0141 A Novel, Orally Available Orexin 2 Receptor-Selective Agonist, TAK-994, Shows Wake-Promoting Effects Following Chronic Dosing in an Orexin-Deficient Narcolepsy Mouse Model

Introduction

The use of an orexin 2 receptor (OX2R) agonist may be a promising approach for the treatment of narcolepsy type 1. TAK-994 is a novel, orally available OX2R-selective agonist with >700-fold selectivity against orexin 1 receptor. Single administration of TAK-994 ameliorates narcolepsy-like symptoms such as fragmentation of wakefulness and cataplexy-like episodes in orexin/ataxin-3 mice, a narcolepsy mouse model with orexin deficiency. In this study, we evaluated the effect of chronic dosing with TAK-994 on sleep/wakefulness states in orexin/ataxin-3 mice.

Methods

Orexin/ataxin-3 mice were grouped into two cohorts: a control group and a 14-day treatment group. In the control group, vehicle was administered orally to mice three times a day: zeitgeber time 12 (ZT12), ZT15 and ZT18, for 14 days. In the 14-day treatment group, TAK-994 was administered orally to mice at ZT12, ZT15 and ZT18 for 14 days. Electroencephalogram/electromyogram analysis was performed on day 1 and day 14 (ZT12-ZT21), and the subsequent sleep phase (ZT0-ZT10).

Results

On day 1, TAK-994 significantly increased wakefulness time, accompanied by a decrease in non-rapid eye movement (NREM) sleep time and rapid eye movement (REM) sleep time, in orexin/ataxin-3 mice compared with the control group. On day 14, TAK-994 also significantly increased wakefulness time, and decreased NREM sleep time and REM sleep time in orexin/ataxin-3 mice. There were no changes in the time spent in wakefulness, NREM sleep and REM sleep during the subsequent sleep phase after chronic dosing with TAK-994.

Conclusion

Wake-promoting effects of TAK-994 were observed following chronic dosing for up to 14 days in orexin/ataxin-3 mice with no rebound of sleep. Overall, there was no clear difference in efficacy between the single and repeated administration of TAK-994 in orexin/ataxin-3 mice.

Support

This work was conducted by Takeda Pharmaceutical Company Limited.

Pneumococcal vaccination reduces in-hospital mortality, length of stay and medical expenditure in hospitalized elderly patients

Pneumococcal vaccination has been shown to reduce occurrence of invasive pneumococcal diseases in elderly patients. In this study, we investigated the real-world efficacy of pneumococcal vaccination implemented in elderly individuals in Japan. We reviewed the in-patient database of Juntendo University Hospital and selected elderly patients (≥65 years-old) who had received in-patient care in the general medicine department during 2014-2018. A total of 1355 patients were retrospectively enrolled and comprised of 1045 unvaccinated and 315 vaccinated elderly individuals. Prior vaccination was found associated with all-cause shorter hospital stays (adjusted RR = 0.66, 95% CI = 0.57 to 0.76) and less medical expenditure (adjusted RR = 0.76, 95% CI = 0.66 to 0.87) compared with no vaccination, as well as protection for all-cause in-hospital mortality (adjusted OR = 0.42, 95% CI = 0.22 to 0.83). The association of shorter hospital stays and less medical expenditure with vaccination was also observed in the context of pneumonia, although no altered risk in mortality was observed. In conclusion, this study is one of the first reporting real-world data after the initiation of pneumococcal vaccination program in 2014 in Japan. The national PPV23 vaccination program contributed to the reduction of all-cause in-patient days, mortality, and medical expenses in the elderly aged ≥65 years. Further data is warranted to evaluate the contribution from influenza vaccination and protein-conjugate based pneumococcal vaccine.

Prevalence of human papillomavirus in oral gargles and tonsillar washings

OBJECTIVES

Human papillomavirus (HPV) infection drives carcinogenesis in the oropharynx. No standard sampling or HPV detection methods for evaluating oropharyngeal HPV infection exist. The prevalence of oral HPV infection in Japan is unknown.

MATERIALS AND METHODS

We examined 435 healthy Japanese individuals to address whether adding tonsillar washing to oral gargling would improve HPV detection. We compared HPV assessment using GENOSEARCH HPV31 versus nested PCR and direct sequencing. Associations between HPV infection and demographic and behavioral characteristics were examined.

RESULTS

Most participants who were HPV-positive based on oral gargles were also HPV-positive based on tonsillar washings: 11 (64.7%) of 17 on nested PCR and 12 (70.6%) of 17 on GENOSEARCH HPV31. Although HPV infection was more prevalent in oral gargles followed by tonsillar washings than in oral gargles alone, the difference was not statistically significant (nested PCR, 4.8% vs. 3.9%, P = 0.46; GENOSEARCH HPV31, 5.3% vs. 3.9%, P = 0.33). The overall agreement between nested PCR and GENOSEARCH HPV31 was 98.6%, with 76.0% positive agreement. The overall prevalence of oral HPV infection in Japan was 5.7% (95% confidence interval, 3.9-8.3%). Men had a significantly higher prevalence of oral HPV infection than women (8.3% vs. 2.6%, P = 0.02). Infection increased with number of lifetime sexual partners (P < 0.001 for trend).

CONCLUSION

The oropharynx is probably the major source of HPV-infected cells in oral gargles. Oral gargling could be a standard sampling method for evaluating oropharyngeal HPV infection. GENOSEARCH HPV31 could be an option for oral HPV detection.

Chronotherapy of Non-Steroidal Anti-Inflammatory Drugs May Enhance Postoperative Recovery

Postoperative pain relief is crucial for full recovery. With the ongoing opioid epidemic and the insufficient effect of acetaminophen on severe pain; non-steroidal anti-inflammatory drugs (NSAIDs) are heavily used to alleviate this pain. However, NSAIDs are known to inhibit postoperative healing of connective tissues by inhibiting prostaglandin signaling. Pain intensity, inflammatory mediators associated with wound healing and the pharmacological action of NSAIDs vary throughout the day due to the circadian rhythm regulated by the clock genes. According to this rhythm, most of wound healing mediators and connective tissue formation occurs during the resting phase, while pain, inflammation and tissue resorption occur during the active period of the day. Here we show, in a murine tibia fracture surgical model, that NSAIDs are most effective in managing postoperative pain, healing and recovery when drug administration is limited to the active phase of the circadian rhythm. Limiting NSAID treatment to the active phase of the circadian rhythm resulted in overexpression of circadian clock genes, such as Period 2 (Per2) at the healing callus, and increased serum levels of anti-inflammatory cytokines interleukin-13 (IL-13), interleukin-4 (IL-4) and vascular endothelial growth factor. By contrast, NSAID administration during the resting phase resulted in severe bone healing impairment.

