POS1396 DAMAGE PROGRESSION OF FINGER JOINT CARTILAGE EVALUATED BY ULTRASOUND AND X-RAY IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA)

Background:

Cartilage damage in RA has been evaluated by joint space narrowing (JSN) in X-ray, while it is not a direct evaluation of cartilage. Previously we have confirmed the usefulness of the direct imaging of finger joint cartilage by ultrasound (US) in patients with RA [1].

Objectives:

We aimed to examine the temporal changes of US cartilage thickness in RA patients.

Methods:

We enrolled 53 RA patients in whom the cartilage thickness of finger joints was measured by US and had radiographs of both hands at baseline and 1-year later. The cartilage of metacapophalangeal and proximal interphalangeal joints of 2nd to 5th fingers were bilaterally visualized at the middle portion from a longitudinal dorsal view. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by static images. In addition, the JSN of the corresponding joints was scored using a hand X-ray by van der Heijde-modified Sharp method. Continuous variables from the two groups were analyzed using the Mann-Whitney U test or Wilcoxon signed-rank test. The relationships among the continuous variables were assessed using the Spearman’s rank correlation coefficient.

Results:

The median age of the patients was 68 years and the median disease duration was 6.3 years. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1mm (median 6.5 mm) at baseline, and it was significantly correlated with total JSN score of the same joints (ρ=-0.63, p<0.001). The cartilage thickness was inversely correlated with disease duration (rho=-0.40, p=0.003), but not associated with age nor height. The decrease in cartilage thickness over 1 year was evident in patients with persistent moderate to high disease activity by the DAS28-CRP (n=10; median -6.2%) as compared with other patients (n=43; median -1.2%, p=0.004 versus active patients).

Conclusion:

This pilot study demonstrated the progression of cartilage damage by sustained RA activity, supporting the validity and usefulness of joint cartilage thickness evaluation by ultrasound in patients with RA.

References:

[1]Ogura T, et al. Arthritis Care Res 2019 Oct 25.

Table 1.

SALIENT FEATURES OF THE 9 PATIENTS PRESENTING WITH RETINAL TOXICITY DUE TO HCQ

Sl.NoAgeGenderWeight(Kg)Primary DiagnosisDoseDuration(Years)Detection Method UsedRecommended Dose(mg/Day)Received Dose(mg/Day)Cumulative Dose(grams)FUNDUSEXAM.SD-OCTHVF10-2FAF147F58SLE2904004383RPE ChangesThinning/Photoreceptor LossDefects seen-220F46SLE2302001462Multiple Small Drusens In Paramacular AreaMultipleDrusensNormalPerifoveal autofluorescence spots-drusens323F50SLE2504001461RPE ChangesRPEDisruptionsDefects seen-430F55SLE275200731NormalNormalParacentral Scotoma-550F49RA2452005117Early Bull’s Eye MaculopathyRPEAtrophyDefects seen-672F60RA30020073010RPE AtrophyFR AbsentRPEAtrophyGeneral reduction in sensitivity-765M57.4RA2872001462RPE ChangesRPEDisruptions & Thinning NotedDefects seen-862F70RA3502002193Chorioretinal AtrophyAlteredRPEMembraneDefects seen-959M71.6RA3582002924RPE ChangesRPEDisruptionsNormal-

F:Female; M:Male; SLE:Systemic Lupus Erythematosus; RA: Rheumatoid Arthritis, FUNDUS EXAM.: Fundus Examination; SD-OCT:Spectral Domain-Optical Coherence Tomography, HVF 10-2:Humphrey Visual Field 10-2; FAF: Fundus Autofluorescence, RPE:Retinal Pigment Epithelium; FR:Foveal Reflex

Disclosure of Interests:

None declared

Staging laparoscopy for pancreatic cancer using intraoperative ultrasonography and fluorescence imaging: the SLING trial

This prospective trial revealed the additional diagnostic value of staging laparoscopy with contrast-enhanced intraoperative ultrasonography and indocyanine green-fluorescence imaging, detecting radiologically occult liver metastases and other occult metastases effectively for patients with high-risk resectable or borderline resectable pancreatic cancer. The 2-year survival rate of patients without occult metastasis was significantly better than that of patients with occult metastasis. These favourable results for patients without occult metastasis indicate that an enhanced screening strategy and modern multidisciplinary treatment may improve the outcome even of patients affected by high-risk advanced pancreatic cancer.

State-of-the-art staging worth the effort

A genetically defined signature of responsiveness to erlotinib in early-stage pancreatic cancer patients: Results from the CONKO-005 trial

Background

high recurrence rates of up to 75% within 2 years in pancreatic ductal adenocarcinoma (PDAC) patients resected for cure indicate a high medical need for clinical prediction tools and patient specific treatment approaches. Addition of the EGFR inhibitor erlotinib to adjuvant chemotherapy failed to improve outcome but its efficacy in some patients warrants predictors of responsiveness.

Patients and Methods

we analysed tumour samples from 293 R0-resected patients from the randomized, multicentre phase III CONKO-005 trial (gemcitabine ± erlotinib) with targeted sequencing, copy number, and RNA expression analyses.

