in patients with cancer-associated VTE.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTE among 29 Japanese centers between January 2010 and August 2014. The present study population consisted of 695 cancer-associated VTE patients. The primary outcome measure in the present study was recurrent VTE, which was defined as PE and/or DVT with symptoms accompanied by confirmation of a new thrombus or exacerbation of the thrombus by objective imaging examinations or autopsy. Discontinuation of anticoagulation was defined as a withdrawal of anticoagulation therapy lasting &gt;14 days for any reason. We selected clinically relevant variables and variables with P values &lt;0.1 in a univariate analysis as potential risk factors, and constructed a multivariable Cox proportional hazard model for recurrent VTE incorporating the anticoagulation therapy status as a time-updated covariate.

Results

Among the 695 study patients, recurrent VTE occurred in 78 patients, of whom 54 (69%) occurred within 6 months. The cumulative incidence of recurrent VTE was 7.7% at 3-months, 8.9% at 6-months, 11.8% at 1-year, and 17.7% at 5-years. The cumulative incidence of discontinuation of anticoagulation therapy was 18.0% at 3-months, 29.5% at 6-months, 43.4% at 1-year, and 66.5% at 5-years. The cumulative 5-year incidence of recurrent VTE was most frequent in patients with uterus/ovary cancer (26.0%), followed by those with lung cancer (24.7%). The multivariable Cox proportional hazard model revealed that chronic kidney disease (HR, 2.27; 95% CI, 1.36–3.77, P=0.002), a high D-dimer level at the time of VTE diagnosis (HR, 2.85; 95% CI, 1.71–4.74, P&lt;0.001), advanced cancer (HR, 1.69; 95% CI, 1.05–2.72, P=0.03) and discontinuation of anticoagulation therapy (HR, 2.66; 95% CI, 1.53–4.63, P&lt;0.001) were independently associated with an increased risk of recurrent VTE. No cancer site was independently associated with an increased risk for recurrent VTE when adjusting for the above mentioned risk factors in the multivariable Cox proportional hazard model, although the risk of recurrent VTE numerically differed according to the cancer site.

Conclusions

Among patients with cancer-associated VTE, chronic kidney disease, a high D-dimer level at the time of VTE diagnosis, advanced cancer, and discontinuation of anticoagulation therapy were independent risk factors of recurrence.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation Figure 1Figure 2

Granulomatous-lymphocytic Interstitial Lung Disease Associated with Good's Syndrome That Responded to Immunoglobulin Therapy

Good's syndrome is associated with thymoma and acquired immunodeficiency. A 54-year-old man visited our hospital with a complaint of cough. Chest imaging revealed diffuse nodular shadows and anterior mediastinal mass. Hypogammaglobulinemia and a decreased B lymphocyte count were found by a laboratory evaluation. The lung nodules markedly regressed after immunoglobulin therapy. The mediastinal mass and remaining nodule were surgically resected and diagnosed as a type AB thymoma and a necrotizing epithelioid granuloma with T lymphocyte-dominant alveolitis, respectively. The overall appearances of these lesions were mostly in line with the spectrum of granulomatous-lymphocytic interstitial lung disease associated with Good's syndrome.

Outcomes of robot-assisted versus conventional laparoscopic low anterior resection in patients with rectal cancer: propensity-matched analysis of the National Clinical Database in Japan

BACKGROUND

Robot-assisted laparoscopic surgery has several advantages over conventional laparoscopy. However, population-based comparative studies for low anterior resection are limited. This article aimed to compare peri-operative results of robot-assisted low anterior resection (RALAR) and laparoscopy.

METHODS

This retrospective cohort study used data from patients treated with RALAR or conventional laparoscopic low anterior resection (CLLAR) between October 2018 and December 2019, as recorded in the Japanese National Clinical Database, a data set registering clinical information, perioperative outcomes, and mortality. Of note, the registry does not include information on the tumour location (centimetres from the anal verge) and diverting stoma creation. Perioperative outcomes, including rate of conversion to open surgery, were compared between RALAR and CLLAR groups. Confounding factors were adjusted for using propensity score matching.

