[Conflicts in the end-of-life care: Interviews with care staff by Buddhist priests and researchers]

AIM

Interprofessional communication and collaboration is essential for a better end-of-life and death, where individual dying people are respected and their satisfaction is the goal. The aim of this study is to explore 1) ethical conflicts viewed by care staff of geriatric institutions, 2) their views about geriatric medicine, and 3) their views about religion in the context of institutional end-of-life care.

METHODS

Semi-structured interviews were conducted by Buddhist priests and researchers with nine care workers who worked in nursing homes or long-stay geriatric hospitals. This interview was conducted as part of a research project that investigated the feasibility of the engagement of religious workers in the geriatric care setting.

RESULTS

Regarding ethical conflicts, six themes were merged: difficulty in knowing the will of the person being cared for, dissonance with the family, older person's wish to die, losing the purpose for living, staff not being used to death, and families not being used to death. Regarding geriatric medicine, eight themes were merged: gratitude for cooperation, persuasive explanation, not accepting death, not allowing patients to share a peer's death, cold attitude, being drug therapy centered, not being person-centered, and heavy burden for patients. Regarding religion, five themes were merged: expectation for salvation, barrier to hospitals, already involved in nursing homes, explicit religious traits are acceptable, and favorable character of religious workers in institutions.

CONCLUSIONS

Communication between geriatric physicians, care staff, and mainstream religious workers, with the aim of providing a better quality of end-of-life and death, is beneficial in a super-aged society.

Short coupling with high burden of atrial ectopy in twenty-four hour holter recording predicts recurrence of atrial arrhythmia after atrial fibrillation ablation

Background

Atrial arrhythmia recurrence is experienced in up to 20% of patients after initially receiving a catheter ablation for atrial fibrillation (AF). Therefore, it is important to define predictors of atrial arrhythmia recurrence. Atrial ectopy (AE) with short coupling interval (S-AE) has been reported to be a trigger of AF. On the other hand, high burden of AE has been reported to be a useful predictor of atrial arrhythmia recurrences after AF ablation. Thus, the combination of the incidence of S-AE and AE burden during a 24-hour Holter recording could be a useful predictor of atrial arrhythmia recurrence after AF ablation.

Purpose

To investigate this hypothesis, we performed a retrospective case-controlled study.

Methods

We enrolled 180 patients who underwent their first catheter ablation procedure for AF and performed a 24-hour Holter recording between 90 to 365 days after their ablation procedure. Patients who performed an additional ablation procedure before the Holter recording were excluded. Finally, we analyzed 173 patients (age: 65±10 years, female: 28.3%, non-paroxysmal: 27.7%). The Holter recordings were analyzed by the same experienced technicians. We defined AE as a narrow QRS complex occurring >25% than prior R-R interval, and S-AE as AE occurring >55% earlier than expected. The relationship between the characteristics of AE during the Holter recording and atrial arrhythmia recurrences was investigated.

Results

The Holter recordings were performed at a median of 103 (IQR: 98–138) days after ablation. The median number of AE were 144 (IQR: 54–699) beats per day, and S-AE was recorded in 49 patients (28.3%). Forty-two patients (24.3%) had a recurrence of atrial arrhythmia during a median 488-day follow up period. Patients with S-AE had a recurrence of atrial arrhythmia more frequently than those without S-AE (44.9% vs 16.1%, p<0.001). We found the cut-off point of AE burden as 241 beats per day by the receiver operating characteristic curve with 74% sensitivity and 70% specificity to predict atrial arrhythmia recurrence. We divided the patients into four groups according to the presence or absence of S-AE and high AE burden. In the Kaplan-Meier analysis, patients with S-AE and high AE burden had the highest atrial arrhythmia recurrence rate (Log-rank test: p<0.001). In the Cox multivariate analysis, S-AE with high AE burden was an independent predictor of atrial arrhythmia recurrence (HR: 4.27, 95% CI: 2.32–7.85, p<0.001).

Conclusion

For AF patients who underwent their first catheter ablation, S-AE (>55% earlier than expected) with high AE burden (>241 beats per day) during the 24-hour Holter recording predicted recurrences of atrial arrhythmia. These results can help to develop follow-up strategies after AF ablation.

Funding Acknowledgement

Type of funding source: None

Coexistence of osteoporosis and atherosclerosis in pheochromocytoma: new insights into its long-term management

Osteoporosis and atherosclerosis frequently coexist in patients with pheochromocytoma. The presence of osteoporosis may predict that of atherosclerosis and vice versa in patients with PHEO. These findings have implications for the long-term management of the pheochromocytoma and its potential chronic complications.