Findings

a total of 1086 mutations and 4157 copy-number aberrations (CNAs) with a mean of 17.9 /tumour were identified. Main pathways affected by genetic aberrations were the MAPK-pathway (99%), cell cycle control (92%), TGFβ signalling (77%), chromatin remodelling (71%), and the PI3K/AKT pathway (65%). Based on genetic signatures extracted with non-negative matrix factorization we could define five patient clusters, which differed in mutation patterns, gene expression profiles, and survival. In multivariable Cox regression analysis, SMAD4 aberrations were identified as a negative prognostic marker in the gemcitabine arm, an effect that was counteracted when treated with erlotinib (DFS: HR=1.59, p = 0.016, and OS: HR = 1.67, p = 0.014). Integration of differential gene expression analysis established SMAD4 alterations with low MAPK9 expression (n = 91) as a predictive biomarker for longer DFS (HR=0.49; test for interaction, p = 0.02) and OS (HR = 0.32; test for interaction, p = 0.001).

Interpretation

this study identified five biologically distinct patient clusters with different actionable lesions and unravelled a previously unappreciated association of SMAD4 alteration status with erlotinib effectiveness. Confirmatory studies and mechanistic experiments are warranted to challenge the hypothesis that SMAD4 status might guide addition of erlotinib treatment in early-stage PDAC patients.

Feasibility of an intensified myeloablative conditioning regimen consisting of busulfan, fludarabine, cytarabine, and total body irradiation before single cord blood transplantation in elderly patients

The optimal conditioning regimen for stem cell transplantation in elderly patients remains to be established. We developed a novel preparative regimen using fludarabine 180 mg/m², intravenous busulfan 12.8 mg/m², cytarabine 8 g/m², and 4-Gy total body irradiation before cord blood transplantation (CBT) in patients older than 55 years with various hematological malignancies. All but one patient received graft-versus-host disease (GVHD) prophylaxis consisting of cyclosporine (CsA) and short-term methotrexate (sMTX). Thirty-three patients were included in this study, with a median age of 64 years (range 56-70). The disease risk index was high or very high in 67% of patients, and 73% had a disease status other than complete remission. The probabilities of overall survival and disease-free survival at 3 years were 60 and 57%, respectively. The cumulative incidences of relapse and non-relapse mortality at 3 years were 18 and 25%, respectively. Regimen-related toxicities were generally tolerable. Disease-free survivors (n = 20) stopped immunosuppressants at a median of 7.4 months (range 2.6-25.0), in all cases by the time of the last follow-up. In conclusion, this highly myeloablative conditioning regimen resulted in a high probability of disease-free, GVHD-free, immunosuppressant-free survival after single CBT.(190 words).

A regulatory element in the 3'-untranslated region of CEBPA is associated with myeloid/NK/T-cell leukemia

OBJECTIVES

CCAAT/enhancer-binding protein α (CEBPA) is an essential transcription factor for myeloid differentiation. Not only mutation of the CEBPA gene, but also promoter methylation, which results in silencing of CEBPA, contributes to the pathogenesis of acute myeloid leukemia (AML). We sought for another differentially methylated region (DMR) that associates with the CEBPA silencing and disease phenotype.

METHODS

Using databases, we identified a conserved DMR in the CEBPA 3'-untranslated region (UTR).

RESULTS

Methylation-specific PCR analysis of 231 AML cases showed that hypermethylation of the 3'-UTR was associated with AML that had a myeloid/NK/T-cell phenotype and downregulated CEBPA. Most of these cases were of an immature phenotype with CD7/CD56 positivity. These cases were significantly associated with lower hemoglobin levels than the others. Furthermore, we discovered that the CEBPA 3'-UTR DMR can enhance transcription from the CEBPA native promoter. In vitro experiments identified IKZF1-binding sites in the 3'-UTR that are responsible for this increased transcription of CEBPA.

CONCLUSIONS

These results indicate that the CEBPA 3'-UTR DMR is a novel regulatory element of CEBPA related to myeloid/NK/T-cell lineage leukemogenesis. Transcriptional regulation of CEBPA by IKZF1 may provide a clue for understanding the fate determination of myeloid vs. NK/T-lymphoid progenitors.

Ventricular tachycardia in cardiac sarcoidosis -prognosis, characterization of ventricular substrates and outcomes of treatment-

Background

The prognosis, the underlying substrate and clinical outcomes of treatment are unclear in patients with cardiac sarcoidosis (CS)-related ventricular tachycardia (VT).

Objective

This study investigated the prognosis and the relationship between electroanatomical mapping (EAM) and imaging findings in patients with CS-related VT.

Methods

A total of 203 CS patients (Age 68.1±11.6 years, 87 males) were enrolled at two tertiary care medical centers between 2000 and 2018. All met the 2016 Japanese Circulation Society guidelines for diagnosis of CS. They were followed for a composite of major adverse cardiac events (MACE) including cardiac death, heart transplantation, unscheduled hospitalization for heart failure, and life-threatening ventricular arrhythmias. Distribution of late gadolinium enhancement (LGE) on cardiac MRI (CMR) and/or an abnormal myocardial 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography at diagnosis were examined. The relationship between EAM and the image findings were also analyzed in patients with radiofrequency ablation (RFA) for VT.