RESULTS

Of 21 415 patients treated during the study interval, 20 220 were reviewed. Two homogeneous groups of 2843 patients were created by propensity score matching. The conversion rate to open surgery was significantly lower in the RALAR group than in the CLLAR group (0.7 versus 2.0 per cent; P < 0.001). The RALAR group had a longer operating time (median: 352 versus 283 min; P < 0.001), less intraoperative blood loss (15 versus 20 ml; P < 0.001), a lower in-hospital mortality rate (0.1 versus 0.5 per cent; P = 0.007), and a shorter postoperative hospital stay (median: 13 versus 14 days; P < 0.001) compared with the CLLAR group. The CLLAR group had a lower rate of readmission within 30 days (2.4 versus 3.3 per cent; P = 0.045).

CONCLUSION

These data highlight the reduced conversion rate, in-hospital mortality rate, intraoperative blood loss, and length of postoperative hospital stay for rectal cancer surgery in patients treated using robot-assisted laparoscopic surgery compared with laparoscopic low anterior resection.

Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis

Background

In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure–derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated.

Objectives

The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory–based environment.

Methods

In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease.

Results

Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUC_{diastolic FFR}: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUC_FFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113).

Conclusions

Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906)

Non-cardiovascular disorders in a contemporary cardiovascular intensive care unit in Japan

BACKGROUND

In the modern US cardiovascular intensive care unit (CICU), the incidence of non-cardiovascular disorders has increased and non-cardiovascular disorders are associated with an increase in morbidity and mortality. In Japan, however, data regarding the association between non-cardiovascular disorders and outcomes in the CICU are limited.

METHODS

This study examined 490 consecutive admissions to a closed CICU at the Nippon Medical School Hospital from January to December 2017. Characteristics, diagnoses, treatments, and outcomes of admitted patients were identified.

RESULTS

The most common primary diagnosis was acute coronary syndrome (50.4%), followed by acute heart failure (20.0%), arrhythmia (6.7%), and non-cardiovascular diseases (3.7%). The mortality rate and median length of stay (LOS) in the CICU were 4.7% and 4 (interquartile range, 2-8) days, respectively. Of all patients, 42.2% (n = 207) developed non-cardiovascular complications such as acute respiratory failure, acute kidney injury, or sepsis during CICU stay. Multivariate logistic regression analysis revealed that acute respiratory failure and sepsis were significantly associated with mortality in the CICU (odds ratio, 11.014 and 25.678, respectively; both p<0.05). The multiple linear regression analysis showed that acute kidney injury was significantly associated with LOS in the CICU (β=0.144, p = 0.002).

CONCLUSIONS

Approximately half of patients admitted to the CICU had non-cardiovascular disorders including non-cardiovascular disease and non-cardiovascular complications, which were significantly associated with mortality and LOS in the CICU.

Gastrointestinal bleeding increases the risk of subsequent cardiovascular events in patients with acute cardiovascular diseases requiring intensive care

Gastrointestinal (GI) bleeding worsens the outcomes of critically ill patients in the intensive care unit (ICU). Owing to a lack of corresponding data, we aimed to investigate whether GI bleeding during cardiovascular-ICU (C-ICU) admission in acute cardiovascular (CV) disease patients is a risk factor for subsequent CV events. Totally, 492 consecutive C-ICU patients (40.9% acute coronary syndrome, 22.8% heart failure) were grouped into GI bleeding (n = 27; 12 upper GI and 15 lower GI) and non-GI bleeding (n = 465) groups. Thirty-nine patients died or developed CV events during hospitalization, and 453 were followed up from the date of C-ICU discharge to evaluate subsequent major adverse CV events. The GI bleeding group had a higher Acute Physiology and Chronic Health Evaluation II score (20.2 ± 8.2 vs. 15.1 ± 6.8, p < 0.001), higher frequency of mechanical ventilator use (29.6% vs. 13.1%, p = 0.039), and longer C-ICU admission duration (8 [5–16] days vs. 5 [3–8] days, p < 0.001) than the non-GI bleeding group. The in-hospital mortality rate did not differ between the groups. Of those who were followed-up, CV events after C-ICU discharge were identified in 34.6% and 14.3% of patients in the GI and non-GI bleeding groups, respectively, during a median follow-up period of 228 days (log rank, p < 0.001). GI bleeding was an independent risk factor for subsequent CV events (adjusted hazard ratio: 2.23, 95% confidence interval: 1.06–4.71; p = 0.035). GI bleeding during C-ICU admission was independently associated with subsequent CV events in such settings.