The estimated impact of the 5-year national vaccination program on the trend of 23-valent pneumococcal polysaccharide vaccine vaccination rates in the elderly in Japan, 2009-2018

Pneumonia is the third most common cause of death in Japan. Low vaccination rates are thought to be related to low levels of public subsidy. Since 2014, the Japanese government has offered subsidies through a 5-year national routine vaccination program of the 23-valent pneumococcal polysaccharide vaccine (PPV23) for older adults at age ≥65 years with 5-year age intervals. We previously reported that, 2 years into the 5-year program, the estimated vaccination rate was 40.6% at the end of 2015, a significant increase compared with periods before the program introduced. Here, we present an update on the estimated vaccination coverage of the 5-year national routine vaccination program at the end of 2018. The PPV23 vaccination rates were calculated by dividing the cumulative amount shipped to each municipality by the population aged ≥65 years. At the end of 2018, the completion of the 5-year national immunization program, the estimated cumulative vaccination rate was 74%. Stepwise regression analysis revealed that the annual PPV23 vaccination rate significantly increased after 2014 (from 2 to 5% prior to 2014, to 10-11% after 2014), and remained steady for 2014-2018. Our findings suggest that the 5-year national routine vaccination subsidy program was successful in achieving a steady and higher vaccination rate of PPV23 in Japan.

P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography

【Background】

Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.

【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.

CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.

The postoperative course was good and he was discharged without any complications.

【Discussion】

False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.

We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.

We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.

Abstract P1480 Figure. Triple aneurysms

1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography

Background

Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS.

Case

A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure.

He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function.

PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved.

Discussion

POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS.

Abstract 1638 Figure. Intra-cardiac echocardiography

P1713 A case of quadricuspid aortic valve complicated with infective endocarditis diagnosed by 3D transesophageal echocardiography

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease with an estimated incidence of 0.008% to 1.46%. The functional status of QAV is predominantly a pure aortic regurgitation. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic echocardiography (TTE) is suitable for the diagnosis but, transesophageal echocardiography (TEE), especially 3-dimensional (3D) TEE, is a tool for the accurate definition of the valve anatomy.

Clinical case

A 60-year-old female underwent a head CT for intermittent headaches for one month ago. She was admitted to neurosurgery in our hospital diagnosed of subarachnoid hemorrhage. Four mm aneurysm was found on the periphery of the right middle cerebral artery on CT examination, and a cerebral aneurysm coil embolization was performed with a catheter in emergency. The possibility of infectious cerebral aneurysm was pointed out, and we examined in cardiovascular internal medicine. TTE revealed moderate aortic regurgitation. The ventricular septum exhibits sigmoid septum. A mobile mass was found near the left ventricular outflow tract in the sigmoid septum. TEE revealed a hypoplasia cusp (accessory cusp) is found between non coronary cusp and right coronary cusp. Aortic valve leaflets have become thickened and regurgitation from the central part of the cusps. 3DTEE was able to more accurately visualize that only the accessory cusp was hypoplastic, and the size of the other three leaflets appears almost the same. Similarly, vegetation on the left ventricular outflow tract were clearly revealed by 3DTEE.

Based on the above, it was diagnosed that quadricuspid aortic valve complicated with infective endocarditis (IE) with aortic valve regurgitation. After treatment with antibiotics according to IE, surgical treatment was scheduled.

Discussion

QAV is a rare congenital heart disease, and TTE is an important imaging tool for accurate diagnosis. Furthermore, TEE, especially 3DTEE, was a more appropriate diagnostic method in QAV and IE.

Abstract P1713 Figure. 3DTEE

Bacterial co-infection and early mortality among pulmonary tuberculosis patients in Manila, The Philippines

OBJECTIVE

To investigate the prevalence of bacterial co-infection and its effect on early mortality among hospitalised human immunodeficiency virus (HIV) negative pulmonary tuberculosis (PTB) patients in Manila, the Philippines.

DESIGN

A prospective observational study was conducted at a national infectious disease hospital. HIV-negative PTB patients aged 13 years hospitalised from November to December 2011 and from December 2012 to May 2013 were enrolled. Sputum samples were tested for Mycobacterium tuberculosis and six respiratory bacterial pathogens using polymerase chain reaction (PCR).

RESULTS

Of 466 patients, 228 (48.9%) were TB-PCR-positive. Overall, bacterial pathogens in purulent sputum were detected in 135 (29.0%) patients: Haemophilus influenzae was the most common bacterium (21.2%), followed by Streptococcus pneumoniae (7.9%). The prevalence of bacterial co-infection did not differ between TB-PCR-positive and -negative patients. A total of 92 (19.7%) patients died within 2 weeks. Bacterial co-infection was significantly associated with an increased risk of 2-week mortality among TB-PCR-positive patients (adjusted risk ratio [aRR] 1.67, 95%CI 1.03-2.72). This association was also observed but did not reach statistical significance among TB-PCR-negative patients (aRR1.7, 95%CI 0.95-3.02).

CONCLUSION

Bacterial co-infection is common and contributes to an increased risk of early mortality among HIV-negative PTB patients.

P4386Prognostic value of pressure-strain curve analysis by echocardiography for cardiac death in patients with congestive heart failure

Background

Pressure-strain curve analysis (PS-curve) is novel method of echocardiographic evaluation for left ventricular (LV) systolic myocardial work including the effect of blood pressure. However, the prognostic value of PS-curve for prospective cardiac death in patients with congestive heart failure (CHF).

Purpose

To elucidate the prognostic value of PS-curve analysis for cardiac death in patients with CHF.

Methods

We enrolled 63 consecutive sinus-rhythm patients with CHF admission who were evaluated by PS-curve analysis before discharge (76.0±13.3 years, 39 males). Endpoint was set as all cardiac death.

Results

Observation period was median 327 days [25%: 91, 75%: 656 days], and the longest period was 1004 days. Five patients died for cardiac causes. Multivariate Cox regression analysis (stepwise regression) revealed diastolic blood pressure (BP) and global constructive work (GCW) were independent predictors (Hazard ratio: 0.854, 0.996, P value: 0.016, 0.019, respectively). ROC curve analysis demonstrated GCW ≤601 had high diagnostic performance for cardiac death (specificity 0.891, sensitivity 0.800, area under ROC 0.824). Kaplan-Meyer curve analysis indicated the group with GCW ≤601 was worse cardiac prognosis (Logrank P<0.001).

