Improving the Prognosis of Pancreatic Cancer Through Early Detection: Protocol for a Prospective Observational Study

Background

Pancreatic cancer is associated with high mortality and its rates of detection are very low; as such, the disease is typically diagnosed at an advanced stage. A number of risk factors for pancreatic cancer have been reported and may be used to identify individuals at high risk for the development of this disease.

Objective

The aim of this prospective, observational trial is to evaluate a scoring metric for systematic early detection of pancreatic cancer in Mie Prefecture, Japan.

Methods

Eligible patients aged 20 years and older will be referred from participating clinics in the Tsu City area to the Faculty of Medicine, Gastroenterology, and Hepatology at Mie University Graduate School, until September 30, 2022. Participants will undergo a detailed examination for pancreatic cancer. Data collection will include diagnostic and follow-up imaging data and disease staging information.

Results

The study was initiated in September 2020 and aims to recruit at least 150 patients in a 2-year period. Recruitment of patients is currently still underway. Final data analysis is expected to be complete by March 2025.

Conclusions

This study will provide insights into the feasibility of using a scoring system for the early detection of pancreatic cancer, thus potentially improving the survival outcomes of diagnosed patients.

Trial Registration

UMIN-CTR Clinical Trials Registry UMIN000041624; https://tinyurl.com/94tbbn3s

International Registered Report Identifier (IRRID)

DERR1-10.2196/26898

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<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.

Cardio-renal protective effects of SGLT2 inhibitors in patients with type 2 diabetes mellitus and severely impaired renal function

Background

Prognostic impact of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors on cardiovascular and renal outcome was unknown in patients with type-2 diabetes mellitus (DM) and severely impaired renal function.

Methods

From July 2015 to December 2020, patients with type-2 DM who were taken SGLT2 inhibitors for more than six months were retrospectively screened. Patients with estimated glomerular filtration rate (eGFR) over 60ml/min/1.73m2 were excluded. We divided those patients into two groups by eGFR; less than 45ml/min/1,73m2 were group A and 46–60ml/min/m2 were group B. Randomly selected patients with DM not taking SGLT2 inhibitors and having severe renal dysfunction: eGFR less than 45ml/min/m2 (Group C) were set as controls. The primary outcome was a composite of cardiovascular/renal death, initiation of dialysis, doubling of the serum creatine level, decline in the eGFR more than 30%, nonfatal myocardial infraction, nonfatal stroke, and hospitalization for heart failure.

Results

Totally 418 patients were enrolled. Median age was 71 years (group A, n=106), 64 years (group B, n=115), and 77 years (group C, n=201) (p<0.001). After median 24 months follow-up, primary endpoints were observed 24.5% in group A, 4.3% in group B, 36.8% in group C (p<0.001). In Kaplan-Meier analysis, significantly lower incidence of primary endpoints were observed in SGLT2 groups (group A and B) than controls (p<0.001, Figure 1). In patients with severe renal dysfunction, taking SGLT2 inhibitors tended to decrease future renal event (Figure 2). The incidence of SGLT2 related adverse events was not different between 2 groups (A and B).

Conclusions

Even in patients with severe renal dysfunction, SGLT2 inhibitors would have cardio-renal protective effects without drug-related adverse effects.

Funding Acknowledgement

Type of funding sources: None.

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Background

Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise.

There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA.

Methods

This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287).

Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2.

Results

The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P<0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p<0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P<0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p<0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P<0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039).

Conclusions

The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

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 <1600 (26.9%), 800≤ Ly <1200 (28.6%), Ly <800 (13.5% of patients). The decrease of total cholesterol (TC) was assigned with TC≥180mg/dL (28.9%), 140≤ TC <180 (42.2%), 100≤ TC <140 (26.7%), TC <100 (2.1% of patients). The decrease of albumin (Alb) was assigned and doubled with Alb≥3.5g/dL (45.7%), 3≤ Alb <3.5 (35.1%), 2.5≤ Alb <3 (15.2%), Alb <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<0.0001, P<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

Impact of polypharmacy on prognosis in patients with acute decompensated heart failure: from the CURE-HF registry

Background

Polypharmacy would be associated with poor prognosis in patients with heart failure (HF).

Methods

In 863 patients who discharged after treatment for HF were prospectively enrolled. Number of tablets prescribed at discharge was counted. Death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for HF were tracked.

Results

In our study cohort (median age, 78), 447 patients experienced adverse events during median 503 days follow-up. In Kaplan-Meier analysis, a greater number of prescribed tablets was associated with future adverse cardiac events in the crude population. Although patients with the greater number of non-HF medications showed worse outcome, those of HF medications were not associate with the outcome (Figure). Furthermore, the number of tablets was an independent predictor of future cardiovascular events after adjustment for age, gender, B-type natriuretic peptide, hemoglobin, albumin, estimated glomerular filtration rate, and left ventricular ejection fraction (HR 95% CI: 1.295 (1.066–1.573), p=0.009).

Conclusions

Polypharmacy was associated with poor prognosis. Although the numbers of tablets and non-HF medications were significantly associated with worse out come in HF patients, the number of HF medications was not.