INTRODUCTION

Pheochromocytoma (PHEO), a catecholamine-producing tumor, is often found incidentally, and it may be present for years before it is diagnosed. However, long-term exposure to catecholamines excess may induce chronic complications, such as osteoporosis and atherosclerosis. We aimed to evaluate concomitant osteoporosis and atherosclerosis in patients with PHEO.

METHODS

Fifty-one patients with PHEO and 51 patients with a non-functional adrenal tumor were compared radiographically for the prevalence of vertebral fracture (VF), a typical osteoporotic fracture, and abdominal aortic calcification (AAC).

RESULTS

In patients with PHEO, the prevalence of AAC was higher in those with VF (58%) than in those without (6%, p < 0.001). AAC was associated with VF after adjusting for age and sex (odds ratio, 1.53; 95% confidence interval, 1.07-2.46; p = 0.003) in patients with PHEO. The degree of catecholamine excess correlated with the presence of VF and AAC (p = 0.007). The prevalence of VF was higher in patients with PHEO (37%) than those with non-functional AT (12%, p = 0.005), but the prevalence of AAC was comparable between the two groups (25% and 19%, p = 0.636). VF and AAC more frequently coexisted in patients with PHEO (22%) than in those with non-functional AT (2%, p = 0.003).

CONCLUSION

This study represents the first demonstration that osteoporosis and atherosclerosis frequently coexist in patients with PHEO. The presence of osteoporosis may predict that of atherosclerosis and vice versa in patients with PHEO. These findings have implications for the long-term management of the PHEO and its potential chronic complications.

Non-destructive sex-specific monitoring of early embryonic growth rate in light brown broiler eggs using light transmission and its correlation with hatching time and chick weight

1. Monitoring early embryonic growth rate (EGR) has significant economic and animal welfare benefits. This study focuses on monitoring sex-specific early EGR using light transmission, and correlating this with hatching time and chick weight. For broiler eggs in particular, spectral masking of the light brown eggshells needed to be addressed. This was done using longitudinal visible transmission spectroscopy combined with eggshell colour image analysis. 2. Prior to incubation, colour images of eggs were captured followed by daily measurements of transmission spectra of eggs from days one to nine of incubation. The sex of the eggs was subsequently verified 2 d after hatching. 3. To accurately and sensitively determine sex differences in EGR using light transmission, while minimising interference from eggshell colour and thickness, the ratio of longitudinal transmissions was determined to be most effective at 575 and 610 nm. 3. Embryonic growth was detectable from d 3 (72 h) of incubation, 24 h earlier than previously reported lateral transmission measurements. However, at this time, low blood levels meant that no significant sex-differences (P > 0.05) for the mean T575/T610 ratio were detectable. This may have been due, in part, to spectral masking from the light brown eggshells. At d 7, female embryos had a significantly lower (P < 0.05) mean T575/T610 ratio than males. 4. Although the T575/T610 ratio had low correlations with hatching time and hatch-weight of chicks, this could be a good starting point for further non-destructive investigations for such predictions. 5. In conclusion, the methodology had the sensitivity to differentiate sex-specific early EGR in broiler eggs, even with pigmented eggshells, and has the potential to advance precision hatchery management and poultry research.

FRI0103 ASSOCIATION BETWEEN SEROPOSITIVITY AND DISCONTINUATION OF INFLIXIMAB IN RHEUMATOID ARTHRITIS

Background:

Infliximab is still a widely used biologic agent in treatment of rheumatoid arthritis (RA). Because infliximab is expensive and can have adverse events, identification of factors that predict an adequate response to this treatment has been investigated.

Objectives:

In this study, we investigated the association between rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) status and the discontinuation of infliximab therapy due to adverse events or insufficient response in bio-naïve patients with RA.

Methods:

This study included patients enrolled in the Tsurumai Biologic Communication Registry in Japan. A crude comparison of infliximab discontinuation between seropositive and seronegative patients was using Kaplan-Meier analysis and log-rank test. We evaluated the associations between the specified baseline characteristics and discontinuation of infliximab therapy using Cox proportional hazard regression. We could not perform simultaneous assessments of the impact of RF and ACPA seropositivity on clinical efficacy becasue of collinearity.

Results:

Baseline characteristics of the patients included in this study are shown in Table 1 and the crude comparison between RF and ACPA status is shown in Figure 1. RF and ACPA seropositivity was significantly predictive of discontinuation of infliximab therapy after adjusting for baseline characteristics, including age, sex, stage, class, disease activity at baseline, and prednisolone use (Table 2). The hazard ratio was 1.99 (95% confidence interval 1.25, 3.18) for RF and 2.73 (95% confidence interval 1.24, 6.02) for ACPA.