Cox Hazard Regression Analysis Univariate Multivariate (stepwise regression) Hazard Ratio 95% CI P Hazard Ratio 95% CI P BP systole (mmHg) 0.915 0.85–0.99 0.026 BP diastole (mmHg) 0.915 0.84–0.99 0.043 0.854 0.75–0.97 0.016 LVDd (mm) 1.064 1.01–1.12 0.025 NA LVDs (mm) 1.066 1.01–1.12 0.016 LVEF (%) 0.963 0.91–1.02 0.221 LAD (mm) 1.197 1.06–1.36 0.005 GWE 0.937 0.88–0.99 0.041 GWI 0.998 0.99–0.99 0.041 NA GCW 0.998 0.99–0.99 0.037 0.996 0.99–0.99 0.019 GWW 0.996 0.98–1.01 0.502 Considering multicollinearity, we excluded GWI and LVDd (correlation coefficient: GWI and GCW = 0.979, LVDd and LVDs = 0.942).

Conclusion

Pressure-strain curve analysis had powerful predictive value for cardiac death in patients with CHF.

P1645Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with a history of heart failure: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). Recent studies suggest that VEGF-D appears to be a biomarker of pulmonary congestion and heart failure in both dyspnea patients and the general population. However, the prognostic value of VEGF-D in suspected or known CHD patients with a history of heart failure is unknown.

Methods

Serum VEGF-D levels were measured in 253 suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 54 patients died from any cause, 24 died from cardiovascular disease, and 35 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.44; 95% confidence interval [CI], 1.18–1.75), cardiovascular death (HR, 1.73; 95% CI, 1.32–2.25), and MACE (HR, 1.49; 95% CI, 1.14–1.89). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.471; 95% CI, 0.176–0.766; P=0.002; integrated discrimination improvement [IDI], 0.036; 95% CI, 0.008–0.064; P=0.011) and cardiovascular death (NRI, 0.722; 95% CI, 0.326–1.118; P<0.001; IDI, 0.063; 95% CI, 0.005–0.122; P=0.033), but not that of MACE (NRI, 0.453; 95% CI, 0.100–0.805; P=0.012; IDI, 0.028; 95% CI, −0.007–0.063; P=0.116).

Conclusions

In suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause and cardiovascular mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

P1704The impact of electrocardiographic changes upon resuscitation from out-of-hospital cardiac arrest on mortality

Background

The serial electrocardiographic changes in patients following out-of-hospital cardiac arrest (OHCA) are unclear.

Purpose

To evaluate serial electrocardiographic changes and to predict all-cause mortality in patients following OHCA.

Methods

We retrospectively studied 101 OHCA patients (70±16 years, 49 male) who achieved a return of spontaneous circulation (ROSC) and survived for ≥3hours. Twelve-lead electrocardiograms (ECGs) were evaluated twice in each patient: initial-ECG, after achieving ROSC; and 2nd-ECG, after receiving the initial evaluation in the emergency room. Patients were divided into two groups: S-group, those surviving for 28 days, and D-group, those dying within 28 days. Multivariate Cox regression analyses were performed to predict the 28-day survival following OHCA. A Kaplan-Meier curve analysis for the 28 day mortality stratified by the QRS morphology and rhythm of initial-ECG was performed.

Results

Among variables of initial-ECG, there were significant differences between the group-S and group-D (table). Multivariate analysis with a step-wise regression demonstrated that age, lactate, and QRS duration of the initial-ECG were significant predictors of all-cause mortality (Odds ratio (OR): 1.04, 1.21, 1.02, p: 0.002, 0.001, 0.001, respectively). Kaplan-Meier analysis revealed that a complete right bundle branch block (CRBBB) of initial-ECG and presence of atrial fibrillation were associated with an increased risk of all-cause mortality (Picture).

Serial change of ECG variables Initial-ECG 2nd-ECG Group S Group D p Group S Group D p Heart Rate [/min] 109±23 105±31 0.527 88±21 94±23 0.341 Af [N,%] 10 (25%) 27 (52%) 0.018* 3 (9%) 6 (26%) 0.134 QRS duration [ms] 111±18 139±33 0.001* 107±29 111±30 0.623 Morphology 0.001* 0.284 – Normal [N,%] 30 (75%) 10 (19%) 29 (81%) 14 (61%) – CRBBB [N,%] 5 (13%) 30 (57%) 5 (14%) 5 (22%) – CLBBB [N,%] 1 (2%) 0 0 1 (4%) – IVCD [N,%] 4 (10%) 13 (24%) 2 (6%) 3 (13%) Comparing variables between group S and group D stratified by initial ECG and delayed ECG. QRS morphology were examined, normal, complete right bundle branch block (CRBBB), complete left bundle branch block (CLBBB), and unspecific interventricular conduction delay (IVCD).

Study flow diagram, KM curve analysis

Conclusions

The QRS duration and morphology upon resuscitation were associated with an increased risk of all-cause mortality following OHCA.

P3639Vascular endothelial growth factor-C and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor-C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary heart disease (CHD). However, the prognostic value of VEGF-C in patients with suspected but no history of CHD is still unclear.

Methods

Serum VEGF-C levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.69; 95% confidence interval [CI], 0.58–0.83) and cardiovascular death (HR, 0.72; 95% CI, 0.52–0.998), but not with MACE (HR, 0.91; 95% CI, 0.74–1.13). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.282; 95% CI, 0.121–0.443; P<0.001; integrated discrimination improvement [IDI], 0.009; 95% CI, 0.003–0.016; P=0.005), but not that of cardiovascular death (NRI, 0.178; 95% CI, r=−0.103–0.458; P=0.214; IDI, 0.004; 95% CI, r=−0.002–0.009; P=0.194) or MACE (NRI, 0.037; 95% CI, r=−0.162–0.235; P=0.717; IDI, 0.000; 95% CI, r=−0.0004–0.0005; P=0.872).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, a low VEGF-C value may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5643Simple 12-leads electrocardiography can predict cardiac death in patients with complete left bundle branch block

Background

Patients with complete left bundle branch block (CLBBB) generally fall in two categories: CLBBB with good prognosis and poor prognosis. However, a simple electrocardiography (ECG) was considered impossible to predict the two categories.

Purpose

To elucidate the possibility of 12-leads ECG for predicting cardiac prognosis in patients with CLBBB

Methods

To estimate myocardial damage and left ventricular function, the ECG was performed with semiconductor SPECT simultaneously. Among consecutive 5864 patients who underwent ECG gated SPECT, finally 103 sinus-rhythm patients were enrolled. The observed period of them was median 632 days, and primary endpoint was set as cardiac death.

Results

Eight patients fell into cardiac death. Cox univariate analysis showed ventricular activation time (VAT: duration from onset of Q wave to peak of R wave) in V1 lead, T wave amplitude in aVR (aVR T-amp), and multiple fragmented QRS (At least 2 fQRS in LV anterior/inferior/lateral wall), and left ventricular ejection fraction, standard deviation of phase analysis (Phase SD), and summed rest score were significant predictors. After optimization of all significant continuous predictors by ROC curve analysis, all the significant predictors were analyzed by multivariate Cox analysis (stepwise regression). VAT in V1 (Hazard ratio: 4.594, P=0.034), aVR T-amp ≥-85microV (HR: 11.11, P=0.029), and Phase SD≥48.7 (HR6.047, P=0.035) were independent predictors. Kaplan-Meyer curve analysis demonstrated VAT V1≥70 and aVR T amp≥-85 showed the worst prognosis (P=0.008).