Funding Acknowledgement

Type of funding sources: None.

Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan: a cohort study

Background

There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial.

Purpose

We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan.

Methods

From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referred non-invasive imaging tests, 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1 year.

Results

Patients with ≥10% myocardial ischemia (n=173) were older than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (9.1% vs. 1.2%, P<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant (adjusted hazard ratio [95% confidence interval], 2.40 [1.09–5.26], P=0.029).

Conclusion

The presence of ≥10% myocardial ischemia was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.

Funding Acknowledgement

Type of funding sources: None. Study flowchartOutcomes

Novel variant of the glycerol-3-phosphate dehydrogenase-1 Like (GPD1-L) gene in Japanese Brugada syndrome patients

Background

The incidence of Brugada syndrome (BrS) varies among racial groups. Several studies reported Glycerol-3-Phosphate Dehydrogenase 1-Like (GPD1-L) gene is associated with BrS. However, most of these studies were reported from Western countries, so the evidence about GPD1-L mutation is limited especially among Asian BrS patients. This study aimed to search for rare variants in GPD1-L among Japanese BrS patients and to investigate the pathogenicity.

Method

We performed whole-exome sequencing for patients with Brugada type 1 ECG pattern from Japanese multicenter BrS cohort consisting of SCN5A-negative BrS probands (n=288) and controls (n=372). We conducted patch-clamp study in human embryonic kidney (HEK) 293 cells cotransfected with the wild-type sodium channel (SCN5A) and wild-type or mutant GPD1-L expression plasmid.

Results

We identified a rare variant in GPD1-L, p.D262N (c.784g>a) in 2 of 288 BrS probands, which was not identified in 372 controls. The minor allele frequency of the variant is 0.0014% in the Genome Aggregation Database. One proband was a 49-year-old man and the other was 34-year-old man who both developed a ventricular fibrillation. ECGs of both probands showed Brugada Type 1 pattern after administration of the pilsicainide. In functional study, coexpression of D262N GPD1-L with SCN5A in HEK293 cells significantly reduced inward sodium currents compared with wild-type GPD1-L. Additionally, inward sodium currents with D262N were similar to those with A280V GPD1-L, which was associated with BrS in previous reports (Figure). Also, several pathogenicity prediction programs, such as SIFT (score: 0.031) and PolyPhen2 (score: 0.937) predicted deleterious effects of GPD1-L D262N.

Conclusion

We identified a rare variant in GPD1-L at the rate of 0.7% in Japanese BrS patients without SCN5A mutations. GPD1-L, p.D262N reduces inward sodium currents and may be a novel susceptible variant for BrS in the Japanese population.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Current–voltage curve

Erratum: Spin Current Noise of the Spin Seebeck Effect and Spin Pumping [Phys. Rev. Lett. 120, 037201 (2018)]

This corrects the article DOI: 10.1103/PhysRevLett.120.037201.

Preparation and Readout of Multielectron High-Spin States in a Gate-Defined GaAs/AlGaAs Quantum Dot

We report the preparation and readout of multielectron high-spin states, a three-electron quartet, and a four-electron quintet, in a gate-defined GaAs/AlGaAs single quantum dot using spin filtering by quantum Hall edge states coupled to the dot. The readout scheme consists of mapping from multielectron to two-electron spin states and a subsequent two-electron spin readout, thus obviating the need to resolve dense multielectron energy levels. Using this technique, we measure the relaxations of the high-spin states and find them to be an order of magnitude faster than those of low-spin states. Numerical calculations of spin relaxation rates using the exact diagonalization method agree with the experiment. The technique developed here offers a new tool for the study and application of high-spin states in quantum dots.

Large-Scale Prospective Genome-Wide Association Study of Oxaliplatin in Stage II/III Colon Cancer and Neuropathy

IMPORTANCE

The severity of oxaliplatin (L-OHP)-induced peripheral sensory neuropathy (PSN) exhibits substantial interpatient variability, and some patients suffer from long-term, persisting PSN.

OBJECTIVE

To identify single-nucleotide polymorphisms (SNPs) predicting L-OHP-induced PSN using a genome-wide association study (GWAS) approach.

DESIGN, SETTING, PARTICIPANTS

A large prospective GWAS including 1,379 patients with stage II/III colon cancer who received L-OHP-based adjuvant chemotherapy (mFOLFOX6/CAPOX) under the phase II (JOIN/JFMC41) or the phase III (ACHIVE/JFMC47) trial.

MAIN OUTCOMES AND MEASURES

First, GWAS comparison of worst grade PSN (grade 0/1 vs. 2/3) was performed. Next, to minimize the impact of ambiguity in PSN grading, extreme PSN phenotypes were selected and analyzed by GWAS. SNPs that could predict time to recovery from PSN were also evaluated. In addition, SNPs associated with L-OHP-induced allergic reactions (AR) and time to disease recurrence were explored.

RESULTS

No SNPs exceeded the genome-wide significance (p < 5.0 × 10^-8) in either GWAS comparison of worst grade PSN, extreme PSN phenotypes, or time to recovery from PSN. Association study focusing on AR or time to disease recurrence also failed to reveal any significant SNPs.

