Metabolomic/lipidomic-based analysis of plasma to diagnose hepatocellular ballooning in patients with non-alcoholic fatty liver disease: A multicenter study

AIM

Liver biopsy is still required for the diagnosis of hepatocellular ballooning and inflammation, which are important histological features of non-alcoholic steatohepatitis. We undertook this multicenter, cross-sectional study to identify novel blood markers for the diagnosis of hepatocellular ballooning.

METHODS

We enrolled 176 patients, of whom 132 were proven by liver biopsy as having non-alcoholic fatty liver disease (NAFLD) and classified as non-ballooning (ballooning grade 0) (n = 83) or ballooning (ballooning grade 1 and 2) (n = 49) by a central pathology review. We carried out gas chromatography-mass spectrometry, hydrophilic interaction liquid chromatography tandem mass spectrometry, and lipidomics with plasma.

RESULTS

As correlates of hepatocellular ballooning, among the clinical parameters, serum type IV collagen 7S correlated most significantly with the ballooning grade (correlation coefficient [CC] = 0.463; P < 0.001). Among the metabolic/lipidomic markers, phosphatidylcholine (PC) (aa-44:8) correlated most significantly with the ballooning grade (CC = 0.394; P < 0.001). The area under the receiver operating characteristic curve of type IV collagen 7S, choline, and lysophosphatidylethanolamine (LPE) (e-18:2), was 0.846 (95% confidence interval, 0.772-0.919).

CONCLUSIONS

Plasma levels of PC were positively correlated, and those of lysophosphatidylcholine and LPE were negatively correlated with hepatocellular ballooning in NAFLD patients. These non-invasive metabolic/lipidomic-based plasma tests might be useful to distinguish between cases of NAFLD with and without hepatocellular ballooning.

Comparative assessments of mortality from and morbidity of circulatory diseases in association with extreme temperatures

BACKGROUND

This study evaluated vulnerable subpopulation on mortality, emergency room visits (ERVs) and outpatient visits associated with ambient daily temperature from 2000 to 2014 using vital statistics and insurance claims of Taiwan.

METHODS

We used the distributed lag non-linear model to assess circulatory disease-specific deaths, ERVs, and outpatient visits by mean temperature after controlling particulate matter (PM₁₀) and other covariates. Lag effect of temperature changes on health risks accumulated for 0-10 days associated with low temperature and for 0-5 days for high temperature were evaluated. Cause-specific pooled relative risk (RR) and 95% confidence intervals (CI) were estimated for the whole population of Taiwan using random-effects meta-analysis.

RESULTS

We used reference temperatures of 60th percentiles for mortality from circulatory diseases, 99th percentile for ERVs of circulatory diseases, 2nd percentile for ERVs of heart diseases and ischemic heart disease, 53th percentile for ERVs of cerebrovascular disease, and 12-16th percentiles for outpatient visits of circulatory diseases. The lag effects peaked at lag 4-5 day for low temperature exposure and at lag 0 for high temperature exposure. Pooled cold related health risk was the highest for mortality from and ERV of circulatory diseases with RR of 1.41 (95% CI: 1.34, 1.49) and 1.41 (95% CI: 1.35, 1.48), respectively, as daily mean temperatures was at 1st percentile (12.8 °C). Heat related health risk was significant for mortality from heart diseases [RR = 1.12 (95% CI: 1.07, 1.18)] and ischemic heart diseases [RR = 1.13 (95% CI: 1.06, 1.20)] as daily mean temperatures was at 99th percentile (29.9 °C).

CONCLUSIONS

Health authority should evaluate the effectiveness of adaptive policy, strategy, and actions responding to extreme temperatures to prevent mortality from circulatory diseases.

Future increase in elderly heat-related mortality of a rapidly growing Asian megacity

Urban dwellers are at risk of heat-related mortality in the onset of climate change. In this study, future changes in heat-related mortality of elderly citizens were estimated while considering the combined effects of spatially-varying megacity’s population growth, urbanization, and climate change. The target area is the Jakarta metropolitan area of Indonesia, a rapidly developing tropical country. 1.2 × 1.2 km² daily maximum temperatures were acquired from weather model outputs for the August months from 2006 to 2015 (present 2010s) and 2046 to 2055 (future 2050s considering pseudo-global warming of RCP2.6 and RCP8.5). The weather model considers population-induced spatial changes in urban morphology and anthropogenic heating distribution. Present and future heat-related mortality was mapped out based on the simulated daily maximum temperatures. The August total number of heat-related elderly deaths in Jakarta will drastically increase by 12~15 times in the 2050s compared to 2010s because of population aging and rising daytime temperatures under “compact city” and “business-as-usual” scenarios. Meanwhile, mitigating climate change (RCP 2.6) could reduce the August elderly mortality count by up to 17.34%. The downwind areas of the densest city core and the coastal areas of Jakarta should be avoided by elderly citizens during the daytime.

Health Effects of Asian Dust: A Systematic Review and Meta-Analysis

BACKGROUND

Potential adverse health effects of Asian dust exposure have been reported, but systematic reviews and quantitative syntheses are lacking.

OBJECTIVE

We reviewed epidemiologic studies that assessed the risk of mortality, hospital admissions, and symptoms/dysfunction associated with exposure to Asian dust.

METHODS

We performed a systematic search of PubMed and Web of Science to identify studies that reported the association between Asian dust exposure and human health outcomes. We conducted separate meta-analyses using a random-effects model for mortality and hospital admissions for a specific health outcome and assessed pooled estimates for each lag when at least three studies were available for a specific lag.

RESULTS

We identified 89 studies that met our inclusion criteria for the systematic review, and 21 studies were included in the meta-analysis. The pooled estimates (percentage changes) of mortality from circulatory and respiratory causes for Asian dust days vs. non-Asian dust days were 2.33% [95% confidence interval (CI): 0.76, 3.93] increase at lag 0 and 3.99% (95% CI: 0.08, 8.06) increase at lag 3, respectively. The increased risk for hospital admissions for respiratory disease, asthma, and pneumonia peaked at lag 3 by 8.85% (95% CI: 0.80, 17.55), 14.55% (95% CI: 6.74, 22.94), and 8.51% (95% CI: 2.89, 14.44), respectively. Seven of 12 studies reported reduced peak expiratory flow, and 16 of 21 studies reported increased respiratory symptoms associated with Asian dust exposure. There were substantial variations between the studies in definitions of Asian dust, study designs, model specifications, and confounder controls.

DISCUSSION

We found evidence of increased mortality and hospital admissions for circulatory and respiratory events. However, the number of studies included in the meta-analysis was not large and further evidences are merited to strengthen our conclusions. Standardized protocols for epidemiological studies would facilitate interstudy comparisons. https://doi.org/10.1289/EHP5312.

Comparing the effectiveness of magnesium oxide and naldemedine in preventing opioid-induced constipation: a proof of concept, single institutional, two arm, open-label, phase II, randomized controlled trial: the MAGNET study

Background

Patients taking opioids are known to develop opioid-induced constipation (OIC), which reduces their quality of life. The aim of this study is to compare magnesium oxide with naldemedine and determine which is more effective in preventing OIC.

Methods

This proof-of-concept, prospective, randomized controlled trial commenced in Japan in March 2018. Initially, a questionnaire-based survey will be conducted targeting adult patients with cancer who concomitantly commenced opioid treatment and OIC prevention treatment. Patients will then be randomly allocated to a magnesium oxide group (500 mg thrice daily) or a naldemedine group (0.2 mg once daily). Each drug will be orally administered for 12 weeks. The primary endpoint is defined as any improvement in scores on the Japanese version of Patient Assessment of Constipation Quality of Life questionnaire (JPAC-QOL) from baseline to 2 weeks of treatment.