Results

During a median follow-up of 53 months, 87 of the 203 patients (43%) experienced a MACE. Baseline factors associated with MACE were presence of sustained VT (HR, 2.43, 95% CI 1.54–3.85, P&lt;0.001), left ventricular ejection fraction below 50% (HR, 1.95 95% CI 1.07–3.56, P=0.029), and abnormal myocardial FDG uptake (HR, 2.42 95% CI 1.04–5.61, P=0.039). Overall, 69 of the 203 patients (34%) experienced sustained VT. Abnormal myocardial FDG uptake was significantly more prevalent in patients with VT than in those without (92.7% vs. 78.5%, P=0.02). A total of 25 patients (9.9%) required RFA for CS-related VT (Age 64.0±8.7 years, 12 males, 1.32±0.56 RFAs per patient). Abnormal electrocardiograms (EGM) were observed in 22 of the 25 patients (88%). LGE was more frequent than abnormal FDG uptake in areas with an abnormal EGM (77% vs. 41%; P=0.002). Over a mean follow-up period of 67-months, 13 of the 25 patients with RFA (52%) remained free of VT episodes (Figure). VT recurred in nine of the 12 patients with RFA and in 17 of the 47 patients without RFA, but was suppressed by intensive pharmacologic therapy such as the combined use of amiodarone and sotalol. In patients with CS-related VT, survival without experiencing a MACE did not differ in participants with or without RFA.

Conclusions

In our 203 CS patients, sustained VT and abnormal FDG uptake were associated with worse cardiac outcomes. The prevalence of abnormal FDG uptake was significantly higher in patients with CS-related VT, LGE on CMR was more frequent within localized areas of an abnormal EGM, suggesting that both scar itself and the associated inflammation were involved in the pathogenesis of CS-related VT. Successful RFA of CS-related VT is still challenging, and recurrence is common. Preprocedural CMR can be useful in detecting abnormal EGMs that are potential targets for substrate ablation.

Funding Acknowledgement

Type of funding source: None

Cardiac function at diagnosis is important prognostic factor in patients with cardiac sarcoidosis -from Japanese nationwide questionnaire survey-

Background

Sarcoidosis is a systemic non-caseating granulomatous disease of unknown etiology. Cardiac involvement (cardiac sarcoidosis, CS) has been reported to be an important prognostic factor in this disease because of heart failure and/or ventricular arrhythmia, and corticosteroid therapy is usually prescribed to prevent cardiac events. However, little is known about the relationship of cardiac function and concomitant corticosteroid therapy on later cardiac events in CS.

Objective

We evaluated the relationship between prognosis and left ventricular ejection fraction (LVEF) at the time of diagnosis in CS patients from the Japanese nationwide questionnaire survey.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, or who underwent cardiac transplantations were excluded, and 420 patients (287 females, mean age 60±13 years old, median follow-up periods 1864 days [interquartile range: 845–3159 days]) were analyzed. The relationship of adverse events (all-cause death, cardiovascular death, and appropriate ICD [Implantable Cardioverter Defibrillator] discharge) and LVEF (with corticosteroid 84%) (low LVEF: LVEF≤35% n=98 [with corticosteroid in 78%], moderate LVEF: LVEF 35–50% n=104 [with corticosteroid in 93%], normal LVEF: 50≤LVEF n=218 [with corticosteroid in 83%]) were evaluated respectively.

Results

89 CS patients developed all-cause death (n=50), cardiovascular death (n=30) or appropriate ICD discharge (n=48). The frequency of corticosteroid therapy was not different in the each LVEF group, but Kaplan-Meier analysis revealed that all-cause death, cardiovascular death, and all cardiovascular adverse events were more observed in lower LVEF group (log-rank p&lt;0.0001). Furthermore, multivariate Cox hazard analysis revealed that LVEF was a most important independent prognostic factor in CS.

Conclusion

This Japanese nationwide questionnaire survey data showed that initial LVEF was an independent and strong prognostic predictor in CS, therefore primary prevention would be needed even after starting corticosteroid in patients with decreased cardiac function.

Funding Acknowledgement

Type of funding source: None

Long time clinical course of cardiac sarcoidosis with corticosteroid therapy -from Japanese nationwide questionnaire survey-

Background

Sarcoidosis is a systemic inflammatory syndrome of unknown etiology and cardiac involvement has been reported to be an important prognostic factor in this disease. An autopsy study has reported that the frequency of this cardiac involvement (cardiac sarcoidosis: CS) varies in the different countries and races and very frequent in Japanese patients. We therefore performed the nationwide questionnaire survey and try to clarify the clinical characteristics and corticosteroid effect in CS, especially focused on arrhythmic events in this disease.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, or who underwent cardiac transplantations were excluded, and 420 patients (287 females, median follow-up periods 1864 days [interquartile range: 845–3159 days]) were analyzed. The clinical outcome and corticosteroid effect were evaluated.

Results

Clinical characteristics at diagnosis was as follows: female dominant (68%), mean age of 60±13 years old, mean left ventricular ejection fraction was 49±16%. Arrhythmic events were very frequently observed as an initial cardiac manifestation in 263 patients (62%) of CS, of which atrioventricular block (AVB) in 174 (41%), ventricular tachycardia (VT) in 73 (17%) and AVB with VT in 17 (4%) (Figure 1A). Pacemaker was implanted in 166 patients (40%) and defibrillators was 137 patients (33%). Corticosteroid was prescribed in 144 (83%) of 174 patients with AVB and in 62 (85%) of 73 patients with VT. Initial dose was mean 47.9 mg and maintenance dose of mean 7.3 mg. Corticosteroid improved VT as good as AVB (27% vs. 29%). However, corticosteroid sometimes worsened VT events compared with AVB (10% vs. 2%) (Figure 1B). During the course of follow-up, 32 patients were needed to increase corticosteroid in 23 of AVB and 10 of VT cases. However, there were no difference in mortality between the groups, whether or not to increase corticosteroid. All survival rate was 92% (5-year mortality), 83% (10-year mortality) and free from all cause death and defibrillator charge was 81% (5 year), 71% (10 year).