CONCLUSION AND RELEVANCE

Our results highlight the challenges of utilizing SNPs for predicting susceptibility to L-OHP-induced PSN in daily clinical practice.

Bronchial carcinoid tumor managed with bronchial artery embolization before endobronchial resection: A case report

Endobronchial resection using a bronchoscope is often selected as treatment for carcinoid tumors located in the central airways. However, massive bleeding is one of the most serious complications during bronchoscopic surgery. Here, we report the case of a 77‐year‐old female with a typical carcinoid tumor located in the right truncus intermedius who underwent bronchial artery embolization (BAE) one day before endobronchial intervention using a flexible bronchoscope. The tumor was successfully resected without bleeding. BAE prior to endobronchial resection of carcinoid tumors may be useful for reducing the risk of bleeding.

Impact of the 12-gene recurrence score assay on deciding adjuvant chemotherapy for stage II and IIIA/B colon cancer: the SUNRISE-DI study

BACKGROUND

Recent advances in adjuvant chemotherapy for early colon cancer have widened physicians' recommendations on the regimen and duration (3 or 6 months) of the treatment. We conducted this prospective study to evaluate whether the 12-gene recurrence score (12-RS) assay affected physicians' recommendations on adjuvant treatment selection.

PATIENTS AND METHODS

Patients with stage IIIA/IIIB or stage II colon cancer were enrolled. After the patients discussed adjuvant treatment with their treating physicians, the physicians filled in the questionnaire before assay indicating the treatment recommendation. When the 12-RS assay results were available, the physicians again filled in the questionnaire after assay. The primary endpoint was the rate of change in treatment recommendations from before to after the assay, with a threshold rate of change being 20%. Patients with stage IIIA/B to II were enrolled in a ratio of 2 : 1.

RESULTS

Overall, the treatment recommendations changed in 40% of cases after obtaining 12-RS assay results. Recommendations were changed in 45% (80/178; 95% confidence interval, 37% to 53%; P < 0.001) and 30% (29/97; 95% confidence interval, 21% to 40%; P < 0.001) of patients with stage IIIA/B and II colon cancer, respectively. Patients with stage IIIA/B cancer had significantly more change than those with stage II cancer (P = 0.0148). From before to after the 12-RS assay, the percentage of patients whose physicians reported being confident in their treatment recommendations significantly increased from 54% to 81% in stage IIIA/B (P < 0.001) and from 65% to 83% in stage II (P < 0.001).

CONCLUSION

Our study confirmed the usefulness of the 12-RS assay in aiding the physician-patient decision-making process for tailoring adjuvant chemotherapy for stage IIIA/B colon cancer.

A multicenter cohort study of osimertinib compared with afatinib as first-line treatment for EGFR-mutated non-small-cell lung cancer from practical dataset: CJLSG1903

Background

FLAURA, the prospective trial of osimertinib as a first-line therapy compared with first-generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), did not show superior survival benefit for osimertinib in either the subgroup of Asians or the subgroup with the L858R mutation. In addition, the superiority of osimertinib compared with second-generation EGFR-TKI is thus far unclear.

Patients and methods

We reviewed the clinical data of all consecutive patients who were treated with osimertinib or afatinib as first-line therapy between May 2016 and October 2019 from 15 institutions in Japan. We defined the groups based on first-line EGFR-TKI as the afatinib group and the osimertinib group. Outcomes included time to discontinuation of any EGFR-TKI (TD-TKI), overall survival (OS), and time to treatment failure, with propensity score analysis carried out as an exploratory analysis in the survival and subgroup analyses.

Results

A total of 554 patients were enrolled. Data on 326 patients in the osimertinib group, and 224 patients in the afatinib group were analyzed. TD-TKI adjusted by propensity score in the afatinib and osimertinib groups was 18.6 months (95% confidence interval 15.8 to 22.0) and 20.5 months (95% confidence interval 13.8 to not reached), respectively, without significant difference (P = 0.204). OS adjusted by propensity score favored the afatinib group with a significant difference (P = 0.018). Subgroup analysis with propensity score showed that patients with L858R and without brain metastasis had superior survival benefit with afatinib compared with osimertinib (P < 0.001).

Conclusions

TD-TKI in the afatinib group was not significantly prolonged compared with the osimertinib group in the practical data. In the exploratory analysis of patients with L858R-mutated non-small-cell lung cancer without brain metastasis, afatinib showed more benefit in OS over osimertinib.

•

The large-scale practical data of 550 patients who were treated with osimertinib or afatinib as first-line therapy were analyzed.

•

The superiority of osimertinib compared with afatinib could not be demonstrated in all populations.

•

Osimertinib therapy showed effectiveness in patients with brain metastasis.

•

Afatinib therapy showed potential benefit in patients with L858R mutation and without brain metastasis.