Femtometer atomic displacement, the root cause for multiferroic behavior of CuO unearthed through polarized Raman spectroscopy

Recently, CuO has been proposed as a potential multiferroic material with high transition temperature. Competing models based on spin current and ionic displacements are invoked to explain ferroelectricity in CuO. The theoretical model based on ionic displacement predicted very small displacement (∼10^-5Å) along thebaxis. Experimentally detecting displacements of such a small amplitude in a particular direction is extremely challenging. Through our detailed angle resolved polarized Raman spectroscopy study on single crystal of CuO, we have validated the theoretical study and provided direct evidence of displacement along thebaxis. Our study provides important contribution in the high temperature multiferroic compounds and showed for the first time, the use of the polarized Raman scattering in detecting ionic displacements at the femtometer scale.

Preclinical proof-of-concept study: antisense-mediated knockdown of CALM as a therapeutic strategy for calmodulinopathy

Background

Calmodulin (CaM) is a ubiquitous Ca2+ sensor molecule encoded by three distinct calmodulin genes, CALM1–3, and has an important role for cardiac ion channel function. Recently, heterozygous missense mutations in CALM genes were reported to cause a new category of life-threatening genetic arrhythmias such as long-QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT), which is called as “calmodulinopathy”. The patients with calmodulinopathy show poor prognosis and there is no effective treatment for them.

Purpose

Considering the dominant-negative effect of mutant calmodulin proteins produced by heterozygous missense mutations in CALMs, we aimed to prove the concept of antisense-based therapy to treat calmodulinopathy using human iPS cell-derived cardiomyocyte (hiPSC-CM) model.

Methods

We designed multiple locked nucleic acid (LNA) gapmer-antisense oligonucleotides (ASOs) targeting CALM2 and analyzed the silencing efficiency and toxicity in cultured cells to select the most potent ASO. Using CMs differentiated from hiPSCs which were generated form a 12-year-old boy with LQTS carrying a heterozygous CALM2-N98S mutation, CALM2 expression and action potentials (APs) were analyzed to evaluate the efficacy of ASOs.

Results

We identified several ASOs which reduced CALM2 expression without affecting cell viability in human cultured cells (HepG2) (ASO 50 nM, n=2; Figure 1A). Considering further experiments in vivo mouse model, we investigated the CALM2 silencing activity in mouse cultured cells (3T3-L1) without transfection (free-uptake) (ASO 1 μM, n=2; †ASOs have homologous sequence between human and mouse; Figure B). After free-uptake CALM2 silencing analysis in 3T3-L1 cells, we identified that ASO #2 has the most potent CALM2 silencing activity and low cytotoxicity (Figure 1B). ASO #2 effectively reduced CALM2 expression even in hiPSC-CMs (ASO(−): n=3, lipofection: n=4, free-uptake: n=3; P&lt;0.05; Figure 1C). In action potential recordings, we demonstrated that ASO #2 ameliorated prolonged AP durations (APD90) in N98S-hiPSC-CMs at 0.5 Hz pacing (ASO(−): 666±123 ms (n=7), lipofection: 329±21 ms (n=8), free-uptake: 388±34 ms (n=12); P&lt;0.05; Figure 1D).

Conclusion

Our results using patient-derived hiPSC-CM model suggest that ASO-based therapy might be a promising strategy for the treatment of calmodulinopathy.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Nissan Chemical Corporation

Impact of lipoprotein(a) levels on angiographic severity of femoropopliteal lesions

Background

High lipoprotein(a) [Lp(a)] levels are a risk factor for peripheral artery disease (PAD). However, the association between Lp(a) levels and angiographic severity of PAD has not been systematically studied.

Purpose

The aim of this study was to assess the impact of Lp(a) levels on angiographic severity of femoropopliteal lesions in patients with PAD.