Cox Regression after Optimization by ROC Univariate Multivariate (Stepwise regression) HR 95% CI P HR 95% CI P VAT I ≥70 6.861 1.759–26.76 0.006 4.594 1.126–18.75 0.034 T amp in aVR ≥−85 27.34 3.458–216.2 0.002 11.11 1.274–96.85 0.029 Multiple fQRS 3.836 1.081–13.61 0.037 LVEF ≤37% 7.250 1.874–28.04 0.004 SD ≥48.7 17.30 3.671–81.57 <0.001 6.047 1.133–32.28 0.035 SRS≥17 4.178 1.206–14.48 0.024 SD: standard deviation of histogram by phase analysis of SPECT; SRS: summed rest score by myocardial perfusion analysis of SPECT.

Conclusion

Simple 12-leads ECG could predict the prognosis of patients with CLBBB.

5195Growth differentiation factor-15 and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine, which plays an important role in the regulation of the inflammatory response, growth and cell differentiation. Elevated GDF-15 was found in various diseases including diabetes and stable CHD, and was reported to predict mortality and cardiovascular events in general or established CHD population. However, the prognostic value of GDF-15 in suspected or known CHD patients with diabetes is unknown.

Methods

Serum GDF-15 levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.66; 95% confidence interval [CI], 1.48–1.86), cardiovascular death (HR, 1.63; 95% CI, 1.34–1.99), and MACE (HR, 1.41; 95% CI, 1.20–1.65). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.344; 95% CI, 0.172–0.517; P<0.001; integrated discrimination improvement [IDI], 0.049; 95% CI, 0.026–0.072; P<0.001), but not that of cardiovascular death (NRI, −0.013; 95% CI, −0.300–0.274; P=0.931; IDI, 0.023; 95% CI, 0.003–0.043; P=0.026) or MACE (NRI, 0.059; 95% CI, −0.151–0.268; P=0.583; IDI, 0.005; 95% CI, −0.004–0.015; P=0.244).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated GDF-15 levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

P5529Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with diabetes is unknown.

Methods

Serum VEGF-D levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.34; 95% confidence interval [CI], 1.21–1.47), cardiovascular death (HR, 1.40; 95% CI, 1.18–1.62), and MACE (HR, 1.22; 95% CI, 1.07–1.40). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.258; 95% CI, 0.088–0.429; P=0.003; integrated discrimination improvement [IDI], 0.013; 95% CI, 0.002–0.024; P=0.022), but not that of cardiovascular death (NRI, 0.046; 95% CI, −0.245–0.336; P=0.759; IDI, 0.013; 95% CI, −0.005–0.031; P=0.146) or MACE (NRI, 0.064; 95% CI, −0.146–0.274; P=0.552; IDI, 0.001; 95% CI, −0.002–0.004; P=0.557).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5526Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with chronic kidney disease: a subanalysis of the ANOX study

Background

Chronic kidney disease (CKD) is an independent risk factor for the development and progression of coronary heart disease (CHD). Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with CKD is unknown.

Methods

Serum VEGF-D levels were measured in 999 suspected or known CHD patients with CKD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 154 patients died from any cause, 61 died from cardiovascular disease, and 96 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.41; 95% confidence interval [CI], 1.27–1.56), cardiovascular death (HR, 1.48; 95% CI, 1.28–1.71), and MACE (HR, 1.34; 95% CI, 1.18–1.53). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.272; 95% CI, 0.100–0.445; P=0.002; integrated discrimination improvement [IDI], 0.015; 95% CI, 0.003–0.027; P=0.013), but not that of cardiovascular death (NRI, 0.230; 95% CI, −0.029 to 0.488; P=0.082; IDI, 0.012; 95% CI, −0.007 to 0.031; P=0.207) or MACE (NRI, 0.102; 95% CI, −0.106 to 0.310; P=0.337; IDI, 0.005; 95% CI, −0.005 to 0.015; P=0.337).

Conclusions

In suspected or known CHD patients with CKD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury

Background

Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking.

Purpose

Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry.

Methods

Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a >0.3mg/dl absolute or >1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores.

Results

Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P<0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P<0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575).

CV according to CKD/NCDR AKI risk score

Conclusions

Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI.

Acknowledgement/Funding

KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer

P3765Low vascular endothelial growth factor-C was a predictor for cardiovascular events in patients with atrial fibrillation and suspected or known coronary artery disease: a subanalysis of the ANOX study

Background

Lymphatic system has been considered to play an important role in cardiovascular disease. We recently reported that vascular endothelial growth factor-C (VEGF-C), a central player in lymphangiogenesis, predicted all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, relationship between VEGF-C and atrial fibrillation (AF) remains unclear.

Methods

The ANOX study is a multicenter, prospective cohort study of 2,418 patients with suspected CAD, to determine the predictive value of possible novel biomarkers related to angiogenesis or oxidative stress for major adverse cardiovascular events (MACE) among patients undergoing elective angiography. Blood samples were collected from the arterial catheter sheath at the beginning of coronary angiography. Serum levels of VEGF-C, as well as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-I (cTnI), and high-sensitivity C-reactive protein (hsCRP), were measured. The outcome was a MACE defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

Of a total of 2,418 patients, 261 patients had AF at baseline. AF group were older, and had more chronic kidney disease, history of heart failure, and history of stroke, but less diabetes, dyslipidemia, and CAD. The median level of NT-proBNP, cTnI, and hsCRP were higher in AF group [AF vs non-AF: NT-proBNP, 1048 pg/ml vs 162 pg/ml (p<0.0001); cTnI, 0.0003 ng/ml, vs 0.0 ng/ml (p<0.0001); hsCRP, 1.43 ug/ml vs 0.88 ug/ml (p=0.0005)], whereas median level of VEGF-C was lower in AF group [3107 pg/ml vs 3590 pg/ml (p<0.0001)]. AF was associated with lower VEGF-C and higher hsCRP after adjustment for potential confounders. During the 3-year follow-up, 29 (11.1%) patients in AF group and 136 (6.3%) patients in non-AF group developed MACE (p=0.007). Incidence of stroke was higher in AF group (17 (6.5%) vs 52 (2.4%); p<0.0009), despite that the incidence of cardiovascular death and myocardial infarction were similar between the groups. We divided the entire cohort into two groups based on the lowest quartile of VEGF-C or highest quartile of other biomarkers, lowest quartile of VEGF-C (log rank p=0.0004), as well as highest quartile of cTnI (log rank p=0.0009), were significantly associated with MACE in AF group. After adjustment for established risk factors and these biomarkers, both lowest quartile of VEGF-C (HR, 2.73; 95% CI, 1.27–6.06) and highest quartile of cTnI (HR, 2.54; 95% CI, 1.08–6.09) were significantly associated with MACE in AF group.