A case of acute inhalation injury caused by premeditated chlorine gas exposure

Chlorine is a toxic gas that causes severe inhalation injury. We report the case of a 43-year-old woman who inhaled chlorine gas generated by mixing household bleach and vinegar. She was referred to our hospital because she had developed respiratory failure. Chest computed tomography (CT) showed diffuse ground-glass opacity and the tree-in-bud pattern. We diagnosed acute inhalation injury compatible with that due to chlorine gas exposure. Six days after admission, her respiratory symptoms and abnormal CT findings fully resolved without the use of bronchodilators or corticosteroids. This is the first report of a patient with acute inhalation injury caused by intentional chlorine gas exposure. It is considered that chlorine gas reached her respiratory tract and induced widespread injury from bronchioles to alveoli.

Study of the K_{L}→π^{0}νν[over ¯] Decay at the J-PARC KOTO Experiment

The rare decay K_{L}→π^{0}νν[over ¯] was studied with the dataset taken at the J-PARC KOTO experiment in 2016, 2017, and 2018. With a single event sensitivity of (7.20±0.05_{stat}±0.66_{syst})×10^{-10}, three candidate events were observed in the signal region. After unveiling them, contaminations from K^{±} and scattered K_{L} decays were studied, and the total number of background events was estimated to be 1.22±0.26. We conclude that the number of observed events is statistically consistent with the background expectation. For this dataset, we set an upper limit of 4.9×10^{-9} on the branching fraction of K_{L}→π^{0}νν[over ¯] at the 90% confidence level.

Recurrence of atrial fibrillation after catheter ablation is associated with major adverse cardiac and cerebrovascular events: insights from AF frontier ablation registry

Background

Recent observational studies have suggested that catheter ablation for atrial fibrillation (AF) is significantly associated with reduced risk for stroke, cardiovascular events and all-cause death. However, little is known whether late recurrence of AF after catheter ablation is associated with worse clinical outcomes.

Purpose

We aimed to clarify whether late recurrence of AF after catheter ablation is associated with major adverse cardiac and cerebrovascular events (MACCE).

Methods

We retrospectively investigated 2,737 participants (74.4% men, mean age 63.4±10.3 years, 62.7% paroxysmal AF) who received first catheter ablation for AF and completed follow-up more than 3 months after the procedure from AF Frontier Ablation Registry, a multicenter cohort study in Japan. We evaluated an association between late recurrence of AF after catheter ablation and first MACCE in cox-regression hazard models adjusted for known risk factors. MACCE were defined as stroke/transient ischemic attack (TIA), cardiovascular events or all-cause death. Late recurrence was defined as AF relapse more than 3 months after the procedure.

Results

During a mean follow-up period of 25.2 months, 2,070 patients (75.6%) were free from AF after catheter ablation and 122 patients (4.5%) had MACCE (ischemic stroke 18 [14.8%], hemorrhagic stroke 16 [13.1%], TIA 7 [5.7%], hospitalization for heart failure 19 [15.6%], acute coronary syndrome 19 [15.6%], hospitalization for other cardiovascular events 24 [20%] and all-cause death 19 [15.6%]). The MACCE occurred significantly more frequently in the recurrence group than in non-recurrence group (7.5% vs. 3.5%; hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.28–2.65; P=0.001) (Figure). Multivariate analysis revealed that baseline age (HR 1.05; 95% CI 1.03–1.08; P&lt;0.001), heart failure (HR 1.76; 95% CI 1.17–2.66; P=0.007), old myocardial infarction (HR 4.49; 95% CI 2.59–7.81; P&lt;0.001), non-ischemic cardiomyopathy (HR 2.56; 95% CI 1.47–4.46; P=0.001), left atrial diameter (HR 1.22 per 5-mm increase; 95% CI, 1.06–1.41; P=0.006) and recurrence of AF (HR 1.69; 95% CI 1.17–2.44; P=0.005) were independently associated with the incidence of MACCE after catheter ablation.

Conclusion

In the Japanese multicenter cohort of AF ablation, late recurrence of AF was independently associated with increased MACCE, suggesting the significance of sinus rhythm maintenance by catheter ablation.

Kaplan-Meier curves for MACCE

Funding Acknowledgement

Type of funding source: None

The impact of an empiric superior vena cava isolation added to pulmonary vein isolation for non-paroxysmal atrial fibrillation associated with left atrial low voltage areas

Introduction

Left atrial low-voltage areas (LVAs) are associated with recurrence after radiofrequency catheter ablation of atrial fibrillation (AF). However, the impact of LVAs on recurrence after an empiric pulmonary vein isolation (PVI) plus superior vena cava isolation (SVCI) strategy for non-Paroxysmal AF (PAF) patients remains unclear.

Purpose

We evaluated the impact of LVAs on the recurrence of atrial tachyarrhythmias (ATs)/AF in patients who underwent an empiric SVCI added to the PVI for non-PAF.

Methods

We enrolled 153 consecutive patients with non-PAF who underwent a PVI alone (PVI group; n=51) or empiric PVI plus SVCI (PVI+SVCI group; n=102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (&lt;0.5 mV). No patients underwent a substrate modification of the LVAs. We divided the patients into two groups based on the LVAs (with or without an LVA &gt;5% of the left atrial surface area) and investigated the ATs/AF free survival rate after the initial and multiple procedures.