Table 1.

Characteristics of RA patients at baseline by RF and ACPA status

RF (n = 344;ACPA (n = 250;985 patient-years)824 patient-years)RFRFACPAACPApositivenegativepositivenegative(n = 263)(n = 81)P†(n = 211)(n = 39)P†Age, years (SD)55.7 (12.3)54.6 (13.9)0.4855.4 (12.3)49.7 (14.3)0.01Female, no. (%)205 (78.2)66 (81.5)0.64170 (80.6)28 (71.8)0.28DAS28ESR (SD)5.50 (1.33)4.95 (1.51)0.0055.54 (1.28)4.61 (1.82)0.0005Stage I+II/III+IV, no. (%)81/174 (31.8/68.2)25/50 (33.3/66.7)0.7861/139 (30.5/69.5)15/20 (42.9/57.1)0.17Class I+II/III+IV, no. (%)155/102 (60.3/39.7)52/22 (70.3/29.7)0.14126/72 (63.6/36.4)23/12 (65.7/34.3)0.85Current MTX treatment, %10010011001001MTX dose, mg/week (SD) ‡7.56 (2.16)7.80 (2.22)0.47.82 (2.20)7.31 (2.66)0.22Current PSL treatment, no. (%)141 (68.1)37 (56.1)0.077128 (67.4)19 (55.9)0.24PSL dose, mg/day (SD) ‡3.98 (3.91)2.70 (2.74)0.013.73 (3.78)2.63 (2.85)0.11BMI, kg/m2(SD)22.6 (3.88)21.3 (4.22)0.122.0 (4.10)22.5 (3.33)0.68

Data are presented as mean, unless otherwise stated. SD: standard deviation

† Chi-square test for categorical variables and t-test for continuous variables.

‡ MTX dose and PSL dose were mean value in patients with concomitant MTX and PSL treatment, respectively.

Table 2.

Cox proportional hazard regression for infliximab therapy due to adverse event and insufficient response

Model including RF status (n = 226)Model including ACPA status (n = 182)VariableHR (95% CI)PVariableHR (95% CI)PRF positive1.99 (1.25-3.18)0.0037ACPA positive2.73 (1.24-6.02)0.012Age at baseline0.99 (0.98-1.01)0.43Age at baseline0.99 (0.98-1.01)0.36Sex (referent: male)1.21 (0.76-1.94)0.41Sex (referent: male)0.99 (0.60-1.62)0.96Prednisolone use1.03 (0.71-1.49)0.85Prednisolone use1.02 (0.67-1.56)0.92Stage III + IV (referent: I + II)1.01 (0.99-1.03)0.17Stage III + IV (referent: I + II)1.01 (0.98-1.03)0.54Class III + IV (referent: I + II)0.99 (0.98-1.02)0.73Class III + IV (referent: I + II)0.99 (0.97-1.01)0.55DAS28ESR at baseline0.95 (0.83-1.10)0.54DAS28ESR at baseline0.99 (0.84-1.18)0.97

Conclusion:

RF and ACPA seropositivity in bio-naïve patients with RA correlated with a higher rate of infliximab discontinuation due to adverse events or ineffectiveness.

Disclosure of Interests:

Yoshikazu Ogawa: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

Multiple time-scale beats in aurora: precise orchestration via magnetospheric chorus waves

The brightness of aurorae in Earth’s polar region often beats with periods ranging from sub-second to a few tens of a second. Past observations showed that the beat of the aurora is composed of a superposition of two independent periodicities that co-exist hierarchically. However, the origin of such multiple time-scale beats in aurora remains poorly understood due to a lack of measurements with sufficiently high temporal resolution. By coordinating experiments using ultrafast auroral imagers deployed in the Arctic with the newly-launched magnetospheric satellite Arase, we succeeded in identifying an excellent agreement between the beats in aurorae and intensity modulations of natural electromagnetic waves in space called “chorus”. In particular, sub-second scintillations of aurorae are precisely controlled by fine-scale chirping rhythms in chorus. The observation of this striking correlation demonstrates that resonant interaction between energetic electrons and chorus waves in magnetospheres orchestrates the complex behavior of aurora on Earth and other magnetized planets.

Sarcopenic obesity is associated with a faster decline in renal function in people with type 2 diabetes

AIM

To evaluate the association between sarcopenic obesity and the decline in estimated GFR in people with type 2 diabetes.