Conclusions

AF was associated with lower level of VEGF-C, and low VEGF-C as well as high cTnI might serve as an independent predictor of MACE in patients with AF and suspected or known CAD.

P2688A novel risk factor of stent restenosis after drug-eluting stent implantation; Involvement of triglyceride deposit cardiomyovasculopathy, coronary atherosclerosis with triglyceride deposition

Background

Triglyceride deposit cardiomyovasculopathy (TGCV) is a novel disease concept characterized by the excessive accumulation of triglyceride in cardiomyocytes and vascular smooth muscle cells, leading to coronary artery disease (CAD), heart failure, and arrhythmia. However, it is rarely known whether TGCV contributes to the increased risk of vascular failure after drug eluting stent (DES) implantation.

Purpose

The aim of this study was to evaluate vascular failure after 2nd generation DES implantation in patients with TGCV.

Methods

Among 637 consecutive patients suspected of having CAD who underwent both coronary angiography and iodine-123-β-methyliodophenyl-pentadecanoic acid (BMIPP) scintigraphy between 2010 and 2018, we analyzed the data from 92 patients who met the inclusion criteria (shown in Table and Figure). Ninety-two patients were allocated to the presence (TGCV group, 11 patients) or absence (control group, 81 patients) of TGCV. All of 92 patients were implanted 2nd generation DES and underwent planned follow up coronary angiography. Control patients were diagnosed of diabetes mellitus. Binary restenosis (ISR), defined as angiographic luminal diameter ≥50% by quantitative coronary angiography, target lesion revascularization (TLR), In-stent late loss and restenosis morphology were assessed in 23 stents of TGCV group and 120 stents of control group.

Results

There were no significant differences in baseline characteristics between the two groups except for the prevalence of hypertension. In-stent late loss was greater in TGCV than in control (0.45 (−0.04 to 3.33) vs. 0.15 (−0.18 to 2.75), p=0.ehz748.10067), resulting in greater incidence of ISR and TLR in TGCV than in control (34.8% vs. 10.0%, p=0.0017; 21.7% vs. 6.7%, p=0.021, respectively). On multivariable logistic regression analysis, TGCV was found to be a significant and independent predictor for ISR after 2nd generation DES implantation. Regarding restenosis morphology, diffuse and occlusive pattern of ISR, were more frequently observed in TGCV than control (87.5% and 33.3%, Fisher's exact test p=0.028).

Table 1.The 4th edition diagnostic criteria for TGCV Items Clinical findings 2 points I) BMIPP scintigraphy Wash-Out Rare <10% II) Diffuse narrowng coronary arteries 1 point III) Jordans anomaly in peripheral blood smear IV) Diabetes Decision 4 points or more → Definite TGCV

Figure 1

Conclusion

Patients with TGCV showed the greater incidence of vascular failure even after 2nd generation DES implantation, contributing to the novel risk factor for coronary intervention even in the 2nd DES era.

White Matter Abnormalities in Multiple Sclerosis Evaluated by Quantitative Synthetic MRI, Diffusion Tensor Imaging, and Neurite Orientation Dispersion and Density Imaging

BACKGROUND AND PURPOSE

A number of MR-derived quantitative metrics have been suggested to assess the pathophysiology of MS, but the reports about combined analyses of these metrics are scarce. Our aim was to assess the spatial distribution of parameters for white matter myelin and axon integrity in patients with relapsing-remitting MS by multiparametric MR imaging.

MATERIALS AND METHODS

Twenty-four patients with relapsing-remitting MS and 24 age- and sex-matched controls were prospectively scanned by quantitative synthetic and 2-shell diffusion MR imaging. Synthetic MR imaging data were used to retrieve relaxometry parameters (R1 and R2 relaxation rates and proton density) and myelin volume fraction. Diffusion tensor metrics (fractional anisotropy and mean, axial, and radial diffusivity) and neurite orientation and dispersion index metrics (intracellular volume fraction, isotropic volume fraction, and orientation dispersion index) were retrieved from diffusion MR imaging data. These data were analyzed using Tract-Based Spatial Statistics.

RESULTS

Patients with MS showed significantly lower fractional anisotropy and myelin volume fraction and higher isotropic volume fraction in widespread white matter areas. Areas with different isotropic volume fractions were included within areas with lower fractional anisotropy. Myelin volume fraction showed no significant difference in some areas with significantly decreased fractional anisotropy in MS, including in the genu of the corpus callosum and bilateral anterior corona radiata, whereas myelin volume fraction was significantly decreased in some areas where fractional anisotropy showed no significant difference, including the bilateral posterior limb of the internal capsule, external capsule, sagittal striatum, fornix, and uncinate fasciculus.

CONCLUSIONS

We found differences in spatial distribution of abnormality in fractional anisotropy, isotropic volume fraction, and myelin volume fraction distribution in MS, which might be useful for characterizing white matter in patients with MS.

P3635Vascular endothelial growth factor-D and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. In clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in patients with suspected but no history of CHD is unknown.

Methods

Serum VEGF-D levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.29; 95% confidence interval [CI], 1.17–1.42), cardiovascular death (HR, 1.37; 95% CI, 1.20–1.56), and MACE (HR, 1.22; 95% CI, 1.08–1.37). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.165; 95% CI, 0.004–0.325; P=0.044; integrated discrimination improvement [IDI], 0.012; 95% CI, 0.002–0.023; P=0.013), but not that of cardiovascular death (NRI, 0.078; 95% CI, r=−0.203–0.359; P=0.586; IDI, 0.014; 95% CI, r=−0.009–0.037; P=0.235) or MACE (NRI, r=−0.011; 95% CI, r=−0.207–0.184; P=0.337; IDI, 0.003; 95% CI, r=−0.003–0.009; P=0.354).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Treatment of finger phalangeal fractures using the Ichi-Fixator system: A prospective study of 12 cases

External fixators are an effective treatment option for comminuted or unstable phalangeal fractures. We developed a new linked-wire type of external fixator (the Ichi-Fixator) for finger phalangeal fractures, which enables fine adjustment of the fixation under fluoroscopy guidance either in a static way or with distraction through small screws inside the fixator. This technique was designed to improve on the stability and rigidity of conventional percutaneous Kirchner wire fixation. We assessed the effectiveness of the fixator through 12 cases of open or percutaneous fixation in comminuted or unstable phalangeal fractures. All patients were examined for postoperative complications, functional recovery, pain on visual analog scale (VAS), and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score at the final follow-up visit. Patients could perform all routine activities with normal grip strength and a full range of hand motion without pain after treatment. This treatment, which reduces the postoperative discomfort and may allow an immediate return to work, will clearly boost patient satisfaction. Linked-wire type external fixation enhances the security of fixation, facilitates postoperative mobilization, and may allow an immediate return to work.