Results

LVAs were identified in 65% and 73% of the PVI and PVI + SVCI groups, respectively (P=0.319). In the PVI group, the 18-month ATs/AF-free survival was 61% of the patients without LVAs and 27% of patients with LVAs after the initial session (P=0.018) (Figure 1-A). Seventy-two percent of the patients without LVAs and 46% of those with LVAs were free from ATs/AF after multiple sessions (P=0.083) (Figure 1-B). In the PVI+SVCI group, 50% of the patients with LVAs and 61% of those without LVAs had no recurrence after the initial session (P=0.374) (Figure 2-A). Moreover, there was no significant difference in the 18-month ATs/AF-free survival between the patients with and without LVAs after multiple sessions (73% vs. 79%; P=0.520) (Figure 2-B).

Conclusion

A PVI alone strategy for non-PAF patients with LVAs had limited efficacy for the outcomes, even with multiple procedures. However, an SVCI may have the potential to compensate for an impaired outcome in patients with LVAs.

Funding Acknowledgement

Type of funding source: None

A decrease in tricuspid regurgitation pressure gradient during follow-up in patients with heart failure

Objective

This study aimed to investigate the prognostic impact of the decrease in tricuspid regurgitation pressure gradient (TRPG) at 6-month follow-up in patients after discharge with heart failure (HF).

Background

No previous study has reported the association between TRPG decrease during follow-up and clinical outcomes in HF.

Methods

Among 748 patients with 6-months follow-up echocardiography after discharge from the acute decompensated heart failure in 19 centers in Japan, we analyzed 721 patients with available TRPG data and divided into two groups: the decrease in TRPG group (N=179) and no decrease in TRPG group (N=542). We defined the decrease in TRPG as &gt;10mmHg decrease compared in the initial hospitalization. The primary outcome measure was a composite of all cause deaths and hospitalization due to HF.

Results

The patients in the decrease in TRPG group had a lower prevalence of hypertension, dyslipidemia, atrial fibrillation, and a reduced EF, higher levels of blood albumin and lower levels of sodium than those in no decrease in TRPG group. The median follow-up duration after the follow up echocardiography was 302 (inter quartile range: 206–490), with a 90.9% follow up rate at 6-month. The cumulative 6-month incidence of the primary outcome measure was significantly lower in the decrease in TRPG group than in no decrease in TRPG group (12.2% vs. 18.9%, P=0.0011). After adjusting confounders, the excess risk of the decrease in TRPG relative to no decrease in TRPG for the primary outcome measure remained significant (HR: 0.60, 95% CI 0.34–0.99). There were no significant interactions between the subgroup factors and the effect of the decrease in TRPG for primary outcomes.

Conclusions

HF patients with the decrease in TRPG at 6-month after discharge had a lower risk of clinical outcome than those without decrease in TRPG.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of free-fat mass index on elderly patients with acute decompensated heart failure: from CURE-HF registry

Background

Free-Fat Mass Index (FFMI) is an indicator of malnutrition and sarcopenia. We hypothesized that low FFMI would be associated with worse prognosis in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Free-Fat Mass Index was calculated dividing the square of the patients heights in meters into lean body mass. All-cause mortality (cardiovascular, non-cardiovascular) was followed-up by telephone interview and chart review.

Results

In our study cohort (median age, 78 [range 72–87]), FFMI was 16.7 [15.2, 18.0]. All-cause mortality was observed in 211 patients during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower FFMI was associated with all-cause mortality. Furthermore, FFMI was an independent predictor of mortality after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, low FFMI was associated with both cardiac and non-cardiac mortality in patients with HF with reduced ejection fraction (EF) (Log-rank p=0.002, p=0.013, respectively) (Figure). Furthermore, low FFMI was significantly associated non-cardiac death in patients with preserved EF (Log-rank p=0.033) (Figure).

Conclusions

Free-Fat Mass Index was significantly associated with mortality in elderly patients with HF.

Funding Acknowledgement

Type of funding source: None

Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure

Background/Introduction

Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared.

Purpose

To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients.

Methods

Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death.

Results

Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p&lt;0.001) and AHEAD + BNP (NRI: 0.43, p&lt;0.001).

Conclusion

The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration.

ROC curves

Funding Acknowledgement

Type of funding source: None

Phenotypic difference of sarcopenia in the prediction of mortality for elderly patients with heart failure: from CURE-HF registry

Background

Sarcopenia and malnutrition are associated with mortality in elderly patients with heart failure (HF). However, impact of phenotypic difference of sarcopenia on mortality is not well investigated. We hypothesized that evaluation using both body mass index (BMI) and free-fat mass index (FFMI) enabled distinction of phenotypic difference of sarcopenia and risk stratification for mortality in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Body mass index and FFMI was evaluated. Free-fat mass index was calculated dividing the square of the patients' heights in meters into lean body mass. All-cause mortality was followed-up. Patients were divided into 3 subgroups according to BMI and FFMI values, and compared incidence of mortality among them.