Discussion

The primary endpoint is change in JPAC-QOL score from baseline to 2 weeks of intervention. The key secondary endpoint will be change in spontaneous bowel movements at 2 and 12 weeks of intervention. This study will determine whether magnesium oxide or naldemedine is more effective for the prevention of OIC.

Trial registration

University Hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000031891. Registered March 25, 2018.

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

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

How urban characteristics affect vulnerability to heat and cold: a multi-country analysis

BACKGROUND

The health burden associated with temperature is expected to increase due to a warming climate. Populations living in cities are likely to be particularly at risk, but the role of urban characteristics in modifying the direct effects of temperature on health is still unclear. In this contribution, we used a multi-country dataset to study effect modification of temperature-mortality relationships by a range of city-specific indicators.

METHODS

We collected ambient temperature and mortality daily time-series data for 340 cities in 22 countries, in periods between 1985 and 2014. Standardized measures of demographic, socio-economic, infrastructural and environmental indicators were derived from the Organisation for Economic Co-operation and Development (OECD) Regional and Metropolitan Database. We used distributed lag non-linear and multivariate meta-regression models to estimate fractions of mortality attributable to heat and cold (AF%) in each city, and to evaluate the effect modification of each indicator across cities.

RESULTS

Heat- and cold-related deaths amounted to 0.54% (95% confidence interval: 0.49 to 0.58%) and 6.05% (5.59 to 6.36%) of total deaths, respectively. Several city indicators modify the effect of heat, with a higher mortality impact associated with increases in population density, fine particles (PM2.5), gross domestic product (GDP) and Gini index (a measure of income inequality), whereas higher levels of green spaces were linked with a decreased effect of heat.

CONCLUSIONS

This represents the largest study to date assessing the effect modification of temperature-mortality relationships. Evidence from this study can inform public-health interventions and urban planning under various climate-change and urban-development scenarios.

Air quality co-benefits from climate mitigation for human health in South Korea

Climate change mitigation efforts to reduce greenhouse gas (GHG) emissions have associated costs, but there are also potential benefits from improved air quality, such as public health improvements and the associated cost savings. A multidisciplinary modeling approach can better assess the co-benefits from climate mitigation for human health and provide a justifiable basis for establishment of adequate climate change mitigation policies and public health actions. An integrated research framework was adopted by combining a computable general equilibrium model, an air quality model, and a health impact assessment model, to explore the long-term economic impacts of climate change mitigation in South Korea through 2050. Mitigation costs were further compared with health-related economic benefits under different socioeconomic and climate change mitigation scenarios. Achieving ambitious targets (i.e., stabilization of the radiative forcing level at 3.4 W/m²) would cost 1.3-8.5 billion USD in 2050, depending on varying carbon prices from different integrated assessment models. By contrast, achieving these same targets would reduce costs by 23 billion USD from the valuation of avoided premature mortality, 0.14 billion USD from health expenditures, and 0.38 billion USD from reduced lost work hours, demonstrating that health benefits alone noticeably offset the costs of cutting GHG emissions in South Korea.

Short term association between ozone and mortality: global two stage time series study in 406 locations in 20 countries

OBJECTIVE

To assess short term mortality risks and excess mortality associated with exposure to ozone in several cities worldwide.

DESIGN

Two stage time series analysis.

SETTING

406 cities in 20 countries, with overlapping periods between 1985 and 2015, collected from the database of Multi-City Multi-Country Collaborative Research Network.

POPULATION

Deaths for all causes or for external causes only registered in each city within the study period. MAIN OUTCOME MEASURES: Daily total mortality (all or non-external causes only).

RESULTS

A total of 45 165 171 deaths were analysed in the 406 cities. On average, a 10 µg/m³ increase in ozone during the current and previous day was associated with an overall relative risk of mortality of 1.0018 (95% confidence interval 1.0012 to 1.0024). Some heterogeneity was found across countries, with estimates ranging from greater than 1.0020 in the United Kingdom, South Africa, Estonia, and Canada to less than 1.0008 in Mexico and Spain. Short term excess mortality in association with exposure to ozone higher than maximum background levels (70 µg/m³) was 0.26% (95% confidence interval 0.24% to 0.28%), corresponding to 8203 annual excess deaths (95% confidence interval 3525 to 12 840) across the 406 cities studied. The excess remained at 0.20% (0.18% to 0.22%) when restricting to days above the WHO guideline (100 µg/m³), corresponding to 6262 annual excess deaths (1413 to 11 065). Above more lenient thresholds for air quality standards in Europe, America, and China, excess mortality was 0.14%, 0.09%, and 0.05%, respectively.

CONCLUSIONS

Results suggest that ozone related mortality could be potentially reduced under stricter air quality standards. These findings have relevance for the implementation of efficient clean air interventions and mitigation strategies designed within national and international climate policies.

NO-mediated activation of KATP channels contributes to cutaneous thermal hyperemia in young adults

Local skin heating to 42°C causes cutaneous thermal hyperemia largely via nitric oxide (NO) synthase (NOS)-related mechanisms. We assessed the hypothesis that ATP-sensitive K⁺ (K_ATP) channels interact with NOS to mediate cutaneous thermal hyperemia. In 13 young adults (6 women, 7 men), cutaneous vascular conductance (CVC) was measured at four intradermal microdialysis sites that were continuously perfused with 1) lactated Ringer solution (control), 2) 5 mM glibenclamide (K_ATP channel blocker), 3) 20 mM N^G-nitro-l-arginine methyl ester (NOS inhibitor), or 4) a combination of K_ATP channel blocker and NOS inhibitor. Local skin heating to 42°C was administered at all four treatment sites to elicit cutaneous thermal hyperemia. Thirty minutes after the local heating, 1.25 mM pinacidil (K_ATP channel opener) and subsequently 25 mM sodium nitroprusside (NO donor) were administered to three of the four sites (each 25-30 min). The local heating-induced prolonged elevation in CVC was attenuated by glibenclamide (19%), but the transient initial peak was not. However, glibenclamide had no effect on the prolonged elevation in CVC in the presence of NOS inhibition. Pinacidil caused an elevation in CVC, but this response was abolished at the glibenclamide-treated skin site, demonstrating its effectiveness as a K_ATP channel blocker. The pinacidil-induced increase in CVC was unaffected by NOS inhibition, whereas the increase in CVC elicited by sodium nitroprusside was partly (15%) inhibited by glibenclamide. In summary, we showed an interactive effect of K_ATP channels and NOS for the plateau of cutaneous thermal hyperemia. This interplay may reflect a vascular smooth muscle cell K_ATP channel activation by NO.

Nasogastric Tube Feeding Versus Total Parenteral Nutrition in Older Dysphagic Patients with Pneumonia: Retrospective Cohort Study

OBJECTIVES

Many older patients with pneumonia cannot intake orally after admission and may need nutritional care such as nasogastric tube feeding or total parenteral nutrition. This study sought to compare in-hospital outcomes between patients receiving nasogastric tube feeding and total parenteral nutrition.

DESIGN

This is a retrospective cohort study.

SETTING

A hospital-based database constructed by the Diagnosis Procedure Combination survey data comprising more than 100 acute-care hospitals.