METHODS

We enrolled 745 people with type 2 diabetes (mean age 64.6 years, 53.6% men). Body composition was evaluated using dual-energy X-ray absorptiometry. Skeletal muscle index, calculated as appendicular non-fat mass (kg) divided by height squared (m² ), was used to determine sarcopenia. Sarcopenic obesity was defined as the coexistence of sarcopenia and a ratio of android to gynoid fat mass greater than the median values in each gender. The association of sarcopenic obesity both with the annual rate of decline in estimated GFR and a >30% decline in estimated GFR was evaluated using multivariate linear regression models and Cox proportional hazard models, respectively.

RESULTS

Participants with sarcopenic obesity were at an increased risk of a high annual rate of decline in estimated GFR, even after adjustment for the confounding variables (standardized β = -0.228, P <0.001). Sarcopenic obesity was also significantly associated with risk of a >30% decline in estimated GFR (hazard ratio 4.52, 95% CI 2.16-9.47; P < 0.01) in multivariate model.

CONCLUSIONS

Sarcopenic obesity evaluated by dual energy X-ray absorptiometry is associated with a faster decline in renal function in people with type 2 diabetes.

Trajectory of criterion symptoms of major depression under newly started antidepressant treatment: sleep disturbances and anergia linger on while suicidal ideas and psychomotor symptoms disappear early

OBJECTIVE

In modern psychiatry, depression is diagnosed with the diagnostic criteria; however, the trajectory of each of the criterion symptoms is unknown. This study aims to examine this.

METHODS

We made repeated assessments of the nine diagnostic criterion symptoms with the Patient Health Questionnaire-9 (PHQ-9) among 2011 participants of a 25-week pragmatic randomised controlled trial of sertraline and/or mirtazapine for hitherto untreated major depressive episodes. The changes from baseline were estimated with the mixed-effects model with repeated measures. The time to disappearance of each symptom was modeled using the Kaplan-Meier survival analysis.

RESULTS

The total score on PHQ-9 was 18.5 (SD = 3.9, n = 2011) at baseline, which decreased to 15.3 (5.2, n = 2011) at week 1, to 11.5 (5.9, n = 1953) at week 3, to 7.8 (6.0, n = 1927) at week 9, and to 6.0 (5.9, n = 1910) at week 25. Suicidal ideas, psychomotor symptoms decreased rapidly, while anergia and sleep disturbance also decreased but only slowly. The survival analyses confirmed the primary analyses.

CONCLUSIONS

Upon initiation of antidepressant treatment, patients with newly treated major depressive episodes can expect their suicidal ideas and psychomotor symptoms to disappear first but sleep disturbances and anergia to linger on.

P4601Reduced exercise capacity and clinical outcomes following acute myocardial infarction

Background

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. The purpose of this study is to assess the associated factors and clinical influence of exercise capacity measured by CPX in AMI patients.

Methods

Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9±11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed five days after the onset of AMI. Reduced exercise capacity was defined as peak oxygen consumption (peak VO2) ≤12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed.

Results

Among 136 patients, reduced exercise capacity (peak VO2 ≤12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atria. Median follow-up term was 12 months (interquartile range: 9–22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2≤12 than those with peak VO2>12 (p<0.001). Multivariate logistic analysis showed that E/e' (Odds ratio, 1.19, 95%, confidence interval 1.09 to 1.31, p<0.001) was an independent predictor of reduced exercise capacity (peak VO2≤12).

Cumulative incidence of clinical events

Conclusion

Diastolic dysfunction is associated with reduced exercise capacity following successful primary PCI in AMI patients and may lead to poorer clinical outcomes.

A case with good response to belimumab for lupus nephritis complicated by IgG4-related disease

Immunoglobulin (Ig)G4-related disease (IgG4-RD) is an unusual complication of systemic lupus erythematosus (SLE). We report a case in which belimumab proved efficacious for not only SLE, but also IgG4-RD. A 58-year-old Japanese woman had suffered from photodermatosis and erythema on the limbs for 20 years. She presented in slight fever and fatigue since 2016. Laboratory data showed hypergammaglobulinemia, proteinuria and positive results for anti-nuclear antibody and anti-double-stranded DNA antibody. Furthermore, elevated levels of serum IgG4 were detected. Contrast-enhanced computed tomography disclosed multiple areas of poor enhancement in the kidneys. The patient was diagnosed with lupus nephritis and IgG4-RD from renal biopsy. Treatment was started with prednisolone at 40 mg/day and mycophenolate mofetil. Proteinuria and serological findings improved initially, but tapering the dose of glucocorticoid proved difficult. After treatment was started with belimumab, clinical symptoms and proteinuria resolved completely. The dose of glucocorticoid was successfully tapered and serum concentration of IgG4 fell further. This appears to represent the first report of a case in which both SLE and IgG4-RD were effectively treated using belimumab.