Conclusion

Fatal arrhythmia is commonly observed in CS as a primary symptom. Corticosteroid sometimes worsen ventricular arrhythmia and appropriate defibrillator discharge was common. Thus, careful attention for activating ventricular arrhythmia would be needed during the follow-up period even after corticosteroid therapy.

Funding Acknowledgement

Type of funding source: None

Long-term follow up ventricular tachycardia patients with preserved cardiac function -from Japanese cardiac sarcoidosis nationwide questionnaire survey-

Background

Prior ventricular tachycardia (VT) and low left ventricular ejection fraction (LVEF) are the most important prognostic factors in cardiac sarcoidosis (CS). Recently diagnosis of CS was renewed according to Japanese new guidelines. Patients with preserved cardiac function often have VT events, thus new guidelines recommends to assess the implantable cardioverter defibrillator (ICD) implantation for CS patients with preserved LVEF (35%≤LVEF&lt;50%). However, the long-term prognosis of CS patients with preserved LVEF is unclear.

Objective

In CS patients with preserved LVEF, we evaluated the prognosis between VT manifestation and non-VT manifestation groups at CS diagnosis from Japanese nationwide questionnaire survey.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, who had LVEF≤35%, LVEF&gt;50%, or who underwent cardiac transplantations were excluded. 104 patients with LVEF 35–50% (67 females, mean age 60±15 years old, median follow-up periods 2134 days [interquartile range: 758–2935 days]) were analyzed. The prognosis between VT manifestation and non-VT manifestation groups at CS diagnosis were evaluated.

Results

30 patients had VT manifestation at CS diagnosis and 24 patients (80%) received ICDs. 74 patients had no VT manifestation at CS diagnosis and 19 patients (44%) received ICDs during follow up period. All-cause mortality was not different between two groups (Figure). Appropriate ICD therapy of non-VT manifestation group was significantly lower compared with that of VT manifestation group (log-rank p=0.001), however considerable number (n=7, 15%) of non-VT manifestation group had appropriate ICD therapy event during follow-up period. Cox hazard analysis revealed that concomitant non-sustained VT (NSVT) with atrioventricular block (AVB) was a predictor of appropriate ICD therapy in non-VT manifestation group.

Conclusion

This nationwide survey showed that considerable number of CS patients with preserved LVEF had VT events, independent of VT manifestation. Concomitant NSVT with AVB was a predictor of VT events, and ICD implantation should be assessed.

Funding Acknowledgement

Type of funding source: None

Beneficial effects of balloon pulmonary angioplasty on clinical outcomes in patients with residual pulmonary hypertension after pulmonary endarterectomy

Background

Although pulmonary endarterectomy (PEA) is an established surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH), a part of patients after PEA show residual pulmonary hypertension, leading to limited exercise capacity. Recently, several studies have indicated that balloon pulmonary angioplasty (BPA) improves hemodynamics, exercise capacity and prognosis in inoperable CTEPH patients. However, the effects of BPA in patients with residual pulmonary hypertension after PEA remain to be elucidated.

Aim

In the present study, we investigated comprehensive efficacy of BPA on hemodynamics, exercise capacity and right ventricular function in those with residual pulmonary hypertension after PEA.

Methods

From October 2010 to February 2019, 227 patients with CTEPH underwent PEA in our institution. Right heart catheterization after PEA (median follow up period from PEA to right heart catheterization 39 [10.5, 90] months) showed that 55 patients showed residual PH (mean pulmonary artery pressure (mPAP)≥25mmHg), and 38 of them referred to BPA (mean age 57 years old, male 8 (21%)) due to residual symptoms. In 29 out of 38 patients (76%) who completed BPA and underwent follow-up right heart catheterization, we examined hemodynamics, exercise capacity and right ventricular function before and after BPA. Follow-up examination was performed 3 months after last BPA session.

Results

In this study population (N=29), PEA significantly improved mPAP (47±7 to 38±10 mmHg), pulmonary vascular resistance (PVR, 14.6±4.6 to 9.2±4.6 WU) and right ventricular ejection fraction measured by magnetic resonance imaging (26.6±11.3 to 38.4±6.8%) (Figure). Median period from PEA to first BPA procedure was 42 [13.5, 94] months. Total session number during study period was 160 sessions, and mean session number of BPA was 5.5±1.5 per patient. Follow-up study revealed that BPA additionally improved mPAP (38±10 to 27±8 mmHg) and PVR (9.2±4.6 to 5.1±2.2 WU) (Figure). Similarly, 6-minute walk distance (393±125 to 452±125 m) and peak VO2 (16.4±3.8 to 18.1±4.6 ml/min/kg, p&lt;0.05) were increased, and WHO functional class also significantly improved by BPA (I/II/III/IV, 0/21/8/ 0 to 1/27/1/0, p&lt;0.01). In addition, right ventricular ejection fraction (38.4±6.8 to 44.2±7.1%) was increased after BPA (Figure). There were no procedure-related deaths and major lung injuries requiring oral intubation during study period. 3-year survival in patients after BPA was 100% (median follow-up period after last BPA session, 32 [18, 46] months).