PARTICIPANTS

The study included consecutive older inpatients aged >65 years admitted to participating hospitals with a diagnosis of pneumonia from 2014 through 2017.

MEASUREMENTS

We compared patients who received total parenteral nutrition and those who received nasogastric tube feeding in terms of characteristics and outcomes.

RESULTS

Among the included inpatients, a total of 336 (73.2%) patients received total parenteral nutrition and 123 (26.8%) patients received nasogastric tube feeding. Patients with nasogastric tube feeding had less in-hospital mortality (13.8% vs 27.1%, p = 0.003) and a smaller number of complications (mean; 0.71 vs 1.44, p <0.001), shorter length of hospital stay (mean; 27.6 vs 48.9, p <0.001), more discharges home (72.4% vs 35.1%, p <0.001), and more discharges without oral intake (65.9% vs 45.8%, p <0.001) than patients with total parenteral nutrition. The same results were obtained in propensity score analysis.

CONCLUSIONS

Older patients with pneumonia treated with total parenteral nutrition were significantly more likely to have higher in-hospital mortality than those receiving nasogastric tube feeding.

Effect of tofogliflozin and pioglitazone on hepatic steatosis in non-alcoholic fatty liver disease patients with type 2 diabetes mellitus: A randomized, open-label pilot study (ToPiND study)

Background

The incidence of nonalcoholic fatty liver disease (NAFLD) has increased recently and is related to obesity and the associated surge in type 2 diabetes mellitus (DM) and metabolic syndrome diagnoses. We aim to compare the effectiveness of tofogliflozin and pioglitazone treatment on hepatic steatosis in patients with NAFLD with type 2 DM.

Methods

This is an open label, prospective, randomized exploratory study. Patients who meet the inclusion criteria and do not meet any exclusion criteria will undergo magnetic resonance imaging (MRI)-based proton density fat fraction (MRI-PDFF). Patients with ≥10% liver fat content on MRI-PDFF will be randomly assigned to receive tofogliflozin 20 mg per day (n = 20) or pioglitazone 15–30 mg per day (n = 20). MRI will be performed after 24 weeks following initiation of medication therapy. Then, patients will take tofogliflozin and pioglitazone in combination in both groups for 24 weeks. MRI will be performed again at 48 weeks (24 weeks after initiation medication in combination).

Results

Our study's primary endpoint will be change in hepatic steatosis measured by MRI-PDFF at 24 weeks after medication therapy. The secondary endpoint will be change in alanine aminotransferase at 24 weeks of medication therapy and the main exploratory endpoint will be changes in liver fat content and liver sclerosis at 48 weeks of medication.

Conclusions

We will compare the effectiveness of tofogliflozin and pioglitazone treatment using MRI for improving hepatic steatosis in patients with NAFLD complicated by DM and investigate if the combination of these two medications is effective for treating NAFLD.

Trial registration

This trial is registered in the Japan Registry of Clinical Trials (jRCTs031180159).

Protocol version

1.2, 14 December 2018.

Synergic effect between high temperature and air pollution on mortality in Northeast Asia

High temperature and air pollutants have been reported as potential risk factors of mortality. Previous studies investigated interaction between the two variables; however, the excess death risk due to the synergic effect (i.e. interaction on the additive scale) between the two variables has not been investigated adequately on a multi-country scale. This study aimed to assess the excess death risk due to the synergism between high temperature and air pollution on mortality using a multicity time-series analysis. We collected time-series data on mortality, weather variables, and four air pollutants (PM₁₀, O₃, NO₂, and CO) for 16 metropolitan cities of three countries (Japan, Korea, and Taiwan) in Northeast Asia (1979-2015). Quasi-Poisson time-series regression and meta-analysis were used to estimate the additive interaction between high temperature and air pollution. The additive interaction was measured by relative excess risk due to interaction (RERI) index. We calculated RERI with relative risks (RR) of the 99th/10th, 90th/90th, and 99th/90th percentiles of temperature/air pollution metrics, where risk at the 90th/10th percentiles of temperature/air pollution metrics was the reference category. This study showed that there may exist positive and significant excess death risks due to the synergism between high temperature and air pollution in the total population for all pollutants (95% lower confidence intervals of all RERIs>0 or near 0). In final, we measured quantitatively the excess death risks due to synergic effect between high temperature and air pollution, and the synergism should be considered in public health interventions and a composite warning system.

Suicide and Ambient Temperature: A Multi-Country Multi-City Study

BACKGROUND

Previous literature suggests that higher ambient temperature may play a role in increasing the risk of suicide. However, no multi-country study has explored the shape of the association and the role of moderate and extreme heat across different locations.

OBJECTIVES

We examined the short-term temperature-suicide relationship using daily time-series data collected for 341 locations in 12 countries for periods ranging from 4 to 40 y.

METHODS

We conducted a two-stage meta-analysis. First, we performed location-specific time-stratified case-crossover analyses to examine the temperature-suicide association for each location. Then, we used a multivariate meta-regression to combine the location-specific lag-cumulative nonlinear associations across all locations and by country.

RESULTS

A total of 1,320,148 suicides were included in this study. Higher ambient temperature was associated with an increased risk of suicide in general, and we observed a nonlinear association (inverted J-shaped curve) with the highest risk at 27°C. The relative risk (RR) for the highest risk was 1.33 (95% CI: 1.30, 1.36) compared with the risk at the first percentile. Country-specific results showed that the nonlinear associations were more obvious in northeast Asia (Japan, South Korea, and Taiwan). The temperature with the highest risk of suicide ranged from the 87th to 88th percentiles in the northeast Asian countries, whereas this value was the 99th percentile in Western countries (Canada, Spain, Switzerland, the UK, and the United States) and South Africa, where nearly linear associations were estimated. The country-specific RRs ranged from 1.31 (95% CI: 1.19, 1.44) in the United States to 1.65 (95% CI: 1.40, 1.93) in Taiwan, excluding countries where the results were substantially uncertain.

DISCUSSION

Our findings showed that the risk of suicide increased with increasing ambient temperature in many countries, but to varying extents and not necessarily linearly. This temperature-suicide association should be interpreted cautiously, and further evidence of the relationship and modifying factors is needed. https://doi.org/10.1289/EHP4898.

Predicted temperature-increase-induced global health burden and its regional variability

An increase in the global health burden of temperature was projected for 459 locations in 28 countries worldwide under four representative concentration pathway scenarios until 2099. We determined that the amount of temperature increase for each 100 ppm increase in global CO₂ concentrations is nearly constant, regardless of climate scenarios. The overall average temperature increase during 2010-2099 is largest in Canada (1.16 °C/100 ppm) and Finland (1.14 °C/100 ppm), while it is smallest in Ireland (0.62 °C/100 ppm) and Argentina (0.63 °C/100 ppm). In addition, for each 1 °C temperature increase, the amount of excess mortality is increased largely in tropical countries such as Vietnam (10.34%p/°C) and the Philippines (8.18%p/°C), while it is decreased in Ireland (-0.92%p/°C) and Australia (-0.32%p/°C). To understand the regional variability in temperature increase and mortality, we performed a regression-based modeling. We observed that the projected temperature increase is highly correlated with daily temperature range at the location and vulnerability to temperature increase is affected by health expenditure, and proportions of obese and elderly population.