Methods

We retrospectively analyzed a single-center database including 108 patients (74±8 years, 69% male) who underwent endovascular therapy for de novo femoropopliteal lesions and measured Lp(a) levels before therapy between June 2016 and September 2019. Patients were divided into low Lp(a) [LP(a) &lt;30 mg/dL; 77 patients] and high Lp(a) [LP(a) ≥30 mg/dL; 31 patients] groups. Trans-Atlantic Inter-Society Consensus (TASC) II classification, calcification [referring to peripheral arterial calcium scoring system (PACSS) classification] and lesion length were compared between the groups.

Results

Median Lp(a) was 16 (7–31) mg/dL.The prevalence of TASC II class D (13% vs 38%, P&lt;0.01) and severe calcification (PACSS 4) (6% vs 23%, P=0.02) was significantly higher and lesion length was longer (123±88 mm vs 175±102 mm, P&lt;0.01) in the high Lp(a) group than in the low Lp(a) group.(Table and Figure) In multivariate analysis, Lp(a)≥30 was an independent predictor for TASC II class D (HR=3.67, P=0.02) and PACSS 4 (HR=4.97, P=0.02) prevalence.

Conclusion

Lp(a) was associated with angiographic severity of femoropopliteal lesions in patients with PAD.

Comparison of angiographic severity

Funding Acknowledgement

Type of funding source: None

High-dose statin therapy and the risk of haemorrhagic stroke in Asian patients with stable coronary artery disease: insights from the REAL-CAD study

Background/Introduction

The REAL-CAD study identified that aggressive lipid lowering with high-dose statin reduced cardiovascular events also in Japanese patients with coronary artery disease (CAD). However, data from the SPARCL trial found that the benefits of high-dose atorvastatin treatment were partially offset by an increase in haemorrhagic stroke (HS). Although meta-analysis showed statin does not increase HS in Western countries, the evidence about the relation between statin and HS in Asian countries is still conflicting. In addition, the CREDO-Kyoto score is one of the prediction scorings for bleeding after coronary revascularization and might be a useful tool for the prediction of HS in this cohort. Recognizing the risk of HS and predicting of HS in the Asian cohort is clinically important.

Purpose

This study examined the factors associated with HS using the REAL-CAD cohort. Furthermore, we evaluated the performance of the CREDO-Kyoto bleeding risk score to predict HS in this cohort. We also performed the corresponding analysis of ischaemic stroke for reference purposes.

Methods

We sub-analysed the REAL-CAD study, prospective, multicentre, randomized, open-label, blinded endpoint study, in which 13,054 Japanese patients with stable CAD were randomized to high-dose (4 mg/day) or low-dose (1 mg/day) pitavastatin. Associations for stroke were determined using competing risk models: the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of haemorrhagic and ischaemic stroke in REAL-CAD trial. Patients were categorized to low (score 0), moderate (score 1–2), and high (score&gt;3) according to CREDO-Kyoto bleeding score for predicting of HS.

Results

The HS events in high-dose group tended to be higher than low-dose group (4mg vs. 1mg: 43 (0.7%) vs. 30 (0.5%)). The associated factors of HS on univariate analysis were non-prior myocardial (hazard ratio (HR): 0.62, 95% CI: 0.39–0.99) and non-prior cerebral (HR: 0.25, 95% CI: 0.09–0.70) infarction, atrial fibrillation (HR: 2.4, 95% CI: 1.2–4.7), prior HS (HR: 4.2, 95% CI: 1.5–11.8), anaemia (HR: 2.4, 95% CI: 1.4–4.1), and non-statins use before run-in period (HR: 0.52, 95% CI: 0.28–0.99). High-dose pitavastatin was not a correlate with HS. The multivariate analysis revealed anaemia might have a relation with HS (HR: 4.3, 95% CI: 0.90–20.6). The number of HS was the highest in the high CREDO-Kyoto bleeding score group (Figure 1, HR: 2.4, 95% CI: 1.3–4.6), whereas there was no significant difference in the number of HS between the moderate- and low-risk groups (HR: 1.4, 95% CI: 0.84–2.3).

Conclusions

High-dose pitavastatin was not associated with the incidence of HS in this large Japanese cohort with stable CAD. High CREDO-Kyoto bleeding score was associated with HS as compared with low or moderate scores, even each of the variables consisting of CREDO-Kyoto score was not associated with HS.

Figure 1

Funding Acknowledgement

Type of funding source: None