Conclusion

In CTEPH patients with residual pulmonary hypertension after PEA, additional BPA significantly improved hemodynamics, right ventricular function, exercise capacity and residual symptoms without severe complications, leading to good prognosis. These results suggest that combination therapy of PEA and BPA could be an effective therapeutic option for post PEA patients with residual symptoms and exercise limitation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Micro-embolic risks during radiofrequency and cryoballoon-ablation of atrial fibrillation -analysis from real-time carotid artery doppler monitoring-

Background

Catheter ablation of atrial fibrillation (AF) is associated with risks of silent cerebral events. However, the timing of intraprocedural micro-embolic events or differences between open-irrigated radiofrequency (RF) and cryoballoon (Cryo) ablation are unclear. Newly developed real-time carotid artery Doppler is a simple non-invasive method to detect micro-embolic signals (MESs) during ablation.

Objective

We investigated the timing of detecting MESs during RF and Cryo ablation of AF.

Methods

During the first pulmonary vein isolation (PVI) session of AF, MESs were monitored by real-time carotid artery Doppler monitoring throughout the procedure. The MES counts were collected and evaluated separately during the different steps of the procedure (Figure).

Results

Thirty-three AF patients (RF/Cryo: 22/11 cases, 9 females, 69.5±11.6 y.o) were included. PVI was successfully accomplished in all patients with no major complications. The MES count was significantly greater in the RF group than Cryo group (table). In both groups, left atrial (LA) access (interatrial puncture) and sheaths insertion to the LA generated a significant number of MESs (RF: 1690 of 9116 MESs [18.5% of the total MESs], Cryo: 793 of 2285 MESs [34.7%]). In the RF group, MESs were observed incessantly during PVI (Figure). The LA dwell time was significantly longer in the RF group than Cryo group (table). In the RF group, the MES count was significantly greater in the longer LA dwell time group (LA dwell time &gt;130min) than the shorter group (464.2±179.7 vs 302.6±138.2: P=0.049). During the cryo-applications in the Cryo group, the MESs were greatest during the first cryoballoon application (625 of 2285 MESs [27.4%]).

Conclusions

There were more MESs during RF ablation than cryoablation. MESs were recorded during a variety of steps throughout the procedure. In the RF group, most of MESs were recorded incessantly during radiofrequency ablation and greater number of MESs were recorded in patients with longer LA dwell time. In the Cryo group, most of MESs occurred during phases with a high probability of gaseous emboli.

Funding Acknowledgement

Type of funding source: None

The safety of catheter ablation of atrial fibrillation in elderly patients -analysis of the nationwide database in Japan, JROAD-DPC-

Background

“Age” is one of the major concerns and determinants of the indications for catheter ablation (CA) of atrial fibrillation (AF). There are little safety data on CA of AF according to the age. This study aimed to assess the safety of CA in elderly patients undergoing CA of AF.

Methods and results

We investigated the complication rate of CA of AF for the different age groups (&lt;60 years, 60–65, 65–70, 70–75, 75–80, 80–85, and ≥85) by a nationwide database (Japanese Registry Of All cardiac and vascular Diseases [JROAD]-DPC). The JROAD-DPC included 73,296 patients (65±11 years, 52,883 men) who underwent CA of AF from 516 hospitals in Japan. Aged patients had more comorbidities and a significantly increased CHADS2 score and higher rate of female according to a higher age. The overall complication rate was 2.6% and in-hospital mortality was 0.05%. By comparing each age group, complications occurred more frequently in higher aged groups. A multivariate adjusted hazard ratio revealed an increased age was independently and significantly associated with the overall complications (odds ratio was 1.25, 1.35, 1.72, 1.86, 2.76 and 3.13 respectively; reference &lt;60 years).

Conclusions

The frequency of complications was significantly higher according to a higher age. We should take note of the indications and procedure for CA of AF in aged patients.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Intramural Research Fund 17 (Kusano) for Cardiovascular Diseases of the National Cerebral and Cardiovascular Center

SAT0113 DISCORDANCE OF CLINICAL REMISSION AND IMAGING REMISSION BY ULTRASONOGRAPHY IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH BIOLOGIC AGENTS

Background:

Residual synovitis can be detected by sensitive modalities such as ultrasonography in patients with rheumatoid arthritis in clinical remission. On the other hand, a previous study has shown that ultrasound-guided treatment provides modest benefit compared to a conventional strategy aiming clinical remission in early patients. It is still unclear how discordant clinical remission is from imaging remission by ultrasonography in patients treated with biologic agents

Objectives:

To clarify the discordance between clinical remission and imaging remission in patients with rheumatoid arthritis treated with biologic agents.

Methods:

Patients with rheumatoid arthritis who were treated with biologic agents and in clinical remission defined as disease activity score for 28 joints (DAS28)<2.6 were enrolled. All patients were performed comprehensive ultrasound examination of 44 joints as well as physical examinations. Ultrasound images of gray scale (GS) and power doppler (PD) were evaluated with a semi-quantitative score of 0-3. Imaging remission with ultrasound was defined as no PD signal detected in any joints. Clinical information was collected from their medical charts.