Autotaxin is a valuable biomarker for the prediction of liver fibrosis in patients with non-alcoholic fatty liver disease

AIM

We investigated the characteristics of serum autotaxin (ATX) and its diagnostic performance for liver fibrosis in a large cohort of patients with non-alcoholic fatty liver disease (NAFLD).

METHODS

We compared the usefulness of ATX and other fibrosis markers in 307 biopsy-confirmed NAFLD patients. In addition, in 145 participants with NAFLD, we compared the diagnostic performance of ATX with that of non-invasive imaging methods (vibration-controlled transient elastography and magnetic resonance elastography [MRE]).

RESULTS

Serum ATX concentration was significantly correlated with fibrosis stage in male and female NAFLD patients. In male patients, the area under the receiver operating characteristic (AUROC) curve values of ATX for the diagnosis of ≥stage 1, ≥stage 2, ≥stage 3, and ≥stage 4 fibrosis were 0.65, 0.75, 0.81, and 0.95, respectively. In female NAFLD participants, the AUROC values were all >0.81. The sensitivity of ATX was highest for the diagnosis of ≥stage 2 and ≥stage 3 fibrosis in both men and women with NAFLD. In the comparison between ATX and non-invasive imaging methods, the AUROC for MRE was the highest at every stage of fibrosis.

CONCLUSIONS

Serum ATX concentration is significantly correlated with fibrosis stage in NAFLD patients. The diagnostic accuracy of ATX for liver fibrosis is lower than that of MRE, but the sensitivities of ATX for the diagnosis of ≥stage 2 and ≥stage 3 were highest. We conclude that ATX is useful for the selection of patients requiring further evaluation for liver fibrosis.

Future projections of temperature-related excess out-of-hospital cardiac arrest under climate change scenarios in Japan

BACKGROUND

Recent studies have reported associations between global climate change and mortality. However, future projections of temperature-related out-of-hospital cardiac arrest (OHCA) have not been thoroughly evaluated. Thus, we aimed to project temperature-related morbidity for OHCA concomitant with climate change.

METHODS

We collected national registry data on all OHCA cases reported in 2005-2015 from all 47 Japanese prefectures. We used a two-stage time series analysis to estimate temperature-OHCA relationships. Time series of current and future daily mean temperature variations were constructed according to four climate change scenarios of representative concentration pathways (RCPs) using five general circulation models. We projected excess morbidity for heat and cold and the net change in 1990-2099 for each climate change scenario using the assumption of no adaptation or population changes.

RESULTS

During the study period, 739,717 OHCAs of presumed cardiac origin were reported. Net decreases in temperature-related excess morbidity were observed under higher emission scenarios. The net change in 2090-2099 compared with 2010-2019 was -0.8% (95% empirical confidence interval [eCI]: -1.9, 0.1) for a mild emission scenario (RCP2.6), -2.6% (95% eCI: -4.4, -0.8) for a stabilization scenario (RCP4.5), -3.4% (95% eCI: -5.7, -1.0) for a stabilization scenario (RCP6.0), and - 4.2% (95% eCI: -8.3, -0.1) for an extreme emission scenario (RCP8.5).

CONCLUSIONS

Our study indicates that Japan is projected to experience a substantial net reduction in OHCAs in higher-emission scenarios. The decrease in risk is limited to a specific morbidity cause, and a broader assessment within climate change scenarios should consider other direct and indirect impacts.

Functional analysis of a novel G87V TNFRSF1A mutation in patients with TNF receptor-associated periodic syndrome

Tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS) is an autoinflammatory disease that is caused by heterozygous mutations in the TNFRSF1A gene. Although more than 150 TNFRSF1A mutations have been reported to be associated with TRAPS phenotypes only a few, such as p.Thr79Met (T79M) and cysteine mutations, have been functionally analyzed. We identified two TRAPS patients in one family harboring a novel p.Gly87Val (G87V) mutation in addition to a p.Thr90Ile (T90I) mutation in TNFRSF1A. In this study, we examined the functional features of this novel G87V mutation. In-vitro analyses using mutant TNF receptor 1 (TNF-R1)-over-expressing cells demonstrated that this mutation alters the expression and function of TNF-R1 similar to that with the previously identified pathogenic T79M mutation. Specifically, cell surface expression of the mutant TNF-R1 in transfected cells was inhibited with both G87V and T79M mutations, whereas the T90I mutation did not affect this. Moreover, peripheral blood mononuclear cells (PBMCs) from TRAPS patients harboring the G87V and T90I mutations showed increased mitochondrial reactive oxygen species (ROS). Furthermore, the effect of various Toll-like receptor (TLR) ligands on inflammatory responses was explored, revealing that PBMCs from TRAPS patients are hyper-responsive to TLR-2 and TLR-4 ligands and that interleukin (IL)-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF) are likely to be involved in the pathogenesis of TRAPS. These findings suggest that the newly identified G87V mutation is one of the causative mutations of TRAPS. Our findings based on unique TRAPS-associated mutations provide novel insight for clearer understanding of inflammatory responses, which would be basic findings of developing a new therapeutic and prophylactic approach to TRAPS.

The Role of Humidity in Associations of High Temperature with Mortality: A Multicountry, Multicity Study

BACKGROUND

There is strong experimental evidence that physiologic stress from high temperatures is greater if humidity is higher. However, heat indices developed to allow for this have not consistently predicted mortality better than dry-bulb temperature.

OBJECTIVES

We aimed to clarify the potential contribution of humidity an addition to temperature in predicting daily mortality in summer by using a large multicountry dataset.

METHODS

In 445 cities in 24 countries, we fit a time-series regression model for summer mortality with a distributed lag nonlinear model (DLNM) for temperature (up to lag 3) and supplemented this with a range of terms for relative humidity (RH) and its interaction with temperature. City-specific associations were summarized using meta-analytic techniques.

RESULTS

Adding a linear term for RH to the temperature term improved fit slightly, with an increase of 23% in RH (the 99th percentile anomaly) associated with a 1.1% [95% confidence interval (CI): 0.8, 1.3] decrease in mortality. Allowing curvature in the RH term or adding terms for interaction of RH with temperature did not improve the model fit. The humidity-related decreased risk was made up of a positive coefficient at lag 0 outweighed by negative coefficients at lags of 1-3 d. Key results were broadly robust to small model changes and replacing RH with absolute measures of humidity. Replacing temperature with apparent temperature, a metric combining humidity and temperature, reduced goodness of fit slightly.

DISCUSSION

The absence of a positive association of humidity with mortality in summer in this large multinational study is counter to expectations from physiologic studies, though consistent with previous epidemiologic studies finding little evidence for improved prediction by heat indices. The result that there was a small negative average association of humidity with mortality should be interpreted cautiously; the lag structure has unclear interpretation and suggests the need for future work to clarify. https://doi.org/10.1289/EHP5430.

Ambient Particulate Air Pollution and Daily Mortality in 652 Cities

BACKGROUND

The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias.

METHODS

We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 μm or less (PM₁₀) and fine PM with an aerodynamic diameter of 2.5 μm or less (PM_2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived.

RESULTS

On average, an increase of 10 μg per cubic meter in the 2-day moving average of PM₁₀ concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM_2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations.

CONCLUSIONS

Our data show independent associations between short-term exposure to PM₁₀ and PM_2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).

Distribution of liver stiffness in non-alcoholic fatty liver disease with higher fibrosis-4 index than low cut-off index

BACKGROUND AND AIM

In the condition of high prevalence of non-alcoholic fatty liver disease (NAFLD), a new diagnostic algorithm to efficiently identify NAFLD patients with significant fibrosis is urgently required. We evaluated the predictive ability of the fibrosis-4 index (FIB-4 index) for significant liver fibrosis (F ≥ 2) in a cohort of Japanese patients with NAFLD.