Evaluation of the effect of a heat-killed lactic acid bacterium, Enterococcus faecalis 2001, on oral candidiasis

The effect of a preparation of heat-killed Gram-positive lactic acid bacteria Enterococcus faecalis 2001 (EF-2001) on oral candidiasis was evaluated by two studies. An in vitro study was performed to assess the inhibitory effect on mycelial growth of Candida strains isolated from a patient with oral candidiasis, and a clinical study was done in patients with oral candidiasis. In the in vitro study, EF-2001 inhibited mycelial growth of IT-1, a Candida strain isolated from a patient with oral candidiasis, at concentrations ≥2.34×109 cells/ml. An open clinical study was performed in 13 patients with oral candidiasis. The subjects took a powder containing 7.5×1011 heat-killed EF-2001 once a day before bedtime for seven consecutive days. In 11 of the 12 patients available for analysis (92%), the oral Candida load (cfu/swab) showed a significant decrease (P=0.01079, d=-0.437). There was a 55% decrease of Candida albicans and a 93.8% decrease of Candida glabrata. The following symptoms showed significant improvement: tinnitus (P=0.048, d=-0.462), cold feeling (P=0.048, d=-0.463), and depression (P=0.019, d=-0.34). In addition, 4 out of 26 oral symptoms tended to improve. These results suggest that EF-2001 significantly decreased the oral Candida load in patients with oral candidiasis by inhibiting mycelial growth and that EF-2001 is an effective treatment for oral candidiasis.

Polarization control with an X-ray phase retarder for high-time-resolution pump-probe experiments at SACLA

Control of the polarization of an X-ray free-electron laser (XFEL) has been performed using an X-ray phase retarder (XPR) in combination with an arrival timing diagnostic on BL3 of the SPring-8 Angstrom Compact free-electron LAser (SACLA). To combine with the timing diagnostic, a pink beam was incident on the XPR crystal and then monochromated in the vicinity of samples. A high degree of circular polarization of ∼97% was obtained experimentally at 11.567 keV, which agreed with calculations based on the dynamical theory of X-ray diffraction. This system enables pump-probe experiments to be operated using circular polarization with a time resolution of 40 fs to investigate ultrafast magnetic phenomena.

The Efficacy of 2% Topical Rebamipide on Conjunctival Squamous Metaplasia and Goblet Cell Density in Dry Eye Disease

Purpose: To clarify the pharmacological effects of 2% rebamipide eye drops on mucosal membrane functions of the ocular surface epithelium, we investigated keratoconjunctival alterations at the cellular level in this study.

Methods: Fifteen patients with definite dry eye disease were recruited from outpatient clinics of the Department of Ophthalmology, Ichikawa General Hospital. The patients received treatment with 2% rebamipide eye drops q.i.d for 12 weeks. Symptom score assessment, tear film breakup time, fluorescein and lissamine green ocular surface vital staining, grading of lid wiper epitheliopathy, Cochet–Bonnet corneal sensitivity, assessment of squamous metaplasia grades, and goblet cell density calculations from conjunctival impression cytology samples, as well as evaluation of nucleocytoplasmic ratios and corneal epithelial cells from in vivo confocal microscopy images before and 3 months after treatment were performed.

Results: The mean symptom scores, tear film breakup time values, ocular surface fluorescein and lissamine green vital staining scores, and lid wiper scores showed a significant improvement after treatment (P < 0.01). The mean squamous metaplasia grade also showed a significant improvement (1.2 ± 0.1 → 0.3 ± 0.1) 3 months after treatment (P = 0.004). There were similar significant improvements in the mean corneal epithelial cell density (660.1 ± 62.6 → 1015.5 ± 43.5 cells/mm²) (P = 0.002) and nucleocytoplasmic ratios (0.1 ± 0.0 → 0.2 ± 0.0) (P = 0.0042) after treatment.

Conclusions: Topical use of 2% rebamipide for 3 months was associated with improvements in ocular surface differentiation due to changes of mucosal functions at the cellular level. These alterations may explain objective and subjective improvements in dry eye disease.

Metabolic tumor volume of metastatic lymph nodes and survival after total laryngectomy in laryngeal and hypopharyngeal cancer

OBJECTIVES

The prognostic value of metabolic tumor volume (MTV) in locally advanced laryngeal or hypopharyngeal cancer is established in the setting of chemoradiotherapy, while it remains unknown in the setting of upfront total laryngectomy.

MATERIALS AND METHODS

We retrospectively analyzed 88 patients receiving total laryngectomy and neck dissection, using Cox regression models.

RESULTS AND CONCLUSION

Variables related to metastatic lymph node were associated with overall survival, whereas those related to primary tumor were not. In multivariable models, MTV of metastatic lymph nodes (N-MTV) as a continuous variable (Akaike's information criterion (AIC), 277.5) was equivalent to pathological nodal status (AIC, 278.2; P = 0.40), and superior to pathological nodal classification as an ordinal variable (AIC, 281.4; P < 0.05) in ability of predicting death. The risk of death was increased by 1.2-fold (95% confidence interval (CI), 1.0-1.4; P = 0.03) every 10-ml increment of N-MTV, while patients with pN+ disease were at a higher risk of death by 2.9-fold (95% CI, 1.0-12.2; P < 0.05) compared with patients with pN0 disease. Using recursive partitioning analysis (RPA), we classified the patients as having a low, intermediate, or high risk of death on the basis of N-MTV and extranodal extension (ENE). This RPA classification system exhibited greater concordance with overall survival than the classification considering pathological nodal status and ENE (AIC, 275.8 versus 281.4; P = 0.02). In the setting of upfront total laryngectomy, N-MTV is a critical predictor of mortality. A staging system in which N-MTV is incorporated may better inform adjuvant treatment decisions.

Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device

BACKGROUND AND PURPOSE

The flow-diverter device has been established as a treatment procedure for large unruptured intracranial aneurysms. The purpose of this study was to compare the usefulness of Silent MR angiography and time-of-flight MRA to assess the parent artery and the embolization state of the aneurysm after a flow-diverter placement.

MATERIALS AND METHODS

Seventy-eight large, unruptured internal carotid aneurysms in 78 patients were the subjects of this study. After 6 months of treatment, they underwent follow-up digital subtraction angiography, Silent MRA, and TOF-MRA, performed simultaneously. All images were independently reviewed by 2 neurosurgeons and 1 radiologist and rated on a 4-point scale from 1 (not visible) to 4 (excellent) to evaluate the parent artery. The aneurysmal embolization status was assessed with 2 ratings: complete or incomplete occlusion.