Results:

A total of 41 patients were enrolled with 22 patients treated with tumor necrosis factor (TNF)-α inhibitors and 19 with interleukin (IL)-6 inhibitors. The mean age, female ratio, the mean disease duration, and the mean duration of clinical remission were 60 years old, 87%, 5.1 years and 11.5 years. The imaging remission by ultrasonography was observed only in 51.2 %. When patients were divided according to biologic agents, baseline characteristics including median age, disease duration and clinically remission duration were comparable between both groups, while the rates of seropositivity and the stage of radiological progression was higher in IL-6 group (seropositivity, p=0.04; radiological progression, p=0.02). The mean DAS28 was 1.93 in the TNFα group and 1.02 in the IL-6 group. The discordance of clinical remission and imaging remission was observed in 28.6% of the TNFα group and 71.4% of the IL-6 group (p=0.03). The residual synovitis scores of GS and PD in 44 joints were significantly lower in the TNFα than the IL-6 group (GS, 1.1±1.8 vs 4.7 ± 4.6, p<0.01; PD, 0.6 ± 1.3 vs 3.3 ± 3.5, p<0.01, respectively). A receiver operating characteristic curve demonstrated an optimal score of DAS28 that discriminated imaging remission as 1.89 in the TNFα group and 1.25 in the IL-6 group.

Conclusion:

Our results showed that there was substantial discordance between clinical remission and imaging remission, especially in the patients treated with IL-6 inhibitors. In patients treated with biologic agents, clinical remission should be assessed more stringently than the usual 2.6, and ulltrasound-guided management may be useful.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15.

[2]Iwamoto T, et al. Arthritis Care Res (Hoboken). 2014;66(10):1576-81

[3]Tanaka Y. Ann Rheum Dis 2010;69:1286 –91

[4]Kaneko Y, et al. Ann Rheum Dis 2018;77:1268–1275

[5]Brown AK, et al. Arthritis Rheum 2008;58: 2958 – 67.

Acknowledgments:

We would like to thank Harumi Kondo for their assistance.

Disclosure of Interests:

Yasushi Kondo: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Shuntaro Saito: None declared, Yuichiro Ohta: None declared, Komei Sakata: None declared, Yumiko Inoue: None declared, Chihiro Takahashi: None declared, Kazuoto Hiramoto: None declared, Jun Inamo: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

AB1123 PROGRESSION OF FINGER JOINT CARTILAGE DAMAGE EVALUATED BY ULTRASOUND IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Cartilage damage in rheumatoid arthritis (RA) has been evaluated by joint space narrowing (JSN) in X-ray, despite the fact that it is not a direct evaluation of cartilage. We have recently reported that direct evaluation of finger joint cartilage thickness evaluated by ultrasound (US) is valid and useful for patients with RA1).

Objectives:

In this study, we aimed to examine the progression of cartilage damage in RA patients.

Methods:

Forty-six patients with RA who had completed the US evaluation of finger joint cartilage thickness at baseline and after 1 year were included in this study. The cartilage thickness of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of 2nd to 5th fingers were bilaterally visualized and measured at the middle portion of MCP and PIP joints from a longitudinal dorsal view, with approximately 90 degrees flexion. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by calculating the pixel counts on DICOM images.

Results:

In patients, 78% were female, the median age was 68 years and the median disease duration of the patients was 6 years. The median DAS28-CRP at baseline was 2.6. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1 mm (median 6.4 mm) at baseline, and it was significantly correlated with disease duration (ρ=-0.423, p=0.003). A significant decrease from the baseline in the cartilage thickness (median -1.6%) was observed after 1 year (p=0.041). Furthermore, patients with persistently moderate/high disease activity for 1 year by DAS28-CRP (n=9) showed a greater decrease in the cartilage thickness than the remaining patients with controlled disease activity (n=37) (median -5.9% versus -1.5%, respectively, p=0.029).

Conclusion:

This study further supported the validity and usefulness of joint cartilage thickness evaluation by US in patients with RA.

References:

[1]Ogura T, et al. Arthritis Care Res 2019 Oct 25.

Disclosure of Interests:

Takehisa Ogura: None declared, Ayako Hirata: None declared, Sayaka Takenaka: None declared, Yuki Inoue: None declared, Takaharu Kagtagiri: None declared, Yuto Takakura: None declared, Hideki Ito: None declared, Hideto Kameda Grant/research support from: Abbvie, Asahi-Kasei, Chugai, Eisai, Mitsubishi-Tanabe and Novartis, Consultant of: Abbvie, Boehringer, Celgene, Eli Lilly, Janssen, Novartis, Sanofi, UCB, Speakers bureau: Abbvie, Asahi-Kasei, BMS, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Novartis and Pfizer

0594 Can a Deep Convolutional Neural Network Extract Diagnostic Information on Obstructive Sleep Apnea from Images?

Introduction

Lateral cephalometric radiography is a simple way to provide craniofacial soft/hard tissue profiles specific for patients with obstructive sleep apnea (OSA) and may thus offer diagnostic information on the disease. We hypothesized that a machine learning technology, a deep convolutional neural network (DCNN), could make it possible to detect OSA based solely on lateral cephalometric radiographs without the need for either large amounts of subjective/laboratory data or skilled analyses.

Methods

In this diagnostic study, a DCNN was developed (n=1,258) and tested (n=131) using data from 1,389 lateral cephalometric radiographs obtained from individuals diagnosed with severe OSA (n=867; apnea hypopnea index &gt;30/hour) or non-OSA (n=522; apnea hypopnea index &lt; 5) at a single center for sleep disorders from March, 2006 to February, 2017. Three kinds of data sets were prepared by changing the area of interest using a single image; original image without any modification (Full Image), image containing a facial profile, upper airway, craniofacial soft/hard tissues, and image containing part of the occipital region (upper left corner of the image; Head Only). A radiologist and an orthodontist also performed a manual cephalometric analysis of the Full Image for comparison. Observers were blinded to the patient groupings. Data analysis was performed from April, 2018 to August, 2019. When the predictive score obtained from the DCNN analysis exceeded the threshold (0.50), the patient was judged to have OSA. The primary outcome was diagnostic accuracy in terms of area under the receiver-operating characteristic curve.

Results

The sensitivity/specificity was 0.87/0.82 for Full Image, 0.88/0.75 for Main Region, 0.71/0.63 for Head Only, and 0.54/0.80 for the manual analysis. The area under the curve was the highest for Main Region (0.92): 0.89 for Full Image, 0.70 for Head Only, and 0.75 for the manual analysis.

Conclusion

A DCNN identified individuals with OSA with high accuracy. This is a useful approach that does not require any laborious analyses in a primary care setting or in remote areas where an initial specialized OSA diagnosis is not feasible.

Support

This study was supported in part by the Japan Society for the Promotion of Science (grant numbers 17K11793, 19K10236).

0486 Impact of Intrinsic Factors on Efficacy of Lemborexant: Subgroup Analyses of SUNRISE-2

Introduction

Lemborexant (LEM), a dual orexin receptor antagonist, demonstrated significant benefits vs placebo on patient-reported sleep outcomes in adults age ≥18y in SUNRISE-2 (NCT02952820; E2006-G000-303). The impact of intrinsic factors (sex, race, and region) on LEM efficacy outcomes was assessed.

Methods

SUNRISE-2 was a randomized, double-blind, global phase 3 study in adults age ≥18y with insomnia disorder (Full Analysis Set, n=949). Subjects received placebo (n=318) or LEM (5mg [LEM5], n=316; 10mg [LEM10]; n=315) for 6 months. At 6 months, placebo subjects were rerandomized to LEM for another 6 months (not reported here); LEM subjects remained on their assigned dose. Sleep diary-based (subjective) sleep onset latency (sSOL) and wake after sleep onset (sWASO) were assessed for prespecified patient subgroups including: sex (male [n=302], female [n=647]), race (white [n=679], black [n=76], Asian [n=178]), and region (North America [n=302], Europe/New Zealand [n=483], Asia [n=164]). Analyses were not controlled for multiplicity.

Results

LEM5 and LEM10 provided numerically greater median reductions (improvement) from baseline in sSOL vs placebo at 6 months in across all subgroups examined. Also, LEM5 and LEM10 led to mean reductions (improvement) from baseline at 6 months in sWASO for all subgroups. While several subgroups had small numbers of subjects, changes from baseline in sSOL and sWASO were in the direction of improvement in the majority of subgroups. Pharmacokinetic analyses showed no important differences in exposure by these factors.

Conclusion

LEM treatment demonstrated efficacy in improving sSOL and sWASO across patient subgroups, supporting common dosing instructions for both sexes and all races.

Support

Eisai Inc.

0474 Long-Term Efficacy and Safety of Lemborexant in Elderly Adults with Insomnia Disorder: Results from SUNRISE-2

Introduction

In SUNRISE-2 (NCT02952820; E2006-G000-303), the dual orexin receptor antagonist lemborexant (LEM) demonstrated significant benefit versus placebo (PBO) on subjective sleep endpoints over 6mo in subjects age ≥18y; benefits were sustained over 12mo. Here we present 12mo efficacy and safety data for LEM from the elderly (≥65y) subgroup.

Methods

SUNRISE-2 was a 12mo, randomized, double-blind, PBO-controlled (first 6mo [Period 1]), global phase 3 study. During Period 1, subjects were randomized to PBO or LEM (5mg, [LEM5]; 10mg, [LEM10]). During Period 2 (second 6mo), LEM subjects continued their assigned dose while PBO subjects were rerandomized to LEM5 or LEM10 (not reported here). Patient-reported (subjective) sleep endpoints were assessed from sleep diary data (sleep onset latency [sSOL]; sleep efficiency [sSE]; wake after sleep onset [sWASO]).

Results

Of the 949 subjects in the Full Analysis Set, 262 were age ≥65y. At 6mo, in subjects ≥65y, median sSOL significantly decreased from baseline for LEM5 (−21.7) and LEM10 (−26.0) versus PBO (−10.8; P&lt;0.0001, P&lt;0.01, respectively). At 12mo, LEM5 and LEM10 subjects maintained decreases in median sSOL (−29.3, −34.3, respectively). At 6mo, the mean (SD) increase from baseline in sSE was significantly larger versus PBO (8.5[13.3]) for LEM5 (16.9[13.6]; P&lt;0.001) and LEM10 (14.9[15.9]; P&lt;0.01). At 12mo, mean (SD) increase in sSE was maintained for LEM5 (18.1[12.5]) and LEM10 (18.0[16.8]). At 6mo, mean (SD) change from baseline in sWASO was significantly decreased versus PBO (−26.5 [52.9]) for LEM5 and LEM10 (−54.8[64.4], P&lt;0.01; −51.4[69.3], P&lt;0.05, respectively). At 12mo, mean (SD) decrease in sWASO was maintained for LEM5 (−58.6[46.0]) and LEM10 (−60.9[80.4]). Over 12mo, the most common (&gt;10% either group) treatment emergent adverse events with LEM5 and LEM10, respectively, were somnolence (9.3%, 19.0%), nasopharyngitis (9.3%, 10.7%), and headache (10.5%, 6.0%).

Conclusion

In elderly subjects, LEM demonstrated efficacy at 6mo, which persisted at 12mo; LEM was well tolerated.

Support

Eisai Inc.

0473 Effectiveness and Safety of Lemborexant in Subjects Previously Treated with Placebo for 6 Months in SUNRISE-2

Introduction

In SUNRISE-2 (NCT02952820; E2006-G000-303), while lemborexant (LEM) provided significant benefit versus placebo (PBO) on sleep-diary measurements over 6mo, some improvement was noted in PBO subjects. We report outcomes from PBO subjects rerandomized to LEM during the last 6mo of SUNRISE-2.

Methods

SUNRISE-2 was a randomized, double-blind, global phase 3 study in adults (≥18y) with insomnia disorder. Subjects received PBO or LEM (5mg [LEM5]; 10mg [LEM10]) for 6mo. PBO subjects were rerandomized to LEM for another 6mo; LEM subjects continued assigned treatment. Changes from 6mo baseline (calculated after PBO completion) in subjective sleep onset latency (sSOL), subjective sleep efficiency (sSE), and subjective wake after sleep onset (sWASO) are reported for rerandomized subjects.

Results

At study baseline for PBO subjects (n=318), median sSOL (min) was 55.9, mean (SD) sSE (%) and sWASO (min) were 61.3 (17.8) and 132.5 (80.2), respectively. The 6mo baseline values for rerandomized PBO-LEM5 (n=133) and PBO-LEM10 (n=125) subjects, respectively, were: median sSOL, 31.2, 34.3; mean (SD) sSE, 70.5 (20.2), 71.1 (18.0); mean (SD) sWASO, 105.1 (80.6), 100.1 (84.6). Median sSOL decreased from the 6mo baseline after 1mo (PBO-LEM5, −3.2; PBO-LEM10, −2.9) and 6mo (PBO-LEM5, −2.7; PBO-LEM10, −5.0). Mean (SD) sSE increased from the 6mo baseline after 1mo (PBO-LEM5, 3.9 [12.1]; PBO-LEM10, 3.5 [8.1]) and 6mo (PBO-LEM5, 3.9 [13.6]; PBO-LEM10, 4.5 [13.0]). Mean (SD) sWASO decreased after 1mo (PBO-LEM5, −8.5 [49.4]; PBO-LEM10, −5.7 [36.1]) and 6mo (PBO-LEM5, −8.2 [49.0]; PBO-LEM10, −10.0 [58.8]). Treatment-emergent adverse events incidence was similar during PBO (62.7%) and LEM treatment (PBO-LEM5, 54.9%; PBO-LEM10, 57.7%). Adverse events were consistent with those seen in the initial 6mo of treatment for patients originally randomized to LEM.

Conclusion

Rerandomization to LEM was associated with additional improvement in sleep outcomes following the PBO-related response. LEM benefit was evident after 1mo and was sustained throughout treatment. LEM was well tolerated.

Support

Eisai Inc.

Search for η^{'} Bound Nuclei in the ^{12}C(γ,p) Reaction with Simultaneous Detection of Decay Products

We measured missing mass spectrum of the ^{12}C(γ,p) reaction for the first time in coincidence with potential decay products from η^{'} bound nuclei. We tagged an (η+p) pair associated with the η^{'}N→ηN process in a nucleus. After applying kinematical selections to reduce backgrounds, no signal events were observed in the bound-state region. An upper limit of the signal cross section in the opening angle cosθ_{lab}^{ηp}<-0.9 was obtained to be 2.2  nb/sr at the 90% confidence level. It is compared with theoretical cross sections, whose normalization ambiguity is suppressed by measuring a quasifree η^{'} production rate. Our results indicate a small branching fraction of the η^{'}N→ηN process and/or a shallow η^{'}-nucleus potential.

Attention-deficit/hyperactivity disorder and physical multimorbidity: A population-based study

Background:

There has been little research on the association of attention-deficit/hyperactivity disorder (ADHD) with co-occurring physical diseases. The aim of this study was to examine the association between possible ADHD and physical multimorbidity (i.e. = 2 physical diseases) among adults in the English general population.

Methods:

Data were analyzed from 7274 individuals aged = 18 years that came from the Adult Psychiatric Morbidity Survey 2007. ADHD symptoms were assessed with the Adult Self-Report Scale (ASRS) Screener. Information was also obtained on 20 self-reported doctor/other health professional diagnosed physical health conditions present in the past 12 months. Multivariable logistic regression and mediation analyses were conducted to assess the associations.

Results:

There was a monotonic relation between the number of physical diseases and possible ADHD (ASRS score = 14). Compared to those with no diseases, individuals with = 5 diseases had over 3 times higher odds for possible ADHD (odds ratio [OR]: 3.30, 95% confidence interval [CI]: 2.48–4.37). This association was observed in all age groups. Stressful life events (% mediated 10.3–24.3%), disordered eating (6.8%), depression (12.8%), and anxiety (24.8%) were significant mediators in the association between possible ADHD and physical multimorbidity.

Conclusion:

Adults that screen positive for ADHD are at an increased risk for multimorbidity and several factors are important in this association. As many adults with ADHD remain undiagnosed, the results of this study highlight the importance of detecting adult ADHD as it may confer an increased risk for poorer health outcomes, including physical multimorbidity.