METHODS

We prospectively calculated the FIB-4 index in patients who were incidentally diagnosed as fatty liver in medical checkups and then conducted liver stiffness measurement by vibration-controlled transient elastography (VCTE) only in patients in whom the FIB-4 index was more than the low cut-off index (> 1.45).

RESULTS

Of the 5929 people who underwent medical checkups, a total of 1374 people were identified as having fatty liver. Among these, we performed VCTE in 106 patients in whom the FIB-4 index was higher than 1.45. The distribution of the fibrosis stage as estimated by VCTE in the patients was as follows: F0, 52.8%; F1, 10.3%; F2, 21.6%; F3, 11.3%; and F4, 3.7%. The positive predictive value of the FIB-4 index for detecting NAFLD with significant fibrosis was 36.6%. The minimum value of the FIB-4 index was constant for each estimated fibrosis stage.

CONCLUSIONS

This is the first prospective study to evaluate the usefulness of the FIB-4 index as the first step to screen NAFLD patients with significant fibrosis. In Japan, addition of one further step that combined with the FIB-4 index is necessary to meaningfully reduce the number of patients needing liver stiffness measurement or liver biopsy.

Assessment of 10-year changes in liver stiffness using vibration-controlled transient elastography in non-alcoholic fatty liver disease

AIM

Although liver biopsy is the gold standard for the diagnosis and staging of non-alcoholic fatty liver disease (NAFLD), repeated assessment of patients' liver tissue conditions are impractical. We assessed the 10-year changes in liver stiffness measurements (LSM) utilizing vibration-controlled transient elastography in NAFLD patients.

METHODS

From January 2006 to September 2007, LSM was carried out for 97 biopsy-proven NAFLD patients. Of these, 34 patients underwent 10-year LSM reassessments (14 of them with paired biopsies).

RESULTS

We evaluated the changes in the fibrosis stage as estimated using LSM (FS-LSM). Over a 10-year period, 32.4% had FS-LSM progression, 50% had static disease, and 17.6% had FS-LSM improvement. From among the initially diagnosed non-alcoholic steatohepatitis patients, 18% had progressed to considerable stage 4 (cirrhosis) 10 years later. In this cohort, none of the patients who had been initially diagnosed as FS-LSM stage 0 had progressed to cirrhosis 10 years later. The changes in LSM were correlated with the change in the histological fibrosis stage, the NAFLD activity score, and the change in the sum of the steatosis, activity, and fibrosis score. Improving more than 1 body mass index (kg/m² ) and having a higher initial aspartate aminotransferase, alanine aminotransferase (ALT), or ALT responder (>30% improvement or reduction to less than 40 IU/L) were factors contributing to LSM improvements (≥2 kPa).

CONCLUSIONS

Vibration-controlled transient elastography is likely to become a more clinically important tool for the long-term monitoring of NAFLD patients.

Brønsted Acid-Initiated Formal [1,3]-Rearrangement Dictated by β-Substituted Ene-Aldimines

The rearrangement of ene-aldimines is a useful reaction for affording homoallylic amines. Despite their utilities in synthetic chemistry, the rearrangement for accessing homoallylic amines substituted at the 2-position remains elusive. In this study, the Brønsted acid-initiated formal [1,3]-rearrangement of ene-aldimines was developed to synthesize 2,4,4-substituted homoallylic amines that were otherwise inaccessible previously. Our study reveals an intermolecular pathway in which the rearrangement proceeds via a protonation-mediated 2-azaallenium cation.

Modeling Future Projections of Temperature-Related Excess Morbidity due to Infectious Gastroenteritis under Climate Change Conditions in Japan

BACKGROUND

Climate change has marked implications for the burden of infectious diseases. However, no studies have estimated future projections of climate change–related excess morbidity due to diarrhea according to climate change scenarios.

OBJECTIVES

We aimed to examine temperature-infectious gastroenteritis associations throughout Japan and project temperature-related morbidity concomitant with climate change for the 2090s.

METHODS

Weekly time series of average temperature and morbidity for infectious gastroenteritis cases in the period 2005-2015 were collated from the 47 Japanese prefectures. A two-stage time-series analysis was adopted to estimate temperature-infectious gastroenteritis relationships. Time series of present and future average daily temperature fluctuations were projected for the four climate change scenarios of representative concentration pathways (RCPs) according to five general circulation models. Excess morbidity for high and low temperatures and the net change in the period 1990–2099 were projected for each climate change scenario by assuming the absence of adaptation and population alterations.

RESULTS

In the period 2005–2015, 11,529,833 infectious gastroenteritis cases were reported. There were net reductions in temperature-induced excess morbidity under higher emission scenarios. The net change in the projection period 2090-2099 in comparison with 2010–2019 was [Formula: see text] (95% empirical confidence interval [eCI]: [Formula: see text], 0.5) for RCP2.6, [Formula: see text] (95% eCI: [Formula: see text], [Formula: see text]) for RCP4.5, [Formula: see text] (95% eCI: [Formula: see text], [Formula: see text]) for RCP6.0, and [Formula: see text] (95% eCI: [Formula: see text], [Formula: see text]) for RCP8.5, and the higher the emissions scenario, the larger the estimates reductions. Spatial heterogeneity in the temperature-morbidity relationship was observed among prefectures (Cochran Q test, [Formula: see text]; [Formula: see text]).

CONCLUSIONS

Japan may experience a net reduction in temperature-related excess morbidity due to infectious gastroenteritis in higher emission scenarios. These results might be because the majority of temperature-related diarrhea cases in Japan are attributable to viral infections during the winter season. Further projections of specific pathogen-induced infectious gastroenteritis due to climate change are warranted. https://doi.org/10.1289/EHP4731.

Highly Planar and Completely Insulated Oligothiophenes: Effects of π-Conjugation on Hopping Charge Transport

Elucidating the nature of long-range intramolecular charge transport in π-conjugated molecules is of great importance for the development of organic electronic materials. However, the effects of the degree of π-conjugation on the hopping charge transport have not been experimentally explored so far owing to the lack of π-conjugated backbones with different conjugation degrees and several-nanometer lengths. Here we develop highly planar and completely insulated oligothiophenes between 0.85 and 9.64 nm in length. As compared to distorted oligothiophenes, single-molecule conductance measurements of the planar molecules show (i) a smaller activation energy and larger electrical conductance in the hopping transport regime and (ii) a shift in crossover between tunneling and hopping conduction toward a short molecular length. Theoretical calculations indicate that small reorganization energies and narrow energy gaps derived from the planar backbones result in these superior characteristics. This study reveals that the planarity of π-conjugation has significant advantages for hopping charge transport.