Results

In our study cohort (median age, 78 [range 72–87]), BMI was 21.1 [18.9, 23.8] and FFMI was 16.7 [15.2, 18.0]. 211 patients were experienced all-cause mortality during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower BMI and lower FFMI was associated with all-cause mortality (Log-rank p&lt;0.001, p&lt;0.001, respectively). Furthermore, FFMI was an independent predictor of adverse events after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, comparing with low-BMI and low-FFMI subgroup, better prognosis was observed in the other 2 subgroups (Log-rank p&lt;0.001, p=0.022, Figure 1).

Conclusions

Phenotypic difference was evident in elderly patients with HF. A combination of BMI and FFMI would be useful for risk stratification of mortality in those patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Novel index of arterial reflected waves, Arterial Velocity pulse Index, relates to muscle sympathetic nerve activity independent of Arterial Pressure volume Index in patients with hypertension

Background

Arterial reflected wave is determined by not only atherosclerosis but also sympathetic nerve activity. Recently, Arterial Velocity pulse Index (AVI), which is an index of arterial reflected waves, and Arterial Pressure volume Index (API), which is an index of volume of a conductive blood vessel, have been proposed as new index of arterial stiffness. However, it is unclear whether API and AVI would be associated with muscle sympathetic nerve activity (MSNA) in hypertensive subjects.

Purpose

The purpose of this study was to evaluate the correlation between AVI, API and MSNA in hypertensive subjects.

Method

41 hypertensive patients and 40 non-hypertensive subjects were included in this study. We performed a cross-sectional, observational study. Hypertension (HT) was defined as systolic blood pressure (SBP) ≥140 mmHg, diastolic blood pressure (DBP) ≥90 mmHg or medical treatment for HT. AVI and API was measured by NAS-1000 (Nihon Koden, Japan). MSNA, central sympathetic outflow to peripheral muscle, was recorded directly from peroneal nerve. MSNA was expressed by burst frequency (bursts/minute) and burst incidence (bursts/100heartbeats). Blood pressure, heart rate and MSNA were recorded simultaneously.

Results

Age, systolic and diastolic pressure were significantly higher in hypertensive patients compared to control (40±15 vs 61±13 years, p&lt;0.001; 142±16 vs 113±9 mmHg, p&lt;0.001; 81±14 vs 67±9 mmHg, p&lt;0.001). MSNA and AVI were significantly augmented in hypertensive patients compared to control (34±11 vs. 23±6 bursts/min, p&lt;0.05; 26±7 vs. 16±4, p&lt;0.05). AVI was correlated with MSNA in each group (hypertension: r=0.59, P&lt;0.001, non-hypertension: r=0.51, p&lt;0.001). However, no correlation was shown between API and MSNA in each group (hypertension: r=0.22, p=0.15, non-hypertension: r=0.07, p=0.63). Multiple regression analysis also showed MSNA was significantly related with AVI but was not with API.

Conclusion

Our finding showed that AVI relates to MSNA independent of API in patients with hypertension. It suggested that Novel index of arterial reflected waves, AVI, is helpful to estimate augmented SNA in hypertensive subjects regardless of volume of a conductive blood vessel.

Funding Acknowledgement

Type of funding source: None

The impact of hyperuricemia on all patients and low-BMI patients after endovascular treatments: from I-PAD registry

Background

Hyperuricemia (≥7.0 mg / dl) is known to be one of the risks of arteriosclerosis. For a long time, it has been said that metabolic syndrome and high-BMI has been implicated to hyperuricemia and also that it's a consequence of those patient background, not a cause of arteriosclerosis. Now, the accumulation of data about hyperurisemia is still not enough. Also the importance of secondary prevention for patients after endovascular treatment (EVT) is still unclear too.

Purpose

To investigate the impact of hyperuricemia on prognosis of all patients and low-BMI patients after EVT.

Methods

From July 2015 to July 2016, 335 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. And we divided them into 2 groups; with hyperuricemia or not, and analyzed them. In addition to that, among them, we selected 245 low-BMI patients (&lt;25) and divided them into 2 groups; with hyperuricemia or not, and analyzed them. The primary end point was all-cause-death and the secondary endpoint was MACLE (Major Adverse Cardiovascular and limbs Events) at 3-years.

Result

At 3 years in the patients group with hyperuricemia, overall survival and freedom from MACLE were significantly lower (57.7% vs 83.4% P=0.0012; 30.3% vs 68.6% P=0.0095) than the group without hyperuricemia. Even among the low-BMI patients, in the patients with hyperuricemia, overall survival and freedom from MACLE were significantly lower (55.2% vs 77.1% P=0.003; 48.2% vs 69.9% P=0.002) than the patients without hyperuricemia at 3 years.

Conclusion

In this study, the prognosis of patients after EVT with hyperuricemia was worse than the patient without. And even among the low-BMI patients, The prognosis after EVT with hyperuricemia was worse than the patient without.