RESULTS

The mean scores of Silent MRA and TOF-MRA regarding the parent artery were 3.18 ± 0.72 and 2.31 ± 0.86, respectively, showing a significantly better score with Silent MRA (P < .01). In the assessment of the embolization of aneurysms on Silent MRA and TOF-MRA compared with DSA, the percentages of agreement were 91.0% and 80.8%, respectively.

CONCLUSIONS

Silent MRA is superior for visualizing blood flow images inside flow-diverter devices compared with TOF-MRA. Furthermore, Silent MRA enables the assessment of aneurysmal embolization status. Silent MRA is useful for assessing the status of large and giant unruptured internal carotid aneurysms after flow-diverter placement.

Abstract P1-11-07: Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment

BACKGROUND:

Anthracycline-containing regimens are standard treatment options in adjuvant and neoadjuvant chemotherapy in breast cancer. Chemotherapy-induced nausea and vomiting (CINV) is experienced frequently in patients receiving these regimens, but the risk factors for CINV are unknown.

OBJECTIVE:

The aim of this study was to investigate risk factors for CINV in anthracycline-containing regimens retrospectively.

METHODS:

Data were collected from the JONIE study, which was conducted in order to estimate the efficacy of zoledronic acid in a neoadjuvant setting from March 2010 to June 2012 (UMIN000003261). A total of 180 patients were recruited, and we used CINV data from the first cycle of FEC100 treatment and patient backgrounds. As the protocol regulation allowed the use of antiemetic drugs,in the first cycle of the FEC100 regimen, patients received various types of antiemetic agents, which we classified into four groups: Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1) (DEX+5-HT3+NK1) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3) (DEX+5HT3) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+dopamine receptor antagonist (DRA) (DEX+5HT3+DRA) group; and Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1)+ dopamine receptor antagonist (DRA) (DEX+5-HT3+NK1+DRA) group. Risk factors were selected from patient backgrounds and the combinations of antiemetic drugs. In patient backgrounds, the body mass index (BMI) was stratified into 3 categories: Less than 18.5 (underweight group); equal to or more than 18.5 but less than 25 (standard BMI group); and equal to or more than 25 (overweight group). The risks for CINV were analyzed by univariate and multivariate analyses. P values of less than 0.05 were defined as significant.

RESULTS:

In a univariate analysis of nausea, the body mass index (BMI) was the only significant factor (P&lt;0.05). On the other hand, BMI and the combination of antiemetic drugs were significant factors in vomiting. (P&lt;0.05 and 0.005, respectively). In a multivariate analysis of nausea, the P value for BMI was 0.02. The odds ratio for the underweight group was 7.745 (confidence interval: 2.171 to 27.634) compared with the standard BMI group. In a multivariate analysis of vomiting, BMI and the combination of antiemetic drugs were significant risk factors (P=0.025 and 0.023, respectively). The odds ratio for the underweight group was 3.481 (confidence interval: 1.183 to 10.241)compared with the standard BMI group. Furthermore, the odds ratios in the DEX+5-HT3+DRA and DEX+5HT3 groups were 5.005 (confidence interval: 1.543 to 16.239) and 4.178 (confidence interval: 1.428 to 12.222), respectively, compared with the DEX+5-HT3+NK1 group, which was consistent with the CINV guidelines in 2011.

CONCLUSIONS:

This study revealed that BMI was the most important risk factor for nausea, and that BMI and the combination of antiemetic drugs were risk factors for vomiting. Underweight-patients tend to have CINV in anthracycline-containing regimen. The DEX+5-HT3+NK1 group was the best antiemetic drug combination. These result show that following the CINV guideline treatment is mandatory in order to prevent CINV.

Citation Format: Hayashi M, Nakazawa K, Hasegawa Y, Horiguchi J, Miura D, Ishikawa T, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Tanino Y, Yamada K, Kimura K, Akazawa K, Kohno N. Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-07.

Abstract P4-10-15: Obesity influences the character of the breast cancer in postmenopausal women in Japan

Background: We know Estrogen Receptor (ER) positive and/or Progesterone Receptor (PgR) positive tumors tend to develop more frequently in obese individuals in postmenopausal women. However, the average body size of a Japanese woman is relatively smaller than that of a Caucasian woman. There are few reports about the influence of the obesity to the character of the Japanese breast cancer women and the tendency is not clear. The aim of this study is to clarify whether the tendency is the same even in Japanese breast cancer women. Furthermore, we investigate whether HER2 expression (HER2) and Ki-67 index (Ki-67) have some relations with the height (HT), the weight (WT) and the body mass index (BMI) in Japanese breast cancer women.

Methods: HT and WT of 279 Japanese women with breast cancer in Kitamurayama hospital were evaluated. The mean HT and WT of them are 153.6cm and 54.9kg. Subsequently, the women's BMI (WT/(HT)2) was calculated. The mean BMI was 23.3. The ER and PgR were stained for immunohistochemical (IHC) analysis. Regardless of the intensity, stained cases were defined as positive. HER2 was divided into HER2 negative (IHC score 0, +1 and/or FISH negative) or positive (IHC score +3 and/or FISH positive). Ki-67 was determined by staining with MIB-1 antibody, and the cutoff value was decided on 20%, and divided into two groups of more than 20% (Higher) and less than 20% (Lower). Then, we examined the relationship of HT, WT and BMI with ER, PgR, HER2 and Ki-67 in postmenopausal and premenopausal women.

Result: In postmenopausal women, WT and BMI were significantly higher in ER positive (p=0.0230, p=0.0129). WT and BMI were also significantly higher in PgR positive (p=0.0049, p=0.0294,). There was no significant difference between HER2 positive and Her2 negative, and between Ki-67 Higher and Ki-67 Lower either. In premenopausal women, no significant association was observed in all items.

Conclusion: In postmenopausal women, HT did not have the significant difference between ER (and PgR) positive and ER (and PgR) negative. However, ER (and PgR) positive were significantly higher in WT and BMI. It was thought that the obesity influences the character of the breast cancer in postmenopausal women. Compared to less obese postmenopausal Japanese women with breast cancer, more obese postmenopausal Japanese women have a propensity for developing hormone sensitive tumors.

Citation Format: Suzuki M, Takei H. Obesity influences the character of the breast cancer in postmenopausal women in Japan [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-15.

Abstract OT1-05-04: Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial)

Background: It is well known that the prognosis of non pCR TNBC patients was poor after anthracycline and taxan treatment. For such patients, capecitabine seems to be effective to reduce recurrence based on the HR 0.58 of the CREATE X trial (Masuda, N. et al. Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy. N Engl J Med. 376, 2147. 2017) . However, the target of capecitabine is still unclear for TNBC. We classified non pCR tumors as BRCAness and Sporadic using BRCAness test(MRC-Holland, Amsterdam, the Netherlands). The recurrence rate of the BRCAness group was about 70%. Carboplatine is expected to be effective against BRCAness tumors, as it is a DNA damaging agent. In this study BRCAness can be checked just before carboplatin treatment using surgical specimens. Then the efficacy of carboplatin will be directly known to make comparison between DFS in the carboplatin group and that of the observation group.

Trial design: This is anopen label, randomized phase III study that will enroll TNBC with residual invasive cancer after surgery with preoperative chemotherapy including both anthracycrine and taxan. Patients are randomly assigned to either the carboplatin group or observation group. The patients in the carboplatin group are treated with carboplatin at AUC 6 and those in the observation group are observed at only 3 years.

Eligibility criteria:

1) ER and PgR&lt;1%, HER2 0, 1+ or 2+ with FISH negative on core needle biopsy before the chemotherapy and surgical specimens.

2) Preoperative chemotherapy including both anthracycrine and taxan.

3) Residual invasive cancer on breast tumors or lymph node metastasis in surgical specimens.

4) 20-79 year old women.

5) No chemotherapy within 5 years.

6) Not bilateral breast cancer, without metastasis, no prior breast cancer.

7) No severe bone marrow suppression.

Specific aims:Primary objective is DFS (Disease Free Survival). Secondary objectives are overall survival and safety.

STATISTICAL METHODS:

The 3 years recurrence rate of the observation group was estimated as 40% and hazard ratio at 0.58 based on the CREATE X trial. For both groups, 135 patients are necessary. This study is powered to approximately 80% to test the superiority of carboplatin group at a 2-sided α=0.05 using a stratified log-rank test.

Activation Date:22ndMarch 2018. No patients had been enrolled till 3rd July.

Citation Format: Tanino H, Suzuki M, Kaise H, Miyashita M, Chishima T, Hayashi M, Miyoshi Y, Futamura M, Ohtani S, Nagahashi M, Ohta T, Kosaka Y, Ishikawa T, Hasegawa Y, Kubota T, Sangai T, Iwatani T, Yamada A, Akazawa K, Kohno N. Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-05-04.

Phase Angle Is a Useful indicator for Muscle Function in Older Adults

AIM

Phase angle (PhA) can be determined through bioelectrical impedance analysis and is a unique variable for skeletal muscle. The objective of this study was to evaluate the relationship between PhA and muscle mass/quality in older adults. In addition, we attempted to determine the cutoff value of PhA for poor muscle function.

METHODS

Community-dwelling Japanese older men (n=285, 81.1±7.1 years) and women (n=724, 80.4±6.8 years) participated in this study and were classified into four groups based on the Asian Working Group for Sarcopenia (normal, presarcopenia, dynapenia, and sarcopenia). We measured PhA using bioelectrical impedance analysis, muscle quantity and quality indicators using ultrasonography, muscle strength, and physical performance and compared them in four groups. We also tried to determine the cutoff value of PhA for poor muscle function.

RESULTS

We found a significant difference in PhA among the four groups in men (P<0.05), and the dynapenia (3.61±0.75°) and sarcopenia groups (3.40±0.74°) showed significantly lower values than the normal group (4.50±0.86°) (P<0.05), but not the presarcopenia group (4.12±0.85°). In women, a significant difference was also observed among the four groups (P<0.05), and the dynapenia (3.41±0.65°) and sarcopenia groups (3.31±0.66°) showed significantly lower measures than the normal group (4.14±0.71°) (P<0.05), but not the presarcopenia group (4.07±0.51°). The receiver-operating characteristic curve analysis indicated the best cutoff value of PhA (men: 4.05°, women: 3.55°) to discriminate sarcopenia and dynapenia from normal and presarcopenia.

CONCLUSION

These findings suggest that PhA is a useful indicator for muscle function.

The effects of teriparatide on acceleration of bone healing following atypical femoral fracture: comparison between daily and weekly administration

We compared the effectiveness of promoting bone healing between two teriparatide preparations for atypical femoral fracture (AFF). A total of 45 AFFs were included in this study, and we compared the duration of bone union. Teriparatide administered by daily injection enhanced bone union more than weekly administration in complete AFFs.

INTRODUCTION

The efficacy of teriparatide for atypical femoral fracture (AFF) has been recently reported. Although two different teriparatide preparations can be used to treat osteoporosis in Japan, daily or weekly injection, all previous reports on the effectiveness of teriparatide for AFF only examined daily injection formulations. Therefore, we compared the promotion of bone healing between the two teriparatide preparations for AFF.

METHODS

A total of 45 consecutive AFFs in 43 Japanese patients were included in this study. They received either a daily 20-μg teriparatide injection (daily group; n = 32) or a once-a-week 56.5-μg teriparatide injection (weekly group; n = 13). We compared the clinical background and duration of bone union between these two groups.

RESULTS

When all patents were included, the fracture healing time was not significantly different between the two groups. Only patients with complete AFFs had significantly fewer daily bisphosphonate or denosumab injections than the weekly group (P < 0.05). The fracture healing time in the daily group (6.1 ± 4.1 months) was significantly shorter than that in the weekly group (10.1 ± 4.2 months) (P < 0.05). Even if the influence of bisphosphonate or denosumab usage was excluded, a similar significant difference was observed in the fracture healing time (P < 0.05). There was no significant difference between the two groups among patients with incomplete AFFs.

CONCLUSIONS

Daily teriparatide injections enhance bone union more than weekly injections in complete AFF patients.

Clinical and Histological Study on Direct Pulp Capping With CO2 Laser Irradiation in Human Teeth

The study aimed to histologically evaluate wound healing of exposed human pulp on direct pulp capping using super-pulsed CO₂ laser preirradiation. In this single-blind clinical trial, 28 third molar teeth of 17 volunteers were randomly capped with either CO₂ laser irradiation (n=14) or Dycal (calcium hydroxide cement; n=14) and restored using resin composite. The laser was operated in super-pulsed mode (pulse duration, 0.2 ms; interval, 5.8 ms; 0.003 J/pulse). The irradiation conditions were a power output of 0.5 W, an irradiation time of 15 seconds, repeat mode (10-ms irradiation and 10-ms intervals, for a total beam exposure time of 7.5 seconds), total applied energy of 3.75 J, and an activated air-cooling system. Each tooth was extracted at six or 12 months posttreatment and prepared for histological evaluation. We evaluated the parameters of pulp tissue disorganization, inflammatory cell infiltration, reparative dentin formation (RDF), and bacterial penetration. There were no significant differences between groups for all parameters at each postoperative period (Mann-Whitney U-test, p>0.05). CO₂ laser irradiation completely controlled bleeding and exudate from the exposed pulp. The CO₂ laser group had a tendency to delay RDF compared with the Dycal group, but 4 of 7 teeth from the CO₂ laser group showed a complete dentin bridge at 12 months posttreatment.