Site-specific hourly resolution wet bulb globe temperature reconstruction from gridded daily resolution climate variables for planning climate change adaptation measures

Changes in the environmental heat stress need to be properly evaluated to manage the risk of heat-related illnesses, particularly in the context of climate change. The wet bulb globe temperature (WBGT) is a useful index for evaluating heat stress and anticipating conditions related to heat-related illness in the present climate, but projecting the WBGT with a sufficiently high temporal and spatial resolution remains challenging for future climate conditions. In this study, we developed a methodological framework for estimating the site-specific hourly resolution WBGT based on the output of general circulation models using only simple calculations. The method was applied to six sites in Japan and its performance was evaluated. The proposed method could reproduce the site-specific hourly resolution WBGT with a high accuracy. Based on the developed framework, we constructed future (2090s) projections under two different greenhouse gas emission pathways. These projections showed a consistent rise in the WBGT and thus the capacity to perform physically demanding activities is expected to decrease. To demonstrate the usefulness of the projected WBGT in planning adaptation measures, we identified the optimal working schedules which would minimize outdoor workers' exposure to heat at a specific site. The results show that a substantial shift in the working time is required in the future if outdoor workers are to compensate the effect of increased heat exposure only by changing their working hours. This methodological framework and the projections will provide local practitioners with useful information to manage the increased risk of heat stress under climate change.

The association between temperature variability and cause-specific mortality: Evidence from 47 Japanese prefectures during 1972-2015

BACKGROUND

In the context of climate change, extreme temperature events are known to be associated with increased mortality risk. However, data about the mortality risk related to temperature variability (TV) accounting for both intra- and inter-day variations in temperature are limited.

OBJECTIVES

The present study aims to quantify the associations between TV and cause-specific mortality in Japan, evaluate whether the effects of TV are modified by prefecture-level characteristics and examine the temporal trend in mortality risk of TV.

METHODS

Data on daily all-cause and 11 cause-specific mortality and meteorological variables in 47 Japanese prefectures from 1972 to 2015 were collected. TV was defined as the standard deviation of daily minimum and maximum temperatures during exposure days. A quasi-Poisson regression model combined with a distributed lag non-linear model was firstly applied to assess the prefecture-specific mortality effects of TV, adjusting for potential confounders. The pooled effects of TV at the national level were then obtained via a meta-analysis through the restricted maximum-likelihood estimation. Potential effect modification by prefecture characteristics was firstly examined using a meta-regression analysis, and the joint modification of season and humidity was then evaluated after including product terms in two-stage analyses. Finally, the temporal trend in TV effects was evaluated by a random-effect meta regression model after obtaining the prefecture-year-specific effects.

RESULTS

TV had significant adverse effects on all-cause and cause-specific mortality. The effects of TV were more detrimental to those with asthma and senility. In general, the estimates of mortality risk increased with longer exposure days. A 1 °C increase in TV at 0-7 days of exposure was associated with a 0.9% (95% confidence intervals: 0.82%-0.98%) increase in all-cause mortality. All-cause mortality risk of TV showed a decreasing trend during our study period. TV effects were larger in densely populated prefectures and on warm and humid days.

CONCLUSIONS

TV-related death is a significant issue in Japan that requires effective interventions.

Precision Analysis of the ^{136}Xe Two-Neutrino ββ Spectrum in KamLAND-Zen and Its Impact on the Quenching of Nuclear Matrix Elements

We present a precision analysis of the ^{136}Xe two-neutrino ββ electron spectrum above 0.8 MeV, based on high-statistics data obtained with the KamLAND-Zen experiment. An improved formalism for the two-neutrino ββ rate allows us to measure the ratio of the leading and subleading 2νββ nuclear matrix elements (NMEs), ξ_{31}^{2ν}=-0.26_{-0.25}^{+0.31}. Theoretical predictions from the nuclear shell model and the majority of the quasiparticle random-phase approximation (QRPA) calculations are consistent with the experimental limit. However, part of the ξ_{31}^{2ν} range allowed by the QRPA is excluded by the present measurement at the 90% confidence level. Our analysis reveals that predicted ξ_{31}^{2ν} values are sensitive to the quenching of NMEs and the competing contributions from low- and high-energy states in the intermediate nucleus. Because these aspects are also at play in neutrinoless ββ decay, ξ_{31}^{2ν} provides new insights toward reliable neutrinoless ββ NMEs.

[A Case of Malignant Ameloblastoma Associated with Uncontrollable Hypercalcemia]

Approximately 20-30% of cancers are associated with hypercalcemia, and this is a complication often encountered in cancer care. Hypercalcemia causes disorders such as disturbance of consciousness and, in severe cases, kidney failure and even death. In this report, we present a case of malignant ameloblastoma associated with uncontrollable hypercalcemia followed by a life-threatening disease course. In this case, hypercalcemia shortened the period of home care, and the medical staff could have extended this period by acquiring knowledge that leads to early detection and better control of hypercalcemia. In addition, the choice of the place for end-of-life care may have been expanded by considering the treatment of not only the malignant tumor but also hypercalcemia as its complication.

[Retrospective Observational Study on Chemical Coping]

Chemical coping also has an idea that it is an early stage of abuse and dependence of opioids, it is important to grasp the frequency, complaints, and risk factors of chemical coping. In this study, observational research was performed backwardly with 549 people using opioids who were newly requested to the palliative care team. Results revealed that 13 of 549 patients (2.4%)were diagnosed with chemical coping. In terms of a breakdown of the complaint, and it was following rate and reasons, 6 people(46%)felt easy, 2 people(15%)were anxious, 2 people(15%)could sleep, 2 people(15%)had unknown reasons, and 1(8%)was calm. Characteristics of each patient diagnosed with chemical coping included frequent psychiatric symptoms such as life expectancy of 3 months, opioid oral administration period of 1 year or more, disease incidence period of 1 year or more, anxiety, delirium, and depression. One benign disease also confirmed the transition to opioid dependence.

Abstract P4-08-16: Validation of the AJCC eighth edition prognostic stage compared with the anatomic stage for breast cancer with a Japanese single-institutional cohort

Background: The American Joint Committee for Cancer (AJCC) 8th edition cancer staging system for breast cancer incorporated biologic factors in addition to the 7th edition anatomic stage. We analyzed how the new AJCC 8th edition prognostic stage refined its stratification compared with the anatomic stage.

Methods: We reviewed the data of 4,134 patients with stage I to III breast cancer who underwent surgery at Tokyo Metropolitan Komagome Hospital between 2000 and 2016. The anatomic stage and prognostic stage were re-staged according to the AJCC 8th edition staging manual. Patients who received neoadjuvant chemotherapy or had bilateral breast cancer and those with unknown clinicopathologic factors were excluded. The 21-gene Oncotype DX breast recurrence score was not used for staging in this study.

Results: A total of 2,469 patients with a median follow-up of 4.7 years (range 0.1-15.5 years) were identified. According to the anatomic stage, there were 1,259 patients of stage IA, 132 of IB, 591 of IIA, 206 of IIB, 130 of IIIA, 14 of IIIB and 73 of IIIC. According to the prognostic stage, there were 1,610 patients of stage IA, 331 of IB, 236 of IIA, 73 of IIB, 85 of IIIA, 43 of IIIB and 27 of IIIC. Sixty-four patients (2.6%) could not be assigned using the new staging system for the presence of micrometastases in lymph nodes with tumors larger than 2 cm. The 5-year disease-free survival (DFS) rates according to the anatomic stage were 97.4% for stage IA, 97.1% for IB, 95.8% for IIA, 86.5% for IIB, 77.9% for IIIA, 49.2% for IIIB and 54.9% for IIIC. According to the prognostic stage, the 5-year DFS rates were 97.9% for stage IA, 92.9% for IB, 91.2% for IIA, 79.8% for IIB, 67.4% for IIIA, 53.3% for IIIB and 38.7% for IIIC. Compared with the AJCC anatomic stage, the prognostic stage was increased in 148 patients (6.2%) and decreased in 808 patients (32.8%). For those in whom the stage changed, the change was by one stage up or down in 463 (19.3%), by 2 stages up or down in 401 (16.7%) and by 3 stages up or down in 92 (3.8%). Of the 1,842 patients with hormone receptor (HR)-positive and human epidermal growth factor 2 (HER2)-negative (HR+/HER2-) disease, 40.5% (745/1842) of cases were downstaged, and 0.7% (1/1842) were upstaged.

Discussion: The AJCC 8th edition prognostic staging system provided more refined stratification than the anatomic stage. In the Japanese cohort, the proportion of the downstaging rate was higher than the upstaging rate, and the prognostic evaluation of HR+ patients in particular was improved.

Citation Format: Miyamoto H, Saita C, Onishi M, Goto R, Iwamoto N, Honda Y, Aruga T. Validation of the AJCC eighth edition prognostic stage compared with the anatomic stage for breast cancer with a Japanese single-institutional cohort [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 P4-08-16.

Effects of Extreme Temperatures on Mortality and Hospitalization in Ho Chi Minh City, Vietnam

There is a lack of research focusing on the association of temperature with mortality and hospitalization in developing countries with tropical climates and a low capacity to cope with the influences of extreme weather events. This study aimed to examine and compare the effect of temperature, including heat waves, on mortality and hospitalization in the most populous city of Vietnam. We used quasi-Poisson time series regression coupled with the distributed lag non-linear model (DLNM) to examine the overall pattern and compare the temperature-health outcome relationship. The main and added effects of heat waves were evaluated. The main effect of heat waves significantly increased the risk of all cause-specific mortality. Significant main effects of heat waves on hospitalization were observed only for elderly people and people with respiratory diseases (elderly, relative risk (RR) = 1.28, 95% confidence interval (CI) = 1.14–3.45; respiratory diseases, RR = 1.3, 95% CI = 1.19–1.42). The RRs of the main effect were substantially higher than those of the added effect in mortality; the same was applicable for hospitalizations of people with respiratory diseases and elderly people. The findings of this study have important implications for public health adaptation and prevention program implementation in the protection of residents from the adverse health effects of temperature.

Carotid chemoreceptors have a limited role in mediating the hyperthermia-induced hyperventilation in exercising humans

Hyperthermia causes hyperventilation at rest and during exercise. We previously reported that carotid chemoreceptors partly contribute to the hyperthermia-induced hyperventilation at rest. However, given that a hyperthermia-induced hyperventilation markedly differs between rest and exercise, the results obtained at rest may not be representative of the response in exercise. Therefore, we evaluated whether carotid chemoreceptors contribute to hyperthermia-induced hyperventilation in exercising humans. Eleven healthy young men (23 ± 2 yr) cycled in the heat (37°C) at a fixed submaximal workload equal to ~55% of the individual's predetermined peak oxygen uptake (moderate intensity). To suppress carotid chemoreceptor activity, 30-s hyperoxia breathing (100% O₂) was performed at rest (before exercise) and during exercise at increasing levels of hyperthermia as defined by an increase in esophageal temperature of 0.5°C (low), 1.0°C (moderate), 1.5°C (high), and 2.0°C (severe) above resting levels. Ventilation during exercise gradually increased as esophageal temperature increased (all P ≤ 0.05), indicating that hyperthermia-induced hyperventilation occurred. Hyperoxia breathing suppressed ventilation in a greater manner during exercise (-9 to -13 l/min) than at rest (-2 ± 1 l/min); however, the magnitude of reduction during exercise did not differ at low (0.5°C) to severe (2.0°C) increases in esophageal temperature (all P > 0.05). Similarly, hyperoxia-induced changes in ventilation during exercise as assessed by percent change from prehyperoxic levels were not different at all levels of hyperthermia (~15-20%, all P > 0.05). We show that in young men carotid chemoreceptor contribution to hyperthermia-induced hyperventilation is relatively small at low-to-severe increases in body core temperature induced by moderate-intensity exercise in the heat. NEW & NOTEWORTHY Exercise-induced increases in hyperthermia cause a progressive increase in ventilation in humans. However, the mechanisms underpinning this response remain unresolved. We showed that in young men hyperventilation associated with exercise-induced hyperthermia is not predominantly mediated by carotid chemoreceptors. This study provides important new insights into the mechanism(s) underpinning the regulation of hyperthermia-induced hyperventilation in humans and suggests that factor(s) other than carotid chemoreceptors play a more important role in mediating this response.

Respiratory mechanics and cerebral blood flow during heat-induced hyperventilation and its voluntary suppression in passively heated humans

We investigated whether heat-induced hyperventilation can be voluntarily prevented, and, if so, how this modulates respiratory mechanics and cerebral blood flow in resting heated humans. In two separate trials, 10 healthy men were passively heated using lower body hot-water immersion and a water-perfused garment covering their upper body (both 41°C) until esophageal temperature (Tes ) reached 39°C or volitional termination. In each trial, participants breathed normally (normal-breathing) or voluntarily controlled minute ventilation (VE ) at a level equivalent to that observed after 5 min of heating (controlled-breathing). Respiratory gases, middle cerebral artery blood velocity (MCAV), work of breathing, and end-expiratory and inspiratory lung volumes were measured. During normal-breathing, VE increased as Tes rose above 38.0 ± 0.3°C, whereas controlled-breathing diminished the increase in VE (VE at Tes  = 38.6°C: 25.6 ± 5.9 and 11.9 ± 1.3 L min-1 during normal- and controlled-breathing, respectively, P < 0.001). During normal-breathing, end-tidal CO2 pressure and MCAV decreased with rising Tes , but controlled-breathing diminished these reductions (at Tes  = 38.6°C, 24.7 ± 5.0 vs. 39.5 ± 2.8 mmHg; 44.9 ± 5.9 vs. 60.2 ± 6.3 cm sec-1 , both P < 0.001). The work of breathing correlated positively with changes in VE (P < 0.001) and was lower during controlled- than normal-breathing (16.1 ± 12.6 and 59.4 ± 49.5 J min-1 , respectively, at heating termination, P = 0.013). End-expiratory and inspiratory lung volumes did not differ between trials (P = 0.25 and 0.71, respectively). These results suggest that during passive heating at rest, heat-induced hyperventilation increases the work of breathing without affecting end-expiratory lung volume, and that voluntary control of breathing can nearly abolish this hyperventilation, thereby diminishing hypocapnia, cerebral hypoperfusion, and increased work of breathing.

Significant effects of exposure to relatively low level ozone on daily mortality in 17 cities from three Eastern Asian Countries

BACKGROUND

Studies have examined the variation in mortality risk associated with ambient ozone. We conducted an international cooperation study for investigating the non-linear ozone-mortality association accounting for lag effect and for examining the ozone level with significant health effect.

METHODS

Daily counts of total non-accidental death and ambient air pollutant concentration were obtained in 17 cities from 3 Eastern Asian countries or regions (Taiwan, Korea, and Japan). The total study period was from 1979 to 2010 and differed by city based on data availability. The ozone-mortality association in each city was estimated by running a time-series quasi-Poisson regression model, allowing for overdispersion. The city-specific estimates were then pooled by country by using multivariate random effects meta-analysis.

RESULTS

The non-linear ozone exposure-mortality response curves were generated in 17 cities from Taiwan, Korea, and Japan. The association curves in the three countries all showed increased mortality with elevated ozone, and the significant mortality effects of ozone exposure were observed at level higher than 40, 50, and 40 ppb for Taiwan, Korea, and Japan, respectively. These associations are unaffected by co-pollutant of particulate matter in Taiwan and Japan. But the potential confounding effect of co-pollutant could not be ignorable in Korea.

CONCLUSIONS

Our study provides evidence that exposure to a relative low level of ambient ozone is associated with an increased risk of mortality. Our results emphasize the continual need to examine the existing standard by documenting potential human adverse effects.

New microwave ablation system for unresectable liver tumors that forms large, spherical ablation zones

BACKGROUND AND AIM

The aim of this study was to assess the efficacy of a new microwave ablation (MWA) system, the Emprint Ablation System, for the ablation of unresectable large liver tumors (≥ 30 mm).

METHODS

Twenty-one hepatic tumors (mean diameter, 34.7 mm) from 21 patients who underwent percutaneous MWA were included in this cross-sectional study. A volume analyzer based on computed tomography imaging was used for all patients within the month before and month after the procedure to evaluate the shape and volume of ablation zones. In addition, computed tomography imaging was performed again 3 months after the procedure to evaluate the presence of residual tumors and local recurrence.

RESULTS

Mean ablation time was 11.3 min, and mean overall procedure time was 33.4 min. An ablated adrenal gland-induced Takotsubo (stress) cardiomyopathy occurred immediately after MWA as a major complication in one patient. Roundness index A, B, and C presented a mean value of 0.94, 0.94, and 1.01, respectively (all values near 1 is a perfect sphere), indicating that a spherical ablation zone was achieved. The mean ablation volume was larger than the volume of tumors (24.5 vs 41.7 cm³ ). Residual tumors were confirmed in only 4.8% of tumors after a single ablation session. There was no local recurrence.

CONCLUSIONS

In our experience, the new MWA system provides an effective treatment option for unresectable large liver tumors. However, to ablate the liver tumors safely, it is necessary to consider the surrounding organs, such as the adrenal glands.

Magnetic resonance elastography increases usefulness and safety of non-invasive screening for esophageal varices

BACKGROUND AND AIMS

The Baveno VI criteria enable non-invasive screening for esophageal varices. However, these criteria were established based on studies examining a large proportion of patients with viral hepatitis and relatively few patients with non-alcoholic fatty liver disease (NAFLD). Furthermore, because vibration-controlled transient elastography (VCTE) has a high incidence of measurement error, improved criteria are needed. We aimed to develop criteria based on magnetic resonance elastography (MRE) even among patients with NAFLD.

METHODS

We performed a cross-sectional analysis of patients who had undergone MRE and/or VCTE as well as an esophagogastroduodenoscopy. The patients were classified as having either a low risk or a high risk of varices. The optimal cut-offs for ruling out esophageal varices were calculated for the MRE and VCTE liver stiffness measurement (LSM), the platelet count in an estimation cohort, and the cut-offs were then evaluated using validation cohorts composed of patients who had undergone only MRE or VCTE.

RESULTS

The study included 627 patients (39% with NAFLD). The optimal cut-off values for the MRE-LSM and the platelet count were 4.2 kPa and 18.0 × 10⁴ /μL, respectively. An MRE-LSM of 4.2 kPa plus a platelet count of 18.0 × 10⁴ /μL had a negative predictive value of 1.00 for both low-risk plus high-risk varices as well as for high-risk varices in a validation cohort, enabling the presence of varices to be ruled out.

CONCLUSIONS

Magnetic resonance elastography might enable a safer avoidance of screening endoscopy, with a smaller measurement error, among patient populations with a high prevalence of NAFLD.

Health impact assessment of PM2.5-related mitigation scenarios using local risk coefficient estimates in 9 Japanese cities

Previous studies have highlighted the negative effects of PM_2.5 on mortality, expressed in terms of attributable deaths and life years lost. However, there are very few studies assessing the health impacts of air pollution in terms of economic burden/benefits. This study assessed the health impact of two hypothetical interventions among sex- and age-specific risk populations using a robust risk estimation and economic valuation process. We utilized the sex- and age-stratified daily all-cause mortality together with the daily PM_2.5 of the 9 Japanese cities from 2002 to 2008 in estimating the relative risks. The estimated risks were then utilized for the economic valuation of co-benefits/burden with respect to the two hypothetical PM_2.5-related mitigation scenarios, in comparison to status quo, namely: i) decrease to Japanese standards, and ii) decrease to WHO standards. Impact of these interventions on health were assessed using the following HIA metrics: attributable mortality, attributable years life lost, and environmental health impact. A 10-μg/m³ increase in PM_2.5 would increase the risk by 0.52% (95% CI: -0.91% to 1.99%) for all-cause mortality, with varying risk estimates per subgroup. High economic burdens were estimated at status quo, with particularly distinct burden difference for age-specific mortality; 0.40 trillion yen (0-64 y.o.) and 1.50 trillion yen (>64 y.o.). If stricter standards, relative to status quo, were to be enforced, i.e. WHO standard, there is a potential to yield economic benefits in the same risk population; 0.26 trillion yen (0-64 y.o.) and 0.98 trillion yen (>64 y.o.). We did not observe any substantial difference with the burden and benefit related to sex-specific mortality. Using the estimated local risk coefficients complemented with the valuation of the risks, policymaking entities will have the opportunity to operate their own HIA to assess the relevant air pollution-related health impacts.

[Gut microbiota and nonalcoholic steatohepatitis]

Nonalcoholic fatty liver disease (NAFLD), especially nonalcoholic steatohepatitis (NASH), is a disease that may lead to liver cirrhosis or hepatocellular carcinoma. The number of patients is increasing steadily and the pathology is diverse. Effective treatment is still mainly focused on diet and exercise therapy. With the advent of the next-generation sequencer, the intestinal flora in NAFLD/NASH is being elucidated. We believe that elevation of endotoxin in the blood caused by intestinal bacterial dysbiosis caused by intestinal permeability enhancement is important for NASH pathology and control of intestinal permeability enhancement has a new possibility for treatment of NAFLD/NASH.

Association between diurnal temperature range and mortality modified by temperature in Japan, 1972-2015: Investigation of spatial and temporal patterns for 12 cause-specific deaths

Many previous literatures suggested that high temperature and diurnal temperature range (DTR) are prominent risk factors to increase risk of mortality. However, the role of effect modification of temperature on the DTR-related mortality is unclear. We examined whether temperature was an effect modifier on the DTR-mortality association and how the modification patterns differed by cause of deaths and different regional climates using a nationwide 47 prefecture data in Japan (1972-2015). We used a two-stage analysis. For the first stage, we used a time-series regression with a distributed lag model to estimate the DTR-mortality association according to five levels of temperature (extreme cold, cold, moderate, hot, and extreme hot days) for each prefecture stratified by twelve cause-specific deaths. Then, we applied a meta-analysis to pool the estimates across the 47 prefectures in Japan and separately by cooler vs. warmer regions. Our findings showed that the risk of mortality associated with DTR was strongly modified by temperature for all causes and cardiovascular deaths (p < 0.001) in the total population, suggesting that the influence of DTR on mortality increases at higher levels of temperature. These findings were consistent across warmer and cooler regions. Similar patterns were observed for respiratory and renal disease deaths which demonstrated the associations with DTR were the highest during extreme hot days, although it was statistically not significant and varied depending on the climate regions. Our findings suggest that the DTR-related mortality may be modified by daily mean temperature and the most elevated during extremely hot temperatures.