Funding Acknowledgement

Type of funding source: None

Rare SCN10A variants associated with cardiac conduction system diseases

Background

The genetic bases of cardiac conduction-system disease (CCSD) range from ion channelopathies to mutations in many other genes. Genome-wide association studies have shown common variants in SCN10A influence cardiac conduction. However, it has not yet to be determined whether vulnerability to CCSD is associated with rare coding sequence variation in the SCN10A gene.

Purpose

We sought to determine the clinical impact of rare variants in SCN10A in patients with CCSD and classified the variants according to the 2015 American College of Medical Genetics and Genomics (ACMG) standards and guidelines.

Methods

We performed screening for rare variants (minor allele frequency ≤0.001) in SCN10A in CCSD patients with an onset at a young age under 65 or those who had a family history of pacemaker implantation (PMI) (n=40; 18 female; mean age, 41±18 years). We transiently expressed engineered variants in ND 7/23 cells, and conducted whole-cell voltage clamp experiments to clarify the functional properties of the Nav1.8 current.

Results

We identified nine rare variants in SCN10A in 7 patients. Two patients were carriers of two rare variants in SCN10A and 5 were carriers of one rare variant in SCN10A. Four patients were affected with sinus node dysfunction, 1 were atrioventricular block, and 2 were both dysfunctions. We performed electrophysiological study for 8 of 9 rare variants. It demonstrated that 2 rare variants showed gain-of-function, and 3 rare variants showed loss-of-function. We finally determined 5 likely pathogenic variants in SCN10A in 5 patients (12.5%) according to the ACMG standards and guidelines. All 5 patients underwent a pacemaker implantation at an average age of 43±16.

Conclusions

These results demonstrate that SCN10A variants play a pivotal role in enhanced susceptibility of CCSD. We suggest the importance for screening SCN10A variants in clinical settings.

Funding Acknowledgement

Type of funding source: None

B-Type natriuretic peptide predicts major adverse cardiac and cerebrovascular events after catheter ablation of atrial fibrillation: insights from AF frontier ablation registry

Background

High plasma B-Type natriuretic peptide (BNP) level is associated with cardiac events or stroke in patients with atrial fibrillation (AF). However, it is still unknown whether BNP predicts worse clinical outcomes after catheter ablation ofAF.

Purpose

We aimed to see if plasma BNP level is associated with major adverse cardiac and cerebrovascular events (MACCE) after catheter ablation of AF.

Methods

We retrospectively analyzed 1,853 participants (73.1% men, mean age 63.3±10.3 years, 60.7% paroxysmal AF) who received first catheter ablation of AF with pre-ablation plasma BNP level measurement and completed follow-up more than 3 months after the procedure from AF Frontier Ablation Registry, a multicenter cohort study in Japan. We evaluated an association between plasma BNP level before catheter ablation and first MACCE in cox-regression hazard models adjusted for known risk factors. MACCE were defined as stroke/transient ischemic attack (TIA), cardiovascular events or all-cause death.

Results

The mean plasma BNP level was 120.2±3.7 pg/mL. During a mean follow-up period of 21.9 months, 57 patients (3.1%) suffered MACCE (ischemic stroke 8 [14.0%], hemorrhagic stroke 5 [8.8%], TIA 5 [8.8%], hospitalization for heart failure 11 [19.2%], acute coronary syndrome 9 [15.8%], hospitalization for other cardiovascular events 8 [14.0%] and all-cause death 11 [19.2%]). Plasma BNP level of patients with MACCE were significantly higher than those without MACCE (291.7±47.0 vs 114.7±3.42 pg/mL, P&lt;0.001). Multivariate analysis revealed that plasma BNP level (hazard ratio [HR] per 10 pg/mL increase 1.014; 95% confidence interval [CI] 1.005–1.023; P=0.001), baseline age (HR 1.052; 95% CI 1.022–1.084; P=0.001), heart failure (HR 2.698; 95% CI 1.512–4.815; P=0.001), old myocardial infarction (HR 3.593; 95% CI 1.675–7.708; P=0.001) and non-ischemic cardiomyopathy (HR 2.676; 95% CI 1.337 - 5.355; P=0.005) were independently associated with MACCE. At receiver-operating characteristic curve analysis, plasma BNP level before catheter ablation ≥162.7 pg/mL was the best threshold to predict MACCE (area under the curve: 0.71). Kaplan-Meier curve analysis (Figure) showed that the cumulative incidence of MACCE was significantly higher in patients with a BNP ≥162.7 pg/mL than in those with a BNP below 162.7 pg/mL (HR 4.85; 95% CI 2.86–8.21; P&lt;0.001).

Conclusions

Elevation of plasma BNP level was independently related to the increased risk of MACCE after catheter ablation ofAF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Meiers Squibb

Changes of QT interval in the acute phase after pulmonary vein isolation for paroxysmal atrial fibrillation

Introduction

Pulmonary vein isolation (PVI) affects ganglionated plexi (GP) around the atrium, leading to a modification of the intrinsic cardiac autonomic system (ANS). In animal models, GP ablation has a potential risk of QT prolongation and ventricular arrhythmias. However, the impact of PVI on QT intervals in humans remains unclear.

Purpose

This study aims to evaluate the Impact of PVI on QT interval in patients with paroxysmal atrial fibrillation.

Methods

We analyzed consecutive 117 PAF patients for their first PVI procedures. 12-lead ECG was evaluated at baseline, 4 hr, day 1, 1 month, and 3 months after ablation. Only patients with sinus rhythm on 12-lead ECG at each evaluation point without antiarrhythmic drugs were included.

Results

Heart rate significantly increased at 4 hr, day 1, and 1 month. Raw QT interval prolonged at 4 hr (417.1±41.6 ms, P&lt;0.001) but shortened at day 1 (376.4±34.1 ms, P&lt;0.001), 1 month (382.2±31.5 ms, P&lt;0.001), and 3 months (385.1±32.8 ms, P&lt;0.001) compared to baseline (391.6±31.4 ms). Bazett- and Fridericia- corrected QTc intervals significantly prolonged at 4hr (Bazett: 430.8±27.9 ms, P&lt;0.001; Fridericia: 425.8±27.4 ms, P&lt;0.001), day1 (Bazett: 434.8±22.3 ms, P&lt;0.001; Fridericia: 414.1±23.7 ms, P&lt;0.001), 1M (Bazett: 434.8±22.3 ms, P&lt;0.001; Fridericia: 408.2±21.0 ms, P&lt;0.05), and 3M (Bazett: 420.1±21.8 ms, P&lt;0.001; Fridericia: 407.8±21.1 ms, P&lt;0.05) compared to baseline (Bazett: 404.9±25.2 ms; Fridericia: 400.0±22.6 ms). On the other hand, Framingham- and Hodges- corrected QTc interval significantly prolonged only at 4hr (Framingham: 424.1±26.6 ms, P&lt;0.001; Hodges: 426.8±28.4 ms, P&lt;0.001) and at day1 (Framingham: 412.3±29.3 ms, P&lt;0.01; Hodges: 410.6±40.2 ms, P&lt;0.05) compared to baseline (Framingham: 399.2±22.7 ms; Hodges: 400.7±22.8 ms). At 4 hr after ablation, raw QT and QTc of all formulas significantly prolonged than baseline. Raw QT and QTc prolongation at 4hr after ablation were more frequently observed in female patients. Multiple regression analysis revealed that female patient is a significant predictor of raw QT and QTc interval prolongation of all formulas 4hr after PVI.

Conclusions

Raw QT and QTc prolonged after PVI, especially in the acute phase. Female patient is a risk factor for QT prolongation in the acute phase after PVI.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of serum procalcitonin in non-small cell lung cancer

INTRODUCTION

Increased serum procalcitonin (PCT), a well-known biomarker for sepsis, has been reported in several cancer types. We aimed to investigate the prognostic impact of PCT in non-small cell lung cancer (NSCLC).

METHODS

Medical records of 51 consecutive patients with NSCLC (Aichi Medical University Hospital) admitted between July 2017 and July 2018 were retrospectively reviewed. The patients were divided into PCT-low (PCT < 0.1 ng/mL) and PCT-high (PCT ⩾ 0.1 ng/mL) groups, and their clinical characteristics and survival were compared.

RESULTS

In contrast to the PCT-low group (n = 24), the PCT-high group (n = 27) showed significantly worse Performance Status (PS) and overall survival (OS) (PS 0-2/3-4, 16/8 versus 12/15, p = 0.034; median OS, not reached versus 127 days, p < 0.001), irrespective of the presence of infection (p = 0.785). Multivariate analysis showed that the disease stage (IV versus I-III) and high PCT level (⩾0.1 versus <0.1 ng/mL) were significantly worse prognostic factors with hazard ratios of 3.706 (p = 0.023) and 3.951 (p = 0.010), respectively.

CONCLUSION

The results suggest that serum PCT in NSCLC was elevated regardless of the presence of infection. Higher PCT levels are associated with poor PS and shorter OS in NSCLC.

Preoperative MRI for predicting pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Severe inflammation with necrosis and fibrosis of the gallbladder in acute cholecystitis increases operative difficulty during laparoscopic cholecystectomy. This study aimed to assess the use of preoperative MRI in predicting pathological changes of the gallbladder associated with surgical difficulty.

METHODS

Patients who underwent both preoperative MRI and early cholecystectomy for acute cholecystitis between 2012 and 2018 were identified retrospectively. On the basis of the layered pattern of the gallbladder wall on MRI, patients were classified into three groups: high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI). The endpoint was the presence of pathological changes of the gallbladder associated with surgical difficulty, such as necrosis, abscess formation and fibrosis.

RESULTS

Of 229 eligible patients, pathological changes associated with surgical difficulty were found in 17 (27 per cent) of 62 patients in the HSI group, 84 (85 per cent) of 99 patients in the ISI group, and 66 (97 per cent) of 68 patients in the LSI group (P < 0·001). For detecting these changes, intermediate to low signal intensity of the gallbladder wall had a sensitivity of 90 (95 per cent c.i. 84 to 94) per cent, specificity of 73 (60 to 83) per cent and accuracy of 85 (80 to 90) per cent.

CONCLUSION

Preoperative MRI predicted pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis.